title: 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.
abstract: OBJECTIVE
  We 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.
  
  
  METHODS
  To 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).
  
  
  RESULTS
  Rates 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).
  
  
  CONCLUSIONS
  As 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.
authors.affiliation: Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders, Portland VA Medical Center, Portland, Oregon 97207, USA. kathryn.corson@va.gov
authors.forename: Kathryn
authors.initials: K
authors.lastname: Corson
authors.forename: Melanie N
authors.initials: MN
authors.lastname: Doak
authors.forename: Lauren
authors.initials: L
authors.lastname: Denneson
authors.forename: Megan
authors.initials: M
authors.lastname: Crutchfield
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Soleck
authors.forename: Kathryn C
authors.initials: KC
authors.lastname: Dickinson
authors.forename: Martha S
authors.initials: MS
authors.lastname: Gerrity
authors.forename: Steven K
authors.initials: SK
authors.lastname: Dobscha
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D059350:Chronic Pain / Q000188:drug therapy*; D003299:Cooperative Behavior; D019468:Disease Management; D019983:Guideline Adherence; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D059352:Musculoskeletal Pain / Q000188:drug therapy*; D010147:Pain Measurement; D010348:Patient Care Team / Q000458:organization & administration / Q000592:standards; D010353:Patient Education as Topic / Q000592:standards; D010820:Physicians / Q000592:standards*; D011320:Primary Health Care / Q000592:standards*; D016032:Randomized Controlled Trials as Topic; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid