Economic Evaluations of Acute Pain Service Programs

A Review of Federal and Statewide Guidelines and Their Effects on Orthopedics

In the past three decades, the use of opioids has risen tremendously. Pain was named the "fifth patient vital sign" in the 1990s, and from that point, opioid usage has continued to grow throughout the 2010s leading to its recognition as a crisis. The United States is responsible for 80% of the global opioid usage while only accounting for less than 5% of the global population. Previously opioids were mostly used to treat acute pain, however, opioids have been most recently used to manage chronic pain as well. The opioid crisis has presented new challenges in treating pain while preventing the abuse of these medications in a system that lacks standardization of treatment guidelines across the United States. Therefore, the authors of this review examine the current national recommendations to help manage the ongoing opioid crisis and explore how they may impact orthopedic patient care.

Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain

Patients with severe burn injuries often require split-thickness skin grafting to expedite wound healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Peripheral nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. The purpose of this case series is to assess the safety, feasibility, and clinical efficacy of a recently demonstrated novel continuous LAM (lateral, anterior, medial) femoral cutaneous block technique in a larger cohort. The study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 and May 2021 who had the continuous LAM block performed for donor site pain by the acute pain service team. Demographics were reported with descriptive statistics and morphine milligram equivalents (MME) were analyzed via Friedman analysis of variance. Forty-seven patients had a total of 53 blocks placed, where 2 patients received the LAM block on two separate occasions and 4 patients had bilateral LAM blocks placed. Most were African-American males, but mechanism of injury varied. Over half had a neurologic (17%) or psychiatric history (34%) outside of substance use. Almost three-quarters had a history of substance use with 17% being opioids, and a quarter had a history of polysubstance use. Median day from admission to LAM was 7 (2.5, 11.5) with a median duration of 4 (3, 5) days. Temperature and pressure sensation were reduced at the donor site. Quadricep strength remained intact, and median day until first ambulation after LAM placement was 2 (1, 3) days. Pain was adequately controlled, and there were no significant adverse events associated with the block. There was a significant reduction in MME after block placement (p < .001). Continuous peripheral nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids or multimodal regimens. The novel LAM technique reduced sensation and pain without inhibiting early ambulation, and patients were able to fully participate in their rehabilitation.

An Observational Study to Assess Postoperative Pain Control and Formulate a Comprehensive Approach to the Implementation of Policy Change for Pain Control in Postoperative Units

Background Postoperative pain control irrespective of the magnitude of surgery has always remained a challenge for clinicians and healthcare workers. Good postoperative pain control is pivotal for unremarkable recovery and shorter hospital stays. Unfortunately, there is no uniform approach across the globe to address postoperative pain control. This provoked our thought to conduct a prospective observational study in our center to assess the already existing efficacy of pain management. Materials and methods This is a prospective observational study conducted in a tertiary care center in Coimbatore, India. The aim of this study is to assess the efficacy of an ongoing pain management system to compare it with standards in the literature to introduce changes and re-examine the results. A total of 100 patients who underwent major surgical procedures from various specialities were included after satisfying the inclusion criteria. The study was conducted over a period of four months to collect data from patients in the postoperative ward. Data were collected, pain-related variables were tabulated, and deficits were identified. Standardized pain assessment tools were not used. The results suggested the need for a policy change for quality improvement. This article gives reports on initial study results and plans to address the deficits in the current pain management system. A systematic and schematic approach for the implementation of the policy change and the framework for the new acute pain service team aiming at quality improvement have been discussed in detail. Results The results show that 28 patients were prescribed only routine paracetamol and rescue nonsteroidal anti-inflammatory drugs (NSAIDs). At rest, 56 patients had some pain, and 29 complained of moderate to severe pain. On movement, only seven patients had no pain, 48 had mild pain, and 45 had moderate to severe pain. Only 12 patients out of 100 had good sleep, 27 had moderate, and 43 had little sleep. Twelve patients had no sleep due to continuous ongoing pain in spite of ongoing pain control modalities. Sixteen patients complained of undue delay in receiving their analgesics. Twenty-two patients were dissatisfied, and 44 suggested the need for improvement of current pain control strategies. These data clearly suggest that the pain control strategies are inadequate and need improvement undoubtedly for quality improvement. The Wendy Hirsch model is chosen to create a framework for implementing a new change, and a detailed report is done to present to the hospital quality control department. These changes will be done after the approval, and a post-implementation outcome will be studied. Conclusion Good postoperative pain control is of paramount significance for both patients and healthcare professionals. With the current availability of various pain relief modalities, one should consider establishing a pain control pathway, if possible an acute pain team with a systematic approach. These measures not only improve patient satisfaction but also improve postoperative outcomes and better ways of utilizing healthcare resources.

The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis

Background

Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA).

Material and methods

This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0–10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management.

Results

Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st–3rd quartile: 6 (3.75–8) vs. 5 (3–7), p = 0.023; maximum pain intensity: 7 (5–9) vs. 5 (3–8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47–154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = −2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = −1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management.

Conclusion

In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps

Objective

In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below.

Setting

Expert commentary.

Methods

Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management.

Conclusions

Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

Economic analysis of implementing virtual reality therapy for pain among hospitalized patients

Virtual reality (VR) has emerged as a novel and effective non-pharmacologic therapy for pain, and there is growing interest to use VR in the acute hospital setting. We sought to explore the cost and effectiveness thresholds VR therapy must meet to be cost-saving as an inpatient pain management program. The result is a framework for hospital administrators to evaluate the return on investment of implementing inpatient VR programs of varying effectiveness and cost. Utilizing decision analysis software, we compared adjuvant VR therapy for pain management vs. usual care among hospitalized patients. In the VR strategy, we analyzed potential cost-savings from reductions in opioid utilization and hospital length of stay (LOS), as well as increased reimbursements from higher patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The average overall hospitalization cost-savings per patient for the VR program vs. usual care was $5.39 (95% confidence interval –$11.00 to $156.17). In a probabilistic sensitivity analysis across 1000 hypothetical hospitals of varying size and staffing, VR remained cost-saving in 89.2% of trials. The VR program was cost-saving so long as it reduced LOS by ≥14.6%; the model was not sensitive to differences in opioid use or HCAHPS. We conclude that inpatient VR therapy may be cost-saving for a hospital system primarily if it reduces LOS. In isolation, cost-savings from reductions in opioid utilization and increased HCAHPS-related reimbursements are not sufficient to overcome the costs of VR.

Implementing virtual reality (VR) programs for inpatient pain management can potentially save hospitals money. Recent studies have highlighted VR as an effective alternative to traditional opioid treatments for the management of pain. Brennan Spiegel, at Cedars-Sinai Medical Center in Los Angeles, and colleagues carried out an economic analysis to determine the cost implications of implementing inpatient VR therapy programs for acute pain management in different US hospital settings. They found that such programs are cost-saving when they reduce patients’ length of stay in the hospital. However, the projected costs for inpatient VR programs are higher than the savings that can be made from decreases in opioid use or additional income from Hospital Consumer Assessment of Healthcare Providers and Systems-related reimbursements through increased patient satisfaction alone.

Comprehensive Acute Pain Management in the Perioperative Surgical Home

The careful coordination of care throughout the perioperative continuum offered by the perioperative surgical home (PSH) is important in the treatment of postoperative pain. Physician anesthesiologists have expertise in acute pain management, pharmacology, and regional and neuraxial anesthetic techniques, making them ideal leaders for managing perioperative analgesia within the PSH. Severe postoperative pain is one of many patient- and surgery-specific factors in the development of chronic postsurgical pain. Delivering adequate perioperative analgesia is important to avoid this development, to decrease perioperative morbidity, and to improve patient satisfaction.

Cost Savings from Reducing Pain Through the Delivery of Integrative Medicine Program to Hospitalized Patients

OBJECTIVES

An important task facing hospitals is improving pain management without raising costs. Integrative medicine (IM), a promising nonpharmacologic pain management strategy, is yet to be examined for its cost implications in an inpatient setting. This institution has had an inpatient IM department for over a decade. The purpose was to examine the relationship between changes in patients' pain, as a result of receiving IM therapy, and total cost of care during an inpatient hospital admission.

DESIGN

In this retrospective analysis, data from an EPIC-based electronic health record (EHR) patient demographics, length of stay (LOS), and All Patient Refined Diagnosis Related Groups (APR-DRG) severity of illness measures were utilized. IM practitioners collected and entered patient-reported pain scores into the EHR. The authors regressed the demographic, change in pain, LOS, and APR-DRG variables with changes in pain on total cost for the hospital admission. To estimate cost savings to the hospital, they computed the average reduction in cost associated with reduction in pain by multiplying the coefficient for change in pain by average total cost.

SETTING/LOCATION

A large, tertiary care hospital in Minneapolis, MN.

SUBJECTS

Adult inpatient admissions, 2730, during the study period where patients received IM for pain and met eligibility criteria.

INTERVENTION

IM services provided to inpatients.

OUTCOME MEASURES

Change in pain on an 11-point numeric rating scale before and after initial IM sessions; total costs for hospital admissions.

RESULTS

Both LOS and age were found to increase cost, as did being white, male, married, and having APR-DRG severity coded as extreme. For patients receiving IM therapies, pain was reduced by an average of 2.05 points and this pain reduction was associated with a cost savings of $898 per hospital admission.

CONCLUSIONS

For patients receiving IM therapies, pain was significantly reduced and costs were lowered by about 4%.

Economic Considerations of Acute Pain Medicine Programs

Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.

[Acute pain therapy in German hospitals as competitive factor. Do competition, ownership and case severity influence the practice of acute pain therapy?]

BACKGROUND

Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management.

MATERIAL AND METHODS

A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin).

RESULTS

For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI.

CONCLUSION

In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

Clinical benefits, referral practice and cost implications of an in-hospital pain service: results of a service evaluation in a London teaching hospital

BACKGROUND

In-hospital pain services (IPS) are commonplace, but evidence of efficacy is inadequate, and patients' pain management in any hospital ward remains problematic. This service evaluation aimed to measure the effect of a contemporary IPS, its appropriate use and cost-efficacy.

METHODS

Records of 249 adults reviewed by the IPS in an inner London Teaching Hospital over an 8-month period were analysed for demographic data, interventions, workload and change in pain intensity measured by numerical rating scale (NRS). Non-parametric tests were used to evaluate differences between initial and final NRS. Spearman's rank correlation analysis was used to create a correlation matrix to evaluate associations between all identified independent variables with the change in NRS. All strongly correlated variables (ρ > 0.5) were subsequently included in a binary logistic regression analysis to identify predictors of pain resolution greater than 50% NRS and improvement rather than deterioration or no change in NRS. Finally, referral practice and cost of inappropriate referrals were estimated. Referrals were thought to be inappropriate when pain was not optimised by the referring team; they were identified using a set algorithm.

RESULTS

Initial median NRS and final median NRS were significantly different when a Wilcoxon signed-rank test was applied to the whole cohort; Z = -5.5 (p = 0.000). Subgroup analysis demonstrated no significant difference in the 'mild' pain group; z = -1.1 (p = 0.253). Regression analysis showed that for every unit increase in initial NRS, there was a 62% chance of general and a 33% chance of >50% improvement in final NRS. An estimated annual cost-saving potential of £1546 to £4558 was found in inappropriate referrals and patients experiencing no benefit from the service.

DISCUSSION

Results suggest that patients with moderate to severe pain benefit most from IPS input. Also pain management resources are often distributed inefficiently. Future research is required to develop algorithms for easy identification of potential treatment responders.

Toward Better Pain Management: The Development of a "Pain Stewardship Program" in a Tertiary Children's Hospital

OBJECTIVE

Despite increased focus on pediatric pain, uncontrolled pain is still a problem for hospitalized pediatric inpatients. A program was designed to find patients with uncontrolled pain and develop a framework to oversee their pain management. This report details the development of a pain stewardship program with data from the first year of its activity.

METHODS

Hospitalized inpatients in a tertiary care pediatric center in the mid-Atlantic region were included in the study. Pain scores are recorded every 4 hours in the hospital electronic health record. A report was constructed to find all patients with an average pain score ≥7 in the preceding 12 hours. The charts of these patients were reviewed by our anesthesia pain service, and all patients were grouped into 1 of the following action categories: (1) no action required; (2) telephone call to the patient's attending physician; (3) one-time consultation; (4) consultation with ongoing management; or (5) patient was already on the anesthesia pain service. Demographic data, pain regimens, and outcomes were recorded in a prospectively collected database.

RESULTS

There were 843 records on 441 unique patients. Only 22% required action to be taken by the anesthesia pain service. The pain stewardship database revealed that patients with sickle cell disease or abdominal pain required more frequent attention.

CONCLUSIONS

An electronic health record-based pain stewardship program is an important step in identifying all children in the hospital with undermanaged pain, and it provides a warning system that may improve patient care, outcomes, and satisfaction.

Acute Pain Management/Regional Anesthesia

Effective and efficient acute pain management strategies have the potential to improve medical outcomes, enhance patient satisfaction, and reduce costs. Pain management records are having an increasing influence on patient choice of health care providers and will affect future financial reimbursement. Dedicated acute pain and regional anesthesia services are invaluable in improving acute pain management. In addition, nonpharmacologic and alternative therapies, as well as information technology, should be viewed as complimentary to traditional pharmacologic treatments commonly used in the management of acute pain. The use of innovative technologies to improve acute pain management may be worthwhile for health care institutions.

A follow-up on Acute Pain Services in Germany compared to international survey data

BACKGROUND

After the introduction of instruments for benchmarking, certification and a national guideline for acute pain management, the aim of this study was to describe the current structure, processes and quality of German acute pain services (APS).

METHODS

All directors of German departments of anaesthesiology were invited to complete a postal questionnaire on structures und processes of acute pain management. The survey asked for staff, techniques and quality criteria, which enabled a comparison to previous data from 1999 and surveys from other countries.

RESULTS

Four hundred and eight (46%) questionnaires were returned. APS have increased considerably and are now available in 81% of the hospitals, mainly anaesthesia based. However, only 45% fulfilled the minimum quality criteria, such as the assignment of personnel, the organization of patient care during nights and weekends, written protocols for postoperative pain management, regular assessments and documenting pain scores. Staff resources varied considerably, but increased compared to 1999. Two daily rounds were performed in 71%, either by physicians and nurses (42%), by physicians only (25%) or by supervised nurses (31%). Most personnel assigned to the APS shared this work along with other duties. Only 53% of the hospitals had an integrated rotation for training their specialty trainees.

CONCLUSIONS

The availability of APS in Germany and other countries has increased over the last decade; however, the quality of nearly half of the APS is questionable. Against the disillusioning background of recently reported unfavourable pain-related patient outcomes, the structures, organization and quality of APS should be revisited.

Methodological reviews of economic evaluations in health care: what do they target?

INTRODUCTION AND OBJECTIVES

An increasing number of published studies of economic evaluations of health technologies have been reviewed and summarized with different purposes, among them to facilitate decision-making processes. These reviews have covered different aspects of economic evaluations, using a variety of methodological approaches. The aim of this study is to analyze the methodological characteristics of the reviews of economic evaluations in health care, published during the period 1990-2010, to identify their main features and the potential missing elements. This may help to develop a common procedure for elaborating these kinds of reviews.

METHODS

We performed systematic searches in electronic databases (Scopus, Medline and PubMed) of methodological reviews published in English, period 1990-2010. We selected the articles whose main purpose was to review and assess the methodology applied in the economic evaluation studies. We classified the data according to the study objectives, period of the review, number of reviewed studies, methodological and non-methodological items assessed, medical specialty, type of disease and technology, databases used for the review and their main conclusions. We performed a descriptive statistical analysis and checked how generalizability issues were considered in the reviews.

RESULTS

We identified 76 methodological reviews, 42 published in the period 1990-2001 and 34 during 2002-2010. The items assessed most frequently (by 70% of the reviews) were perspective, type of economic study, uncertainty and discounting. The reviews also described the type of intervention and disease, funding sources, country in which the evaluation took place, type of journal and author's characteristics. Regarding the intertemporal comparison, higher frequencies were found in the second period for two key methodological items: the source of effectiveness data and the models used in the studies. However, the generalizability issues that apparently are creating a growing interest in the economic evaluation literature did not receive as much attention in the reviews of the second period. The remaining items showed similar frequencies in both periods.

CONCLUSIONS

Increasingly more reviews of economic evaluation studies aim to analyze the application of methodological principles, and offer summaries of papers classified by either diseases or health technologies. These reviews are useful for finding literature trends, aims of studies and possible deficiencies in the implementation of methods of specific health interventions. As no significant methodological improvement was clearly detected in the two periods analyzed, it would be convenient to pay more attention to the methodological aspects of the reviews.

Direct cost of connecting, maintaining and disconnecting patient-controlled analgesia pump

Quantitative research that aimed to identify the mean total cost (MTC) of connecting, maintaining and disconnecting patient-controlled analgesia pump (PCA) in the management of pain. The non-probabilistic sample corresponded to the observation of 81 procedures in 17 units of the Central Institute of the Clinics Hospital, Faculty of Medicine, University of Sao Paulo. We calculated the MTC multiplying by the time spent by nurses at a unit cost of direct labor, adding the cost of materials and medications/solutions. The MTC of connecting was R$ 107.91; maintenance R$ 110.55 and disconnecting R$ 4.94. The results found will subsidize discussions about the need to transfer money from the Unified Health System to hospitals units that perform this technique of analgesic therapy and it will contribute to the cost management aimed at making efficient and effective decision-making in the allocation of available resources.

Acute pain medicine in anesthesiology

The American Academy of Pain Medicine and the American Society for Regional Anesthesia have recently focused on the evolving practice of acute pain medicine. There is increasing recognition that the scope and practice of acute pain therapies must extend beyond the subacute pain phase to include pre-pain and pre-intervention risk stratification, resident and fellow education in regional anesthesia and multimodal analgesia, as well as a deeper understanding of the pathophysiologic mechanisms that are integral to the variability observed among individual responses to nociception. Acute pain medicine is also being established as a vital component of successful systems-level acute pain management programs, inpatient cost containment, and patient satisfaction scores. In this review, we discuss the evolution and practice of acute pain medicine and we aim to facilitate further discussion on the evolution and advancement of this field as a subspecialty of anesthesiology.

Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study

STUDY OBJECTIVE

To determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery.

DESIGN

Retrospective analysis of a prospective cohort.

SETTINGS

Operating room, intensive care unit, and Postanesthesia Care Unit of a university hospital.

MEASUREMENTS

Data from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded.

MAIN RESULTS

Patients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99).

CONCLUSIONS

This single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.

The evolution and practice of acute pain medicine

BACKGROUND

In recent years, the field of acute pain medicine (APM) has witnessed a surge in its development, and pain has begun to be recognized not merely as a symptom, but as an actual disease process. This development warrants increased education of residents both in the performance of regional anesthesia as well as in the disease course of acute pain and the biopsychosocial mechanisms that define interindividual variability.

REVIEW SUMMARY

We reviewed the organization and function of the modern APM program. Following a discussion of the nomenclature of acute pain-related practices, we discuss the historical evolution and modern role of APM teams, including the use of traditional, as well as complementary and alternative, therapies for treating acute pain. Staffing and equipment requirements are also evaluated, in addition to the training requirements for achieving expertise in APM. Lastly, we briefly explore future considerations related to the essential role and development of APM.

CONCLUSION

The scope and practice of APM must be expanded to include pre-pain/pre-intervention risk stratification and extended through the phase of subacute pain.

Developing a pediatric pain service

Pediatric pain services were first established in larger pediatric centers over two decades ago. Children's acute pain was poorly managed at the time owing to misconceptions, safety concerns, and variability in practice. While many larger pediatric centers now have acute pain services, there remains a need for better pain management in facilities and geographic locations with fewer resources. Institutional acknowledgement and desire to change, appropriate staffing, and funding are major obstacles. Better recognition and assessment as well safer and more efficacious treatment of pain are the principal objectives when establishing a pain service. It is important to determine whether the proposed service intends to treat acute, chronic, procedural, and/or cancer and palliative pain as each requires different skills and resources. An ideal and comprehensive pediatric pain service should be equipped to diagnose and treat acute, persistent (chronic), procedural, and cancer/palliative pain. It is not feasible or necessary for every hospital to manage all. Establishing the scope of practice (based on case mix and caseload) in any given hospital will determine which resources are desired. Country-specific standards, local staffing, and fiscal constraints will influence which resources are available.

Post-operative pain treatment in Denmark from 2000 to 2009: a nationwide sequential survey on organizational aspects

BACKGROUND

In Denmark, the first acute pain service (APS) was introduced in 1993. An important objective became to facilitate implementation of accelerated post-operative rehabilitation programmes (ACC) in selected procedures in abdominal, gynaecological and orthopaedic surgery. Therefore, it is of considerable interest to study the association between the developments of post-operative pain management and the ACC by sequential analyses from 2000 to 2009.

METHODS

In 2000, 2003, 2006 and 2009, a questionnaire was mailed to all Danish anaesthesiology departments. The headings of the questionnaire were demographics of responder departments, resources allocated to pain management methods, quality assessment methods, research activities and implementation of ACC.

RESULTS

The responder rates varied between 80% and 94% (mean 88%) representing a mean number of anaesthetics of 340.000 per year. The number of APSs in the study period varied in university hospitals between 52% and 71% (P = 0.01), regional hospitals between 8% and 40% (P < 0.01), and local hospitals between 0% and 47% (P < 0.01). The prevalences of departments actively engaged in ACC were 40% in 2000, 54% in 2003, 73% in 2006 and 80% in 2009 (P < 0.01).

CONCLUSIONS

The study, spanning nearly a decade, illustrates that following an increase in number of APSs from 2000 to 2006, followed by a significant decline, a steadily increasing number of departments implemented ACC.

Collaborative quality improvement to manage pain in acute care hospitals

OBJECTIVE

Collaborative quality improvement programs have been successfully used to manage chronic diseases in adults and acute lung complications in premature infants. Their effectiveness to improve pain management in acute care hospitals is currently unknown. The purpose of this study was to determine whether a collaborative quality improvement program implemented at hospital level could improve pain management and overall pain relief.

DESIGN

To assess the effectiveness of the program, we performed a before-after trial comparing patient's self-reported pain management and experience before and after program implementation. We included all adult patients hospitalized for more than 24 hours and discharged either to their home or to a nursing facility, between March 1, 2001 and March 31, 2001 (before program implementation) and between September 15, 2005 and October 15, 2005 (after program implementation).

SETTING

A teaching hospital of 2,096 beds in Geneva, Switzerland.

PATIENTS

All adult patients hospitalized for more than 24 hours and discharged between 1 to 31 March 2001 (before program) and 15 September to 15 October 2005 (after program implementation).

INTERVENTIONS

Implementation of a collaborative quality improvement program using multifaceted interventions (staff education, opinion leaders, patient education, audit, and feedback) to improve pain management at hospital level.

OUTCOME MEASURES

Patient-reported pain experience, pain management, and overall hospital experience based on the Picker Patient Experience questionnaire, perceived health (SF-36 Health survey).

RESULTS

After implementation of the program only 2.3% of the patients reported having no pain relief during their hospital stay (vs 4.5% in 2001, P=0.05). Among nonsurgical patients, improvements were observed for pain assessment (42.3% vs 27.9% of the patients had pain intensity measured with a visual analog scale, P=0.012), pain management (staff did everything they could to help in 78.9% vs 67.9% of cases P=0.003), and pain relief (70.4% vs 57.3% of patients reported full pain relief P=0.008). In surgical patients, pain assessment also improved (53.7.3% vs 37.6%) as well as pain treatment. More patients received treatments to relieve pain regularly or intermittently after program implementation (95.1% vs 91.9% P=0.046).

CONCLUSION

Implementation of a collaborative quality improvement program at hospital level improved both pain management and pain relief in patients. Further studies are needed to determine the overall cost-effectiveness of such programs.

The costs and benefits of extending the role of the acute pain service on clinical outcomes after major elective surgery

BACKGROUND

Acute pain services have received widespread acceptance and formal support from institutions and organizations, but available evidence on their costs and benefits is scarce. Although there is good agreement on the provision of acute pain services after many major surgical procedures, there are other procedures for which the benefits are unclear. Data are required to justify any expansion of acute pain services. In this randomized, controlled clinical trial we compared the costs and effects of acute pain service care on clinical outcomes with conventional pain management on the ward. Patients included in the trial were considered by their anesthesiologist to have either arm be suitable for the procedure.

METHODS

Four hundred twenty-three patients undergoing major elective surgery were randomized either to an anesthesiologist-led, nurse-based acute pain service group with patient-controlled analgesia or to a control group with IM or IV boluses of opioid analgesia. Both groups were treated with medications to treat opioid-related adverse effects and received the usual care from health professionals assigned to the ward. The main outcome measures were quality of recovery scores, pain intensity measures, global measure of treatment effectiveness, and overall pain treatment cost. Cost-effectiveness acceptability curves were drawn to detect a difference in the joint cost-effect relationship between groups.

RESULTS

There was no difference in quality of recovery score on postoperative day 1 between treatment and control groups (mean difference, 0; 95% confidence interval [CI], -0.7 to 0.7; P = 0.94) or in the rate of improvement in quality of recovery score (mean difference, -0.1; 95% CI, -0.4 to 0.1; P = 0.34). The proportion of patients with 1 or more days of highly effective pain management was higher in the acute pain service group than in the control group (86% vs. 75%; P < 0.01). Costs were higher in the acute pain service group (mean difference, US$46; 95% CI, $44 to $48 per patient; P < 0.001). A cost-effectiveness acceptability curve showed that the acute pain service was more cost effective than was control for providing highly effective pain management if the decision maker was willing to pay more than US$546 per patient per 1 day with highly effective treatment.

CONCLUSION

In extending the role of the acute pain service to a specific group of major surgical procedures, the acute pain service was likely to be cost effective.

Patient perception of pain care in hospitals in the United States

STUDY OBJECTIVE

Assessment of patients' perception of pain control in hospitals in the United States.

BACKGROUND

Limited data are available regarding the quality of pain care in the hospitalized patient. This is particularly valid for data that allow for comparison of pain outcomes from one hospital to another. Such data are critical for numerous reasons, including allowing patients and policy-makers to make data-driven decisions, and to guide hospitals in their efforts to improve pain care. The Hospital Quality Alliance was recently created by federal policy makers and private organizations in conjunction with the Centers for Medicare and Medicare Services to conduct patient surveys to evaluate their experience including pain control during their hospitalization.

METHODS

In March 2008, the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was released for review for health care providers and researchers. This survey includes a battery of questions for patients upon discharge from the hospital including pain-related questions and patient satisfaction that provide valuable data regarding pain care nationwide. This study will review the results from the pain questions from this available data set and evaluate the performance of these hospitals in pain care in relationship to patient satisfaction. Furthermore, this analysis will be providing valuable information on how hospital size, geographic location and practice setting may play a role in pain care in US hospitals.

RESULTS

The data indicates that 63% of patients gave a high rating of global satisfaction for their care, and that an additional 26% of patients felt that they had a moderate level of global satisfaction with the global quality of their care. When correlated to satisfaction with pain control, the relationship with global satisfaction and "always" receiving good pain control was highly correlated (r >0.84). In respect to the other HCAHPS components, we found that the patient and health care staff relationship with the patient is also highly correlated with pain relief (r >0.85). The patients' reported level of pain relief was significantly different based upon hospital ownership, with government owned hospitals receiving the highest pain relief, followed by nonprofit hospitals, and lastly proprietary hospitals. Hospital care acuity also had an impact on the patient's perception of their pain care; patients cared for in acute care hospitals had lower levels of satisfaction than critical access hospitals.

CONCLUSIONS

The results of this study are a representation of the experiences of patients in US hospitals with regard to pain care specifically and the need for improved methods of treating and evaluating pain care. This study provides the evidence needed for hospitals to make pain care a priority in to achieve patient satisfaction throughout the duration of their hospitalization. Furthermore, future research should be developed to make strategies for institutions and policy-makers to improve and optimize patient satisfaction with pain care.