CHOIR Results Demonstrate Shortest Path Between Primary Care and Pain Medicine for the Most Complex Patients

Feb. 18, 2016, PALM SPRINGS, Calif. –- The care of complex patients with pain exhibits a closer connection between primary care and the specialty of pain medicine than that seen with less complex patients, Stanford researchers reported today. Results presented in a scientific poster at the 32nd Annual Meeting of the American Academy of Pain Medicine described the construction of a network algorithm to better characterize the relationship between primary care and pain medicine.

“We attempted to measure patient complexity by the number of specialty clinics each patient goes to and by their psychological distress,” said lead author Ming-Chih Kao, MD, PhD, a clinical assistant professor within the Stanford University School of Medicine in Palo Alto, Calif. “We found that the nature of care coordination is structurally different for complex patients. For complex patients who also have chronic pain, the coordination between primary care and pain medicine is particularly essential to the overall delivery of care.” 
The research team previously reported results that found the main driver of patient experience depends less on the individual provider than on the overall coordination among the clinic, the primary care physician and all others who participate in delivery of care. Building on that work, the researchers further studied the nature and role of care coordination for the pain medicine specialty, focusing on the organizational aspects and the multi-faceted nature of healthcare delivery for patients with many needs. 
In data analyzed from the Collaborative Health Outcome Information Registry (CHOIR), a total of 11,941 patients with chronic pain were seen across 160 clinics in 38 specialties and primary care. Each specialty represented a vertex on the network. Graph theory-based statistical methods were used to measure the collaborative relationships among specialties in this network.
The researchers discovered that the shortest path of three included dermatology and orthopedics (mean 3.47 +/- SD 0.54). Interestingly, though, for the 1,806 patients who visited at least six specialties, pain medicine and primary care were consistently strongly connected with shortest path distance of one (p<0.001). The finding was persistent for patients with more complexity.

“In our observation, pain medicine is at once closest to primary care and farthest from it,” Dr. Kao said, explaining that for the common pain complaints seen in primary care — back pain, neck pain and headache — pain medicine specialists typically get referrals only after several other specialties have been tried and failed.
The CHOIR platform is a learning health system created at Stanford in partnership and with funding through the National Institutes of Health. As a platform for learning health systems, CHOIR captures not only patient-reported outcomes but also clinical data in the electronic medical record system. More information on the CHOIR platform is at
“This work highlighted the power of combining clinical data with patient-reported outcomes,” Dr. Kao said.

Poster 175 – Network of Coordinated Care: Collaborative Relationship of Pain Medicine with Primary Care for Complex Patients with Pain: A Large-Scale Network Study Using a Learning Health System Platform

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American Academy of Pain Medicine