Struktur der ambulanten Schmerztherapie in Deutschland

[Presentation of an innovative interdisciplinary and cross-sector therapeutic concept for pain patients as part of a regional selective contract]

Hintergrund

Eine gestufte Versorgung in der Behandlung chronisch schmerzkranker Patient*innen ist in Deutschland nur in Ansätzen vorhanden. Vor dem Hintergrund der aktuellen Pandemiebedingungen hat sich eine Unter- und Fehlversorgung weiter verschärft.

Ziel

Entwicklung und Aufbau eines sektorenübergreifenden Behandlungskonzepts für schmerzkranke Patient*innen im Rahmen eines Selektivvertrags.

Methoden

Eingebettet in bereits vorhandene Versorgungsstrukturen wurden nach vorbezeichneten Kriterien sieben Versorgungspfade (Clinical Pathways, CP) definiert, in die eingeschriebene Patient*innen nach einem interdisziplinären Assessment geleitet werden.

Aufbau

Im CP I verbleiben die Patient*innen in der Regelversorgung. Im CP II wird zusätzlich eine einmalige interprofessionelle Edukation von 3 h zur Prophylaxe weiterer Chronifizierung angeboten. Im CP III gehen die Patient*innen für sechs Monate in eine fachärztlich spezialisierte ambulante Schmerzbehandlung. Das CP IV ist eine teilstationäre multimodale Therapie, bei der viele Präsenztage durch telemedizinische Inhalte mit Unterstützung einer Reha-App ersetzt werden. CP V und VI sind vollstationäre multimodale Behandlungen über acht und 15 Tage. In CP VII kann bei ambulantem psychotherapeutischen Behandlungsbedarf für Patient*innen nach vollstationärer Behandlung zur Überbrückung des Wartezeitraums über sechs Monate eine niederfrequente Psychotherapie erfolgen.

Qualitätssicherung und Evaluation

Die wissenschaftliche Begleitung erfolgt mittels ausgewählter Fragebögen und psychometrischer Testverfahren jeweils drei, sechs und zwölf Monate nach erfolgtem Assessment, um die Inhalte des Vertrags zu evaluieren.

Frühes interdisziplinäres Assessment zur Sekundärprävention chronischer Schmerzen

Schmerz ist ein multikausales biopsychosoziales Phänomen. Das bedeutet für eine angemessene Versorgung ein entsprechendes interdisziplinäres Vorgehen in Diagnostik und Therapie. Faktoren, die bei bestehenden Schmerzen zu einer Chronifizierung beitragen können, sollten frühzeitig im Versorgungsalltag berücksichtigt werden. Dafür sind sektorenübergreifende Vernetzungen sowie interdisziplinäre Versorgungsangebote von großer Bedeutung.

[Pain care in Austrian health care centers: Questionnaire study on the current status of Austrian pain clinics]

BACKGROUND

Pain clinics provide interdisciplinary therapy to treat chronic pain patients and to increase the return-to-work rate. In recent years and due to increased economic pressure in health care, a change in the management of pain in Austrian health care centers has been observed. For the analysis of the current situation, two surveys addressing all Austrian pain clinics were performed.

MATERIALS AND METHODS

In total, 133 heads of Austrian Anesthesia Departments were interviewed online and personally. The data from the first interview were confirmed by an additional telephone survey that was performed by one anesthetist per Austrian state (n = 9).

RESULTS

Currently, 44 Austrian pain clinics are active. During the last 5 years, 9 pain clinics closed. Adding the current active pain clinics together, they represent a total of 17.5 full-time-operated clinics. The most common reasons for closing the pain clinics were lack of personnel (47%), lack of time resources (26%), lack of space resources (11%), and financial difficulties (11%). A reduction of >50% of operating hours during the last 3 years was reported by 9 hospitals. The reasons for not running a pain clinic were lack of personnel (36%), lack of time (25%) and department too small (16%). Estimates between actual and required clinics indicate that 49.5 full-time-operating pain clinics are lacking in Austria, resulting in 74% of the Austrian chronic pain patients not receiving interdisciplinary pain management.

CONCLUSION

Our survey confirmed the closure of 9 pain clinics during the last 5 years due to lack of personnel and time. Pain clinics appear to provide the simplest economic saving potential. This development is a major concern. Although running a pain clinic seems to be expensive at the first sight, it reduces pain, sick leave, complications, and potential legal issues against health care centers, while simultaneously increasing the hospital's competitiveness. Our results show that 74% of Austrian chronic pain patients do not have access to an interdisciplinary pain clinic. Because of plans to further economize resources, Austria may lose its ability to provide state-of-the-art pain therapy and management.

[Practice of regional anesthesia for chronic pain patients in specialized pain services : A nationwide survey in Germany]

BACKGROUND

The prevalence of chronic pain has been estimated to be 19% in the European population and criteria for disabling chronic pain were found in approximately 7% of the German population. Clinical care for these patients is provided in ambulant and hospital-associated facilities. In this context, invasive interventions are part of the diagnosis and treatment of several specific diseases. Current data on the structure of clinical care based regional anesthesia for chronic pain patients in Germany are not available.

OBJECTIVE

This study focused on the application and practice of interventional procedures in the context of pain management.

MATERIAL AND METHODS

An internet-based survey addressing pain facilities and pain specialists in Germany was carried out. The response rate achieved 54%.

RESULTS

Overall 79% of the pain therapists who responded included regional anesthesia techniques in the therapeutic spectrum in up to 25% of patients. The leading indications for invasive procedures were back pain and neuropathic pain. Two thirds of the therapists reported performing a series of blocks. A reduction of pain intensity of 30-50% was often reported as a sufficient criterion for the success of regional anesthesia interventions. Typically, approximately 40% of the chronic pain patients undergoing a series of blocks achieved sufficient pain relief which lasted most commonly for 12 weeks up to 6 months.

CONCLUSION

This survey describes the current structures of specialized pain facilities for regional anesthesia in Germany including responses from predominantly anesthesiologists in a hospital-associated setting. In light of the limited evidence in the literature there is no consensus on the interventional therapeutic management of chronic pain. Especially the application of a series of blocks and the frequency as well as criteria to support continuing or terminating a series of regional anesthesia interventions are not sufficiently evaluated. This survey also gives an incentive for a possible revision of the existing practice in regional anesthesia in the context of multimodal therapy and currently existing guidelines in future clinical studies.

[Specialized pain care in Germany]

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.

[Structure and process quality of multimodal pain therapy. Results of a survey of pain therapy clinics]

Multimodal therapy has demonstrated good clinical effectiveness in the treatment of chronic pain syndromes. However, within the German health system a comprehensive and nationwide access to multimodal therapy is not available and further improvement is therefore necessary. In order to analyze the current status of multimodal therapy and specifically its structural and procedural requirements and qualities, a survey was carried out in 37 pain clinics with established multimodal treatment programs. An anonymous questionnaire was used for data collection. Results demonstrated that a substantial accordance was found between all pain clinics concerning requirements for space, facilities and staff. Structured multidisciplinary assessments were carried out by all pain clinics even though the amount of time allocated for this varied widely. The main focus of multimodal therapy in all facilities was based on a common philosophy with a cognitive-behavioral approach to reduce patient helplessness and avoidance behavior and to increase physical and psychosocial activities as well as to strengthen self-efficacy. Some differences in the ways and means to achieve these goals could be demonstrated in the various programs.

[German pain questionnaire and standardised documentation with the KEDOQ-Schmerz. A way for quality management in pain therapy]

KEDOQ-Schmerz was developed by the German Pain Society (formerly DGSS) as a basic tool for documentation and quality management of pain therapy. It is planned to use KEDOQ-Schmerz as the data basis for nationwide, cross-sectional and independent scientific research in health services in Germany. With comparatively little effort, each participating institution (practices, pain clinics) will be able to provide quality control of their own diagnostic procedures and therapeutic effects by using benchmarking. In future KEDOQ-Schmerz will also be used as a method for external quality management in pain therapy in Germany.

[Chronic pain. Overview of out-patient pain treatment in Austria]

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.

[Patients with chronic pain syndromes. Impact of an individual outpatient therapy program on pain and health-related quality of life]

BACKGROUND

The study was performed to reveal the effect of an individualized personal outpatient therapy program, based on a multidisciplinary assessment, on pain and health-related quality of life in patients with chronic pain.

METHODS

Fifty patients were prospectively evaluated before and 3 months after establishment of an individualized outpatient therapy program. Health-related quality of life, pain and pain-related disability, depression and motivation to adopt self-management of chronic pain were assessed. Therapy adherence was tested with a structured interview.

RESULTS

Only marginal improvements were observed in terms of pain and health-related quality of life. Therapy adherence varied between the different therapies.

CONCLUSIONS

An individualized personal outpatient therapy program has only marginal effects on pain and health-related quality of life in patients with chronic pain.

Fibromyalgia syndrome: prevalence, pharmacological and non-pharmacological interventions in outpatient health care. An analysis of statutory health insurance data

OBJECTIVE

Fibromyalgia syndrome (FMS) is a chronic pain condition impacting on quality of life, causing physical and psychological impairment resulting in limited participation in professional and social life. The objective of this study was to assess the prevalence, recommended pharmacological and non-pharmacological interventions of FMS, patients' characteristics and to compare findings to current research.

METHODS

About 1.6 Mio patients of a German statutory health insurance company (GEK) in 2007 were analyzed for: (a) the prevalence of FMS (ICD-10: M79.7); (b) and comorbid depression (ICD-10: F32/33); (c) the recommended pharmacological and non-pharmacological intervention rates; (d) and characteristics of patients associated with being prescribed recommended interventions.

RESULTS

The (a) standardized prevalence of FMS in 2007 was 0.05% in men and 0.4% in women. (b) 51.9% of the patients with prevalent FMS had a comorbid depression in 2007 (88.2% female). (c) 66% of FMS patients received the recommended pharmacological treatment, 59% physical therapy, 6.1% cognitive-behavioural therapy and 3.4% a combination of these (multi-component therapy, MCT). (d) One year increase in age was associated with a 3% decrease in the predicted odds of receiving MCT (95%, CI 0.95-0.99).

CONCLUSION

The current data indicate an FMS-prevalence that differs from epidemiological surveys and screenings, probably due to methodological differences. Especially females with comorbid depression are affected. The likelihood of receiving MCT is not associated with gender, but with younger age. Yet, the findings seem to indicate insufficient and inadequate treatment, but FMS warrants more research.

Chronic pain in primary care. German figures from 1991 and 2006

Background

Until now only limited research has been done on the prevalence of chronic pain in primary care. The aim of this investigation was to study the health care utilisation of patients suffering from pain. How many patients visit an outpatient clinic because of the symptom of pain? These data were compared with data from a similar study in 1991, to investigate whether improvements had been achieved.

Methods

A total of 1201 consecutive patients visiting outpatient clinics were surveyed in six practices in the western part of Germany on randomly selected days by means of questionnaires. Topics were the point prevalence of pain and the period prevalence of chronic pain, its characteristics and its impact on daily life, as well as data on previous therapies for pain. A retrospective comparison was made with the data from a similar study with same design surveying 900 patients that took place in five practices during 1991.

Results

In 2006, pain was the main reason for consulting a doctor in 42.5% of all patients (1991: 50.3%). Of all respondents, 62% suffered from pain on the particular day of the consultation, and 40% reported that they had been suffering from pain for more than six months (1991: 36.4%). As many as 88.3% of patients with chronic pain reported a negative impact on their daily life due to this pain (1991: 68%), and 88.1% reported impairment of their working life because of chronic pain (1991: 59.1%).

Conclusion

Pain, and chronic pain in particular, is a central problem in primary care. Over the last 15 years, the number of patients suffering from chronic pain has not decreased. In nearly half of all cases, pain is still the reason for health care utilisation in outpatient clinics. Pain represents a major primary health care problem with enormous impact on public health. Improvements can only be achieved by improving the quality of health care at the primary care level.