An institutional ethnography of chronic pain management in family medicine (COPE) study protocol

Providing cost-effective care for the increasing numbers of complex elderly and/or
co-morbid patients is a global problem facing industrialized and non-industrialized
nations 1]. With an aging population and individuals living longer lives, healthcare costs continue
to rise at rates faster than other parts of the economy 2]. In response, payers have sought to contain spending growth through healthcare rationing
and efficiency gains. Exacerbating these challenges are the growing numbers of individuals
with chronic disease and multi- morbidities, a proportion of who develop complex health
conditions. For example, in Ontario, one study estimated that complex patients constitute
1 % of the province’s 13.7 million people but accounted for 34 % of Ontario health
care expenditures 3]. Similar research has identified the same trend from the United States 4] and the United Kingdom and Europe 5]. Costs associated with managing complex care patients have generated a growing sense
of urgency due to the increasing emphasis on accountability, the sustainability of
health care, and pressures posed by population aging.

In many jurisdictions across Canada, governments have launched priority initiatives
to improve the care costs of complex patients. These initiatives have been based on
the assumption that improved coordination will lead to faster care at reduced costs
6]. Often these initiatives have called for researchers to develop innovative models
that are both patient-centred and cost effective. Moreover, in Canada, as well as
in many other countries, one of the main problems identified in the care of complex
patients is poor coordination of services 1]. Poor coordination of services has been described as impeding both good care and
efficient use of health care dollars. It has been estimated that in the province of
Ontario better integration of care would result in savings of $4 to $6 billion per
year from reductions in redundant services, improved coordination and provision of
more appropriate services 2].

At the same time that Ministries of Health, health services researchers and media
are recommending cost-saving measures and creation of new and innovative models of
care, those working in social science have been questioning the nature and framing
of these public policy debates. Many have challenged the hidden assumptions underlying
the import and application of performance measurement and accountability principles
developed in business settings into health care settings 7]–9] and have sought to draw attention to the implications of the resultant discourses
that are shaping public policy debates. They have, for example, challenged the “virtual
realities” created by systems of accounting based on administrative databases 7]–9] that produce this notion of “high users” of health care resources cited above. Nevertheless,
these debates are often not well- integrated into mainstream conversations about health
policy and practice 10].

In this context, our study builds on an innovative Canadian Institutes of Health Research
(CIHR) funded research program that uses a social science lens through which to view
the organization of the care of patients with chronic osteoarthritis (OA) pain, many
of whom have multiple co-morbidities 11]. It is clear that that there is a need for such research as this is where the majority
of patient care takes place and is seen as a key determinant in complex patients’
need for care 12]. Moreover, this research also seeks to explore how other stakeholders are involved
in coordination of care not as separate objects of study but as part of the same patient
care “system”. This will be accomplished by speaking with primary care physicians
and asking them to describe both what they do and who else is involved in the care
they deliver (for example, pharmacy, orthopedic surgeons, physiotherapists) to patients
with multi- morbidities and chronic pain.

Complex patients are the focus of much debate and concern in the contemporary healthcare
context. They are defined as those who have more than one of the following five major
chronic conditions: arthritis, diabetes, heart disease, chronic lower respiratory
tract disease and stroke 13]. Patients with these chronic conditions may also suffer from mental health problems
or addictions 13]. Multi- morbidity is even more important as each condition may influence the care
of the other condition(s), result in interactions between therapies and/or direct
contraindications to therapy and thereby limit life expectancy 14]. At the patient level, multi-morbidity has been found to affect quality of life,
ability to work, disability and mortality 15]. In addition, the process of navigating care across different specialists is burdensome
for patients 16] and is a patient safety issue 3]. Our previous work in patients with osteoarthritis (OA) pain suggests discordance
between the policy goals of improving patient care and the experience of patients
17], 18].

Arthritis, specifically OA, is one of the most common, disabling, and costly chronic
diseases 19]–21]. It is a degenerative joint disease that most commonly affects the knees, hips, hands,
and spine and is characterized by a slow evolution of symptoms (joint pain and stiffness)
and disability over time 22]–24]. Arthritis is the most frequent cause of chronic pain which is debilitating to the
individual and extremely costly to society. Primary care is most often the first contact
for people seeking symptom relief. Truly interprofessional care (IPC) is necessary
to provide appropriate evidence-based pain management and self-management support
for these patients who are seeking appropriate strategies to ameliorate and limit
progression of their chronic pain and resultant disability. Yet achieving successful
IPC often remains an elusive goal in practice 25].

Several research gaps have been identified in relation to primary care in musculoskeletal
care, including OA 26]. These include well-known issues such as a lack of comprehensive management that
includes exercise and weight loss strategies 27], a focus on other chronic conditions or co- morbidities that may be considered more
urgent 28], 29], and low referrals rates to both physiotherapy and total joint arthroplasty 29]. There are also ongoing controversies associated with the use of opioid medication
to manage pain and concerns with possible medication dependence, misuse, and addiction
30]–32]. Finally, at the patient level, there are many socio-economic factors that influence
help-seeking, referral, and treatment, with some patients “falling through the cracks”
33]. However, despite our knowledge of these various gaps, what remains unknown are strategies
or models of care that, while rooted in primary care – the “medical home” for most
patients 34] – are coordinated effectively with other care providers, policymakers, patients,
and their families and offer the benefits of IPC.

Primary care is the context for most OA education and management. The role of context
in health care has been increasingly recognized as important at the local level 35]; however, context is often described in abstract terms and may refer only to a description
of geography or place 36]. The need to investigate the empirical context of the primary care setting, not as
it exists in isolation or in the abstract, but as it pertains to other providers in
the patient journey is critical in order to improve patient care of OA pain management.
This will allow for an exploration of how primary health care is – or could be better–
integrated with other services that play an important role in health, such as housing,
education, and income. The patient-centred medical home has been introduced as a chronic
care model that can reduce costs 37]. It emphasizes the need for “care management” to be based in primary care and has
become increasingly important in Canada as well as internationally 38]. Several studies of care management in primary care show convincing evidence of improving
quality 39]–45]. These studies measured a variety of quality outcomes, including patient satisfaction,
functional ability [capacity to perform basic activities of daily living], mortality,
bed disability days and overall quality of life. The results of care management studies
in primary care are mixed regarding reductions in hospital use and healthcare costs.
All of these studies enrolled patients with multiple chronic conditions who were at
high or moderate risk of incurring major health care costs. Each program placed substantial
emphasis on training the care manager team, keeping care manager panel sizes at reasonable
levels, forging a close relationship between care managers and primary care physicians
and including care manager interactions with patients in-clinic, and at home by telephone.

This study will employ the approach of institutional ethnography (IE) to investigate
how primary care physicians define, encounter and manage complex patients who experience
chronic pain. Our overarching research question is: How do primary care physicians
describe the work they do in caring for patients with complex chronic pain conditions? This question
will become our starting point, rather than the end point, to allow our team to explicate
how care is put together at the level of the institution (macro) with attention to
how care is coordinated in local practice (micro). Using an expanded definition of
work will allow us to understand the many types of work that physicians do (e.g. examining
patients, making phone calls, filling out forms, email) and also alerts us to how
the discourses and concerns of institutions enter into the everyday language of care
providers. This will achieve the following specific objectives:

1. Describe carefully and empirically the work that goes into caring for complex patients
with chronic pain and multi-morbidities beginning from the standpoint of primary care
physicians and working outward to capture the often invisible social relations informing
patient care;

2. Follow in each setting the textual, informal and formal practices implemented by
the providers, as their work is coordinated with that of others in different settings.
This will create a “map” of the social relations of primary care provision of OA chronic
pain management that includes the perspectives of all key stakeholders and will allow
for the creation/augmentation of new models of care that are effective, efficient
and sustainable, ultimately improving the patient’s experience of CARE.

3. Provide a link between everyday experience to broader discourses related to health
care system inefficiencies, integration and patient-centred care. These links will
be the mechanism by which findings from our work can be “ replicated” and applied
to other provinces and internationally.