Management of chronic pain in a rural Australian setting: Findings from the Crossroads-II mixed-methods study

Pain is a strong predictor of poor quality of life and increased societal economic cost due to absenteeism, healthcare costs, sickness or disability benefits.¹ Effectively treating chronic pain, ideally via a multidisciplinary approach,² has been found to improve both physical and psychological symptoms, quality of life and patient functioning.³ However, access to specialist, multidisciplinary pain services might be limited due to extended distance, prohibitive cost and long waiting lists.

It has been estimated that approximately 20% of the adult Australian population lives with chronic pain.⁴ General practitioners (GPs) provide first-line care for patients with chronic pain and continuity of care and can provide care coordination in multidisciplinary teams. In addition, even for patients requiring more specialist care at persistent pain clinics, the strongest predictor of a positive sense of wellbeing was sympathetic treatment by GPs.⁵ Australian studies of chronic pain prevalence have been conducted in general practice⁶ or via national population surveys.⁴ It has been estimated that up to 80% of those living with chronic pain in Australia are not receiving optimal care.⁷ It has been further estimated that 5% of the Australian population aged 15 years or older would benefit from adult persistent pain services; however, only a small proportion of the national population (0.18%), and even less of the non-urban population (0.045%), had accessed these services.⁸

The prevalence of chronic pain and barriers to optimal management in rural Australia are not well understood and have been identified as issues needing attention for health service planning.⁹ Very few pain specialists or specialised chronic pain clinics are located in rural Australia.¹⁰ Rural socioeconomic disadvantage, necessity to travel and pay for specialised care and potential loss of income due to pain and/or disability further compound access to specialised chronic pain care issues in rural areas. The aims of this study were to estimate the prevalence of chronic pain; assess the utilisation of health services, including specialist pain clinics; identify factors associated with self-assessed, well-managed chronic pain; and identify participant-reported solutions for improved chronic pain care in a rural area in Australia.

Methods

The Crossroads-II study¹¹ was conducted in the Goulburn Valley, Victoria, situated approximately 200 km north of the state capital city of Melbourne. The study included the regional centre of Shepparton/Mooroopna (Modified Monash Model [MMM]¹² designation of 3 [large rural town]) and the surrounding smaller towns of Benalla, Seymour and Cobram (each designated MMM4 [medium rural towns]). The Crossroads-II study assessed health, disease and access to care, and results pertaining to diabetes,¹³ atrial fibrillation,¹⁴ dental health¹⁵ and other issues have been published previously. Crossroads-II used similar methodology to the original Crossroads-I study conducted in 2001–03.¹⁶ The results presented here represent a substudy of chronic pain prevalence and access to care within Crossroads-II. There is an outpatient pain clinic available through the public hospital service in Shepparton that uses physiotherapy, psychology and occupational therapy to assist patients to achieve functional goals¹⁷ and has a waitlist of up to four months for the group program, and longer for individualised programs. This clinic opened in 2013 but does not host a specialist pain physician.¹⁷ There is a specialist pain program available through Albury Wodonga Health (situated 175 km from Shepparton) involving a multidisciplinary team and pain specialist.¹⁸ The Albury–Wodonga pain clinic team provides a three-week residential program at no cost to public patients but currently has an extended waitlist (up to six months to commence the program). Similarly, private pain specialists across the state are experiencing high demand, affecting their capacity to see patients, particularly public patients, within short time frames. Due to demand, some private pain specialists have had to close their books to public patients entirely. Additional pain specialist services are available in Melbourne; some are publicly available but often have significant waiting lists and strict referral criteria.¹⁹

Respondents

Households (n=3657) were randomly selected from local government residential rate payer lists. After exclusion of vacant or non-residential addresses, a total of 3112 households were eligible for the survey.¹¹ All residents of these households aged 16 years or over who had lived in the Goulburn Valley for at least six months were invited to participate and provided written informed consent (as required by the ethics committee) on a separate piece of paper to ensure names were not linked to household survey responses. Of the eligible households approached, 2680 individuals from 1895 households consented to participate (61% household response rate). Respondents were asked a series of questions about their health and use of healthcare, in addition to demographic details (see Appendix 1 for sample chronic pain questions) by trained research assistants face to face using tablet technology (iPad; Apple, Cupertino, CA, USA) with REDCap electronic data capture tools (Vanderbilt University, Nashville, TN, USA). Households were repeatedly visited until each adult had indicated their intent to participate or had refused. Many survey questions were validated questions that had been previously used in the Crossroads-I¹⁶ and AusDiab²⁰ studies.

Questionnaire

Chronic pain questions were developed in consultation with a local community healthcare organisation. Participants were asked, ‘Have you ever suffered from, or are currently being treated for any of the following conditions?: Chronic pain’ (yes/no). No specific definition of chronic pain was provided to respondents regarding duration or severity of pain. Participants were asked, ‘Do you feel your pain is well managed?’ (yes/no). Participants were asked the following free-text questions: ‘How would you improve the care of chronic pain in this region?’ and ‘Is there anything that you feel prevents you from managing your pain as well as you would like?’. The percentage of missing data varied slightly for each questionnaire section.

Statistical analysis

Statistical analysis was conducted using IBM SPSS Statistics 27 (IBM Corp., Armonk, NY, USA). Normally distributed data are presented as the mean±standard deviation. Chi-squared tests for independence were undertaken to assess relationships between categorical variables, whereas t-tests were used to compare means between independent groups for continuous variables. For non-normally distributed data (duration of pain and number of comorbidities), the median and interquartile range (IQR) are reported, and between-group analysis used the non-parametric Mann–Whitney U test. Logistic regression assessed factors associated with the perception of well-managed chronic pain. Potential variables were selected because they had been reported to be associated with chronic pain in the literature (age, sex, mental health and employment).²¹ In addition, other variables were included because the authors were interested in their potential involvement in the perception of well-managed pain, namely disability, private health insurance, attendance at a pain clinic, educational attainment, duration of chronic pain and marital status. Participant responses to the free-text questions were analysed by inductive content analysis to identify the frequency of key codes and responses. Briefly, two authors (KG [female scientist and rural health researcher residing in a rural area who had formerly accessed a metropolitan, private pain clinic] and SG [female, rural medical student at the time of analysis, now a GP residing in a rural area]), neither with prior relationships with participants, first became familiar with the data by reading all free-text responses and then developing a list of initial codes. Second, codes were assigned to groups of responses reporting similar issues or solutions and, finally, codes were refined and checked by both authors and matched with the frequency of responses.²²

Ethics approval

Results

Of the 2680 respondents, 42% were male and the mean age was 54±19 years (range 16–97 years). Table 1 compares demographic details of participants with or without chronic pain. Twenty-two per cent of respondents reported having chronic pain. Of those with chronic pain, 60% were female and aged 60±16 years (range 16–94 years). Respondents had experienced their pain for 1–828 months (or 0–69 years), with a median pain duration of 25 months. Those with chronic pain were significantly older (60±16 vs 52±20; P<0.001), had a higher body mass index (30±7 vs 27±6 kg/m²; P<0.001) and had a higher number of comorbid health conditions (median 4.00 [IQR 3.00] vs 2.00 [IQR 2.00]; Mann–Whitney U=927659, P<0.001) than those without chronic pain. Respondents reporting chronic pain were significantly more likely to report depression than respondents who did not report chronic pain (43% vs 20%; P < 0.001). Similarly, those with chronic pain were also significantly more likely to report disability than respondents who did not report chronic pain (51% vs 10%; P<0.001; Table 1). Among people with chronic pain, female respondents had more comorbidities than male respondents (4.1±2.0 vs 3.6±1.9; P=0.001), and those aged ≥65 years had more comorbidities than those aged <65 years (4.3±1.9 vs 3.6±2.0; P<0.001). The percentages of female and male respondents with chronic pain and comorbid heart conditions, diabetes or respiratory conditions were not significantly different, but people aged ≥65 years were more likely to have heart conditions, diabetes or respiratory conditions than those aged <65 years (data not shown).