Management of chronic pain in Italy: proposal for specific priority criteria.

General practitioners often request specialist consultations to manage their patients affected by chronic pain, but in Italy wait times for the consultations are usually very long. For this reason, The Friuli Venezia Giulia region is the first Italian region to start using priority criteria for access to consultation with a pain specialist (brief within 10 days, delayed within 30 days, scheduled within 180 days).

Systematic Review of Multidisciplinary Chronic Pain Treatment Facilities.

This study reviewed the published literature evaluating multidisciplinary chronic pain treatment facilities to provide an overview of their availability, caseload, wait times, and facility characteristics. A systematic literature review was conducted using PRISMA guidelines following a search of MEDLINE, PsycINFO, and CINAHL databases. Inclusion criteria stipulated that studies be original research, survey more than one pain treatment facility directly, and describe a range of available treatments. Fourteen articles satisfied inclusion criteria. Results showed little consistency in the research design used to describe pain treatment facilities. Availability of pain treatment facilities was scarce and the reported caseloads and wait times were generally high. A wide range of medical, physical, and psychological pain treatments were available. Most studies reported findings on the percentage of practitioners in different health care professions employed. Future studies should consider using more comprehensive search strategies to survey facilities, improving clarity on what is considered to be a pain treatment facility, and reporting on a consistent set of variables to provide a clear summary of the status of pain treatment facilities. This review highlights important information for policymakers on the scope, demand, and accessibility of pain treatment facilities.

An analysis of multidisciplinary staffing levels and clinical activity in Australian tertiary persistent pain services.

OBJECTIVE: To document staffing (medical, nursing, allied health [AH], administrative) in Australian multidisciplinary persistent pain services and relate them to clinical activity levels. METHODS: Of the 68 adult outpatient persistent pain services approached (Dec'08-Jan'10), 45 agreed to participate, received over 100 referrals/year, and met the contemporaneous International Association for the Study of Pain criteria for Level 1 or 2 multidisciplinary services. Structured interviews with Clinical Directors collected quantitative data regarding staff resources (disciplines, amount), services provided, funding models, and activity levels. RESULTS: Compared with Level 2 clinics, Level 1 centers reported higher annual demand (referrals), clinical activity (patient numbers) and absolute numbers of medical, nursing and administrative staff, but comparable numbers of AH staff. When staffing was assessed against activity levels, medical and nursing resources were consistent across services, but Level 1 clinics had relatively fewer AH and administrative staff. Metropolitan and rural services reported comparable activity levels and discipline-specific staff ratios (except occupational therapy). The mean annual AH staffing for pain management group programs was 0.03 full-time equivalent staff per patient. CONCLUSIONS: Reasonable consistency was demonstrated in the range and mix of most disciplines employed, suggesting they represented workable clinical structures. The greater number of medical and nursing staff within Level 1 clinics may indicate a lower multidisciplinary focus, but this needs further exploration. As the first multidisciplinary staffing data for persistent pain clinics, this provides critical information for designing and implementing clinical services. Mapping against clinical outcomes to demonstrate the impact of staffing patterns on safe and efficacious treatment delivery is required.

Influence of parental occupation on access to specialised treatment for paediatric chronic pain: a retrospective study.

BACKGROUND: The purpose of this study was to determine patients' travel distances to a tertiary paediatric pain clinic and to analyse the association between travel distance and the parents' occupational skill level and the patients' pain characteristics. PATIENTS AND METHODS: The retrospective study consisted of 2,248 children assessed at the first evaluation. All children (0-20 years) who visited the clinic during a 5-year period (2005-2010) were enrolled in this study. RESULTS: The mean travel distance was 81 km, and the 80 % catchment area was 109 km. Children of parents with a high occupational skill level had a 1.5-fold higher probability of travelling from outside the catchment area. The 80 % catchment area increased constantly with increasing occupational skill level. Additional significant factors for greater distance travelled were high impairment, musculoskeletal pain, long pain duration and a high number of previous physician contacts. CONCLUSION: The association between travel distance and parental occupational skill level suggests that there is social injustice due to access barriers based on socioeconomic deprivation and education. An increase in the number of health care facilities for chronic pain in children would be a first step in rectifying this injustice.

[Specialized pain care in Germany]. / Spezialisierte Schmerzversorgung in Deutschland.

BACKGROUND: In order to characterize the pain care situation in Germany, a health technology assessment (HTA) was carried out on behalf of the German Institute for Medical Documentation and Information (DIMDI). METHODS: An up to date literature search was conducted using the database Pubmed. Reviews and studies which describe the pain care in Germany were included. The Physicians' Health Insurance Associations conducted an additional database survey. RESULTS: Overall 12 studies were included and the results of the analysis showed that there is a lack of some 2,500 curative pain care institutions in Germany. There is also clear under use of inpatient and outpatient institutions in palliative care. The results prove the benefits of the interdisciplinary approach in pain care. DISCUSSION: Further development should strive to increase the provision of pain and palliative care. There is a great need for pain care research in order to concrete the needs.

Introducing interventional pain services in a large african teaching hospital: challenges and opportunities.

There is a need for interventional pain management in the developing world; however, there are many barriers to the introduction of interventional pain therapies. This brief report describes one approach to the introduction of interventional pain medicine to a Nigerian teaching hospital. Although many barriers exist, interventional pain medicine can be brought to the developing world, as demonstrated in this case series.

[Chronic pain. Overview of out-patient pain treatment in Austria]. / Chronischer Schmerz. Überblick über die ambulante Schmerzversorgung in Österreich.

BACKGROUND: Chronic pain is a widespread social problem. This paper reports on the care situation for patients with chronic pain in out-patient community settings in Austria. MATERIALS AND METHODS: The study took the form of a telephone survey together with internet research. Every second out-patient pain service (from a total of 83) was contacted and 21 out of 42 agreed to participate. RESULTS: The number of community-based physicians with a certificate in pain therapy as well as the number of out-patient pain services showed considerable regional variation. Partial or full interdisciplinary teams are a feature of approximately 50% of out-patient pain units and 76% of such services use guidelines according to their own estimation. Pain perception tends to be measured using pain rating scales rather than pain questionnaires. A wide range of treatments is offered either directly or via referral. CONCLUSIONS: Quality criteria relating to the structure of care established by the Austrian Society for Pain have only been partially implemented. Potential for improvement exists particularly with regards to the prevalence of pain-specific training, interdisciplinary teamwork and the measurement of outcomes.

Bilbao cuenta con la primera clínica especializada en el tratamiento multidisciplinar del dolor crónico / No disponible

No disponible

Mejora de la calidad asistencial a los pacientes de la unidad de dolor torácico de un hospital comarcal / Improvement in health care quality for patients from the thoracic/chest pain unit in a regional hospital

Objetivos. Evaluar un ciclo de mejora en pacientes con dolor torácico en urgencias hospitalarias, especialmente los que se benefician de la realización de test de isquemia precoz en nuestro entorno. Material y métodos. Se diseñó un protocolo de atención por grupo multidisciplinario que identifica oportunidades de mejora y prioriza abordar que «la realización de test de isquemia de forma precoz era menor que lo recomendado». Se analizan las causas (diagrama de Ishikawa) y se definen seis criterios de calidad. Se evaluaron estos en una muestra aleatoria de 30 pacientes del total a los que se realizó ergometría en el hospital en el primer semestre de 2007 (n=180) y con encuesta a facultativos. Se introdujeron medidas correctivas: difusión, accesibilidad en intranet, información explícita a nuevos facultativos. La segunda evaluación se realizó durante el primer semestre de 2008 en otra muestra similar de 30 pacientes (n=120). Resultados. En la primera evaluación la clasificación de riesgo según protocolo fue muy baja (incumplimiento del 100%) y se derivaba a consultas de cardiología a pacientes subsidiarios de ingreso en la unidad de dolor torácico y test de isquemia precoz (incumplimiento del criterio del 74%). Tras medidas correctivas, se obtiene una mejora general, pero muy significativa en los anteriores, reduciendo incumplimientos al 17% en clasificación y el 23% en derivaciones. Conclusiones. El ciclo estructurado ha facilitado la solución del problema priorizado en un plazo corto. Las medidas adoptadas han sido fundamentalmente organizativas, dependientes de los profesionales y con coste muy bajo. Enfoques sencillos pero con metodología ordenada deben valorarse antes de la incorporación de tecnologías de mayor coste(AU)

Objectives. The evaluation of an improvement cycle in patients suffering thoracic/chest pain in hospital emergencies, especially in those who could benefit from the early Bruce Treadmill Test. Material and methods. A multidisciplinary group care protocol was designed, which identified improvement opportunities and gave priority to the fact that «an early Bruce Treadmill Test was carried out on fewer occasions than recommended». Causes were analysed (Ishikawa diagram) and six quality criteria were defined. These criteria were evaluated in a random sample of 30 patients out of the total of 180 who used the ergometer at the Hospital in the first six months of 2007, as well as questionnaire for the doctors. Corrective measures were introduced: circulation, accessibility through intranet and explicit information for new employees (doctors). The second evaluation was carried out during the first six-months of 2008 using another random sample of 30 patients from a total of 120. Results. In the first evaluation, the classification of the risk according to the protocol was very low (100% non-compliance) and patients whose admission to the Chest Pain Unit was recommended and an early Bruce Treadmill Test (74% criteria failure) were referred to cardiology clinics. After implementation of the corrective measures, we obtain a general improvement in all the criteria, but very significant from the previous ones, with non-compliances being reduced to 17% in classification and to the 23% in referrals. Conclusions. The structured cycle has helped resolve the priority problem in the short-term. The adopted measures have mainly been organisational, dependent on the professionals involved, and at a very low cost. Simple but organised methodological approaches should be taken into account before the incorporation of higher cost technologies(AU)

[Structure of outpatient pain therapy in Germany. Results of a survey]. / Struktur der ambulanten Schmerztherapie in Deutschland. Ergebnisse einer Umfrage.

Every physician should be able to treat pain regardless of the specialty, but patients with a risk of chronification or chronic pain should receive care from specialized physicians and non-medical professionals. Specialized pain treatment is an additional qualification in Germany, which may be achieved in different specialties by defined structure criteria and experience. The German Society for the Study of Pain and the Professional Association of the German Society of Anesthetists conducted a survey on specialized outpatient pain treatment settings in Germany, encompassing personal and technical equipment, procedures and interdisciplinary multi-professional cooperation. The survey showed a clear increase in the number of pain treatment settings compared to previous surveys, but with a huge span from small single practice or outpatient services at hospitals to large specialized hospitals. However, the quality criteria suggested by the pain treatment societies were not always met. Treatment options for patients with a risk of chronification and chronic pain show regional variations and are insufficiently developed.

Challenges in accessing multidisciplinary pain treatment facilities in Canada.

PURPOSE: The objective of this survey was to examine the services offered by multidisciplinary pain treatment facilities (MPTFs) across Canada and to compare access to care at these MPTFs. METHODS: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain, having a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital and rehabilitation centre administrators in Canada, the Insurance Bureau of Canada, the Workplace Safety and Insurance Board or similar body in each province. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list for each province. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire regarding their MPTF infrastructure, clinical, research, teaching and administrative activities. RESULTS: Completed survey forms were received from 102 MPTFs (response rate 85%) with 80% concentrated in major cities, and none in Prince Edward Island and the Territories. The MPTFs offer a wide variety of treatments including non-pharmacological modalities such as interventional, physical and psychological therapy. The median wait time for a first appointment in public MPTFs is six months, which is approximately 12 times longer than non-public MPTFs. Eighteen pain fellowship programs exist in Canadian MPTFs and 64% engage in some form of research activities CONCLUSION: Canadian MPTFs are unable to meet clinical demands of patients suffering from chronic pain, both in terms of regional accessibility and reasonable wait time for patients' first appointment.

Dedicated multidisciplinary pain management centres for children in Canada: the current status.

PURPOSE: The objective of this study was to examine the services currently offered by multidisciplinary pain treatment facilities (MPTFs) dedicated for pediatric chronic pain management across Canada. METHODS: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of chronic pain and had a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method was previously described in an accompanying article. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list in their respective provinces. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire on their infrastructure, clinical, research, teaching and administrative activities. Only MPTFs dedicated to pediatric populations were included. RESULTS: Only five centres surveyed had dedicated pediatric MPTFs, all located in major cities in five different provinces. While the median wait time was four weeks, it could be as long as nine months in one MPTF. Headache and neuropathic pain were the most commonly treated pain syndromes. All MPTFs included physicians, nurses and psychologists, and used a rehabilitation model that incorporated a wide variety of pharmacological, psychological and physical therapies. All centres provided training for medical and other healthcare professionals, and three of the five centres conducted research. Government funding was the major source of funding for patient services and overhead costs. CONCLUSIONS: There are very few pediatric MPTFs in Canada. These facilities exist in five of ten provinces, each within large urban centres. Limited accessibility leads to variable and prolonged wait times for pediatric patients suffering from chronic pain.

U.S. board-certified pain physician practices: uniformity and census data of their locations.

UNLABELLED: We determined the profiles of the board-certified pain physician workforce and the profiles of those residing near medical pain practices. Data from a mail survey of U.S. pain specialists were compared with U.S. Census data, and different settings and types of practices were contrasted. The 750 respondents (32.1%) were similar to the entire board-certified group in age, geographic distribution, and primary specialty. Although pain practices were underrepresented in rural areas, their prevalence was unrelated to other demographic data. Ninety-six percent of pain physicians treated chronic pain; 84% followed patients longitudinally; 31% worked in an academic environment; 50% had an interdisciplinary practice; and 29% focused on a single modality. Academics were more likely to be neurologists (P < .05) and to have had a pain fellowship (P < or = .0001). Modality-oriented practitioners were more likely to be anesthesiologists (P < or = .0001) and were less likely to follow patients with chronic pain longitudinally (P < or = .0001), provide training to fellows, prescribe controlled substances (P < or = .0001, respectively), or require an opioid contract (P < or = .01). Although boarded specialists learn from similar curricula and must pass a certifying examination, their practices vary considerably. Data are needed to further clarify the nature of workforce variation, its impact on patient care, and the role of other pain management clinicians. PERSPECTIVE: A survey of board-certified pain specialists reveals considerable variation in practice and a total number of specialists that is probably insufficient to meet the needs of the population with chronic pain. The location of pain management practices largely corresponds to census data, with the exception of underrepresentation in rural areas.

Vertebroplastía percutánea en el manejo del dolor de las fracturas vertebrales por compresión / Percutaneous cement vertebral augmentation in vertebral compression fractures: an update

Las fracturas vertebrales por compresión son de alta prevalencia y se relacionan principalmente a osteoporosis y cáncer. Frecuentemente tienen consecuencias devastadoras en la calidad de vida de los pacientes. Aquellos pacientes que no responden al tratamiento conservador se pueden beneficiar de una técnica mínimamente invasiva, la vertebroplastía, para reforzar la vértebra fracturada con cemento y así controlar el dolor. La vertebroplastía es un procedimiento ambulatorio con baja tasa de efectos colaterales cuando la realiza un médico con experiencia y el entrenamiento adecuado. Su tasa de éxito va del 65 al 95 por ciento, dependiendo de la indicación. Sólida evidencia científica se requiere aún para apoyar su amplio uso clínico.

Vertebral compression fractures are highly prevalent. Osteoporosis and cancer are the main causes. As a consequence patients endure excruciating breakthrough pain and debilitating experience that affect their quality of life. Those individuals that do not respond to classic treatment might benefit of vertebral cement augmentation. This is a totally ambulatory procedure aimed to control pain and stabilize the bone. Percutaneous approach is usually undertaken. Long lasting pain relief results in 65 to 95 percent of patients with a very low profile of complications when the procedure is done by experienced practitioners. Randomized, blinded and prospective studies are still required.

[Descriptive analysis of chronic pain clinics operating in Spain in 2001]. / Análisis descriptivo en el año 2001 de las Unidades de Tratamiento del Dolor Crónico en España.

OBJECTIVES: To describe the characteristics and care approaches to care of chronic pain clinics operating in Spain in 2001. DESIGN: Cross-sectional mail survey of pain clinics in Spain. SETTING: Chronic pain clinics in Spain. STATISTICAL ANALYSIS: Descriptive statistics of pain clinics responding to the questionnaire. RESULTS: Fifty-six of the 79 pain clinics (70.8%) responded; 57.1% were in public facilities, 55.4% were affiliated with medical schools, and 53.6% were interdisciplinary units. Both acute and chronic pain were treated by 72.4% of the respondents. Anesthesiology departments supervised 89.3% of the clinics. Only 57.1% had staff permanently assigned to the pain clinic. A mean 2194 (SD 2041) visits by patients were received annually. The most commonly applied treatments were drugs, blocks, spinal techniques, and transcutaneous electrical nerve stimulation. Implantable systems were more frequently used in chronic pain clinics than in mixed pain clinics, and in university-affiliated clinics than in non-teaching facilities (P=0.03 in both comparisons). A psychological approach was used more often in interdisciplinary clinics than in units operated by staff from a single specialty (P<0.01). CONCLUSIONS: Chronic pain clinics were not evenly distributed throughout Spain. The number of patients treated at pain clinics was high. The various characteristics of pain clinics--such as funding source, interdisciplinarity, university affiliation, and specialization in chronic pain--a were factors that affected the use of certain treatments.

Análisis descriptivo en el año 2001 de las Unidades de Tratamiento del Dolor Crónico en España / Descriptive analysis of chronic pain clinics operating in Spain in 2001

OBJETIVO: Descripción de las características y actividad asistencial de las Unidades de Dolor Crónico (UDC)de España durante el año 2001.DISEÑO: Estudio transversal basado en una encuesta por correo realizada a las UDC españolas. UNIDAD DE ESTUDIO: UDC españolas. ANÁLISIS: Análisis descriptivo de las UDC que cumplimentaron la encuesta. RESULTADOS: De 79 UDC encuestadas, respondieron56 (70,8%), de las cuales el 57,1% eran públicas, el55,4% desarrollaban actividad docente y el 53,6% eran multidisciplinares. El 72,4% de UDC eran mixtas. El89,3% eran dependientes del Servicio de Anestesiología. Sólo un 57,1% de UCD disponían de personal con dedicación exclusiva. La media del número de visitas anual por UDC fue de 2.194 (±2.041). Los recursos terapéuticos más utilizados fueron los fármacos, los bloqueos, las técnicas espinales y las técnicas de estimulación transcutáneas (TENS). Los sistemas implantables también fueron más frecuentes en las unidades de dolor crónico que en las de dolor mixto así como, también fue más frecuente en las universitarias que en las no universitarias (p= 0,03y p= 0,03 respectivamente). El abordaje psicológico se utilizó más en las multidisciplinares que en las unidisciplinarias (p<0,01). CONCLUSIONES: La distribución geográfica de las UDC en España no fue homogénea. La actividad asistencial de dichas UDC fue importante. Diversas características de las UDC como fuente de financiación, multidisciplinariedad, práctica de docencia universitaria y especialización en sólo dolor crónico, condicionaron la utilización de algunos tratamientos para el dolor

OBJECTIVES: To describe the characteristics and care approaches to care of chronic pain clinics operating in Spain in 2001.DESIGN: Cross-sectional mail survey of pain clinics in Spain. SETTING: Chronic pain clinics in Spain. STATISTICAL ANALYSIS: Descriptive statistics of pain clinics responding to the questionnaire. RESULTS: Fifty-six of the 79 pain clinics (70.8%) responded; 57.1% were in public facilities, 55.4% were affiliated with medical schools, and 53.6% were interdisciplinary units. Both acute and chronic pain were treated by 72.4%of the respondents. Anesthesiology departments supervised89.3% of the clinics. Only 57.1% had staff permanently assigned to the pain clinic. A mean 2194 (SD 2041) visits by patients were received annually. The most commonly applied treatments were drugs, blocks, spinal techniques, and transcutaneous electrical nerve stimulation. Implantable systems were more frequently used in chronic pain clinics than in mixed pain clinics, and in university-affiliated clinics than in non-teaching facilities (P=0.03 in both comparisons).A psychological approach was used more often in interdisciplinary clinics than in units operated by staff from a single specialty (P<0.01).CONCLUSIONS: Chronic pain clinics were not evenly distributed throughout Spain. The number of patients treated at pain clinics was high. The various characteristics of pain clinics—such as funding source, interdisciplinarity, university affiliation, and specialization in chronic pain—a were factors that affected the use of certain treatments

Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey.

BACKGROUND: The study aimed to explore the extent to which NHS acute pain services (APSs) have been established in accordance with national guidance, and to assess the degree to which clinicians in acute pain management believe that these services are fulfilling their role. METHODS: A postal questionnaire survey addressed to the head of the acute pain service was sent to 403 National Health Service hospitals each carrying out more than 1000 operative procedures a year. RESULTS: Completed questionnaires were received from 81% (325) of the hospitals, of which 83% (270) had an established acute pain service. Most of these (86%) described their service as Monday-Friday with a reduced service at other times; only 5% described their service as covering 24 hours, 7 days a week. In the majority of hospitals (68%), the on-call anaesthetist was the sole provider of out of hours services. Services were categorized by respondents as thriving (30%), struggling to manage (52%) or non-existent (17%). There was widespread agreement (> or =85%) on the principles that should underpin acute pain services, and similar agreement on the need for better organizational approaches (95%) rather than new treatments and delivery techniques (19%). CONCLUSIONS: More than a decade since the 1990 report Pain after Surgery, national coverage of comprehensive acute pain services is still far from being achieved. Despite wide consensus about the problems, concrete solutions are proving hard to implement. There is strong support for a two-fold response: securing greater political commitment to pain services and using organizational approaches to address current deficits.

Acute pain management after surgery or in the emergency room in Switzerland: a comparative survey of Swiss anaesthesiologists and surgeons.

The treatment of acute pain remains unsatisfactory despite advances in pain research and the publication of numerous guidelines. The aim of this study was to survey postoperative and emergency room acute pain treatment in Switzerland, particularly regarding compliance with practice guidelines on therapeutic responsibility, treatment algorithms, pain documentation, quality control and education.A representative sample of anaesthesiologists and surgeons (general and orthopaedic) was selected from all Swiss hospitals with regular surgical activity and sent a 256 point questionnaire on acute pain management. Five hundred and seventy five doctors were contacted in 98 hospitals, 44% of doctors (covering 89% of hospitals) returned fully completed questionnaires. Half the respondents work in a hospital with an acute pain service. For postoperative pain management, only 10% of prescription is by algorithm, less than a third of respondents regularly determine pain scores, only 15% perform any statistical analysis of pain management, less than one third regularly meet to discuss management problems, and half claim not to have received-or be receiving-formal (i.e. structured/accredited) pain education. The situation is even less satisfactory for emergency room analgesia. Respondents accept the contribution of postoperative and emergency room analgesia to reduced costs and improved medical outcomes. Asked to highlight their major concerns in acute pain management, lack of education and inadequate organisation are listed in first and second positions. This survey suggests that compliance with published practice guidelines for acute pain management can be improved, and highlights the need for continuing organisational and educational development in acute analgesia, particularly for the emergency room.