Pain Management in Cancer Center Inpatients: A Cluster Randomized Trial to Evaluate a Systematic Integrated Approach—The Edinburgh Pain Assessment and Management Tool

Abstract

Purpose Pain is suboptimally managed in patients with cancer. We aimed to compare the effect of a policy of adding a clinician-delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes. Patients and Methods In a two-arm, parallel group, cluster randomized (1:1) trial, we observed pain outcomes in 19 cancer centers in the United Kingdom and then randomly assigned the centers to either implement EPAT or to continue UC. The primary outcome was change in the percentage of study participants in each center with a clinically significant (≥ 2 point) improvement in worst pain (using the Brief Pain Inventory Short Form) from admission to 3 to 5 days after admission. Secondary outcomes included quality of analgesic prescribing and opioid-related adverse effects. Results Ten centers were randomly assigned to EPAT, and nine were assigned to UC. We enrolled 1,921 patients and obtained outcome data from 93% (n = 1,795). Participants (mean age, 60 years; 49% women) had a variety of cancer types. For centers randomly assigned to EPAT, the percentage of participants with a clinically significant improvement in worst pain increased from 47.7% to 54.1%, and for those randomly assigned to continue UC, this percentage decreased from 50.6% to 46.4%. The absolute difference was 10.7% (95% CI, 0.2% to 21.1%; P = .046) and it increased to 15.4% (95% CI, 5.8% to 25.0%; P = .004) when two centers that failed to implement EPAT were excluded. EPAT centers had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC. Conclusion A systematic integrated approach improves pain outcomes for inpatients in cancer centers without increasing opioid adverse effects.

Pilot randomized trial of an electronic symptom monitoring intervention for hospitalized patients with cancer

“…Importantly, symptom monitoring interventions can improve symptom management, enhance QOL, and prevent hospitalizations among patients with cancer [11][12][13][14]. Prior investigations have focused primarily on patients in the outpatient setting, yet a recent study showed that a pain assessment and management intervention for hospitalized patients with cancer could improve pain outcomes in the inpatient setting [14]. However, this study did not address other important physical and psychological symptoms, which can impact patient outcomes in the inpatient setting [2,7,8].…”

“…Patients' symptom burden represents a modifiable risk factor that, if properly addressed, may improve patient outcomes. Importantly, symptom monitoring interventions can improve symptom management, enhance QOL, and prevent hospitalizations among patients with cancer [11][12][13][14]. Prior investigations have focused primarily on patients in the outpatient setting, yet a recent study showed that a pain assessment and management intervention for hospitalized patients with cancer could improve pain outcomes in the inpatient setting [14].…”

The role of implementation science in improving distress assessment and management in oncology: a commentary on “Screening for psychosocial distress among patients with cancer: implications for clinical practice, healthcare policy, and dissemination to enhance cancer survivorship”

“…A recently published study illustrates the design and conduct of a cluster randomized trial to test a multilevel intervention to improve symptom management. In this study, 19 cancer inpatient units were randomly assigned to implement a clinician-delivered bedside pain assessment and management tool or to continue with usual care [17]. The effects of the intervention were tested by comparing changes in the percentages of patients with a clinically significant improvement in their pain at the inpatient unit level.…”

Progress in pain medicine: where are we now?

“…11,12 Whilst an objective approach to nociception may be possible, the assessment and subsequent management of pain remain subjective, and often suboptimal, even with the use of defined protocols and guidelines. 13 Education of healthcare staff and improved understanding of what factors affect clinical decision-making around analgesia are explored using neuroimaging. Empathy and risk taking were shown to be some of the factors impacting on how patients with pain were managed in the emergency department.…”