Point-of-Care Prognosis for Common Musculoskeletal Pain in Older Adults
ABSTRACT IMPORTANCE Many site-specific, multivariable risk models for predicting the outcome of musculoskeletal pain problems have been published. The overlapping content in these models suggests a common set of generic indicators suitable for use in primary care. OBJECTIVE To investigate whether a brief set of generic prognostic indicators can predict the outcome of musculoskeletal pain in older patients presenting to general practitioners. DESIGN, SETTING, AND PARTICIPANTS A prospective observational cohort study conducted from September 1, 2006, through March 31, 2007, of consecutive patients 50 years or older presenting with noninflammatory musculoskeletal pain to 1 of the 5 participating general practices in the United Kingdom. MAIN OUTCOME MEASURES During consultation, the treating physician assessed and recorded 5 brief generic items (duration of present pain episode, current pain intensity, pain interference with daily activities, presence of multiple-site pain, and ultrashort depression screen) and recorded their overall prognostic judgment. The primary outcome was patient-rated improvement, which was measured 6 months after consultation and cross-validated with repeated measures up to 3 years. RESULTS A total of 194 (48.1%) of 403 participants were classified as having an unfavorable outcome at 6 months. Inclusion of 3 generic prognostic indicators (duration of present pain episode, pain interference with daily activities, and presence of multiple-site pain) in the prognostic model improved on reliance on physicians' prognostic judgment alone (C statistic = 0.72 vs 0.62; net reclassification index = 0.136; proportion correctly classified = 69%). The improvement in prognostic accuracy was attributable to correcting physicians' tendency toward overoptimistic expectations of outcome. CONCLUSIONS AND RELEVANCE Three easy-to-obtain pieces of information followed by systematic recording of the general practitioners' prognostic judgment provide a simple generic assessment of prognosis at point of care in older persons presenting with musculoskeletal problems to primary care practices in the United Kingdom. Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions.
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ABSTRACT: Moderate to severe chronic pain is a problem for 1.7 million children, costing $19.5 billion annually in the United States alone. Risk-stratified care is known to improve outcomes in adults with chronic pain. However, no tool exists to stratify youth who present with pain complaints to appropriate interventions. The Pediatric Pain Screening Tool (PPST) presented here assesses prognostic factors associated with adverse outcomes among youth and defines risk groups to inform efficient treatment decision-making. Youth (n=321, ages 8-18, 90.0% Caucasian, 74.8% female) presenting for multidisciplinary pain clinic evaluation at a tertiary care center participated. Of these, 195 (61.1%) participated at 4-month follow-up. Participants completed the 9-item PPST in addition to measures of functional disability, pain catastrophizing, fear of pain, anxiety, and depressive symptoms. Sensitivity and specificity for the PPST ranged from adequate to excellent, with regard to significant disability (78%, 68%) and high emotional distress (81%, 63%). Participants were classified into low (11%), medium (32%), and high (57%) risk groups. Risk groups did not significantly differ by pain diagnosis, location, or duration. Only 2-7% of patients who met reference standard case status for disability and emotional distress at 4-month follow-up were classified as low-risk at baseline, whereas 71-79% of patients who met reference standard case status at follow-up were classified as high risk at baseline. A 9-item screening tool identifying factors associated with adverse outcomes among youth who present with pain complaints appears valid and provides risk stratification that can potentially guide effective pain treatment recommendations in the clinic setting.Pain 04/2015; DOI:10.1097/j.pain.0000000000000199 · 5.84 Impact Factor
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ABSTRACT: Back pain outcomes may be improved and costs lowered through risk-stratified care, but relative performance of alternative item sets for predicting back pain outcomes has not been well characterized. We compared alternative prognostic item sets based on STarT Back and Chronic Pain Risk screeners in a cohort of patients initiating primary care for back pain. The STarT Back item set was brief and relied on binary responses, whereas the Chronic Pain Risk item set employed scaled responses and assessed pain persistence and diffuse pain. Patients (N = 571) were assessed soon after their initial visit and 502 (88%) were reassessed 4 months later. Items sets based on STarT Back and Chronic Pain Risk prognostic screeners, as well as a combination of items from both, were used to predict Chronic Pain Grade II-IV back pain at 4 months. The area under the receiver operating characteristic curve estimates (95% confidence intervals) were .79 (.74-.83) for items based on the STarT Back, .80 (.75-.83) for items based on Chronic Pain Risk, and .81 (.77-.85) for a composite item set. Differences in prediction were modest. Items from 2 prognostic screeners, and both combined, achieved acceptable and similar prediction of unfavorable back pain outcomes. Given comparable predictive validity, choice among prognostic item sets should be based on clinical relevance, number of items, ease of administration, and item simplicity.The journal of pain: official journal of the American Pain Society 10/2013; DOI:10.1016/j.jpain.2013.09.013 · 4.22 Impact Factor
British Journal of General Practice 07/2014; 64(624):372-4. DOI:10.3399/bjgp14X680749 · 2.36 Impact Factor