1
|
Winston GM, Zimering JH, Newman CW, Reiner AS, Manalil N, Kharas N, Gulati A, Rakesh N, Laufer I, Bilsky MH, Barzilai O. Safety and Efficacy of Surgical Implantation of Intrathecal Drug Delivery Pumps in Patients With Cancer With Refractory Pain. Neurosurgery 2024:00006123-990000000-01156. [PMID: 38700319 DOI: 10.1227/neu.0000000000002978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pain management in patients with cancer is a critical issue in oncology palliative care as clinicians aim to enhance quality of life and mitigate suffering. Most patients with cancer experience cancer-related pain, and 30%-40% of patients experience intractable pain despite maximal medical therapy. Intrathecal pain pumps (ITPs) have emerged as an option for achieving pain control in patients with cancer. Owing to the potential benefits of ITPs, we sought to study the long-term outcomes of this form of pain management at a cancer center. METHODS We retrospectively reviewed medical records of all adult patients with cancer who underwent ITP placement at a tertiary comprehensive cancer center between 2013 and 2021. Baseline characteristics, preoperative and postoperative pain control, and postoperative complication rate data were collected. RESULTS A total of 193 patients were included. We found that the average Numerical Rating Scale (NRS) score decreased significantly by 4.08 points (SD = 2.13, P < .01), from an average NRS of 7.38 (SD = 1.64) to an average NRS of 3.27 (SD = 1.66). Of 185 patients with preoperative and follow-up NRS pain scores, all but 9 experienced a decrease in NRS (95.1%). The median overall survival from time of pump placement was 3.62 months (95% CI: 2.73-4.54). A total of 42 adverse events in 33 patients were reported during the study period. The 1-year cumulative incidence of any complication was 15.6% (95% CI: 10.9%-21.1%) and for severe complication was 5.7% (95% CI: 3.0%-9.7%). Eleven patients required reoperation during the study period, with a 1-year cumulative incidence of 4.2% (95% CI: 2.0%-7.7%). CONCLUSION Our study demonstrates that ITP implantation for the treatment of cancer-related pain is a safe and effective method of pain palliation with a low complication rate. Future prospective studies are required to determine the optimal timing of ITP implantation.
Collapse
Affiliation(s)
- Graham M Winston
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Jeffrey H Zimering
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
- Current affiliation: Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York , New York , USA
| | - Christopher W Newman
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Noel Manalil
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Natasha Kharas
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Neal Rakesh
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
- Current affiliation: Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| |
Collapse
|
2
|
Burge F, Mcintyre P, Kaufman D, Frager G, Pollett A. Family Medicine Residents’ Knowledge and Attitudes about End-of-life Care. J Palliat Care 2019. [DOI: 10.1177/082585970001600302] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The medical management of end-of-life symptoms, and the psychosocial care of the dying and their families have not been a specific part of the curriculum for undergraduate medical students or residency training programs. The purpose of our research was to assess family medicine residents’ knowledge of and attitudes toward care of the dying. All entering (PGY1) and exiting (PGY2) residents of the Dalhousie University Family Medicine Residency Program were given a 50-item survey on end-of-life care. The survey contains two 25-item subscales concerning attitudes/opinions toward end-of-life care, and knowledge about care. Thirty-one of the 33 entering PGY1s (94%) and 26 of the 30 exiting PGY2s (86%) completed the surveys. Overall attitude scores were felt to be high among both groups, with little difference between them. Areas of concern regarding the adequacy of knowledge were found in relation to managing opioid drugs and the symptom of dyspnea. Interventions are now in development to address these issues in the residency program. In an era of subspecialties, the challenge of integrating these areas into the curriculum without creating rotations in specialist palliative care is an issue faced by most family medicine residency programs.
Collapse
Affiliation(s)
- Frederick Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Mcintyre
- Department of Family Medicine, Dalhousie University and Palliative Care Program, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - David Kaufman
- Division of Medical Education, Dalhousie University, Clinical Research Centre, Halifax, Nova Scotia, Canada, INA CUMMINGS, Department of Family Medicine, Dalhousie University and Palliative Care Program, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Gerri Frager
- Department of Pediatrics, Dalhousie University and IWK-Grace Health Centre for Women, Children and Families, Halifax, Nova Scotia, Canada
| | - Ann Pollett
- Cape Breton Regional Health Care, Sydney, Nova Scotia, Canada
| |
Collapse
|
3
|
Abstract
The Canadian Palliative Care Education Group, a committee of the Canadian Society of Palliative Care Physicians, carries out surveys from time to time on the status of palliative care education in Canadian medical schools. We describe the organization of the Canadian Palliative Care Education Group and report on a survey carried out in the 1996–97 academic year. Our data suggest that the emphasis on palliative care varies widely amongst the 16 Canadian medical schools, in concert with the availability of academic staff positions in palliative care. We conclude that the need for palliative care education is supported by rhetoric which remains to be matched by proportionate tangible investment.
Collapse
Affiliation(s)
- Neil Macdonald
- Centre for Bioethics, Clinical Research Institute of Montreal, and Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Marcel Boisvert
- Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Deborah Dudgeon
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Neil Hagen
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
4
|
Abstract
Four dimensions for the provision of end-of-life care by clinicians were identified from a review and synthesis of the Canadian family physician and palliative care literatures. These dimensions are: clinician-patient continuity, timing and location of care, community-centred services, and multidisciplinary care. Indicators of each dimension are presented along with criteria for indicator selection. The analytic framework was refined during the linkage of population-based administrative databases to identify patterns of family physician service provision in the last months of life for persons dying from cancer in Nova Scotia, Canada. Data analysis was framed to inform palliative care policy and programs, as well as to enable comparison among geographic areas within and beyond Canada.
Collapse
Affiliation(s)
- Grace Johnston
- School of Health Services Administration, Dalhousie University Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Frederick Burge
- Department of Family Medicine, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| |
Collapse
|
5
|
Morita T, Tsunoda J, Inoue S, Chihara S. Concerns of Japanese Hospice In Patients about Morphine Therapy as a Factor in Pain Management: A Pilot Study. J Palliat Care 2019. [DOI: 10.1177/082585970001600409] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Tatsuya Morita
- Seirei Hospice, Seirei Mikatabara Hospital, Shizuoka, Japan
| | | | - Satoshi Inoue
- Seirei Hospice, Seirei Mikatabara Hospital, Shizuoka, Japan
| | | |
Collapse
|
6
|
Brazil K, Howell D, Marshall D, Critchley P, Van Den Elzen P, Thomson C. Building Primary Care Capacity in Palliative Care: Proceedings of an Interprofessional Workshop. J Palliat Care 2019. [DOI: 10.1177/082585970702300206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kevin Brazil
- St. Joseph's Health System Research Network, and Department of Clinical Epidemiology and Biostatistics, McMaster University, and Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton
| | - Doris Howell
- Oncology and Blood Disorders Program, University Health Network, and Faculty of Nursing, University of Toronto, Toronto
| | - Denise Marshall
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton
| | | | | | - Caroline Thomson
- St. Joseph's Health System Research Network, Hamilton, Ontario, Canada
| |
Collapse
|
7
|
Affiliation(s)
- Pesach Shvartzman
- Department of Family Medicine and Home Palliative Care Unit, Kupat Holim Clalit, Ben-Gurion University, Beer-Sheva, Israel
| | - Yoram Singer
- Department of Family Medicine and Home Palliative Care Unit, Kupat Holim Clalit, Ben-Gurion University, Beer-Sheva, Israel
| |
Collapse
|
8
|
Dureja GP, Iyer RN, Das G, Ahdal J, Narang P. Evidence and consensus recommendations for the pharmacological management of pain in India. J Pain Res 2017; 10:709-736. [PMID: 28435313 PMCID: PMC5386610 DOI: 10.2147/jpr.s128655] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Despite enormous progress in the field of pain management over the recent years, pain continues to be a highly prevalent medical condition worldwide. In the developing countries, pain is often an undertreated and neglected aspect of treatment. Awareness issues and several misconceptions associated with the use of analgesics, fear of adverse events - particularly with opioids and surgical methods of analgesia - are major factors contributing to suboptimal treatment of pain. Untreated pain, as a consequence, is associated with disability, loss of income, unemployment and considerable mortality; besides contributing majorly to the economic burden on the society and the health care system in general. Available guidelines suggest that a strategic treatment approach may be helpful for physicians in managing pain in real-world settings. The aim of this manuscript is to propose treatment recommendations for the management of different types of pain, based on the available evidence. Evidence search was performed by using MEDLINE (by PubMed) and Cochrane databases. The types of articles included in this review were based on randomized control studies, case-control or cohort studies, prospective and retrospective studies, systematic reviews, meta-analyses, clinical practice guidelines and evidence-based consensus recommendations. Articles were reviewed by a multidisciplinary expert panel and recommendations were developed. A stepwise treatment algorithm-based approach based on a careful diagnosis and evaluation of the underlying disease, associated comorbidities and type/duration of pain is proposed to assist general practitioners, physicians and pain specialists in clinical decision making.
Collapse
Affiliation(s)
| | - Rajagopalan N Iyer
- Department of Orthopaedics, Raja Rajeswari Medical College and Hospital, Bengaluru, Karnataka
| | - Gautam Das
- Daradia Pain Clinic, Kolkata, West Bengal
| | - Jaishid Ahdal
- Department of Medical Affairs, Janssen India, Johnson & Johnson Pvt Ltd, Mumbai, Maharashtra, India
| | - Prashant Narang
- Department of Medical Affairs, Janssen India, Johnson & Johnson Pvt Ltd, Mumbai, Maharashtra, India
| |
Collapse
|
9
|
Singh H, Banipal RPS, Singh B. Assessment of Adequacy of Pain Management and Analgesic Use in Patients With Advanced Cancer Using the Brief Pain Inventory and Pain Management Index Calculation. J Glob Oncol 2016; 3:235-241. [PMID: 28717765 PMCID: PMC5493218 DOI: 10.1200/jgo.2016.004663] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose The objective of this cross-sectional, noninterventional, 6-month observational study was to assess the adequacy of pain management in patients with cancer admitted to the Oncology Department of Guru Gobind Singh Medical College in Faridkot, India. Methods and Materials A total of 348 patients with cancer were recruited for evaluation of the prevalence of inadequate cancer pain management using the Brief Pain Inventory Pain Management Index. Results The current study included 127 males (36.5%) and 221 females (63.5%). The most prevalent cancer type was genitourinary; 268 patients (77%) had inadequately managed pain. A significant correlation was observed between poorly managed pain and age groups, analgesic used, and body mass index. Conclusion Our observation of inadequate pain management among 77% of patients indicates that pain management was insufficient in three quarters of the patients in this study. Accumulating data regarding the inadequacy of cancer pain management is crucial to improve symptom management. Better management of pain not only alleviates pain symptoms but also increases the quality of life for patients with cancer.
Collapse
Affiliation(s)
- Harminder Singh
- All authors: Baba Farid University of Health Sciences, Faridkot, India
| | | | - Baltej Singh
- All authors: Baba Farid University of Health Sciences, Faridkot, India
| |
Collapse
|
10
|
Attitudes and practices of pediatric oncologists regarding methadone use in the treatment of cancer-related pain: results of a North American Survey. J Pediatr Hematol Oncol 2013; 35:103-7. [PMID: 23242323 DOI: 10.1097/mph.0b013e318279e492] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Methadone is effective in the treatment of cancer-related pain in adults. Pediatric oncologists may be reluctant to use methadone, given the paucity of existing research and a lack of familiarity with its use. This study's purpose was to assess pediatric oncologists' experience, comfort and practice of methadone prescription, and determine interest in and appropriate venues for education on methadone. A 22-item survey was sent by electronic mail to 1912 practicing pediatric oncologists. Six hundred thirty-one pediatric oncologists (33%) responded to the survey. Seventy-two percent of respondents reported they prescribe methadone to <10% of their patients receiving opioids. Physicians practicing ≥10 years (84% vs. 76%, P=0.01), at centers that see ≥100 new patients per year (86% vs. 76%, P=0.003), or who have received prior education on methadone (89% vs. 54%, P<0.001) were more likely to have prescribed methadone. The primary reasons respondents did not utilize methadone included a lack of knowledge of methadone's pharmacodynamics (39%), effectiveness (39%), and/or dosing equivalence (34%). Perceived competence with dose equivalence, belief that methadone is effective, and working in a division where >20 patients per year died were all independently associated with having prescribed methadone to >10% of patients on opioids. Eighty-five percent of respondents would like additional education on methadone. Many pediatric oncologists lack experience and education in the use of methadone. Formal education initiatives should be implemented to enhance pediatric oncologists' comfort and expertise in methadone use.
Collapse
|
11
|
Barbera L, Seow H, Husain A, Howell D, Atzema C, Sutradhar R, Earle C, Sussman J, Liu Y, Dudgeon D. Opioid Prescription After Pain Assessment: A Population-Based Cohort of Elderly Patients With Cancer. J Clin Oncol 2012; 30:1095-9. [PMID: 22370317 DOI: 10.1200/jco.2011.37.3068] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The purpose of this study was to measure opioid prescription (OP) rates in elderly cancer outpatients around the time of assessment for pain and to evaluate factors associated with receiving OPs for those with severe pain. Patients and Methods The cross-sectional cohort includes all patients with cancer in Ontario older than age 65 years who completed a pain assessment as part of a provincial initiative of systematic symptom screening. Patients were assigned to mutually exclusive categories by pain score severity: 0, 1 to 3 (mild), 4 to 6 (moderate), and 7 to 10 (severe). We linked multiple provincial health databases to examine the proportion of patients with an OP within 7 days after or 30 days before the assessment date. We examined factors associated with OPs for patients with pain scores of 7 to 10. Results The proportion of patients with an OP increased as pain score severity increased: 10% of those with no pain, 24% of those with mild pain, 45% of those with moderate pain, and 67% of those with severe pain. More specifically, for those with severe pain, 41% filled an OP within 7 days of assessment for pain, and 26% had an OP from the 30 days before assessment for pain, leaving 33% without an OP. In multivariable analysis, factors associated with OPs are younger age, male sex, comorbid illness, cancer type, and assessment at home. Conclusion Despite a generous time window for capturing OPs, the proportion of patients without an OP seems high. Further knowledge translation is required to maximize the impact of the symptom screening initiative in Ontario and to optimize management of cancer-related pain.
Collapse
Affiliation(s)
- Lisa Barbera
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Hsien Seow
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Amna Husain
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Doris Howell
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Clare Atzema
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Rinku Sutradhar
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Craig Earle
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Jonathan Sussman
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Ying Liu
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| | - Deborah Dudgeon
- Lisa Barbera, Amna Husain, Doris Howell, Clare Atzema, Rinku Sutradhar, and Craig C. Earle, University of Toronto; Lisa Barbera, Hsien Seow, Clare Atzema, Rinku Sutradhar, Craig C. Earle, and Ying Liu, Institute for Clinical Evaluative Sciences; Amna Husain, Temmy Latner Centre for Palliative Care, Toronto; Hsien Seow and Jonathan Sussman, McMaster University; Hsien Seow and Jonathan Sussman, Supportive Cancer Care Research Unit, Hamilton; and Deborah Dudgeon, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
12
|
Breuer B, Fleishman SB, Cruciani RA, Portenoy RK. Medical oncologists' attitudes and practice in cancer pain management: a national survey. J Clin Oncol 2011; 29:4769-75. [PMID: 22084372 DOI: 10.1200/jco.2011.35.0561] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the attitudes, knowledge, and practices of US medical oncologists that are related to management of cancer pain. METHODS An anonymous survey was mailed to a geographically representative sample of medical oncologists randomly selected from the American Medical Association's Physician Master File. RESULTS From a total of 2,000 oncologists, 354 responded to the original questionnaire and 256 responded to one of two subsequent shortened versions (overall response rate, 32%). Responders were demographically similar to all US medical oncologists. Using numeric rating scales of 0 to 10, oncologists rated their specialty highly for the ability to manage cancer pain (median, 7; interquartile range [IQR], 6 to 8) but rated their peers as more conservative prescribers than themselves (median, 3; IQR, 2 to 5). The quality of pain management training during medical school and residency was rated as 3 (IQR, 1 to 5) and 5 (IQR, 3 to 7), respectively. The most important barriers to pain management were poor assessment (median, 6; IQR, 4 to 7) and patient reluctance to take opioids (median, 6; IQR, 5 to 7) or report pain (median, 6; IQR, 4 to 7). Other barriers included physician reluctance to prescribe opioids (median, 5; IQR, 3 to 7) and perceived excessive regulation (median, 4; IQR, 2 to 7). In response to two vignettes describing challenging clinical scenarios, 60% and 87%, respectively, endorsed treatment decisions that would be considered unacceptable by pain specialists. Frequent referrals to pain or palliative care specialists were reported by only 14% and 16%, respectively. CONCLUSION These data suggest that, for more than 20 years, a focus on cancer pain has not adequately addressed the perception of treatment barriers or limitations in pain-related knowledge and practice within the oncology community. Additional efforts are needed to achieve meaningful progress.
Collapse
Affiliation(s)
- Brenda Breuer
- Beth Israel Medical Center, New York, NY 10003, USA.
| | | | | | | |
Collapse
|
13
|
The Role of the Physician in Palliative and End-of-Life Care. Palliat Care 2011. [DOI: 10.1016/b978-1-4377-1619-1.00046-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
14
|
Shaw EA, Marshall D, Howard M, Taniguchi A, Winemaker S, Burns S. A Systematic Review of Postgraduate Palliative Care Curricula. J Palliat Med 2010; 13:1091-108. [DOI: 10.1089/jpm.2010.0034] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Elizabeth Ann Shaw
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Denise Marshall
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Palliative Care, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alan Taniguchi
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Palliative Care, McMaster University, Hamilton, Ontario, Canada
| | - Samantha Winemaker
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Palliative Care, McMaster University, Hamilton, Ontario, Canada
| | - Sheri Burns
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
15
|
Zafar SY, Currow DC, Daugherty CK, Abernethy AP. Standards for Palliative Care Delivery in Oncology Settings. Cancer J 2010; 16:436-43. [DOI: 10.1097/ppo.0b13e3181f289f7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
16
|
Mitera G, Zeiadin N, Kirou-Mauro A, DeAngelis C, Wong J, Sanjeevan T, Sinclair E, Danjoux C, Barnes E, Tsao M, Sahgal A, Chow E. Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index. J Pain Symptom Manage 2010; 39:259-67. [PMID: 20152589 DOI: 10.1016/j.jpainsymman.2009.07.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 07/14/2009] [Accepted: 07/14/2009] [Indexed: 11/16/2022]
Abstract
CONTEXT The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization's "analgesic ladder" approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain. OBJECTIVES The aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI. METHODS All patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, "weak" opioids, and "strong" opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearson's r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors. RESULTS One thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P<0.0001). Higher Karnofsky Performance Status (P<0.0001) and breast primary cancer site (P<0.0001) were significantly associated with negative PMI after adjusting for year variable. CONCLUSION Despite publication of numerous cancer pain management guidelines, undermedication appears to be a persistent problem for patients with painful bone metastases referred for radiotherapy.
Collapse
Affiliation(s)
- Gunita Mitera
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada M4N 3M5.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Devi BCR, Tang TS, Corbex M. What Doctors Know About Cancer Pain Management. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/j354v20n02_04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
18
|
Kirou-Mauro AM, Hird A, Wong J, Sinclair E, Barnes EA, Tsao M, Danjoux C, Chow E. Has pain management in cancer patients with bone metastases improved? A seven-year review at an outpatient palliative radiotherapy clinic. J Pain Symptom Manage 2009; 37:77-84. [PMID: 18504094 DOI: 10.1016/j.jpainsymman.2007.12.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2007] [Revised: 12/23/2007] [Accepted: 01/02/2008] [Indexed: 10/22/2022]
Abstract
The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating=0], mild [rating=1-4], moderate [rating=5-6] or severe [rating=7-10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28-95) and the median Karnofsky Performance Status was 70 (range 10-100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.
Collapse
Affiliation(s)
- Andrea M Kirou-Mauro
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|
19
|
|
20
|
Rolnick SJ, Jackson J, Nelson WW, Butani A, Herrinton LJ, Hornbrook M, Neslund-Dudas C, Bachman DJ, Coughlin SS. Pain management in the last six months of life among women who died of ovarian cancer. J Pain Symptom Manage 2007; 33:24-31. [PMID: 17196904 DOI: 10.1016/j.jpainsymman.2006.06.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Revised: 06/27/2006] [Accepted: 06/28/2006] [Indexed: 09/30/2022]
Abstract
Previous studies indicate that the symptoms of many dying cancer patients are undertreated and many suffer unnecessary pain. We obtained data retrospectively from three large health maintenance organizations, and examined the analgesic drug therapies received in the last six months of life by women who died of ovarian cancer between 1995 and 2000. Subjects were identified through cancer registries and administrative data. Outpatient medications used during the final six months of life were obtained from pharmacy databases. Pain information was obtained from medical charts. We categorized each medication based on the World Health Organization classification for pain management (mild, moderate, or intense). Of the 421 women, only 64 (15%) had no mention of pain in their charts. The use of medications typically prescribed for moderate to severe pain ("high intensity" drugs) increased as women approached death. At 5-6 months before death, 55% of women were either on no pain medication or medication generally used for mild pain; only 9% were using the highest intensity regimen. The percentage on the highest intensity regimen (drugs generally used for severe pain) increased to 22% at 3-4 months before death and 54% at 1-2 months. Older women (70 or older) were less likely to be prescribed the highest intensity medication than those under age 70 (44% vs. 70%, P<0.001). No differences were found in the use of the high intensity drugs by race, marital status, year of diagnosis, stage of disease, or comorbidity. Our finding that only 54% of women with pain were given high intensity medication near death indicates room for improvement in the care of ovarian cancer patients at the end of life.
Collapse
Affiliation(s)
- Sharon J Rolnick
- HealthPartners Research Foundation, Minneapolis, Minnesota 55440, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Davis MP, Walsh D. Epidemiology of cancer pain and factors influencing poor pain control. Am J Hosp Palliat Care 2004; 21:137-42. [PMID: 15055515 DOI: 10.1177/104990910402100213] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct pains. The most common type of pain is related to bone metastases. Neuropathic pain occurs in one-third of patients, alone, or as a mix of nociceptive and neuropathic pain. The failure to manage pain properly is due to several factors. In developing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barriers. In developed countries, failure to manage pain properly is usually related to a "disease" rather than a "symptom" model of care, which minimizes symptom management. Other factors include lack of physician education and failure to follow existing guidelines. Patients fear addiction, drug tolerance, and side effects. Despite adequate resources, pain is still undertreated.
Collapse
Affiliation(s)
- Mellar P Davis
- The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | |
Collapse
|
22
|
Cleeland CS, Reyes-Gibby CC, Schall M, Nolan K, Paice J, Rosenberg JM, Tollett JH, Kerns RD. Rapid improvement in pain management: the Veterans Health Administration and the institute for healthcare improvement collaborative. Clin J Pain 2003; 19:298-305. [PMID: 12966255 DOI: 10.1097/00002508-200309000-00003] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Poor pain management persists in health care. Although common practice errors in pain management have been identified and standards and guidelines for pain management have been published, improvement has been modest. With the goal of rapid improvement in pain management, a joint Collaborative (Veterans Health Administration and Institute for Healthcare Improvement) was conducted from May 2000 to January 2001. OBJECTIVE To improve delivery of pain management to VHA patients and to compare team process and patient report data on key goals from selected study units. METHODS Charts were reviewed for outcome and process measures. Measures included changes in percentage of patients with (1) moderate to severe pain, (2) documentation of a pain assessment, (3) documentation of a pain care plan, and (4) documentation that the patient received pain education. RESULTS Seventy teams from 22 Veteran's Integrated Service Networks throughout the U.S. participated. Moderate or severe pain on study units dropped from 24% to 17%; pain assessment increased from 75% to 85%; pain care plans for patients with at least mild pain increased from 58% to 78%; and number of patients provided with pain educational materials increased from 35% to 62%. DISCUSSION Significant progress toward the target goals was reported during the Collaborative period. This improvement needs to be viewed in the context of a VHA system-wide effort to improve pain management. Data suggest that a program of team formation, goal identification, testing and adaptation of recommended system changes, sharing and feedback of process and outcome information can produce significant change in pain management in a major health care organization.
Collapse
Affiliation(s)
- Charles S Cleeland
- Pain Research Group, Department of Symptom Research, U.T. M.D. Anderson Cancer Center, Houston, Texas, USA.
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
BACKGROUND This study is part of a larger questionnaire survey concerned with the views of nursing staff on physical, emotional and spiritual support for terminally ill patients and decision making on the transition to the terminal phase of treatment. AIM This article discusses the results concerning the prevalence of physical pain in patients and with problems in pain management. METHODS A total of 328 nurses working on the inpatient wards of 32 municipal health centres in finland took part. Data were collected with multiple-choice items and one open-ended question, which were part of a larger structured questionnaire. The data were analysed by means of the SPSS statistical software and content analysis. FINDINGS Dying patients often suffered from pain, which was most commonly because of cancer. Intractable pain was common. The problems of pain management concerned attitudes and qualifications related to treating pain, the assessment of the pain, pain management per se and the organization of pain management. CONCLUSION The study highlights the need to increase pain education, discussion and agreement on the principles of pain management in municipal health centres in Finland.
Collapse
Affiliation(s)
- Merja Kuuppelomäki
- Docent, Research and Development Centre for Social Welfare and Health, Seinäjoki, Finland.
| |
Collapse
|
24
|
MacDonald N, Ayoub J, Farley J, Foucault C, Lesage P, Mayo N. A Quebec survey of issues in cancer pain management. J Pain Symptom Manage 2002; 23:39-47. [PMID: 11779667 DOI: 10.1016/s0885-3924(01)00374-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report the results of a cancer pain survey mailed to Quebec hematologist-oncologists and palliative care physicians in 1999. The survey was designed to sample views on the current status of pain management and on obstacles to the provision of adequate pain relief for patients. The survey, formulated by an ethics network centered at the Clinical Research Institute of Montreal, was distributed to all members of the Association of Hematologist-Oncologists of Quebec and to all physician members of the Quebec Palliative Care Association. Responses were obtained from 138 Palliative Care Association members (response rate 61%) and 76 hematologist-oncologists (response rate 45%). Major obstacles reported included inadequate assessment of both contributory psychosocial issues and severity of pain, patient reluctance to take opioids, and inadequate access to non-drug techniques for pain relief. Access to opioids was not regarded as a problem. Both groups felt generally competent in their ability to manage various aspects of cancer pain therapy. They gave little credit to their formal medical school or residency training. Fifty-six percent of the palliative care group and 57% of the hemato-oncologists rated their medical school experience as only "poor" or "fair" on a 4-point scale. Residency ratings were modestly better. We conclude that medical faculties should assign a high priority to teaching health professionals patient assessment techniques. Simple symptom assessment scales should be routinely used in oncology/palliative care practice. Medical school training in pain management is not highly regarded and should be enhanced. We also note that, based on response to the scenario of a patient presenting with severe pain, many physicians, while feeling competent in the use of opioids, may be overly conservative in their initial use.
Collapse
Affiliation(s)
- Neil MacDonald
- Center for Bioethics, Clinical Research Institute of Montreal and McGill University, 110 Pine Avenue West, Montreal, Quebec H2W 1R7, Canada
| | | | | | | | | | | |
Collapse
|
25
|
Sloan PA, LaFountain P, Plymale M, Johnson M, Montgomery C, Snapp J, Sloan D. Implementing cancer pain education for medical students. CANCER PRACTICE 2001; 9:225-9. [PMID: 11879318 DOI: 10.1046/j.1523-5394.2001.009005225.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to develop and pilot a cancer pain education course for medical students, using a structured home hospice visit. DESCRIPTION OF STUDY A 1-hour home hospice visit was presented to 57 senior medical students. The content and objective criteria for the structured home hospice visit were developed by a multidisciplinary group of experts. During a 1-hour interview, students completed a cancer pain history, performed a focused physical examination, and received feedback and teaching regarding the essentials of cancer pain management from the hospice nurse. All students and hospice patients completed a multi-item evaluation questionnaire with a 5-point Likert scale (1=strongly disagree; 5=strongly agree) regarding the structured home hospice visit. RESULTS Most students agreed strongly that the home hospice visit was a positive experience (mean +/- SD 4.8 +/- 0.44) that helped them to understand the management of cancer pain (mean 4.7 +/- 0.46) and opioid-related side effects (mean 4.5 +/- 0.57). Most patients enjoyed visiting with the students (mean 4.90 +/- 0.30), agreed that the visit was not tiring (mean 4.81 +/- 0.51), and felt that they benefited from participating (mean 4.76 +/- 0.54). CLINICAL IMPLICATIONS The authors concluded the following: 1) that medical students benefited from learning about cancer pain assessment and management through the use of a structured home hospice visit; 2) that a structured home hospice visit helped the students to learn the basics of cancer pain management; 3) that patients enjoyed their role as teacher for medical students; and 4) that senior hospice nurses provided excellent instruction for medical students in the management of cancer pain.
Collapse
Affiliation(s)
- P A Sloan
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky 40536, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
|
27
|
Oneschuk D, Hanson J, Bruera E. An international survey of undergraduate medical education in palliative medicine. J Pain Symptom Manage 2000; 20:174-9. [PMID: 11018335 DOI: 10.1016/s0885-3924(00)00172-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 9-item mail survey dealing with availability and characteristics of undergraduate medical education programs in palliative medicine was sent to all medical schools in Canada (16) and the United Kingdom (UK) (30), and 129 randomly selected medical schools in the United States (US) and Western Europe. The overall response rate was 117/175 (67%). The highest percentage of mandatory (required by the university) rotations in palliative medicine was in the UK medical schools (14/22, 64%). Considerably lower numbers were obtained from the other countries: US; 4/37, 11%, Canada; 2/14, 14%, and Western Europe; 8/43, 19% (P = 0.001). Elective rotations in palliative medicine were more readily available in the UK; 18/22, 82% and Canada; 10/14, 71%, compared with the US; 23/37, 62%, and Western Europe; 13/43, 30% (P=0.001). Seventy-two percent (13/18) of UK, 70% (7/10) of Canadian, 59% (16/27) of US, and 9/30 (30%) of Western European medical schools provide educational reading material in palliative medicine (P = 0.014). Case-based learning in small groups and small group discussion were favored by the UK, 14/22 (63%) and 17/22 (77%), respectively, and Canadian medical schools, 8/14 (57%) and 8/14 (57%), respectively (P = 0.176). The number of universities with academic faculty positions for palliative medicine and the median number of positions for the countries were as follows-Canada 8/13 (62%) and 2; UK 12/22 (55%) and 1; US 5/36 (14%) and 1; and Western Europe 9/24 (21%) and 1, respectively (P = 0.001). Besides the UK, mandatory (required) rotations in undergraduate palliative medicine education are lacking in Canadian, US, and Western European medical schools. The median number of 1 academic faculty member per responding medical school is discouraging. In order for undergraduate and postgraduate medical education in palliative medicine to improve, the number of both educational programs and faculty members will need to be increased.
Collapse
Affiliation(s)
- D Oneschuk
- Regional Palliative Care Program, Grey Nuns Community Hospital, Alberta, Canada
| | | | | |
Collapse
|
28
|
Bruera E, Neumann CM, Gagnon B, Brenneis C, Quan H, Hanson J. The Impact of a Regional Palliative Care Program on the Cost of Palliative Care Delivery. J Palliat Med 2000; 3:181-6. [PMID: 15859744 DOI: 10.1089/10966210050085241] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In July 1995 the Edmonton Regional Palliative Care Program (ERPCP) was established in the City of Edmonton to increase the access of patients with terminal cancer to palliative care services, decrease the number of cancer deaths in acute-care facilities, and increase the participation of family physicians in the care of terminally ill patients. The objective of this retrospective study was to determine the cost of implementation of the ERPCP and savings in acute-care facility costs after its implementation. We did this by comparing the cost of care for patients during 1992-93 (prior to the ERPCP) and 1996-97 (with the ERPCP). The main outcome measures were the cost of care and the total hospital stay in days for all patients during their last acute-care hospital admission. The increased funding for the ERPCP was offset by a significant decrease in the overall cost of palliative care in the acute-care facilities. There was a substantial decrease in the palliative care costs in acute facilities from 11,963,846 dollars in 1992/93 to 3,449,055 dollars in 1996/97. This can be explained by the significant decrease in the number of palliative care patient days in acute-care facilities from 22,608 during 1992/93 to 6085 during 1996/97. Physician billings were slightly higher for 1996 as compared to 1992. In 1992, 90% (195,117/427,780) of the billings were made by the specialists (internists, surgeons, and other specialists), while in 1996/97 67% (359,869/537,342) of the payments were made to primary care practitioners (p < 0.0001). Overall, there were estimated saving of 1,650,689 dollars for palliative care costs in 1996/97 as compared to 1992/93. Our results suggest that the establishment of an integrated palliative care program reduced the cost of care. Prospective cost measurement studies are required.
Collapse
Affiliation(s)
- E Bruera
- Department of Symptom Control and Palliative Care, University of Texas, M.D. Anderson Cancer Center, Houston, Texas 77030, USA
| | | | | | | | | | | |
Collapse
|
29
|
|
30
|
Affiliation(s)
- N MacDonald
- Center for Bioethics, Clinical Research Institute of Montreal, Canada
| |
Collapse
|
31
|
Abstract
As many as 90% of patients with cancer-related pain can attain satisfactory relief through available pharmacological and medical means. However, as many as 45% of patients in the earlier stages of cancer and 75% of patients in the advanced stages experience at least some pain. Although published guidelines are available, the research literature suggests that health care providers continue to hold some negative misconceptions about cancer pain and its treatment. Patients also harbor similar misconceptions that contribute to ineffective management. Interventions have been discussed in the literature, and although some have proven successful, much still needs to be done to remedy this problem. This review outlines the published guidelines for cancer pain management and describes the literature related to provider and patient barriers, as well as some interventions designed to facilitate effective cancer pain management.
Collapse
Affiliation(s)
- K L Pargeon
- Department of Psychology, University of Southern Mississippi, Hattiesburg 39406, USA
| | | |
Collapse
|
32
|
|