Martha S. Gerrity

Collaborative care for chronic pain in primary care: a cluster randomized trial.

CONTEXTnChronic pain is common in primary care patients and is associated with distress, disability, and increased health care use.nnnOBJECTIVEnTo assess whether a collaborative intervention can improve chronic pain-related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting.nnnDESIGN, SETTING, AND PARTICIPANTSnCluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008.nnnINTERVENTIONnAssistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care.nnnMAIN OUTCOME MEASURESnChanges over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month).nnnRESULTSnIntervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P = .004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P = .01). Among patients with baseline depression (PHQ-9 score > or = 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P = .003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9.nnnCONCLUSIONnThe assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00129480.

Violence, mental health, and physical symptoms in an academic internal medicine practice

OBJECTIVE: To assess how physical and/or sexual intimate partner violence (IPV), child abuse, and community violence relate to long-term mental and physical problems; to examine the overlap between different forms of violence and the impact of experiencing multiple forms of violence. DESIGN: Cross-sectional survey. SETTING: Three general internal medicine practices affiliated with an academic medical center. PARTICIPANTS: English-speaking women aged 25 to 60. MEASUREMENTS: Telephone or in-person interview and chart review. RESULTS: One hundred seventy-four women completed interviews. A majority of participants experienced more than one form of violence. In separate multivariate analyses, each form of violence was associated with depressive symptoms or with at least 6 chronic physical symptoms, after adjustment for demographic factors and substance abuse. The degree of association with health outcomes was similar for each form of violence (odds ratio [OR], 2.4 to 3.9; P<.003). The association with chronic physical symptoms remained significant for IPV (OR, 3.3; P<.002) and community violence (OR, 3.4; P<.003), even after adjustment for depression and posttraumatic stress disorder. There were dose-response relationships between the number of forms of violence experienced and the odds of depressive symptoms and the odds of multiple chronic physical symptoms. CONCLUSIONS: Multiple types of victimizations may contribute to patients’ current mental health and physical problems. Research or clinical protocols that only focus on one form of violence may underestimate the complexity of women’s experiences and needs.

Measuring adherence to depression treatment guidelines in a VA primary care clinic

The primary objectives of this pilot study were to develop a measure of adherence for depression practice guidelines and to assess the degree to which providers and patients adhere to guidelines in a VA primary care setting. The Depression Guideline Measure (DGM) is based on three national guidelines. The DGM was used to review medical records of 111 patients with Patient Health Questionnaire (PHQ) scores >or=10. Interrater reliability for 15 of 19 DGM checklist items was excellent (kappa > 0.75). There was a broad range of adherence to guideline criteria: only 13.5% of patients were contacted for follow-up within 2 weeks, while 100% of providers documented follow-up plans. Forty percent of patients saw mental health providers, and 63% were prescribed antidepressants. A secondary objective of the study was to explore the relationship between guideline adherence and changes in PHQ scores. Among 51 patients who completed follow-up PHQs, no associations were detected. The results suggest that the DGM shows promise as a reliable measure of guideline adherence and that guideline criteria are frequently not met in busy primary care clinics. More research is needed to determine the validity of the DGM and the impact of guideline adherence on depression outcomes.

“You Always End up Feeling Like You’re Some Hypochondriac”: Intimate Partner Violence Survivors’ Experiences Addressing Depression and Pain

Little is known regarding how providers should use information about intimate partner violence (IPV) to care for depressed patients. Our objective was to explore what depressed IPV survivors believe about the relationship between abuse, mental health, and physical symptoms and to elicit their recommendations for addressing depression. Focus group study. Adult, English-speaking, female, Internal Medicine clinic patients with depressive symptoms and a history of IPV. Thematic analysis using an inductive approach (consistent with grounded theory), at a semantic level, with an essentialist paradigm. Twenty three women participated in 5 focus groups. Although selected because of their depression, participants often felt their greatest concerns were physical. They acknowledged that their abuse history, depression, and physical complaints compound each other. They appreciated the need for health care workers to know about their depression and IPV history to get a “full picture” of their health, but they were often hesitant to discuss such issues with providers because of their fear that such information would make providers think their symptoms were “all in their head” or would encourage providers to discount their pain. Participants discussed difficulties related to trust and control in relationships with providers and gave recommendations as to how providers can earn their trust. Understanding a patient’s IPV history may allow providers to develop a better therapeutic relationship. To treat depression adequately, it is important for providers to reassure patients that they believe their physical symptoms; to communicate respect for patients’ intelligence, experience, and complexity; and to share control.ObjectiveLittle is known regarding how providers should use information about intimate partner violence (IPV) to care for depressed patients. Our objective was to explore what depressed IPV survivors believe about the relationship between abuse, mental health, and physical symptoms and to elicit their recommendations for addressing depression.DesignFocus group study.Patients/ParticipantsAdult, English-speaking, female, Internal Medicine clinic patients with depressive symptoms and a history of IPV.InterventionsThematic analysis using an inductive approach (consistent with grounded theory), at a semantic level, with an essentialist paradigm.Measurements and Main ResultsTwenty three women participated in 5 focus groups. Although selected because of their depression, participants often felt their greatest concerns were physical. They acknowledged that their abuse history, depression, and physical complaints compound each other. They appreciated the need for health care workers to know about their depression and IPV history to get a “full picture” of their health, but they were often hesitant to discuss such issues with providers because of their fear that such information would make providers think their symptoms were “all in their head” or would encourage providers to discount their pain. Participants discussed difficulties related to trust and control in relationships with providers and gave recommendations as to how providers can earn their trust.ConclusionsUnderstanding a patient’s IPV history may allow providers to develop a better therapeutic relationship. To treat depression adequately, it is important for providers to reassure patients that they believe their physical symptoms; to communicate respect for patients’ intelligence, experience, and complexity; and to share control.

Primary Care Clinician Adherence to Guidelines for the Management of Chronic Musculoskeletal Pain: Results from the Study of the Effectiveness of a Collaborative Approach to Pain

OBJECTIVEnWe assessed primary care clinician-provided guideline-concordant care as documented in patients medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team.nnnMETHODSnTo assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (≥30% decrease in Roland-Morris Disability Questionnaire score).nnnRESULTSnRates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively).nnnCONCLUSIONSnAs measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.

Development and preliminary psychometric testing of the centrality of pain scale.

OBJECTIVEnThe objective of the study was to develop and begin to evaluate a new measure of the centrality of pain in patients lives.nnnDESIGNnThe study was designed as a cross-sectional survey and cognitive interviews.nnnSETTINGnThe study was set in an academic general internal medicine clinic.nnnPATIENTSnSixty-five adult internal medicine patients with chronic nonmalignant pain (CNMP) participated in the study.nnnOUTCOME MEASURESnWe assessed content validity and clarity of the 10-item Centrality of Pain Scale (COPS) by soliciting feedback from chronic pain experts and by conducting cognitive interviews with patients with CNMP. We assessed internal consistency reliability using Cronbachs alpha. We assessed construct validity by comparing the COPS with other measures of chronic pain morbidity including pain severity, depression, anxiety, physical and mental health function, posttraumatic stress disorder, quality of life, and provider assessment.nnnRESULTSnHealth care providers felt the COPS had excellent face validity. Cognitive interviews revealed that patients understanding of the items matched the intended construct, the scale measured an important concept, and items were easy to understand. The COPS had excellent internal consistency (alpha = 0.9). It was negatively associated with age (r = -0.29; P = 0.02), but not with other demographic characteristics. Higher COPS scores were associated with poorer physical (r = -0.48; P < 0.001) and mental (r = -0.39; P = 0.002) health function, quality of life (r = -0.36; P = 0.004), and provider assessment of stability (r = -0.38; P = 0.004) as well as with greater pain grade (r = 0.55; P < 0.001), and depression (r = 0.63; P < 0.001). In multivariate analyses, age, physical and mental health function, and depression were independently associated with COPS.nnnCONCLUSIONSnThe COPS has excellent internal consistency and construct validity. Additional studies are needed to further validate the scale.

Online early and other changes in JGIM

We would like to describe some of the changes you will note in the Journal beginning with this issue, the first produced under our tenure as Co-Editors. The goals of these changes are to 1) decrease the time to publication of accepted manuscripts, 2) increase the number of manuscripts published in the Journal to maintain an acceptance rate of approximately 25%, and 3) improve the quality of the reporting and readability of articles. n nThe most exciting change is our move to an “Online Early” or “Online First” publication process to decrease the time between acceptance and publication of a manuscript. JGIM will post articles online before they appear in the print version of the Journal. This will remove some of the delays associated with print publication. Once manuscripts are accepted, they will be immediately copyedited and typeset. Once an author reviews the page proofs, the article will be published online. Electronic articles will be identified by a unique number, the document object identifier (DOI), and contain guidance on how to cite the online article. Besides being available on the JGIM web site, citations and abstracts for electronic articles can be found by searching PubMed and are identified as online early by [Epub ahead of print] in the citation. n nTo increase the number of manuscripts published, we are making several changes in the formatting of the Journal. You will note with this issue that the complete table of contents will appear on the front cover and continue to the back cover when needed. It will not appear again inside the cover. Appendices and supporting material (e.g., questionnaires, curricula, conceptual models, and additional qualitative data) for articles will only be published online. Finally, we are asking authors to decrease the length of their manuscripts and make efficient use of space in tables and figures. We realize that it is harder to write shorter articles and appreciate authors working with us to do so in order to keep JGIMs acceptance rate at 25% without having to raise subscription prices to publish more pages. n nOur final goal is to improve the quality of the reporting and readability of articles. To accomplish this goal, we are asking authors to use the following standard formats: the Consolidated Standards of Reporting Trials (CONSORT) statement1 for reports of randomized controlled trials, the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Quality of Reporting of Meta-analyses (QUOROM) statements2,3 for systematic reviews, the Standards for Reporting of Diagnostic Accuracy (STARD) statement4 for studies of the accuracy and use of diagnostic tests, and the Transparent Reporting of Evaluations with Non-randomized Designs (TREND) statement5 for reports of nonrandomized educational, behavioral, and public health interventions. We also are asking authors to put more data in abstracts, in addition to using a structured abstract. In the review process, the Deputy Editors are providing constructive feedback to authors on ways to improve the quality and readability of the manuscript whether or not it is accepted for publication in the Journal. n nWe hope you, as our authors and readers, will provide us with feedback on how we do in meeting these goals, as well as any other suggestions for improvement.

Thanks to Reviewers

The quality of the papers published in the Journal depends on both the authors and the external reviewers who help the editors select the best papers and improve their presentation. JGIM is incredibly lucky to have such a wonderful group of reviewers: more than 1,100 individuals provided almost 1,500 reviews in the past year, with an average quality score of 4.3 on a 6-point Likert scale. (And our Deputy Editors are tough scorers!) Names of those who have reviewed for us from July 2007 through June 2008 are listed below. We hope this recognition will serve as a token of our gratitude. - The Editors

A New Look and Continued Growth for JGIM

This issue begins JGIM’s 22nd year and the half-way point of our 5-year tenure as Coeditors. This issue also ushers in a number of changes in JGIM, some dramatic, some subtle, and all representing progress in JGIM as a respected peer-reviewed journal. The most obvious and dramatic change is the cover. In consultation with our Deputy Editors and Editorial Board, we have chosen an eye-catching, radically redesigned cover that reflects the dynamic nature of JGIM and the field of general internal medicine.