title: An institutional ethnography of chronic pain management in family medicine (COPE) study protocol.
abstract: BACKGROUND
  Patients with chronic conditions and multiple comorbidities represent a growing challenge for health care globally. Improved coordination of care is considered essential for providing more effective and cost-efficient care for these patients with complex needs. Osteoarthritis is one of the most common and debilitating chronic conditions, is the most frequent cause of chronic pain yet osteoarthritis care is often poorly-coordinated. Primary care is usually the first contact for patients requiring relief from chronic pain. Our previous work suggests discordance between the policy goals of improving patient care and the experience of osteoarthritis patients. We plan to investigate the empirical context of the primary care setting by focusing on primary physicians' conceptualizations and performance of their work in treating complex patients with chronic pain. This will allow for an exploration of how primary health care is - or could be - integrated with other services that play an important role in health care delivery.
  
  
  METHODS
  Our study is an Institutional Ethnography of pain management in family medicine, to be carried out in three phases over 3 years from 2014/15 to 2018. Over the first year we will undertake approximately 80 key informant interviews with primary care physicians, other health care providers, policymakers and clinical experts. In the second year we will focus on mobilizing our networks from year one to assist in the collection of key texts which shape the current context of care. These texts will be analyzed by the research team. In the final year of the study we will focus on synthesizing our findings in order to map the social relations informing care. As is standard and optimal in qualitative research, analysis will be concurrent with data collection.
  
  
  CONCLUSIONS
  Our study will allow us to identify how the work of coordinating care across multiple settings is accomplished, in practice as well as discursively and textually. Ultimately, we will identify links between everyday experience of care for patients with chronic pain, and broader discourses related to health care system inefficiencies, integration and patient-centred care. An expected outcome of this study will be the development of new, or augmentation of existing, models of care, that are based in the local realities of primary care practice.
authors.affiliation: Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada. fiona.webster@utoronto.ca.
authors.forename: Fiona
authors.initials: F
authors.lastname: Webster
authors.affiliation: Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.|Women's College Research Institute, 790 Bay St, 7th Floor, Toronto, ON, M5G 1N8, Canada.
authors.forename: Onil
authors.initials: O
authors.lastname: Bhattacharyya
authors.affiliation: Division of Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, University of Toronto, Toronto, Canada.|Institute of Health Policy, Management and Evaluation, Departments of Physical Therapy and Rehabilitation Science Institute, University of Toronto, 399 Bathurst Street, MP11-322, Toronto, ON, M5T 2S8, Canada.
authors.forename: Aileen
authors.initials: A
authors.lastname: Davis
authors.affiliation: Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.|ICES Central, Primary Care & Population Health Research Program, G1 06, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
authors.forename: Rick
authors.initials: R
authors.lastname: Glazier
authors.affiliation: Department of Psychology, York University, 4700 Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada.|Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth St., 3EB-317, Toronto, ON, M5G 2C4, Canada.
authors.forename: Joel
authors.initials: J
authors.lastname: Katz
authors.affiliation: Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Krueger
authors.affiliation: Dalla Lana Faculty of Public Health, 155 College Street, Toronto, ON, M5G 1L4, Canada.
authors.forename: Ross
authors.initials: R
authors.lastname: Upshur
authors.affiliation: Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room MG 371B, Toronto, ON, M4N 3M5, Canada.
authors.forename: Albert
authors.initials: A
authors.lastname: Yee
authors.affiliation: Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.
authors.forename: Lynn
authors.initials: L
authors.lastname: Wilson
mesh_terms: D000884:Anthropology, Cultural; D059350:Chronic Pain / Q000209:etiology / Q000628:therapy*; D005194:Family Practice; D006801:Humans; D007407:Interviews as Topic; D010003:Osteoarthritis / Q000150:complications / Q000628:therapy*; D059408:Pain Management; D018802:Patient-Centered Care; D058007:Physicians, Primary Care; D011320:Primary Health Care; D036301:Qualitative Research; D012107:Research Design