Teaming in Interdisciplinary Chronic Pain Management Interventions in Primary Care: a Systematic Review of Randomized Controlled Trials

Abstract

Background

Current pain management recommendations emphasize leveraging interdisciplinary teams. We aimed to identify key features of interdisciplinary team structures and processes associated with improved pain outcomes for patients experiencing chronic pain in primary care settings.

Methods

We searched PubMed, EMBASE, and CINAHL for randomized studies published after 2009. Included studies had to report patient-reported pain outcomes (e.g., BPI total pain, GCPS pain intensity, RMDQ pain-related disability), include primary care as an intervention setting, and demonstrate some evidence of teamwork or teaming; specifically, they needed to involve at least two clinicians interacting with each other and with patients in an ongoing process over at least two timepoints. We assessed study quality with the Cochrane Risk of Bias tool. We narratively synthesized intervention team structures and processes, comparing among interventions that reported a clinically meaningful improvement in patient-reported pain outcomes defined by the minimal clinically important difference (MCID).

Results

We included 13 total interventions in our review, of which eight reported a clinically meaningful improvement in at least one patient-reported pain outcome. No included studies had an overall high risk of bias. We identified the role of a care manager as a common structural feature of the interventions with some clinical effect on patient-reported pain. The team processes involving clinicians varied across interventions reporting clinically improved pain outcomes. However, when analyzing team processes involving patients, six of the interventions with some clinical effect on pain relied on pre-scheduled phone calls for continuous patient follow-up.

Discussion

Our review suggests that interdisciplinary interventions incorporating teamwork and teaming can improve patient-reported pain outcomes in comparison to usual care. Given the current evidence, future interventions might prioritize care managers and mechanisms for patient follow-up to help bridge the gap between clinical guidelines and the implementation of interdisciplinary, team-based chronic pain care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-021-07255-w.

BACKGROUND

Chronic pain is a complex problem involving physical, emotional, social, and existential factors unique to each individual.^1,2 Approximately 100 million Americans live with chronic pain, resulting in high-cost burdens on our healthcare system.³ In the USA, much of the responsibility for managing chronic pain falls upon primary care providers. Consultations for pain concerns account for 22% of all primary care encounters.^4,5 Furthermore, primary care providers are the leading prescribers of opioids for chronic pain.⁵ Thus, it is important that pain management interventions encompass primary care to reflect practice patterns and the fact that pain often arises against a background of multimorbidity. Chronic pain management remains challenged by fragmented care, disjointed treatment from multiple providers, and poor outcomes.^3,6

To improve the fragmented delivery of chronic pain care, pain management guidelines recommend integrated, interdisciplinary care.^7,8 Policy standards emphasize the importance of interdisciplinary teams in pain management because of the diverse clinical skills involved in addressing chronic pain with recommended educational, behavioral, and exercise-based approaches.^1–3,9–11 Bringing interdisciplinary skillsets together relies on teams and teamwork; ineffective team coordination can have important consequences for chronic pain patients, including uncontrolled pain episodes and opioid overdose.³ Moreover, poor team coordination may strain clinician-clinician or clinician-patient relationships.^3,12 The importance of teamwork to involve multiple non-physician disciplines at the clinical frontlines of chronic pain management has been further accentuated by the opioid crisis.^7,13,14

Many integrated health care delivery models (e.g., patient-centered medical home)¹⁴ rely on bounded teams with defined team membership and clear roles oriented around shared team goals.^15,16 Teamwork describes the processes of communication, coordination, and collaboration that foster integrated team-based care within bounded teams.¹⁷ However, bounded teams are best at tackling bounded challenges; chronic pain is a variable and dynamic challenge.³ Difficulties organizing across disciplines to meet unique patient needs could contribute to the varied effectiveness of interdisciplinary pain management models.^{3,9,10,18–21}

Since the cause and experience of pain can be so idiosyncratic, bounded teams may struggle to address the needs and therapeutic responses of different pain patients.^3,22 For example, clinicians may need to integrate a specialist outside of an already defined clinical team to enact a patient’s treatment plan. “Teaming” is the dynamic act of bringing individuals together around a task, goal, or patient; teaming can be helpful in meeting patient needs when clinicians need to work together on an ad hoc basis to address the dynamic and multifaceted nature of pain.^22–24 In practice, pain care teams blend both bounded and dynamic elements (e.g., primary care physician and nurse care manager on bounded team consult psychiatrist outside of bounded team). Whether acting as part of a bounded team or transiently teaming, the communication, collaboration, and coordination processes used by clinicians may impact patient outcomes, and thus, both teamwork and teaming deserve consideration when implementing interdisciplinary pain management interventions.

Despite the emphasis on interdisciplinary teams for chronic pain management, there has been limited emphasis on understanding how to promote successful teamwork and teaming in chronic pain interventions. By expanding our definition of teams to incorporate both bounded and unbounded teams, practicing teamwork or teaming, we aimed to identify relevant team structures and processes that may facilitate successful chronic pain management within primary care settings.

METHODS

We systematically reviewed available literature on interdisciplinary chronic pain management interventions incorporating teamwork or teaming in primary care settings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.^25,26 At the outset, we achieved consensus on relevant definitions and a robust study selection process. All stages of the review used dual, independent review (NC, KG, PP, or SZ), with disagreements commonly adjudicated by a third “gold standard” reviewer, an MD with pain management expertise (KL). We registered the protocol²⁷ with PROSPERO (CRD42020191467) in July 2020 and updated our registration in May 2021.

Search Strategy

A professional research librarian (HW) searched the electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EMBASE using a combination of terms for chronic pain, chronic cancer pain, primary care, and randomized controlled trials (RCTs). Using an iterative process, we derived our final search strategy (Appendix I), and we consistently applied it across all databases to identify appropriate studies in June 2020. To check for recently published studies, we updated our search in March 2021. For feasibility, we limited our search to randomized studies or systematic reviews of randomized studies published after 2009 and in the English language. Although we limited our review to studies published in English for feasibility, we also conducted a broader search to capture any potentially relevant non-English studies; no additional studies were identified as potentially relevant after dual review. We did not search gray literature. We uploaded results into Covidence, a web-based platform that helps streamline the systematic review process, which we used for study selection, data extraction, and quality assessment.

Study Selection

The population, intervention, comparator, outcomes, timing, and setting (PICOTS) framework specified our eligibility criteria (Table 1). We piloted our process to ensure shared interpretation of inclusion and exclusion criteria. We obtained full texts of citations judged as potentially eligible by at least two reviewers. We then dually screened (NC, KG, PP, or SZ) full-text publications against the inclusion criteria, using Covidence software to document the flow of citations and reasons for excluding full-text publications.

Table 1.

PICOTS Inclusion/Exclusion Criteria

Population	Inclusion • Adults (≥ 18 years of age) with chronic pain conditions of any etiology or experiencing cancer chronic pain in both treatment and control settings
	Exclusion • Studies of pain in the perioperative period and studies of acute pain
Intervention	Inclusion: interdisciplinary interventions incorporating teaming • Clinicians did not need to belong to a bounded team to provide sufficient evidence of teaming. Instead, teaming, the dynamic action of bringing clinicians together to meet a patient’s needs, was sufficient for inclusion in the review • Teaming was evidenced by: ○ At least two clinicians involved in the delivery of the intervention ○ Clinicians and patients interacting in an ongoing coordination process, defined by communication, coordination, or collaboration over at least two distinct time points
	Exclusion • A single referral between clinicians did not provide sufficient evidence of teaming • Interdisciplinary interventions that layered different care modalities without any communication, coordination, or collaboration between clinicians of different modalities were not included in the intervention
Comparator	• Treatment as usual
Outcomes	Patient-reported discrete pain outcome reported as a numeric value at baseline and post-intervention • Total pain, pain-related disability, pain intensity, pain interference, pain severity, bodily pain, average pain, worst pain, least pain, and current pain Pain scales included (range): • Brief Pain Inventory (0–10) • GCPS: Graded Chronic Pain Scale (0–100) • RMDQ: Roland-Morris Disability Questionnaire (0–24) • NRS: Numerical Rating Scale (0–10) • PDI: Pain-Disability Index (0–10) • WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index (0–100) • SF-36: 36-Item Short Form Survey RAND (0–100) • VAS: Visual analog scale (0–10)
Timing	• Any follow-up period was included
Setting	• If a setting was explicitly defined as primary care by the study authors or if a primary care provider was involved as one of the team members, we accepted the study for inclusion

Inclusion

We included studies that implemented an intervention incorporating teamwork or teaming in primary care to manage chronic pain. Chronic pain: We included pain of any etiology explicitly identified as chronic in the included studies. Most commonly, included studies defined chronic pain as pain persisting for ≥ 3 months despite treatment. Intervention incorporating teamwork or teaming: For the purposes of this study, evidence of teamwork or teaming was defined as at least two clinicians interacting with each other and with patients in an ongoing coordination process, evidenced by clinicians interacting among themselves and/or with the patient over at least two distinct timepoints. A single referral did not provide sufficient evidence of teamwork or teaming, nor did layered care modalities with no communication between clinicians in different disciplines. If a study had multiple intervention arms that incorporated teamwork or teaming, each arm was included as a distinct intervention in the analysis of our review. Primary care: If a setting was explicitly defined as primary care by the study authors or if a primary care provider was involved as one of the team members, we accepted the study for inclusion. A complete list of inclusion criteria is presented in the PICOTS framework (Table 1).

Exclusion

We excluded publications that (1) were not published in the English language, (2) were not randomized controlled trials or systematic reviews, (3) did not include adults in the population, (4) were studies of medication effectiveness, (5) were studies of the effectiveness of technical medical interventions, (6) did not include patients with chronic pain, (7) did not report a numeric patient-reported pain-related outcome measure, (8) did not include primary care, or (9) lacked evidence of teaming. For replicability, we applied the exclusion criteria in this order to ensure consistent reasons for exclusion across reviewers.

Data Collection

Two sets of paired abstractors (NC or SZ and KG or PP) conducted dual data abstraction using the piloted extraction guide (Appendix II). Appendix II demonstrates how we used organizational theories about teams^15,22,28 to inform our abstraction about team structures and processes; the relationship between organizational theories and our abstraction guide is described in more detail in the study protocol.²⁷ We extracted relevant information from all included studies on the team structures (who is involved), team processes (teaming or teamwork; how clinicians and patients collaborated, communicated, and coordinated), and outcomes (patient-reported pain). Two abstractors (NC and PP) independently assessed study quality using the Cochrane Risk of Bias tool before reaching consensus.²⁹

Outcomes

Our primary outcomes were patient-reported measures of pain, pain-related function, or pain-related disability assessed using validated scales (e.g., Brief Pain Inventory,³⁰ Graded Chronic Pain Scale).³¹ Generic functional status and disability measures were determined to be outside the scope of this review. Pain-related outcomes included pain intensity, pain interference, pain severity, bodily pain, total pain, average pain, worst pain, least pain, and current pain, and included pain scales are listed in Table 1.

Data Synthesis

Given the heterogeneity of methods and outcome measures across all included studies, as well as the focus of this review on structures and processes related to teaming, statistical comparisons between studies were not possible. Thus, we narratively summarized our findings, using an a priori list of potentially relevant team structures and processes (Appendix II). We evaluated extracted data across all included studies, focusing on differences between interventions that demonstrated some clinical effect of patient-reported pain and those that lacked evidence of clinically meaningful improvements on patient-reported pain outcomes. Interventions with some clinical effect on pain were defined as interventions with at least one patient-reported pain outcome improving by the minimal clinically important difference (MCID). In contrast, interventions with no clinical effect on pain were defined by lack of minimal clinically important improvement. In investigating interventions for chronic pain patients, we thought it pertinent to consider the MCID as a way to center outcomes that are meaningful to patients.³² When possible, we used MCIDs defined specifically for chronic pain patients,³³ and MCIDs across pain scales are defined and cited in Appendix III.

RESULTS

Literature Selection

In June 2020, we identified 2566 non-duplicate titles of which 85 studies were potentially relevant after title and abstract review. We excluded 69 studies at full-text review and excluded four more studies upon further analysis at the data extraction phase.^34–37 We accepted 12 studies^{9,10,38,39,40–46} for full-text inclusion. All dual review conflicts in the first study selection phase were resolved by a third adjudicator (KL). In April 2021, we identified 288 non-duplicate titles that had been published after our initial search. Of these, 11 studies were identified as potentially relevant after title and abstract review. We excluded 10 studies at full-text review and excluded the remaining study upon further analysis at the data extraction phase due to its lack of control for team structures and processes,⁴⁷ leaving us with our initial 12 included studies. Conflicts during the second dual review process were resolved by reviewer consensus. Table 2 provides a detailed summary of the included studies. Figure 1 depicts the study selection process and reasons for full-text exclusion.

Table 2.

Summary of Included Studies

Author/year	Description of study participants	Setting	Patient-reported pain outcomes: mean change from baseline (effect size)	Description of intervention(s)	Study quality
Aragaonés 201938	Adult patients (18–80 years) experiencing major depressive episode and moderate to severe musculoskeletal pain (n = 328)	8 urban primary care centers	BPI Pain severity:  − 0.22 (0.17) Pain interference:  − 1.44* (0.22)	DROP (Depression and Pain Program): optimized management of major depression, care management, psycho-educational program	Good
Bair 201510†	Veterans (≥ 18 years) with self-reported chronic musculoskeletal pain (n = 241)	5 general medicine clinics and 1 post-deployment clinic within single VA medical center	BPI Pain interference:  − 1.7* (0.26) GCPS Pain severity:  − 11.1 (0.21) RMDQ Pain-related disability  − 3.4* (0.23)	ESCAPE Intervention: stepped care (optimization of analgesic therapy followed by CBT program)	Good
Bruhn 201339	Adults (≥ 18 years) receiving regularly prescribed medication for pain (n = 193)	6 general practice clinics	Intervention 1 GCPS Pain intensity:  − 8.0 (0.38) Pain-related disability:  − 20.0	Intervention 1 Pharmacist prescribing and review: Pharmacist consults patient in person for medication review and develops a treatment plan	Fair
			Intervention 2 GCPS Pain intensity:  − 1.0 (0.14) Pain-related disability:  − 13.4	Intervention 2 Pharmacist review: pharmacist medication + treatment review to create treatment plan for GP	Fair
Clark 201548	Adults (≥ 18 years) with chronic neurological or musculoskeletal pain	Chronic pain center	NRS Average pain:  − 0.96 Worst pain:  − 0.38 Least pain:  − 0.92 Current pain:  − 0.83 PDI Pain-related disability:  − 4.73	Standard telephone consultation: telehealth management via pain specialist to assist PCP with best pain management practices	Fair
Dobscha 20099	Adults (≥ 18 years) with musculoskeletal pain diagnoses (n = 401)	5 primary care clinics within single VA Medical Center	GCPS Pain intensity:  − 4.7 (0.17) Pain interference:  − 5.7 (0.32) RMDQ Pain-related disability:  − 1.4 (0.26)	SEACAP: a collaborative care management team developed treatment recommendations for the patient’s PCP and delivered a 4-session pain workshop to the patients	Good
Gardiner 201940†	Low-income racially diverse adults (≥ 18 years) with non-specific chronic pain and depressive symptoms (n = 155)	1 academic tertiary hospital and 2 affiliated community health centers	BPI Pain interference:  − 1.0* (0.00) Pain severity:  − 1.0* (0.39) Average pain:  − 1.0* (0.00)	Integrative group medical visits: 10 in-person weekly group visits followed by 12 weeks self-management via online platform	Good
Goertz 201741†	Community dwelling, ambulatory adults (65 years) who were experiencing a chronic LBP episode (n = 131)	Clinics of a family medicine residency and a chiropractic research center	NRS Average pain:  − 1.8 (0.18) Worst pain:  − 2.1* (0.06) RMDQ Pain-related disability:  − 2.8 (0.37)	Shared care: 12 weeks of LBP-guideline-based care and individualized chiropractic care, shared treatment plan	Good
Helminen 201542	Adults (35–75 years) with clinical symptoms of knee osteoarthritis (n = 111)	Primary care providers from multiple clinics in Finland	WOMAC Pain: − 22.0* (0.18) NRS Average pain in last week:  − 1.6 (0.04) Worst pain in last week:  − 2.1* (0.30) Average pain in last 3 months:  − 1.6 (0.90) Worst pain in last 3 months:  − 1.8 (0.68) SF-36 Bodily pain:  − 6.3 (0.05)	Cognitive behavioral group intervention: Groups of 8–10 individuals participated in six cognitive behavioral group sessions	Fair
Kroenke 200943†	Adults (≥ 18 years) experiencing comorbid musculoskeletal pain and depression	2 primary care clinical systems (6 community-based clinical sites ad 5 general medicine clinics)	BPI Pain severity:  − 1.08* (0.54) Pain interference:  − 1.88* (0.62) Total pain:  − 1.68* GCPS Pain severity:  − 4.9 (0.32) Pain-related disability:  − 15.3 (0.46) RMDQ Pain-related disability:  − 3.3* (0.54) SF-36 Bodily pain:  − 10.8* (0.44)	SCAMP: stepped care for affective disorders and musculoskeletal pain; optimized antidepressant therapy followed by pain self-management program, relapse prevention	Good
Kroenke 201444	Adults (18–65 years) experiencing chronic regional or localized musculoskeletal pain (n = 250)	5 primary care clinics within single VA medical center	BPI Total pain:  − 1.74* (0.57) Pain severity:  − 1.47* (0.40) Pain interference:  − 2.01* (0.51)	SCOPE: optimized analgesic management through a telecare collaboration supported by patient ASM	Good
Kroenke 201945†	Adult patients (≥ 18 years) with localized musculoskeletal pain or widespread fibromyalgia plus psychiatric comorbidity (n = 294)	6 primary care clinics within single VA Medical Center	BPI Total pain:  − 1.0* (0.01) SF-36 Bodily pain:  − 5.1 (0.08)	CAMMPS: Comprehensive symptom management enhanced with ASM	Good
Lambeek 201046	Adults (18–65 years) with low back pain and at least partially absent from work (n = 134)	10 physiotherapy practices, 1 occupational health service, and 5 hospitals	VAS Pain intensity:  − 0.53 (0.10)	Integrated care: composed of workplace intervention and graded activity program coordinated by integrated care team	Good

All pain scales are defined in Table 1

Abbreviations: DROP Depression and Pain Program, PCP primary care provider, ESCAPE Evaluation of Stepped Care for Chronic Pain, CBT cognitive behavioral therapy, GP general practitioner, SEACAP Study of the Effectiveness of a Collaborative Approach to Pain, CIH complementary integrated health, LBP low back pain, OA osteoarthritis, SCAMP Stepped Care for Affective Disorders and Musculoskeletal Pain, NCM nurse care manager, SCOPE Stepped Care to Optimize Pain Care Effectiveness, CAMMPS Comprehensive vs. Assisted Management of Mood and Pain Symptoms

^*Mean difference ≥ than defined MCID for pain scale

^†Control differed slightly from treatment as usual

Figure 1.

Literature flow.

Quality Assessment

Overall, eight studies had low risk of bias, as defined by the Cochrane Risk of Bias tool.^{9,38,40,43–45} The other four had moderate risk of bias;^39,41,42 no studies included in this review had high risk of bias. Figure 2 summarizes the risk of bias assessment.

Figure 2.

Risk of bias in randomized studies.

Setting and Subjects

All included studies were of interventions for management of chronic pain; our search revealed no studies of interventions promoting teaming for chronic cancer pain in primary care settings. Most studies involved multiple primary care practices in the USA.^{9,10,40,41,43,45} Five studies were conducted either at the Indianapolis Veterans Affairs Medical Center (VAMC)^10,43–45 or the Portland VAMC.⁹ Other studies took place in primary care centers in Canada,⁴⁸ Spain,³⁸ Finland,⁴² and the UK,³⁹ and in physiotherapy practices in the Netherlands.⁴⁶ Sample size ranged between 100 and 300 participants for 11 of the 13 studies. Follow-up duration was 12 months for most of the studies (range 21 weeks to 12 months). The proportion of male patients ranged from 11 to 92%, with higher proportions in those studies conducted within the VA. The mean patient age ranged from 37 to 73 years old. Of the nine studies that reported patient data on race/ethnicity, all but one study⁴⁰ included a majority (≥ 60%) of white patients. Of the 12 included studies, two^39,41 were three-armed randomized studies, one of which had two intervention arms that met our inclusion criteria, resulting in 13 total interventions.

Intervention Outcomes

Of the 13 interventions that met inclusion criteria, eight interventions reported at least one clinically improved patient-reported pain outcome (evidenced by an improvement from baseline greater than defined MCID scores).^{10,38,40–45} Six of these eight interventions had at least half of reported pain outcomes improve by the MCID,^{10,38,40,43–45} while the other two had only a third of the reported pain outcomes improve by the MCID.^41,42 The improved pain outcomes in these interventions were measured using BPI (pain severity,^38,40,43,44 pain interference,^10,40,43,44 total pain ^40,43,44), RMDQ pain-related disability,^10,43 SF-36 bodily pain,⁴³ WOMAC pain subscale,⁴² and NRS^41,42. Mean differences from baseline to post-intervention of all outcomes are reported across interventions in Table 2.

Team Structures

The interventions with some clinical effect on pain outcomes included several similarities in team structures, such as the number of team members and roles of clinicians collaborating in the intervention. The most common clinician role in interventions with some clinical effect was that of a nurse care manager; five interventions with some effect on pain included a care manager.^{10,38,43–45} In contrast, among the interventions without any clinically meaningful effect on pain, only one designated the role of a care manager.⁹ Care manager responsibilities frequently included baseline patient assessment, patient follow-up, and team case review. Other clinician roles included in the interventions demonstrating some clinical effect on pain outcomes included the patient’s primary care physician (PCP), the intervention physician (often with training in primary care or family medicine), a psychologist or mental health practitioner, a physical therapist, a chiropractor, and/or a physician with pain expertise. Of note, all interventions in this review were organized around bounded teams.

Across all interventions, the patient’s usual PCP was involved in the intervention in varying capacities. Five interventions completely replaced the usual PCP with an intervention physician, four of which demonstrated some clinical effect on pain outcomes.^10,40,41,45 Other interventions incorporated the usual PCP by providing treatment recommendations.^42–45 Five interventions included the patient’s usual PCP as a bounded team member; only one of these interventions had a clinical effect on pain outcomes.³⁸ A summary of team structures (i.e., number and role of clinical team members) across interventions is reported in Table 3, and intervention-specific details in Table 4.

Table 3.

Characteristics Across Interventions

	No. of interventions		No. of interventions
Country		Sample size
USA	7	0–100	1
Canada	3	100–200	8
UK	1	200–300	3
Spain	1	> 300	2
Finland	1
Netherlands	1
Chronic pain site		Number of clinical team members
Non-specific/multi-site	10	2	8
Back	2	3	3
Knee	2	4	2
		> 4	1
Clinician type		Mode of intervention delivery
Primary care physician	9	Individual only	8
Study physician	7	Group only	1
Care manager	5	Individual and group	5
Psychologist/mental health practitioner	4	Face-to-face only	7
Pharmacist	3	Telephone only	2
Physical/occupational therapist	4	Face-to-face and telephone	5
Specialist physician/physician with pain expertise	4
Complementary integrated health provider	2
Intervention modalities		Follow-up period
Cognitive behavioral strategies	3	3 months	1
Physical/occupational therapy	2	6 months	4
Medication optimization/monitoring	8	9 months	1
Automated symptom monitoring	2	12 months	7
Take home materials/homework	4	Other	1
Self-management strategies	4
Workplace intervention	1
Teaming with patient		Teamwork among clinical team members
Regularly scheduled patient follow-up	6	Regularly scheduled clinician meetings	5
Prompted patient contact	2	Weekly clinician meetings	2
Follow-up in person	1	Joint review/treatment plan	5
Follow-up over telephone	7	Co-facilitate workshop	4
Teamwork/teaming with usual PCP		Intervention facilitators
PCP bounded team member	5	Clinician training	8
Any communication	8	Dedicated mentorship	2
Via EMR	3	Patient reimbursement	3
Via telephone/fax	3	Physician reimbursement	0
No communication	5

Table 4.

Team Structures and Processes Across Interventions

	Team structures and processes
Intervention*	Bounded team	Provider roles (#)	Designated care manager	Patient case review	Joint patient assessment/treatment development	Co-facilitation of patient workshops	Work with patient’s usual PCP	Pre-scheduled patient follow-up	Prompted patient follow-up	Patient sessions
1. Aragonés 2019*	Y	PCM, PCP (2)	PCM	–	–	–	Treatment plan via EMR	Phone at 1, 2, 3, 6, 9, 12 months (6)	–	9 weekly group psycho-education sessions (2 h each)
2. Bair 2015*	Y	NCM, psychologist, study physician (3)	NCM	Weekly	–	–	–	Phone, bi-weekly (12)	–	–
3. Bruhn 2013	Y	Pharmacist + PCP (2)	–	–	–	–	Treatment plan	–	–	–
4. Bruhn 2013	Y	Pharmacist, PCP (2)	–	–	–	–	PCP agrees to clinical management plan	–	–	–
5. Clark 2015	Y	Pain specialist, PCP (2)	–	1 + 3 months	Pain specialist + PCP	–	Treatment plan + guidance	–	–	–
6. Dobscha 2009	Y	PCM, study physician, PT, PCP (4)	PCM	–	PCM + study physician	Study physician, PT, + PCM	Treatment plan via EMR	Phone bi-monthly (6)	–	4 education sessions (within 4 months)
7. Gardiner 2019*	Y	Study physician, CIH (2)	–	–	–	Study physician + CIH	–	–	–	10 IMGV sessions (2.5 h each)
8. Goertz 2017*	Y	Study physician, chiropractor (2)	–	Frequency unclear	Study physician, chiropractor	–	–	–	–	–
9. Helminen 2015*	Y	Psychologist, PT (2)	–	–	–	Psychologist + PT	Unclear	–	–	6 weekly group CBT sessions (2 h each)
10. Kroenke 2009*	Y	Study physician, NCM (2)	NCM	–	–	–	–	In-person visits (5); phone (8)	–	–
11. Kroenke 2014*	Y	Study physician, NCM, PCP (3)	NCM	Weekly	NCM + physician w/ pain expertise	–	Treatment plan via EMR	Phone at 1 and 3 months	Respond to ASM	–
12. Kroenke 2019*	Y	Study physician, NCM, PCP (3)	NCM	Weekly	Study physician + NCM	–	–	Phone at 1, 4, + 12 weeks	Respond to ASM	–
13. Lambeek 2010	Y	Study physician, PT, OT, occupational physician, PCP (5)	–	Every 3 weeks	–	–	–	–	–	Exercise/workplace protocol

Abbreviations: NCM nurse care manager, PCM psychologist care manager, PT physical therapist, PCP primary care provider (patient’s usual PCP), CMP clinical management plan, EMR electronic medical record, ASM automated symptom management, CIH complimentary integrated health provider, OT occupational therapist, IMGV integrated group medical visit, CBT cognitive behavioral therapy

Team Processes

Across interventions with clinically meaningful improvements on pain, study clinicians did not engage in many common team processes. Three of the interventions with some effect on patient-reported pain outcomes relied on regularly scheduled, weekly telephone conferences among clinical team members to review patient cases;^10,44,45 Goertz also relied on telephone conferences with clinical team members for patient case review, but the conference frequency was unclear.⁴¹ Two interventions lacking evidence of clinically meaningful effects on pain also reviewed patient cases as a team.^46,48 At baseline, three of the interventions with some clinical effect on pain^41,44,45 and two of the interventions with no clinical effect on pain^9,48 described a joint patient assessment or development of treatment plans. Additionally, co-facilitation of patient education workshops was identified as a team process in two of the interventions with some effect on pain outcomes^40,42 and one of the interventions with no effect.⁹ Details of team processes across interventions are reported in Table 4.

The interventions with clinical effects on pain outcomes commonly relied on similar team processes for interacting with the patient. Five of the interventions with some clinical effect on pain relied on multiple, scheduled patient contacts for follow-up after the initial assessment,^{10,38,43–45} although interventions varied in the frequency of patient follow-up (see Table 4 for specifics). All five of these interventions contacted patients via telephone, although Kroenke 2009 also had five scheduled in-person patient visits.⁴³ One intervention with no clinical effect on pain also telephoned for bi-monthly follow-up.⁹ Two of the interventions with some effect on patient-reported pain prompted patient contact, either in response to patient automated symptom monitoring or to a patient request for follow-up.^42,45 The other interventions did not report prompting any patient contact.

DISCUSSION

We conducted a systematic review of high-quality studies incorporating interdisciplinary teamwork and teaming to manage chronic pain in primary care settings and found modest, indirect evidence to inform the current emphasis on interdisciplinary, team-based pain care. A total of 13 randomized interventions, of which eight reported clinically meaningful improvements in pain, comprised our results. While other recent systematic reviews relevant to chronic pain management have synthesized the evidence on multimodal interventions¹¹ and multidisciplinary interventions incorporating patient education,⁴⁹ our systematic review focuses on the specific team structures and processes that are required when bringing multiple disciplines together. Although much of the evidence is nascent, this review demonstrates the promising role that supporting interdisciplinary teamwork can play in improving chronic pain outcomes.

While the team structures varied across interventions in the number and roles of clinician team members, the role of the care manager emerged as a common structural feature of the interventions with some clinical effect on pain outcomes. The literature on healthcare teams reveals that the role of a dedicated manager to direct and coordinate patient care is associated with improved outcomes.^50–52 Care managers play critical roles in coordinating the care of chronic conditions,^50,53,54 in part due to how care management fosters patient-centered care through added patient support.^54,55 Furthermore, care managers could contribute to the establishment of previously identified factors of successful teams, such as team boundedness and enabling team structures because of their frequent communication both with other clinicians and with patients, which may help organize teams around shared goals by ensuring each team member is aware of their specific roles, even as roles dynamically change.¹⁵ Of note, another structural similarity of the included studies was their setting in the VA; almost half of the included studies took place at the VA. This commonality is not surprising given that most pain management occurs in primary care,⁴ and that in VA, the delivery of primary care is organized around “Patient Aligned Care Teams” (PACTs) to manage most pain conditions.^2,14

Although team processes were fairly heterogeneous, we identified patient follow-up as an important facilitator of improved patient pain outcomes. Five of the interventions demonstrating clinical improvements on patient-reported pain outcomes relied upon multiple, pre-determined contacts between an intervention clinician and the patient.^{10,38,43–45} This team process overlapped with the structural role of a designated care manager, in that this was often the individual responsible for patient contact. However, we wanted to highlight patient contact as a distinct process that encouraged teaming with patients. The role of patients as active participants in their own pain care is consistent with the literature on patient-centered care, which highlights self-management and patient empowerment as crucial processes to improve pain outcomes.⁵⁶ Actively incorporating the patient in team processes could help bolster the improvement of patient pain outcomes in future interdisciplinary interventions.

Relying on organizational theories about teams, teamwork, and teaming gave us the necessary framing to analyze team structures and processes across interdisciplinary interventions, even though the organization and effectiveness of teams were not an explicit focus of the interventions. For example, Hackman’s Five Factor Model of successful teams¹⁵ informed our definition, abstraction, and analysis of team structures, and enabled us to observe that all interventions were organized around bounded teams. Although the intervention teams were ultimately identified as bounded, by searching for interventions incorporating teamwork or teaming,²² we were able to capture a broader set of interventions with clues into relevant team structures and processes (only six^9,41,43–46 of the 13 interventions included in this review explicitly identified a “team” responsible for the delivery of care). Leveraging an organizational theory lens provided transparency into important team structures and processes, allowing us to understand how to promote effective teamwork or teaming among interdisciplinary clinicians in the management of chronic pain.

Limitations

In this review, we focused on RCTs including team structures and processes in chronic pain management to synthesize the highest-quality evidence available. Due to our inclusion of only RCTs, the small number of heterogeneous studies limits the generalizability of this systematic review. Furthermore, some of the included RCTs were pilot/feasibility studies.^40,41 Moreover, although MCIDs represent clinically meaningful improvements for patients, using the MCID to synthesize patient-reported pain outcomes also has its limitations. In a systematic review of estimated MCIDs for the WOMAC, MCIDs were defined from 13.3 to 36.0 for the pain subscale in patients who underwent total knee replacement,⁵⁷ demonstrating the wide range that can result from differing methods. However, given the limited evidence informing the design and delivery of pain care involving teamwork and teaming, we believe using the MCID to identify important team structures and features like care management and patient follow-up helped contribute to the growing emphasis on team-based pain care.

Conclusions

This systematic review provides some evidence that interdisciplinary interventions incorporating teamwork and teaming have improved patient-reported pain outcomes in comparison to usual care. However, we identified only 13 interventions incorporating teamwork or teaming in the past 10 years, demonstrating persistent gaps between clinical guidelines and published evidence on the implementation of team-based chronic pain care. As policy and clinical standards continue to emphasize the need for interdisciplinary pain management, chronic pain care models could benefit from applying lessons from organizational theories, working to intentionally promote team structures and processes at the level of implementation. Given the current evidence, future interventions might prioritize care manager and patient follow-up incorporation.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

KG and KL led the conception and design of the systematic review with expert consultation from SS and EY. EK provided critical guidance on PICOTS specification. SZ, NC, PP, and HW were responsible for conducting pilot searches to scope literature and finalize search strategy. KG, NC, PP, and SZ conducted the screening, abstraction, and risk of bias assessment. KL provided adjudication if there were conflicts in abstract or full-text screening. NC and KG led the drafting of the manuscript with substantial written comments from all authors. All authors read and approved the final manuscript.

Data Availability

The datasets during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.