UC Davis

In the United States, roughly a quarter of the population suffers from moderate to severe chronic pain for at least six months out of any given year.1 Chronic pain develops when gradual changes arise in both neurological and immunological levels, leading to the sensitization of pain receptors. This sensitization allows for pain to arise from modest to minimal stimuli.2 The Centers for Disease Control and Prevention (CDC) developed chronic pain management guidelines for responsible opioid prescribing in 2016.3 Although these guidelines are designed to help the provider manage chronic pain, only 56% of patients report satisfaction with their pain level.4 Further, 18% of patients attending a pain clinic sought emergency care, with 6% experiencing a hospital admission.5 Chronic pain puts stress on the body, and the prolonged state of stress may lead to endocrine, cardiovascular, and immune sequelae.6-9

The complexity of managing chronic pain and the adverse health outcomes associated with opioid therapy has encouraged health care professionals to seek out innovative ways to address pain. Problem lists were developed to improve the provider’s awareness of relevant health problems or symptoms and assist in offering appropriate treatment decisions in the setting of various comorbidities.10 It has been demonstrated that keeping the problem list up to date with the patient’s current health problems can improve communication between visits and increase evidence-based treatment for chronic conditions.11-14 However, there is a paucity of research as it pertains to the practical implications of using the problem list in the clinical practice of pain management.

To better understand the relationship between chronic pain documentation on the problem list and utilization of pain-specialty care, this study aims to answer the following questions: (1) What are the patient characteristics associated with chronic pain documentation on the problem list? (2) Is documentation of chronic pain on the problem list associated with the utilization of specialty pain care?

The author conducted a historical cohort analysis of electronic health data from a large health network consisting of 37 acute care hospitals and 445 ancillary care sites. The study population included 12,803 adult patients with a chronic pain diagnosis. The patient cohorts were identified based on the presence or lack thereof of chronic pain on the problem list. Patient medical records were collected for one year after the patient’s initial visit during the study period. The author used a binomial regression analysis to assess the relationships among chronic pain documentation, patient characteristics, and utilization of pain specialty care.

The study design consisted of two parts. In part 1, the author examined the independent and combined contributions of age, race/ethnicity, gender, type of chronic pain diagnosis, opioid prescription, and insurance status to the documentation of chronic pain on the problem list in patients diagnosed with chronic pain. Findings from these analyses indicate that younger age, female, Black non-Hispanic, having a migraine diagnosis, and use of opioid prescriptions were significant predictors of chronic pain documentation on the problem list.

Part 2 of this study examined the association of chronic pain documentation on the problem list to utilization of chronic pain specialty care. A logistic regression explored the association of chronic pain documentation on the problem list and age, gender, race/ethnicity, diagnosis type, insurance status, and opioid prescription on utilization of specialty chronic pain care. The findings from Part 2 of this study indicate that the documentation of chronic pain on the problem list, female, and a diagnosis of other chronic pain were associated with utilization of specialty pain care. Thus, documentation of chronic pain on the problem list should be considered a possible pathway to improve specialty pain care utilization.

Other factors such as primary care provider experience or skill level may influence both the documentation on the problem list and referral for specialty pain care. Therefore, further research is needed to investigate if the association of chronic pain documentation on the problem list is a possible causal link to the utilization of specialty care. As a single location in the electronic health record to enable quick access to essential problems at hand, the problem list is a crucial tool that can assist with the communication of chronic pain from a visit to visit and provider to provider, providing higher quality care through instantaneous alerts and suggestions for patients. The policy implications may also help inform decisions based around value-based care initiatives by suggesting that the problem list may be used as a tool to help communicate about a patient’s pain problem and, therefore, promote early utilization of specialty pain care.