Among older adults discharged from the ED with a diagnosis of musculoskeletal pain, only half of patients reported receiving information about analgesics, and less than one third reported participating in the selection of an analgesic. Patients who reported receiving information about analgesic options or participating in the selection of an analgesic were more likely to be optimally satisfied with the medication prescribed or recommended. In regression models adjusting for sociodemographic characteristics and pain symptoms, the association between information received and satisfaction with the pain treatment persisted, and there was a trend towards greater decreases in pain scores among patients who received information.
Effective management of acute pain in older adults is important both for the relief of suffering and because acute pain may predispose individuals to persistent pain and a decline in physical function.18
Our results indicate that continued pain at one week is common among older individuals seen in the ED with acute musculoskeletal pain, but suggest that the provision of components of shared decision making may improve outcomes for these patients. Further study of shared decision making for analgesic selection in older adults is needed to better understand the relationship between shared decision making and outcomes and to determine if interventions to increase the use of shared decision making can provide a patient-oriented solution to the challenge of optimizing the pharmacologic management of pain in older adults.19–21
The low levels of information sharing and participation reported by patients in the current study suggest that there are barriers to shared decision making regarding analgesic selection for older ED patients. These barriers might include a lack of familiarity with shared decision making or failure to prioritize the effective outpatient treatment of pain in older adults given the limited time available for patient care in the ED.22, 23
Despite these barriers, we believe shared decision making has potential value in the selection of outpatient analgesics for older ED patients. First, components of shared decision making can be applied to a treatment decision occurring at a single visit.24, 25
Second, the provision of information and elicitation of preferences about analgesics may be achieved during the time typically available for patient-provider interactions in the ED. Third, training internists in shared decision making regarding chronic pain has been shown to be feasible;26
and we believe that similar training would be acceptable to emergency providers.
This study has several limitations with implications for both its internal and external validity. Four patient refused to participate because they were experiencing severe pain, were feeling too sick, or wanted to call a doctor. These refusals result in a slightly biased sample. Components of shared decision making were assessed one week after the ED visit and at the same time as outcome measures. Thus, patient reporting of the information provided and participation in the decision may have been influenced by their pain relief. Shared decision making is a complex and interactional process and more detailed assessment methods including whether information was provided verbally or in writing and what information was exchanged between providers and patients might allow for a more complete characterization of the decision making process. The relationship between components of shared decision making in the ED and one week outcomes might be confounded by factors not incorporated into the analysis for this study (e.g., effectiveness of pain management in the ED, physical activity during the intervening period). Although enrolled and eligible but non-enrolled patients were similar in regard to demographic characteristics, pain scores, and pain medications received, in other ways (e.g., social support, education level) enrolled patients might not be a representative sample of older ED patients with acute musculoskeletal pain. The study was conducted at a single academic ED in the Southeastern United States, and most patients received care from resident physicians. Physician communication behaviors, analgesic prescribing practices, and patient preferences may be different in private EDs and in other geographic locations and may vary with physician training. Lastly, we only studied discharged patients. The role of shared decision making during the inpatient and early outpatient treatment of pain among older patients with pain so severe as to require hospital admission also deserves attention.
In summary, we observe associations between components of shared decision making and satisfaction with analgesic choice and decreased pain scores one week after the ED visit. Further research is needed to determine the potential of shared decision making to improve outcomes for older adults with acute musculoskeletal pain.