Using a mathematical model that describes the interplay of clinical decisions and economics, the researchers found that guideline-based cancer pain management offered effective pain relief in 80 percent of patients compared to 30 percent effectiveness for the "as needed" pain management by non-specialty providers. Pain management by oncologists was slightly more effective, but still managed the pain of only 55 percent of patients.
Guideline-based pain management is a targeted approach to addressing pain using a pre-determined treatment plan for patients. In contrast, an "as needed" approach by non-specialty providers is less methodical and its effectiveness varies depending on provider knowledge of pain and treatment intervention as well as patient willingness to report pain and ask for assistance.
The study appears in the November 2003 issue of the American Journal of Managed Care.
"Pain is one of the most commonly feared symptoms of cancer," said David Matchar, M.D., director of the Duke Center for Clinical Health Policy Research and senior author of the paper. "Not all health care providers are equally trained to assess and manage cancer pain. Guidelines can create a level playing field for everyone and it only costs a few pennies more a month to follow these guidelines, but the reduction in pain is significant for patients."
Costs were calculated based on medication cost and all associated fees for anesthesiology and surgical procedures, radiotherapy and physical therapy. After analysis, the guideline-based therapy cost an estimated $1.18 per member of a health-care organization per month; oncology-based care was 95 cents per member per month, and the non-specialty "usual care" cost 65 cents per member per month. Effectiveness of the various strategies was calculated from a re-analysis of the results from a high quality clinical research study of guideline-based cancer pain management.
The guidelines used in the study were based on those issued in 1994 from the U.S. Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) that are based on the World Health Organization's guidelines for cancer pain management called the "WHO Analgesic Ladder." Both set of guidelines utilize round-the-clock long-acting opioids with doses of short-acting opioids as standard. All patients receive non-steroidal analgesics, like aspirin or ibuprofen, or acetaminophen. Opioid side effects are recognized and treated appropriately.
From a literature review of the topic, researchers cited that oncologists tended to follow the guidelines above, but they more frequently prescribed short-term opioids and analgesics. They were also one-third less likely to recognize neuropathic pain.
Pain management by non-specialty providers was more difficult to assess because pain management techniques within this group have not been systematically studied; however, assumptions are that pain is sporadically assessed, and round-the-clock dosing with long-acting opioids, use of short term opioids and treatment of neuropathic pain is infrequent.
Matchar and colleagues used their clinical decision and economic analysis model to examine the effectiveness and cost of all of these methods and found that a systematic approach to pain management was far superior to the other two methods.
"In the world of managed care, a few pennies per member per month is not insignificant, but when you consider the dramatic increase in pain relief it stops being so much of an economic issue as it is a humanitarian one," said Matchar.
Matchar said that there are significant barriers that both doctors and patients face when trying to manage cancer pain. Health-care providers are often not trained properly to assess pain, have an inadequate knowledge of proper medications and interventions, and fear side effects and addiction. Patients, too, worry about addiction and side effects, and they also may have a reluctance to complain.
"By following guidelines, you are managing the pain of the patient who will not speak up and you are assisting the provider who may need more guidance when creating a treatment plan. It's a win-win for both patients and providers," said Matchar.
The study was funded by the Knoll Pharmaceutical Corp. Co-authors on the paper include Amy P. Abernethy, M.D., and Gregory P. Samsa, Ph.D., both of the Duke Center for Clinical Health Policy Research.
Journal
The American Journal of Managed Care