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12 Articles in Volume 12, Issue #4
Causes of Postoperative Pain Following Inguinal Hernia Repair: What the Literature Shows
Persistent Postsurgical Pain
Managing Adverse Drug Effects in Pain: Focus on Triptans and NSAIDs
Nonsurgical Treatments for Ankle Arthritis
Opioid Disposal: Dos and Don’ts
Survey Shows More Education About Fibromyalgia Needed Among Healthcare Providers
Anxiety in a Headache Patient: Case Challenge
“Centralized Pain”: A New Consensus Phrase
Tooth Loss in the Chronic Pain Population
When Prescribed Opioids Go Unused
May 2012 Pain Research Updates
May 2012 Letters to the Editor

Survey Shows More Education About Fibromyalgia Needed Among Healthcare Providers

Ninety-six percent of participants stated it was always or occasionally difficult to diagnose fibromyalgia, and 98% of participants stated fibromyalgia was always or occasionally misdiagnosed. Only 54% of providers were completely or mostly confident in their ability to recognize symptoms of fibromyalgia and only 32% were mostly confident differentiating fibromyalgia from other conditions with similar symptoms.

Fibromyalgia is a chronic pain disorder affecting approximately 2% to 4% of adults in the United States, and more than 5% of patients in general medical practice.1-3 The predominant symptom of fibromyalgia is chronic widespread musculoskeletal pain.1 Patients with fibromyalgia often present with additional symptoms, including sleep disturbance, fatigue, morning stiffness, paresthesias, headaches, and exercise intolerance.1,3 The symptoms of fibromyalgia can be prolonged and debilitating, and contribute to increased healthcare utilization and costs.1,4

Multiple published reports are available describing the results of surveys to assess physicians’ awareness and knowledge of fibromyalgia.5-9 Several of the projects surveyed rheumatologists from foreign countries5,6 or a combination of rheumatologists and general practitioners.7 A detailed questionnaire on fibromyalgia was completed by 172 family physicians in Israel.8 More recently, 1,622 physicians from an international study completed a survey conducted to outline descriptive data on fibromyalgia.9

Limited information is available describing similar physician surveys reviewing fibromyalgia in the United States. The National Fibromyalgia Association (NFA) commissioned an Internet-based survey of 557 physicians in 2007, including 101 primary care physicians.10 Recognizing an increasing focus on fibromyalgia and a developing need for information, we conducted a survey of providers, primarily from Vermont, with the goal of evaluating their awareness and treatment of fibromyalgia.

Methods
Study Design and Sample
Healthcare providers who attended an educational program in Vermont for family physicians and other primary care providers conducted in 2009 and 2010 were invited to participate. The annual program was sponsored by the University of Vermont (UVM), College of Medicine, and reviewed contemporary issues in the practice of family medicine. In addition, members from the Vermont Nurse Practitioners Association (VNPA), and physicians from a large medical practice in Western Massachusetts, were also invited to participate.

Using a convenience sample, a cross-sectional survey was administered to healthcare providers who were attending one of the educational programs, were members of the VNPA, or practiced at the targeted medical clinic. There were no exclusion criteria. Participation was voluntary and the healthcare providers were not compensated for their time. Participants were instructed to only complete the survey once. This study was granted exempt status by UVM’s Committees on Human Subjects Research.

Survey Instrument
The two-page written questionnaire was developed based on published reports previously conducted using surveys to review physicians’ attitudes and practices related to fibromyalgia.6,9,11 Prior to implementation, the survey was pretested for clarity by a small number of providers. The survey asked questions about providers’ demographics, training, awareness, and treatment practices associated with fibromyalgia. The estimated time to complete the survey was fewer than 15 minutes. The survey was designed as a scannable form, requiring the participant to shade an oval for the desired response or, for a limited number of questions, provide a numerical value. The survey did not contain any protected health information and was devoid of any unique identifiers.

Data Analysis
Descriptive statistics were used, when appropriate, to describe the data. As this was exploratory research without an a priori hypothesis, we did not account for multiple comparisons.

Results
A total of 133 prescribers completed the survey. The estimated response rate based on the number of participants attending the programs was 30%. Participants’ demographic information is shown in Table 1. The participants’ mean age was 49.5 years (SD+/-11.1) with a mean of 17.1 years (SD+/-11.3) in practice. Participants displayed a wide range in the number of patients treated with fibromyalgia; 0-200, median 10 patients.

Fibromyalgia Training
Information related to fibromyalgia was received by 66 participants (49.6%) during their professional training, with 52 (39.1%) attending an educational program on fibromyalgia during the previous 2 years. Self-education on fibromyalgia within the previous 2 years was noted by 105 providers (78.9%), and 98 (73.7%) stated they needed more information about the condition. Additional information was requested by 28 nurse practitioners (NPs) (87.5%), 13 physician assistants (PAs) (81.3%), and 54 physicians (66.7%).

Fibromyalgia Awareness
Fibromyalgia was considered a clinical condition by 104 providers (78.2%); 28 NPs (87.5%), 13 PAs (81.3%), and 54 physicians (66.7%). Fibromyalgia was considered both a medical and psychological condition by 107 providers (80.5%). Seventy six (57.1%) of the participants were aware of the 1990 American College of Rheumatology (ACR) criteria for fibromyalgia, including 16 NPs (50%), 8 PAs (50%), and 52 physicians (64.2%).12 Of the providers aware of the criteria, 45 (59.2%) regularly used the guidelines. Additional responses to questions related to fibromyalgia awareness are described in Table 2.

Fibromyalgia Treatment
Forty three (32.8%) out of 131 participants stated they were completely or mostly confident in their ability to treat fibromyalgia. A total of 106 providers (79.7%) prescribed medications to treat fibromyalgia. The medication classes prescribed are shown in Figure 1. Figure 2 describes the non-drug therapies used to treat fibromyalgia. A quantitative pain scale to evaluate pain associated with fibromyalgia was used by 55 providers (45.1%, n=122); NPs used pain scales most often (53.1%), and physicians (34.8%) the least.

Discussion
The results from this cross-sectional survey describe the awareness and treatment practices related to fibromyalgia for a small sample of healthcare prescribers, and support the common belief that fibromyalgia can be a difficult condition to identify and treat. Ninety six percent of participants stated it was always or occasionally difficult to diagnose fibromyalgia, and 98% of participants stated fibromyalgia was always or occasionally misdiagnosed. Only 54% of providers were completely or mostly confident in their ability to recognize symptoms of fibromyalgia and only 32% were mostly confident differentiating fibromyalgia from other conditions with similar symptoms. These findings are consistent with previous results showing healthcare providers’ lack of confidence in diagnosing fibromyalgia. A survey of 1,622 physicians—including 809 primary care physicians—from six European countries, Mexico, and South Korea, showed that 53% found it very or somewhat difficult to diagnose fibromyalgia.9 Results from a survey of 557 physicians conducted on behalf of the NFA showed that less than one-third of participants, including 28% of primary care physicians, were extremely or very confident in their ability to diagnose fibromyalgia.10 In contrast, the same survey found 87% of rheumatologists were extremely or very confident in their ability to diagnose the condition. 

The general unawareness and regular use of available classification criteria may have contributed to the participants’ stated difficulty in diagnosing fibromyalgia. Forty three percent of the participants were not aware of the 1990 ACR criteria for fibromyalgia, and only 59% of the providers who were aware of the criteria regularly used them.12 This finding was very similar to results from another survey that found 45% of physicians were not aware of these classification criteria and 26% did not use the criteria in their clinical practice.9 It should be noted that the current survey was conducted prior to the publication of an alternative proposal by the ACR for the diagnosis of fibromyalgia, which does not rely on the use of tender point diagnostic criteria.13

In addition to providers finding the diagnosis of fibromyalgia challenging, only 33% of participants were completely or mostly confident in their ability to treat fibromyalgia. Medications were prescribed by the majority of providers, with tricyclic antidepressants and the non-steroidal anti-inflammatory drugs being the most commonly prescribed drug classes. A variety of non-drug therapies were also prescribed, with exercise and physical therapy being the most common. The variety in treatment selections supports the recommendation of a multimodal and individualized approach to the management of fibromyalgia.14

The lack of confidence of healthcare providers in diagnosing fibromyalgia may explain why the majority requested additional information and education on the management of fibromyalgia. The need for additional knowledge about fibromyalgia was evident, as 74% of providers, particularly NPs and PAs, stated they needed more information; this was further supported by the finding that 79% of providers had educated themselves on fibromyalgia within the previous 2 years. Increasing the knowledge of healthcare providers about fibromyalgia may overcome delay and avoid reluctance to diagnose the condition.9,15

The survey results align with the findings from the NFA, an advocate for increasing the understanding of fibromyalgia among healthcare providers.10 The NFA implemented a national educational campaign intended to increase knowledge of fibromyalgia among patients, healthcare providers, and the public, and is working on a number of efforts to help bring a better understanding of fibromyalgia to healthcare providers.10,15 The results from the current survey provide the basis for advancing local educational programs and alternative approaches to assist in increasing healthcare provider awareness of fibromyalgia to support the timely diagnosis and management of this disease state.

Limitations
Although the results offer insight into practice patterns related to the management of fibromyalgia, they should be interpreted with the knowledge that our survey has several limitations. The survey required self-reported responses and the questionnaire used has not been validated. The number of participants represents only a small portion of the total providers from each profession within the state, and thus may not accurately reflect general practice patterns or be extrapolated to other geographic areas. The participants were not randomly selected and may represent a group of motivated providers, thus introducing a possible selection bias. There was no provision for interviewing non-participants; thus, we do not know if their practice patterns were different from those of survey participants. Understanding the limitations of this survey provides helpful information and the basis for conducting similar research with a larger sample of healthcare professionals in other regions.

Last updated on: June 19, 2012
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