Do Difficult Encounters Affect Pain Treatment Outcomes? A Prospective Cohort Study.

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

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

Methods: 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 initiating pharmacological, integrative or injection therapy or 12 weeks after invasive procedures. The secondary outcome was lost-to-follow-up.

Results: Among 428 patients seen for new-patient evaluations, 299 patients had follow-up, of which 127 (42.5%) experienced a positive outcome. Patients involved in difficult encounters were less likely to experience a positive outcome (28% vs. 46%; P = 0.02) 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 vs. 28% for patients involved in the most difficult encounters (P = 0.02). Difficult encounters were not associated with lost-to-follow-up. In multivariable analysis evaluating factors associated with difficultness, ≥10% missed appointments (OR 0.69, 95% CI 0.48 to 0.97; P = 04), nonorganic signs (OR 0.42, 95% CI 0.18 to 0.90; P = 0.03), visiting taking longer than expected (OR 0.49, 95% CI 0.25 to 0.96; P = 0.04) and refusal to try a treatment (OR 0.25, 95% CI 0.08 to 0.70; P = 0.01) were associated with poor outcome.

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

Trial registration: Clinicaltrials.gov (NCT05585619); https://clinicaltrials.gov/study/NCT05585619? id=NCT05585619&rank=1.