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(247) Attitudes and beliefs about pain management among providers treating an economically-disadvantaged primary care population
Abstracts
(244) Stanford Patient Experience Questionnaire (SPEQ): Machine-mediated classification of patient experience feedback using natural language processing M Kao, M Leong, R Prasad, A Cullen, T Pacht, G Olson, B Darnall, S Weber, and S Mackey; Stanford University, Palo Alto, CA Patient experience, an emerging marker of healthcare quality to policy makers and payers, is an area where Pain Medicine has historically underperformed. Real-time monitoring of patient feedback may be a critical tool to optimize the patient experience while eliminating the need for manual intervention. Here we leverage the Collaborative Health Outcomes Information Registry (CHOIR) platform and the Stanford Patient Experience Questionnaire (SPEQ) and develop a machine-mediated automatic classification of patient free-text feedback in terms of the sentiment expressed. SPEQ measures patient experience with 20 items in 7 touch points plus one free-text item. Over a threeweek period at an academic multidisciplinary pain center, 628 patients were given SPEQ post-visit, of whom 123 (20%) completed the questionnaire, of whom 63 (51%) provided free-text feedback. The length of the feedback ranged from 2 to 513 words, with an average of 81.5 and SD of 105.8 words. We performed manual coding in terms of 1) aspects of patient experience referenced, 2) sentiment expressed for each aspect, and 3) overall sentiment. Next we performed natural language processing (NLP) using recursive neural network (Socher et al 2013), which rates each sentence as having Positive, Neutral, or Negative sentiment. In order to derive an overall rating of passage-level sentiment, we performed a receiver-operating curve analysis. The optimal cut-off for classifying the feedback as Negative is a threshold of 68.5% or more of the sentences being Negative. There is moderate agreement between machine-mediated rating with single-rater coding, with Kappa of 0.57 and AUC of 0.79. In summary, we have developed an algorithm that enables automatic classification of patient feedback. Large-volume and realtime processing of patient feedback enables organization-wide deployment of patient experience monitoring with low cost and resource burden. Future work will focus on optimizing this algorithm using training data from additional patient feedback.
C07 Pain in Primary Care (245) Establishment of a controlled substance advisory review consult process for patients on chronic opioid therapy K Stevenson, E Collins, J Ebert, D Johnson, J Schiffman, and T Blair; William S. Middleton Memorial Veterans Hospital, Madison, WI In a system where primary care providers prescribe the majority of opioids for chronic pain, there can be significant benefit in terms of continuity of care. However, there are also outsized challenges posed by the subset of patients who struggle with aberrant behaviors. To help providers address these challenges, the William S. Middleton Memorial Veterans Hospital established an Opioid Pain Care Agreement in May 2012 for all patients who are starting chronic opioid therapy. This was superseded in May 2014 by the nationally mandated VA Consent for Long Term Opioid Therapy for Pain. Both documents emphasize the partnership between the provider and patient, discuss risks and benefits of opioids, lay out the expectations of care, and include patient education materials. A Controlled Substance Advisory (CSA) Review Consult was established in May 2012 to allow providers to request a chart review of patients who have been unable to adhere to the terms of the agreements/consents. An interdisciplinary panel consisting of representatives of pain medicine, pharmacy, addiction psychiatry and pain management nursing was established to review the consults and make recommendations. Recommendations could range from follow-up evaluation and testing to publishing an electronic posting that prohibits further prescribing of opioids from the facility for the chronic condition. A recommendation to stop chronic opioids is typically due to patient and/or public safety concerns. In the 30 months of experience, there was substantially increased use of the opioid consents and agreements, and an average of 7.5 CSA Review consults per month. Less than half (45%) resulted in a posting restricting further opioid prescribing. Providers have expressed appreciation for the support the process gives for the decisions they must make in the front line of care.
The Journal of Pain
S37
(246) Racial and ethnic disparities in pain care at a statewide federally qualified health center B Teevan, I Zlateva, and D Middletown, CT
Anderson; Community Health Center, Inc.,
To date most research on racial/ethnic disparities in chronic nonmalignant pain management has evaluated care in settings such as emergency departments, academic primary care, and post-operative settings. However, community health centers, organizations with a specific mission to provide culturally appropriate care and reduce disparities, have not been examined in this context. We hypothesized that there will be less evidence for pain care disparities in such settings. We retrospectively examined the extent to which racial/ ethnic disparities occur in pain care at a statewide, Federally Qualified Health Center in Connecticut for the years 2011-2014. Using data from the electronic health records system we assessed opioid prescribing and monitoring patterns among 8147 Black, White, and Hispanic patients in three cohorts: 1) patients with severe pain (pain score $8); 2) patients with chronic opioid use ($90 days); 3) patients with chronic pain identified using a validated algorithm based on ICD-9 codes for pain, pain intensity, and opioid use. We found substantial differences in pain care among Caucasian, Latino and African American patients. In each cohort across all four years, in comparison to non-white patients, Caucasian patients had an increased odds ratio to: 1) receive an opioid prescription; 2) receive opioids for chronic pain management; and 3) have their pain documented and reassessed at a subsequent visit. In contrast, non-white patients who used opioids chronically for pain management had an increased odds ratio to have urine toxicology screenings and opioid agreements than their white counterparts. Our results are broadly consistent with findings from the literature and suggest that even in community health centers ethnic/racial disparities exist in prescribing medications for pain and in the monitoring of patients who are prescribed opioids.
(247) Attitudes and beliefs about pain management among providers treating an economically-disadvantaged primary care population L Dhingra, R Schiller, S Nosal, R Teets, S Rodriguez, S Shuman, V Rodriguez, R Ginzburg, and R Portenoy; MJHS Institute for Innovation in Palliative Care and The Institute for Family Health, New York, NY Chronic pain is common in economically-disadvantaged, community-dwelling populations. Although most pain care is provided by primary care practitioners, little is known about their attitudes and beliefs towards pain management. We evaluated baseline data from 55 physicians, 4 nurse practitioners and 1 physician assistant participating in a study of a decision support tool for pain management in six Federally Qualified Health Centers in New York State. The sample had a mean (SD) age of 39.3 (11.0) years, 62.0% were women, and had a mean (SD) of 8.8 (9.7) years in practice. Survey results revealed broad variation in attitudes and beliefs. About half (53.4%) agreed ‘‘quite a bit/ completely’’ that the ‘‘majority of chronic pain patients do not receive optimal treatment’’ and 43.3% agreed ‘‘not at all/a little’’ that ‘‘I know enough to provide adequate evaluation and treatment to chronic pain patients.’’ Whereas 13.3% agreed ‘‘somewhat’’ and 16.6% agreed ‘‘quite a bit/completely’’ that ‘‘opioids have no place in chronic pain treatment’’, 16.7% agreed ‘‘a little’’ and 8.3% agreed ‘‘somewhat’’ that ‘‘opioids are underused in chronic pain treatment.’’ Overall, 60.0% agreed ‘‘quite a bit/completely’’ that ‘‘managing chronic pain patients is a frustrating experience’’ and 56.7% agreed ‘‘not at all/a little’’ that ‘‘I have adequate consultation/referral resources to help chronic pain patients.’’ These results suggest that primary care practitioners caring for economically-disadvantaged patients with chronic pain vary greatly in their self-assessed capabilities and their willingness to use a common therapy—opioid therapy. Many are frustrated and unable to identify consultative help. Novel solutions are needed to improve provider education and self-efficacy for pain management.
(244) Stanford Patient Experience Questionnaire (SPEQ): Machine-mediated classification of patient experience feedback using natural language processing M Kao, M Leong, R Prasad, A Cullen, T Pacht, G Olson, B Darnall, S Weber, and S Mackey; Stanford University, Palo Alto, CA Patient experience, an emerging marker of healthcare quality to policy makers and payers, is an area where Pain Medicine has historically underperformed. Real-time monitoring of patient feedback may be a critical tool to optimize the patient experience while eliminating the need for manual intervention. Here we leverage the Collaborative Health Outcomes Information Registry (CHOIR) platform and the Stanford Patient Experience Questionnaire (SPEQ) and develop a machine-mediated automatic classification of patient free-text feedback in terms of the sentiment expressed. SPEQ measures patient experience with 20 items in 7 touch points plus one free-text item. Over a threeweek period at an academic multidisciplinary pain center, 628 patients were given SPEQ post-visit, of whom 123 (20%) completed the questionnaire, of whom 63 (51%) provided free-text feedback. The length of the feedback ranged from 2 to 513 words, with an average of 81.5 and SD of 105.8 words. We performed manual coding in terms of 1) aspects of patient experience referenced, 2) sentiment expressed for each aspect, and 3) overall sentiment. Next we performed natural language processing (NLP) using recursive neural network (Socher et al 2013), which rates each sentence as having Positive, Neutral, or Negative sentiment. In order to derive an overall rating of passage-level sentiment, we performed a receiver-operating curve analysis. The optimal cut-off for classifying the feedback as Negative is a threshold of 68.5% or more of the sentences being Negative. There is moderate agreement between machine-mediated rating with single-rater coding, with Kappa of 0.57 and AUC of 0.79. In summary, we have developed an algorithm that enables automatic classification of patient feedback. Large-volume and realtime processing of patient feedback enables organization-wide deployment of patient experience monitoring with low cost and resource burden. Future work will focus on optimizing this algorithm using training data from additional patient feedback.
C07 Pain in Primary Care (245) Establishment of a controlled substance advisory review consult process for patients on chronic opioid therapy K Stevenson, E Collins, J Ebert, D Johnson, J Schiffman, and T Blair; William S. Middleton Memorial Veterans Hospital, Madison, WI In a system where primary care providers prescribe the majority of opioids for chronic pain, there can be significant benefit in terms of continuity of care. However, there are also outsized challenges posed by the subset of patients who struggle with aberrant behaviors. To help providers address these challenges, the William S. Middleton Memorial Veterans Hospital established an Opioid Pain Care Agreement in May 2012 for all patients who are starting chronic opioid therapy. This was superseded in May 2014 by the nationally mandated VA Consent for Long Term Opioid Therapy for Pain. Both documents emphasize the partnership between the provider and patient, discuss risks and benefits of opioids, lay out the expectations of care, and include patient education materials. A Controlled Substance Advisory (CSA) Review Consult was established in May 2012 to allow providers to request a chart review of patients who have been unable to adhere to the terms of the agreements/consents. An interdisciplinary panel consisting of representatives of pain medicine, pharmacy, addiction psychiatry and pain management nursing was established to review the consults and make recommendations. Recommendations could range from follow-up evaluation and testing to publishing an electronic posting that prohibits further prescribing of opioids from the facility for the chronic condition. A recommendation to stop chronic opioids is typically due to patient and/or public safety concerns. In the 30 months of experience, there was substantially increased use of the opioid consents and agreements, and an average of 7.5 CSA Review consults per month. Less than half (45%) resulted in a posting restricting further opioid prescribing. Providers have expressed appreciation for the support the process gives for the decisions they must make in the front line of care.
The Journal of Pain
S37
(246) Racial and ethnic disparities in pain care at a statewide federally qualified health center B Teevan, I Zlateva, and D Middletown, CT
Anderson; Community Health Center, Inc.,
To date most research on racial/ethnic disparities in chronic nonmalignant pain management has evaluated care in settings such as emergency departments, academic primary care, and post-operative settings. However, community health centers, organizations with a specific mission to provide culturally appropriate care and reduce disparities, have not been examined in this context. We hypothesized that there will be less evidence for pain care disparities in such settings. We retrospectively examined the extent to which racial/ ethnic disparities occur in pain care at a statewide, Federally Qualified Health Center in Connecticut for the years 2011-2014. Using data from the electronic health records system we assessed opioid prescribing and monitoring patterns among 8147 Black, White, and Hispanic patients in three cohorts: 1) patients with severe pain (pain score $8); 2) patients with chronic opioid use ($90 days); 3) patients with chronic pain identified using a validated algorithm based on ICD-9 codes for pain, pain intensity, and opioid use. We found substantial differences in pain care among Caucasian, Latino and African American patients. In each cohort across all four years, in comparison to non-white patients, Caucasian patients had an increased odds ratio to: 1) receive an opioid prescription; 2) receive opioids for chronic pain management; and 3) have their pain documented and reassessed at a subsequent visit. In contrast, non-white patients who used opioids chronically for pain management had an increased odds ratio to have urine toxicology screenings and opioid agreements than their white counterparts. Our results are broadly consistent with findings from the literature and suggest that even in community health centers ethnic/racial disparities exist in prescribing medications for pain and in the monitoring of patients who are prescribed opioids.
(247) Attitudes and beliefs about pain management among providers treating an economically-disadvantaged primary care population L Dhingra, R Schiller, S Nosal, R Teets, S Rodriguez, S Shuman, V Rodriguez, R Ginzburg, and R Portenoy; MJHS Institute for Innovation in Palliative Care and The Institute for Family Health, New York, NY Chronic pain is common in economically-disadvantaged, community-dwelling populations. Although most pain care is provided by primary care practitioners, little is known about their attitudes and beliefs towards pain management. We evaluated baseline data from 55 physicians, 4 nurse practitioners and 1 physician assistant participating in a study of a decision support tool for pain management in six Federally Qualified Health Centers in New York State. The sample had a mean (SD) age of 39.3 (11.0) years, 62.0% were women, and had a mean (SD) of 8.8 (9.7) years in practice. Survey results revealed broad variation in attitudes and beliefs. About half (53.4%) agreed ‘‘quite a bit/ completely’’ that the ‘‘majority of chronic pain patients do not receive optimal treatment’’ and 43.3% agreed ‘‘not at all/a little’’ that ‘‘I know enough to provide adequate evaluation and treatment to chronic pain patients.’’ Whereas 13.3% agreed ‘‘somewhat’’ and 16.6% agreed ‘‘quite a bit/completely’’ that ‘‘opioids have no place in chronic pain treatment’’, 16.7% agreed ‘‘a little’’ and 8.3% agreed ‘‘somewhat’’ that ‘‘opioids are underused in chronic pain treatment.’’ Overall, 60.0% agreed ‘‘quite a bit/completely’’ that ‘‘managing chronic pain patients is a frustrating experience’’ and 56.7% agreed ‘‘not at all/a little’’ that ‘‘I have adequate consultation/referral resources to help chronic pain patients.’’ These results suggest that primary care practitioners caring for economically-disadvantaged patients with chronic pain vary greatly in their self-assessed capabilities and their willingness to use a common therapy—opioid therapy. Many are frustrated and unable to identify consultative help. Novel solutions are needed to improve provider education and self-efficacy for pain management.