[Therapy recommendations in a pediatric outpatient pain clinic : Adherence and effectiveness of implementation]

Exploring the Mechanisms Underlying the Effectiveness of Psychosocial Aftercare in Pediatric Chronic Pain Treatment: A Qualitative Approach

A newly developed specialized psychosocial aftercare program (PAC) for pediatric patients with chronic pain following an intensive interdisciplinary pain treatment (IIPT) was found to be significantly more effective than IIPT alone. This qualitative study aimed to gain further insight into the mechanisms and prerequisites for the effectiveness of this specialized aftercare program. We conducted structured telephone interviews with patients, parents, and health care professionals conducting PAC. A total of 16 interviews were conducted—seven interviews with parents, six interviews with patients, and three interviews with health care professionals—and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Four major themes consisting of 20 subcategories were identified, namely (1) frame conditions, (2) person factors, (3) stabilization and (4) catalyst. The foundations of treatment success are frame conditions, such as flexibility or constancy, and person factors, such as respect or expertise. Based on these foundations, stabilization is achieved through security, mediation, orientation and support. Altogether, these components of PAC reveal their potential as catalysts for further improvement even after discharge from IIPT. Overall, patients and their families emphasized widespread personal relevance and acceptance of the PAC program. The findings of this study may be employed in the development of other aftercare programs or interventions involving families in the context of psychotherapeutic and psychosocial health care.

Effectiveness of a Psychosocial Aftercare Program for Youth Aged 8 to 17 Years With Severe Chronic Pain: A Randomized Clinical Trial

IMPORTANCE

Severe chronic pediatric pain causes individual suffering and significantly affects social functioning and psychological well-being. For children with high pain severity, intensive interdisciplinary pain treatment (IIPT) is a well-established treatment. However, across specialized centers, it is not sufficient for all patients.

OBJECTIVE

To evaluate the effectiveness of a psychosocial aftercare (PAC) program for pediatric patients with severe chronic pain followed up for 6 months after discharge from IIPT.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter randomized clinical trial with 4 assessment points (pre-IIPT, immediately post-IIPT, 3 months, and 6 months) was conducted at 3 pediatric specialized tertiary care pain centers in Germany between September 11, 2018, and March 31, 2020. Included patients were aged 8 to 17 with a severe chronic pain condition who had been admitted for IIPT. Data were analyzed from June 8 to September 4, 2020.

INTERVENTIONS

Patients and their families were randomly assigned to 1 of 2 study groups at inpatient IIPT admission. Both groups received standardized 3- to 4-week IIPT. After IIPT discharge, the intervention group received PAC and the control group received usual care. PAC involved ongoing contact with a social worker for as long as the family requested the support, up to a maximum of 6 months.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was pain at 6 months, measured using the Chronic Pain Grading (CPG), an instrument based on an algorithm indicating severity of the chronic pain disorder. Secondary outcomes included other pain-related and emotional parameters.

RESULTS

A total of 419 patients were randomized (mean [SD] age, 14.3 [2.1] years; 303 [72.3%] girls; 116 [27.7%] boys), with 218 assigned to usual care and 201 assigned to PAC. At baseline in both groups, the median (IQR) CPG was 3 (2-4). Superiority of PAC compared with usual care was demonstrated at 6 months (median [IQR] CPG: usual care, 2 [2-3]; PAC, 1 [1-2]; r = 0.30; 95% CI, 0.17-0.41). Additionally, PAC significantly improved emotional parameters (eg, significant time × group interaction: b = -8.84; P < .001).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that PAC improved pain-related and emotional parameters during the intervention 6 months after discharge from IIPT. Future research is needed to investigate the intervention's long-term effects.

TRIAL REGISTRATION

German Clinical Trials Register ID: DRKS00015230.

Economic long-term effects of intensive interdisciplinary pain treatment in paediatric patients with severe chronic pain: Analysis of claims data

OBJECTIVE

Chronic pain in children and adolescents gives rise to high healthcare costs. Successful treatment is supposed to reduce the economic burden. The objective of this study was to determine the changes in healthcare utilization and expenditures from 1 year before (Pre) intensive interdisciplinary pain treatment (IIPT) to the first (Post 1) and second (Post 2) years after discharge in a sample of paediatric chronic pain patients.

METHODS

Claims data from one statutory health insurance company were analysed for 119 children and adolescents (mean age = 15.3, 68.9% female) who sought IIPT at the German Paediatric Pain Centre. Costs incurred for inpatient treatment, outpatient treatment, medication, remedies and aids were compared before treatment and 2 years after discharge. Healthcare utilization was compared using Wilcoxon signed-rank test, and expenditures using trimmed means and the Yuen's t-test.

RESULTS

Overall costs were significantly lower in the 2 years after IIPT compared to before IIPT (Pre: 3,543€, Post 1:2,681€, Post 2:1937€ (trimmed means)). Healthcare utilization changed significantly; hospitalizations decreased in the years after discharge, while psychotherapies stayed stable in the year after discharge but lessened in the second year.

CONCLUSION

The results of this study support prior findings on the high economic burden of paediatric chronic pain. IIPT may contribute to a transition in healthcare utilization from somatic-focused treatments to more psychological treatments. Overall costs were reduced as soon as the first year after discharge and decreased even further in the second year.

SIGNIFICANCE

This study analyses original claims data from paediatric chronic pain patients in the year before and up to 2 years after intensive interdisciplinary pain treatment in a specialized paediatric pain centre. The analysis of long-term data reveals a continuous cost reduction after intensive interdisciplinary pain treatment and a change in the subsequent outpatient treatment.

[Medical pain care for children and adolescents with chronic pain in Germany : An inventory]

Chronic pain in children and adolescents is increasing in prevalence, affects the quality of life, predisposes to pain in adulthood and causes numerous contacts to the healthcare system. In contrast, the number of therapeutic offers tailored to the special needs of this age group is insufficient and confusing. The working group on pain in children and adolescents of the German Pain Society therefore documented appropriate facilities in a questionnaire survey carried out using a snowball system. The response rate of 27/109 questionnaires was low. Thus, the results may not be entirely representative. Nevertheless, the heterogeneity of the offers and in total an undersupply became very clear. In order to improve the care situation, joint efforts by the various pediatric subdisciplines dealing with pain, an increase in the number of child pain treatment centers and a better networking are necessary.