Spotlight on Pain Management - 14 -Department of Veteran Affairs

SOPM-080712

**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Pain Speaking, Plain Speaking**

**Karl Lorenz, MD, MSHS**

**August 7, 2012**

Bob Kerns:  Hello.  Good morning everybody.  This is Dr. Bob Kerns.  I’m National Program Director for Pain Management.  And it’s my pleasure to welcome you to this month’s Spotlight on Pain Management.

This —For those of you who are new to this, this is a partnership between the National Pain Management Program Office and the HSR&D, Health Services Research and Development, Center for Information Dissemination and Educational Resources, CIDER.  And the HSR&D Pain Research Informatics Medical Co-Morbidities in Education or PRIME Center based here at West Haven, Connecticut.

Today it’s my pleasure to welcome you all to the next in our series.  This will be presented by Dr. Karl Lorenz.  Dr. Lorenz is Director of the VA Palliative Care Quality Improvement Resource Center or QUIRC; isn’t that cute, which focuses on the development and implementation of provider facing clinical informatics tools to improve the delivery of national VA palliative care services.  Dr. Lorenz serves as a palliative care consultant and primary care physician, as well as associate professor at the Geffen School of Medicine at the University of California at Los Angeles and a RAND natural scientist.  Dr. Lorenz has two —was a two-time VA HSR&D Career Development Awardee from 2002 to 2007 and a Commonwealth Packer Health Policy Fellow with [Pancer], Australia from 2007 to 2008 studying the dynamics of performance improvement in Australian cancer system.  His research has encompassed the organization of hospice services, development and evaluation of routine symptom measures, including those for the Minimum Dataset 3 and the evaluation of the routine pain screening in primary care known —otherwise known as Pain is the 5th Vital Sign, conduct of systematic literature reviews and quality measure —and measure development and implementation.

I add to that that Karl has become a close colleague of mine in our work in the pain management community and he’s the principal investigator on one of the core projects of our soon to be funded collaborative research for enhancing and advanced transformational excellence, or CREATE, a new funding mechanism from HSR&D.

Today Karl is going to present on Pain Speaking - Plain Speaking.  And with that, I welcome Karl to join us.

Karl Lorenz:  Thanks, Bob.  And that acronym for CREATE is a mouthful, which apparently explains the title of today’s talk: Plain Speaking - Plain Speaking.

I’d like to give you a relatively straight-forward overview of issues related to pain screening and measurement in the primary care setting, as well as oncology setting,  where we’ve also done a fair bit of work thinking about the challenges of quality measurement.

I will be speaking with two hats, if you will, based on both my experience and research as a primary care physician and a palliative care physician.

Let’s see.  And Heidi, I might need a little help advancing my slides.  I’m not sure why they’re not going.

Moderator:  Okay.  If you bring your cursor down to the lower left hand corner of your screen, there are —there is a left and a right arrow.  

Karl Lorenz:  Okay.

Moderator:  A little bit further.  You should click right on there.  Yes.

Karl Lorenz:  Okay.  Thanks.  All right.  So, the talk today is organized in —roughly, in three sessions or three sections, rather.  

First, I’d like to talk about some considerations and research in clinician and patient-reported pain screening.  And then talk a little bit about the current science of evaluating pain quality.  I’m just going to close very, very briefly by thinking about the implications for VA pain and symptoms research.  And just introduce you to the effective screening for pain study.

This photograph taken during recent research on pain screening shows, I think, the problem here that the talk is intended to illuminate.  And, although, I’m being facetious, obviously; I think, you know, the challenge of pain screening has several important dimensions; one being the challenge of reporting pain.  But, the other being the clinician dimension of perceiving pain and actually perceiving their own importance.  And, ideally, the management of pain would include both so that we have better information about what patients are experiencing and better information about what clinicians are doing, which partly explains, I think, my own research into, if you will, the bookends of this problem.

My first offering or food for thought is a question about what are the missed opportunities in pain management and how could we characterizes them.  I chose this as my first question because the challenge of pain screening could be viewed as ubiquitous.  Pain is such a common complaint and it’s so prevalent in many of the settings that we care for patients in that it almost begs the question of where to start.

I use the domino icon in the upper right hand part of the screen because I also don’t want you to think about a talk on pain screening as only about screening.  As you’ll see in some of the slides that I have to share, I think part of the challenge is divorcing it from other aspects of management.

Pain in a way that’s similar, actually, to other problems in medicine, it’s faced by a number of challenges that are distributional in nature.  One is that of under-treatment and this slide provided to me by a veteran that we cared for here, five or six years ago, illustrated very eloquently for me the suffering and the experience and problems with pain that persist, as I’ll show you in many of our cancer settings and in this case, actually, were related to surgical care.

On the other hand, even as we face challenges in unrelieved pain, we also face challenges of over-treatment and this photograph of a child with a book bag packed with prescriptions is illustrative for me of the dangers of diversion and over use of opioids that have also characterized the flip side of the first part of the problem and begs the question of over use of those medications and also another problem which is lack of access to more appropriate treatments other than drugs.

So, screening can’t be seen in isolation because if it is it risks exacerbating these problems.  And, in fact, I think this slide is a helpful reminder that screening merely provides a signal.  But, the question, I think, for all of us as researchers and as clinicians is how to provide meaning for the signal, how to allow screening to be a pathway, if you will, to go and stop with regard to pain management.  And with regard to go, to be a better route to a variety of treatments other than —other than just drugs.

If you remember the food for thought posed the question of where do we start?  And I think this slide is my schematic version of an article written by Lisa Rubenstein, Becky Yano, Brian Mittman and others in a special issue of Medicare, around 2000, which examined the first steps in the QUERI model.  It really asked the question of how we use data to understand where the problems are the greatest.  Pain screening, like any service, is a physical service.  So, it has, if you will, who, why, where and what dimensions.  And when I think about this problem, again speaking as a person who has a palliative care and primary care perspective, many of the patient settings and settings where these issues are most acute and the burdens are greatest and also, where treatment evidence is strongest, at least in my world, often have been cancer, nursing homes and surgical care.  But, I think this sort of a framework could be applied to thinking about the problem as we —as researchers and as clinicians and policy-makers think about where to spend the effort to improve the problem of screening.

And as I began thinking about this problem of screening, I think even before we get to the research evidence, we have there unknowns about steps we might take to improve the screening  —not only screening problems but screening opportunities, if you will, in various settings.  Varying the interval of screening is a question that I’ve asked myself, especially as we move to real time, more patient reported outcomes and, in particular, the problem of noise is a significant one.

Because screening is, in fact, a signal and part of the problem we have is over-treatment, another question which we might ask ourselves is whether we should be screening for pain and additional problems and, in particular, substance misuse risk, which is such a big issue with regard to many of our veterans and, perhaps, a particular problem in some of the ways that we might manage non-cancer pain.

And again, as I’ve said, I think cancer long term care and surgical settings may be particular opportunities for improving screening if we apply the algorithm that I mentioned of prioritization.

So, with that introduction to the question of screening, I might well ask the next question; well, how much variation in what we want out of pain management is related to its assessment? 

And as I’ve suggested, it’s not really just about the screening.  It’s about the screening and what we do with that information.

So, this is evidence from a study that a wonderful group of investigators conducted in Southern California.  Based here at the greater Los Angeles, the Help Vet Study evaluated a random selection of pain screening events at around, approximately, 700 visits during a one year period spread out throughout the southern California region.  And in representing those events one of the important messages about screening was that it’s not enough.   When we actually evaluated a series of processes of care, we found quite good adherence to screening in primary care, the oncology clinics that we looked at and cardiology clinics that we also examined.  In fact, in ninety-eight percent of case there was adherence to the principle of screening for pain in those particular clinics.

But, the other thing that we found is that clinicians wrestled much more with what to do with the information.  And in only fifteen percent of cases was there a response that corresponded to moderate to severe pain resulting in treatment.  

So, one of the big problems that we have with screening is, in fact, as I suggested initially, the relationship of that information to taking action.

We examined reasons for the gap and there were many.  But, one important one that’s worth highlighting, that we were able to address, is the issue of patients being able to rate their pain and the fact that the providers didn’t necessarily agree that the NRS accurately reflected patient’s pain.  In fact, if you look at the first two categories on this slide you’ll see that only ten percent of people believe that patients provide good ratings of pain and meaningful ratings of their pain as a pain intensity rating and that only twenty-eight percent of clinicians in this sample had confidence that the nurse’s ratings accurately reflected that pain.

There were, of course, other issues that —The one related to medication, I think, and the lack of availability of alternatives is reflected in the middle there.  The idea that only forty-eight percent of people thought that medication would be necessarily the appropriate intervention for severe pain.  But, some of the other answers here are enlightening, too; especially, the concern that pain might have negative consequences on functioning; the fact that only fifty-five percent of providers agreed with it.  In fact, this slide —this information led Erin Krebs and I with a group of talented other individuals to develop an improved pain screening item, rather than the NRS, to incorporate two items for the brief pain inventory.  And here you can see that the PEG, as it’s called, in the dark line, actually reflects well the improvement that patients experienced over time in their pain in the same way that the VPI as a whole illustrated, in the other two hashed lines, reflected that change in improvement.  And that’s because the PEG included —took the NRS and added to it two other items; one on functional interference and emotional interference that reflected those domains that are reflected in the full BPI.

So, one issue related to pain and pain screening, rather, and its impact on pain outcomes is the fact that screening is not related, necessarily, to assessment.  I’m sorry.  Screening is not related, necessarily, to management.  And also, that there are a variety of reasons clinicians may have trouble acting on pain screenings.  One of those, the rating, we address through the PEG.  But, others often relate to the kind of treatments that we have available.

Another observation about the relationship of pain screening to management is that, in fact, in some of our settings pain screening isn’t occurring reliably.  And I only want you to pay attention to the two bars on the right in this slide, which shows you that, to a certain extent, it’s a problem of setting.  In the HELP-Vets Study which was a local study, we found a few problems with pain screening in oncology.  But, in this national study, which we recently conducted, you can see that rates of adherence to pain screening in out-patient and in-patient settings varied quite significantly for patients with advanced cancer.  And this is from a study called the Assist National Study that looked at a random sample of veterans with metastatic lung, pancreatic and colorectal cancer.  And, whereas, pain screening occurred reliably in ninety-six percent of in-patient events or in-patient days, it only occurred in fifty-three percent of similar out-patient opportunities for screening.

So, whereas, in primary care, at least in the HELP-Vets Study, the problem was one of not of assessment occurring.  Here, the problem also includes, just simply, getting those —getting pain assessments done and it’s significantly worse in the out-patient setting.

In fact, a facility-level view of cancer pain screening in a previous special study conducted by Dr. Jennifer Malin shows that in a significant minority of sites around the United States that there were gaps in the occurrence of pain screening for veterans with advanced cancer.  

And you can see, on the left side of the slide that the adherence to basic screening, and even advanced cancer, was very low at certain VAs; although, the median score was in the seventieth percent range.

So, one issue is that screening definitely is not the only challenge.  The challenge is thinking about screening and its signal for management and that many times there are gaps in the relationship of screening to management.  But, that screening itself does fail to occur in a significant minority of patients.  And some of that is setting dependent.  Some of it may be condition dependent.

But, another thought is that implementation is also a large gap —represents a large gap in screening practice.  And this may be true regardless of the approach or platform we follow.  But, I’ll show you that in just a second here.

So, another issue that we looked at in the HELP-Vets Study was a question of whether pain screening was faithful to process.  So, when it actually occurred, when nurses or nurse’s aides, in this case, asked the question of whether the veteran had pain, one of the issues was how the question was asked.  As many of the listeners on the call may know, there’s a sort of formal, recommended approach to the pain screening that adheres to the psychometrics, if you will, of the NRS.  And in many cases we found, actually in approximately half of the cases, in 528 of our events that occurred in our primary care sample, half of those events were informally rated.  And what I mean by that is that the patient indicated that the rating had occurred through the use of an informal query about pain; which might be the kind that I would use, frankly, as a clinician asking someone how their knee is today, rather than using the somewhat formulaic or perceived impersonal approach of the NRS scale.

The implications of this were that a more formal way that adhered to process did seem to be more sensitive in detecting pain.  But, at the same time, it was true that this approach still captured most of the severe pain or more severe pain events.  So, it was somewhat less sensitive; but, less sensitive for lesser pain.

So, to summarize some of the lessons from screening that we observed through our research, and this is from the HELP-Vets Study and from several studies of cancer pain quality, in some settings, even important settings, and cancer care being illustrative of that, screening isn’t happening.  And I think that’s a significant problem.  We, obviously, can’t have better care for pain without having adherence to screening.

But, clinicians do need assessment linked to management.  And that’s a problem, as well, that we certainly found in primary care and, no doubt, is true elsewhere, as well.

Part of the problem is that providers need a measure of pain impact; one that they believe and have confidence in.  And function is an important part of that.  This particular issue, to some extent, we evaluated and addressed in our research through the development of the PEG.  

And finally, we found that implementation of even the simplest measures is challenging and given that we have only partial adherence to the formal process of administering an NRS, I think it raises questions about how many other common screening measures in VA practice may be implemented.  And, in fact, thus, some of the solutions that we consider for something like pain screening may have implications for how we conduct screening for other important things among veterans.

So, this leads me to Food for Thought 4.  And that is that patient reported outcomes are an important and promising alternative to the way that we conduct screening currently.  But, they also raise novel challenges related to screening.  And I’m going to talk about this, really, not in terms of research; but, in terms of some of the questions that I have myself about patient reported outcomes, because, in fact, there’s not a significant amount of research to inform the use of these approaches in daily practice environments.

The first issue might be just what we mean by a patient reported outcome.  And I use the definition of PROMISE, which is a significant NIH effort to develop patient reported measures for symptoms and the PROMISE projects have defined patient reported outcomes as help data reported, provided by the patient through a system of reporting.  They’re really seen as encompassing interviews, surveys and computer assisted methods.  And I think they offer a couple of potential solutions to some of the problems that we’ve observed in screening.

First of all, in some clinics, and oncology might be exemplary of this, we might have a question about why screening isn’t occurring.  My thoughts are that, and sometimes this is a cultural issue, but there may be issues with staff and staffing, as well, that have an impact on how nurses are used —are using their time related to pain screening.  Certainly, a technology solution, a patient reported solution might be, really important in settings where we currently don’t have use.  It may overcome both a cultural barrier and a staff allocation barrier related to the screening task.  So, that’s one opportunity raised by a patient reported approach.

Another thing that we observed is that because some of the variance in pain results relate to variation and adherence to process or implementation then the use of a patient reported outcome may measure —may limit the variance to that,  reflective of the patient’s own state.  And also, reduce that related to the documentation component. 

Documentation component is something we haven’t really talked about.  But , in in-patient pain screening there’s a significant problem where we’ve noted in trying to evaluate in-patient pain ratings and in-patient pain quality, that many times those pain ratings are actually placed in challenging parts of the medical record to retrieve and the medication log, being a primary place for that.

So, these are not trivial potential benefits of using a patient reported approach to understand pain.  But, they are somewhat speculative.

And I think a lot of times, for me, part of the challenge of this process is in interacting with colleagues who may be working on patient reported approaches.  

It seems like this photograph, for me, illustrates a kind of ideal that they have in mind; many times, very portable methods like tablets or mobile phones and a very literate and capable patient who can interact with that platform.

I kind of wonder if there might be certain challenges that we face in the VA that might make such tools hard to use.  And, for me, this might be a worst case scenario, but I imagine the visually impaired, homeless veteran who’s challenged in his hearing might walk into the clinic with a walker, sit down next to a kiosk, being asked to complete a symptom report.  Mildly trying to clarify the task for the clerk, a by-stander offers, I’ll just help you.  Look here and fill this out.  And I see veterans helping one another all the time.  I don’t know why they wouldn’t help one another in completing a task like, potentially, a screening report.

So, there are a number of questions that I ask off the bat in thinking about patient reported outcomes and their application to pain screening.  On the one hand, as I mentioned before, although less sensitive, partially related to the adherence process, it was true that clinician screening focused or tended to detect more severe pain.  And part of the issue may be that the clinician filter is focusing on patients who have superior, if you will, actionability or opportunities for management.  So, the clinician filter may be a valuable one.  And even if patient reported outcomes are more sensitive, some of that may be more information, if you will, than we need.

I think another question about patient reported outcomes is that depending, of course, on how they’re obtained that some patients may be at risk of unreliable reports or difficult reports to obtain.  I, in particular, think about our veterans with mental health concerns, especially those that affect cognition, like schizophrenia or dementia, which might have some similar impact; those with hearing impairment or visual impairment, again, depending on how we operationalize our efforts at patient reports pain inputs. 

 And although it may reduce variants related to the clinician component there are other forms of variants that might be subject to patient reporting.  And, with regards to this, I might point you to a study that I don’t illustrate here with a slide, but that we conducted as part of the HEALTH-Vets Study where we looked at variation in pain reports as a function of patient, clinician and environmental factors.  And, interestingly, we found some salience of each of those domains, the variations of pain reports.  

Environmental or by-stander effects, for example, could be particularly significant when the patient has the tools in their own hands.  And, you know, I think about this as a function of how I might report or how I deal with things when I’m trying to multi-task driving down the road.   So, whatever, you know, I’m supposed to be doing, sometimes I’m in the car with my wife and you’ve got a hamburger in one hand and your smart phone in the other and I think that there may be substantial environmental or by-stander effects related to the use of certain platforms for patient reported outcomes that are harder to control than the relatively constrained environment that we observe in current screening approaches.  And I will say that even under the constrained conditions, we still found statistical significance to the environmental effects.

So, those are some of the questions that I have about patient reported outcomes.  

Now, I think in asking them, I’m sure I risk appearing this way like a Luddite enthusiast.  But, I actually think that the future, without question, incorporates such approaches.  

So, in thinking about this talk and in thinking about some of the work that I hope I conduct and I hope you conduct, I tried to develop, actually, a schematic for what I think the ideal might look like.  And this was my ideal of future assessment.

Now, you do see the Starship Enterprise above and I will say it didn’t fly until 2254.  And so, I’m hopeful that we’ll arrive at this future world well before the Starship Enterprise.  But, I think certain components we may understand relatively soon and certain components, frankly, will take us quite a while to get a handle on.

Getting patient reports about pain is sort of what I just talked about and I think there’s obviously, a large effort under way and supportive mobile technology now that’s going to allow us to do that.  So, it’s likely that, that left hand part of this slide will be increasingly understood in the near term.  And the clinician documented reports represented by the right arrow, I think, also reflect, at least in the VA, our relatively good adherence, certainly, in many settings to obtaining clinician inputs for pain.  

I think the idea of the proxy, the knowledgeable proxy or the by-stander proxy for pain reports is one that we have yet to understand completely.  And, in fact, one of the challenges, I think, in the future world, if you will, is that our understanding of pain will come —or will need to come, actually, from integrating these different inputs and understanding their differences. Not only their intrinsic differences as screening approaches, but challenges related to implementation linking them to management and so forth; all the different problems that we have in a relatively simple approach to pain screening now, but multiplied across these different dimensions.

But, in the end, of course, the hope for that is that we’ll have a more complete view of the patient’s pain and we’ll be able to follow it and respond to it in a more timely and appropriate way.

So, I think that is where we’re going.  And, in fact, I’ll close with a mention of the ESP Project, which hopes to make a bit of a down-payment on the challenge of understanding this multi-dimensional world of pain screening.

So, next I’ll move on to Food for Thought 5, if you will; that feedback is a critical aspect of successful intervention and tell you a little bit about the quality measures that we’ve been developing to provide both process and outcomes for gauging pain management and clinician behavior.

So, with regard to pain screening, it’s important that in dealing with pain that all of us get feedback on our performance.  And, as you can see, if we don’t get that feedback, even sometimes when we do, in the case of this mirror, we tend to have an unrealistic view of ourselves.  So, all of us need a check on our imagination.  

And when we think about quality, I hope I’m not covering territory that’s overly familiar to too many of you, but, of course, we think about it in terms of structure, process and outcome.  And I think our knowledge of the relationship of these factors is really developing still with regard to, especially, how all three of them might relate.  So, it’s hard to say definitively, for example, exactly what excellent structure is and how it might relate to pain outcomes.  Structure is a harder aspect to show relationships to outcomes to, in general.  But, we do have increasingly good information about process and even outcomes.

So, with regard to outcomes, and I speak about the area that I work in, the VA now regularly measures the Bereaved Family Survey, which is an assessment of how families regarded the very last weeks of care among the —for their loved one.  And the BFS does include a survey item that addresses pain.  So, particularly, there, we do have pain outcome items.

An example of process, some of the work that we have done has developed pain items and I’m thinking of the Assess and Care of Vulnerable Elders studies or the ASSIST, cancer quality ASSIST assessing symptom side effect and indicators of supportive treatment.  

So, outcomes, in the case of the Bereaved Family Survey, cover a variety of in-patient —cover in-patient care.  And process sets address geriatrics and primary care; older patients and primary care, cancer and its settings.  So, that’s a fair bit of coverage, actually, which currently we really don’t routinely use pain measures there.  And there are new measure efforts under way in response to the Accountable Care Act where CMS is developing a range of measures.  And, in general, has been moving away from process approaches to outcomes.

One of the things that I would like to stress is that although there may be a certain trendiness, if you will, to emphasizing either outcomes or process; one of things we find in practice, and I think this has been very, very true in interaction with VA teams, is its actually improved care.  Teams really need both.  It’s not enough to tell people that they don’t do well.  You actually have to tell them what they might start on with regard to improvement.  And in the same way, of course, it’s hard to receive information about what you do if you don’t think it really has an impact.  So, process and outcomes together are very powerful and either one left out really takes an important leg, if you will, off the stool.

One of the approaches to quality measurement that hasn’t been evaluated, as far as I know, with respect to pain, but one that I would just raise for this group, especially in terms of, hopefully, inspiring someone to do some great research, would be the use of control charts.  And control charts are sort of a statistical process looking at variations from baseline.  This is an example of a control chart, usually in an industrial application.  But, there are —There have been applications of control charts for quality in Australia.  The state of Queensland, for example, uses them.  And in the United States, I believe, Intermountain Health Care would be an example of a system that has, I believe, experimented with or used statistical control charts.  

But, in looking at departures from baseline, one of the challenges, of course, is to have enough events to evaluate.  And pain might be an example of a symptom where we have regular and significant information about how facilities are doing, even from day to day.  So, the use of control charts would be, I think, a particularly interesting application in trying to understand a performance in the area of pain that, perhaps, has not been tried yet.

I want to show you this, because in talking about patient reported outcomes, one of the interesting questions it might raise is the use of such approaches to evaluating quality.  And this is quite interesting to me because we recently —a group here with —actually led by [Dana Tisnado]; Jennifer Malin, who is not with the VA, currently, and Annie Walling have been looking at the CanCORs pain indicators among veterans; and, actually, recently, showed that using self-report, that rates of both screening and treatment appeared to be fairly high.

This is quite different from what we found in primary care using chart based measures to evaluate pain.  This is a reminder of what we found on the HEALTH-Vets study.  I think it raises, but is not definitive, about the possibility that using patient report might significantly change how we look at performance or how we understand performance.  And, I think, of course, there’s a risk that what patients report about their treatment may reflect their expectations instead of the actual care provided.  

So, one of the things to think about that I don’t —especially as we move towards more patient reported approaches is the use of that for quality measurement understanding performance.  And it may be that, in fact, the method we use to operationalize measures depends, somewhat, on what we aim to get out of them.  But, they are quite different potentially in what they show.

I just briefly mentioned that we have looked —a group of us have looked at the quality of cancer pain management in the VA and found some interesting things.  If veterans with cancer get opioids, as this shows, then in several —in quite a —in several ways performance is pretty good with regard to, for example, providing a short acting with a long acting.  

It’s really interesting that certain differences —certain problems that we found, though, in this case, providing a bowel regimen with chronic opioids have been observed not only in the VA but outside the VA at very similar rates.  And this is an example of the non-adherence to the idea that we should prophylactically[...] constipation [inaudible] use chronic opioids.  And it’s interesting to me that this agrees very closely with what was found, for example, in the University Health Consortium; a rather large consortium of academic facilities across the United States, just a few years ago that looked at this exact indicator.

I think I just —I think I would point out, maybe, this one slide, which again points to the value of quality measurement and looking at processes, in particular.  And one of the kinds of pain indicators that we looked in ASSIST is the treatment of painful complications; in this case, that of bone metastases.  And what we looked at was whether veterans who were extremely frail were offered single fraction therapy for management of their pain rather that multi-fraction therapy.  And as you can see, this graph is blank because, in fact, in, I believe, 23 cases where a veteran would have been eligible for single fraction therapy, we found that it wasn’t offered.  And that’s quite striking because of the —our financial incentives in the VA, of course, support us being able to provide any approach rather than the fraction compensated approach that’s true in the fee for service world.

But, we still don’t do it.  And, I think, it —again, it points to the value of looking at process as an important aspect of quality, not just outcomes.  But, this is quite interesting.  And, of course, we hope to really understand it better.

So, I think that I’ll close by saying that in an era of increasing health related quality of life data, which I do think patient reported outcomes will bring us, that our work on pain will provide a useful paradigm for other symptom’s challenges.  And I do think that this process of moving from assessment to management and the implementation, if you will, of these systems, that pain is going to be exemplary, if you will, or the things that we’ve learned will be exemplary of doing it for other symptoms.  And part of the reason, of course, is that patients tend to be multi-symptomatic.  So, of course, when we’re screening for pain it makes a lot of sense to screen for other things.  And I expect, however, that the management side will be quite a bit more complicated.  In our own work we found different clinician resistance and standards for multiple symptoms reports.  So, in the case of shortness of breath, for example, whereas for pain we had quite a bit of agreement in some of the work that we’ve done, from clinicians, that pain was important to screen for, even if there were problems with process.  But, for shortness of breath, which is arguably quite an impactful symptom, we found quite a bit of clinician resistance to the idea that one should screen for it.  And, interestingly, you know, whereas there may not be complete agreement about how to measure something like pain, for dyspnea, we found quite a bit of heterogeneity; in fact, in practice, an avoidance of scales and a fairly implicit approach.  So, part of the challenge, I think, as we move beyond pain and apply it to other symptoms is that there —whereas it makes sense to screen for symptoms together, the acceptance of doing so and even the way that we operationalize it may be quite a bit different; not to mention the fact that managing these conditions require different and specific approaches.

So, I’m not going to say, really much more about it except that I do think it will happen.  And that we’re trying to make a down-payment on understanding some of these problems now, as Bob mentioned, in the CREATE project through the Effective Screening for Pain study.  And in that study, although there’s much I could say about it, I would just point out that the heart of the study is the idea that we can compare different approaches to screening directly.  And so, using a computer assisted approach, we plan to use the PEG, the three item measure that includes function against the NRS and then compare those to an arm that doesn’t received computerized screening, but rather goes through nursing assessment and documentation of the NRS.  So, allowing us to compare both the platform and the role of the improved pain screening tool, the PEG, to understand their contribution to improved pain screening and the other goal of the study being to understand qualitatively and prototype an approach, to take this information and provide it to clinicians in a way to signal more effective management.

So, I’d like to close here to give people a chance to offer questions.  And I will just summarize by saying that I think there are a number of barriers to pain screening, most of which relate to how pain screens are used or pain assessment information is used and those include, as I’ve hopefully highlighted for you, the clinical relevance of the measure, how it’s linked to, algorithmically, if you will, different management alternatives for patients and then, how we implement these things in practice to make sure that they’re adhered to.

Secondly, I think patient reports are really a significant opportunity and no doubt will become an increasingly important part of how we understand patient’s pain.  They offer a solution to selected facets of the screening problem.  But, it’s really important to recognize that they may pose additional challenges.  Some of which are very significant and greater in magnitude than that to the approach we follow now.

I think it’s really important to recognize that, not only do we —that a full view of pain management includes not only the inputs of pain management, but the outputs and how we monitor and provide feedback on the process.

One of the things that I didn’t mention to you; but, in our some of systematic review on pain and quality improvement, for example, we noted that the cessation of observation of screening often led to people not doing it any longer.  And so, monitoring processes and outcomes of pain are an essential part of improving care for pain.  And, I do think that this, in some sense, is exemplary and that pain will lead us, if you will, or enlighten our path, as we walk down the approach of obtaining additional symptomatic information from patients, which is an important quality of life goal.  But, again, there will be unique and different challenges that we face along the way that will be somewhat specific to —both to other symptoms, but also to how we examine and consider symptoms together.

So, with that I’m going to close and thank you for your attention.  I’ll be happy to answer as many questions as I can.

Moderator:  Fantastic.  Thank you so much.  Bob, do I still have you out here on the call?  Bob thought he might have to step away.  So, I wasn’t sure if he was still out here.

Karl, we actually —We’ve gotten a few questions and I’m not sure if you have this available now or if you would be able to reply off line and we could send it out.  We’ve gotten several requests for references for the studies that you used here.

Karl Lorenz:  Sure.  Uh-huh.  Glad to do that.

Moderator:  So, if we could —

Karl Lorenz:  Of the top of my head or I can send them to you.

Moderator:  if you could send them to me, I do send an e-mail out to everyone tomorrow and we could include that information in there, so that way people would have that available.  So, that’s give you a little time to, also, gather that together.

And also we —Because, obviously, the handout that  we have available is not quite the same as the slide show you were showing right now, would you be able to send me an updated copy of your slides and we can also make that available to everyone?

Karl Lorenz:  I will certainly do that.

Moderator:  Perfect.  Okay.  And for our audience, this is a great opportunity to submit questions.  You can use the Q & A screen located on the dashboard on the right hand side of your screen.  Just type those in and we will get through as many as we can here.

The first question that we have, we have someone who is wondering if you could comments on the huge issue of back pain.

Karl Lorenz:  Oh, boy.  Well, it’s not a particular area of expertise of mine.  I’m not sure exactly what to comment about it.  I guess, that’s the —That would be part of the challenge.  It certainly is a huge problem for veterans.  I think that it’s a little —Well I don’t know where to start, exactly.  

It’s not an area that I’ve worked in, particularly.  It certainly raises the issue, if you will, of chronic pain, of the appropriateness of a range of treatments, especially non pharmacologic treatments, and potential over-use of opioids.  And I think it’s also illustrative of a range of chronic pain complaints where mental health and the emotional dimensions of pain have a particular salience. 

So, it’s a very important type of pain to consider or be aware of.  It’s not anything that my own research has focused on, particularly.  I’m not sure if there’s more I could say about it that would be responsive to the question.

Moderator:  No, that’s fine.  I understand.  It was a big question and that’s okay.  We can move on to the next one.  The next question we have here, what is single fraction therapy?

Karl Lorenz:  So, single fraction therapy is the idea that sometimes with a single treatment of radiotherapy we might get most of the benefit, if you will, of pain relief in the management of bone metastases.  And it’s quite interesting that we don’t do this in the VA, in my view, because again, we don’t face financial incentives in that regard to over-use, as far as I know.  In Medicare, radiotherapists are often paid, I believe, on a per treatment basis.  So, actually, it’s probably better, if you will, to give multiple fractions because you get paid more.  It’s quite interesting that outside of the United States, Canada in particular —I don’t know, actually, what’s done in practice, but there’s been a fair amount of attention in terms of guideline development and advice on providing single fraction approaches.  So, this may be an area in which there’s interesting variation in  practice and where it has implications in terms of quality of life for the patient.  But, that’s, maybe, what I would say about it.  

The simple answer is, of course, that’s it’s just the act of treating a patient one time for the problem and getting most of the benefit.  But, the reason that it’s interesting is because of its quality of life impacts and its relationship, potentially, to both quality and efficiency.

Moderator:  Great.  Thank you.  The next question is, what is your philosophy relational to rational poly-pharmacy in pain management?

Karl Lorenz:  Rational poly-pharmacy?  Uhm — I — Rational poly-pharmacy?  I don’t think I’m a particular expert to talk to about the clinical management of pain.  I mean, besides the fact that I do it as a clinician.  It’s not an area that my research has particularly focused on.  I would acknowledge that there are significant challenges, if you will, to pharmacologic management.  I simply have to say, I guess, that it seems like a lot of the attention and what to avoid —And this is not a great response to the question.  But, a lot of the scrutiny, of course, has been on opioids.  And I do think that the attention is going to be ramped up, not down, as far as I can tell on that particular problem.  So, I guess I would say —Although the question was about pharmacology, my hope is that we’ll actually be spending most of our effort emphasizing alternatives for patients that have chronic pain, especially in settings like primary care and I think that’s where we have a lot of room to grow in terms of our access and —access and improvement, I guess, in therapeutic options.

Moderator:  Great.  That feeds, actually, right into your next question.  Do you have any ideas of how to implement appropriate treatment other than drugs in the VA, when it is not fee reimbursed?  For example, acupuncture, formal exercise, et cetera, where they would not have to pay out-of- pocket.

Karl Lorenz:   I wish Bob were on because I bet he would have some great answers for that.  I speak from a very limited perspective on that.  On a broader view, I know that the CREATE that we’re working on, just to champion some of my colleagues who were part of the CREATE, is definitely investigating some of the behavioral innovations and their use in pain management.  So, that would be an example of efforts that are being made.

I believe that there is increasing openness to the idea of CAM therapies, if you will.  And I’m not sure exactly where that stimulus comes from.  But, it does —It has come to my attention that there’s some interest in understanding their integration in pain management and by that I do mean things like acupuncture and so forth; Tai Chi and other modalities.  So, gosh, I’m not sure —You know, I can only —I can speak as an experienced clinician, if you will.  And I can speak as a person involved in that to an extent.  But, I really think others are championing that and it’s a very important —very important issue for us as clinicians and as researchers, understanding the impact.

Moderator:  Great.  Thank you.  We have two more questions here.  Hopefully, we can get through them quickly.

The next one:  Can you please further comment on how to overcome physician’s reluctance to use the patient assessment?

Karl Lorenz:  Yeah.  Well, I —This is an interesting question.  I believe part of the challenge is providing more meaningful information to clinicians.  And so, you know, when we ask clinicians why they hadn’t acted on pain, of course, a fair number of them said they didn’t believe that pain had a functional impact.  So, maybe, I hope, that part of the answer is giving clinicians better information about how pain may be associated with functional impairment.  So, that’s actually what the PEG, for example, was intended to address.  And I think that’s important, not only to stimulate addressing pain but also, perhaps, to monitoring the effectiveness of things that we might use, whether they’re drugs or other modalities.  

I think that the other thing I would —I guess, I would point to, and maybe this is more of an implementation principle, is involving clinicians in teaming and working together to be successful in managing pain.  And it’s quite striking to me that there is a divergence between, if you will, a nursing related task of assessing pain and this more physician dominated task of managing pain, at least on the primary care work that we did.  And so, another important principle is, probably, teaming and clinician involvement.  And I think those are issues nationally in how we develop, sort of, standardized approaches to these things across our practice environment.  And they’re also, very much, issues for local teams and local-level quality improvement.

Moderator:  Great. Thank you.  Do you have time for one more?

Karl Lorenz:  I’m certainly willing.

Moderator:  Okay.  Let’s get through this quickly here.  The last question:  Can you comment on the current [SHEP] survey to identify patient satisfaction with pain management scores?

Karl Lorenz:  I thought that might come up and, actually, I have to admit I don’t —I’m not that knowledgeable about the content of the SHEP survey.  But, I think Diana Burgess, if I remember, has done some work on the SHEP survey.  So, in this environment, I can’t hear anybody speak up or say anything.  But, I would recommend that you contact her, because I believe she has some experience and interest in that.

Moderator:  Fantastic.  Okay.  That is all of our submitted questions.  Karl, did you have any last minute comments you wanted to make while we’re wrapping up here?

Karl Lorenz:  No.  I would just thank everyone for listening and I’d be very happy to follow up with people personally or individually if they have questions or comments or feedback on anything that I shared today.

Moderator:  Wonderful.  Thank you so much.  And we also want to thank our audience.   Thank you for joining us today.  We really appreciate you taking the time to join us for these live sessions.  

Our next session in this series is scheduled for September 4th at 11 a.m., eastern.  Matt [Bair] will be presenting Evaluation of Stepped Care for Chronic Pain in Iraq —Afghanistan Veterans.  And we’ll be sending registration information out on that to everyone shortly.  We hope you can join us for that.

Dr. Lorenz, thank you so much for presenting today.  We really appreciate the time and effort you put into this session.

Karl Lorenz:  You’re welcome.  Thank you so much for having me.

Moderator:  Thank you.  And we’ll speak with you again sometime in the future.  Thank you every one.  Bye.

**[End of Recording]**

Cambridge Transcriptionswww.ctran.com

Cambridge Transcriptionswww.ctran.com