Do difficult encounters affect pain treatment outcomes? A prospective cohort study

Difficult encounters represent an enormous burden and drain on resources in pain medicine, but their effect on outcomes has not been studied.

To determine the effect of "difficult" encounters on chronic pain outcomes.

In this prospective study, new chronic pain visits were rated by an attending physician and trainee on a 6-point Likert scale and stratified into "difficult" and "non-difficult." The main outcome was successful treatment, defined as a ≥2-point reduction in average pain 4 weeks after initiation of pharmacological, integrative, or simple injection therapy, or 12 weeks after more invasive procedures. The secondary outcome was being lost to follow-up.

Among 428 patients seen for new-patient evaluations, 299 patients had follow-up, of whom 127 (42.5%) experienced a positive outcome. Patients involved in difficult encounters were less likely to experience a positive outcome (28% vs 46%; P = .02) than those not involved in difficult encounters. When stratified into quartiles, difficulty continued to be associated with an unsuccessful outcome, with the easiest encounters translating to a 53% success rate, versus 28% for patients involved in the most difficult encounters (P = .02). Difficult encounters were not associated with loss to follow-up. In multivariable analysis evaluating factors associated with difficultness, missing ≥10% of appointments (OR 0.69, 95% CI: 0.48-0.97; P = .04), non-organic signs (OR 0.42, 95% CI: 0.18-0.90; P = .03), visit taking longer than expected (OR 0.49, 95% CI: 0.25-0.96; P = .04), and refusal to try a treatment (OR 0.25, 95% CI: 0.08-0.70; P = .01) were associated with poor outcome.

Difficult encounters can not only lead to administrative burdens, poor ratings, and lost revenue but also are associated with negative outcomes for chronic pain, a condition notoriously associated with difficult visits.

ClinicalTrials.gov ID: NCT05585619.