Using chart reviews to evaluate a continuing medical education (CME) program.

Context Moore's Expanded Outcomes Framework is a 7 level framework commonly used to assess the outcomes of continuing medical education (CME) programs. Levels 1 to 5 are provider-level outcomes (participation, satisfaction, knowledge, competence, and performance) while levels 6 and 7 are patient- and community-level outcomes. Chart reviews are one method to assess level 5 (performance). ECHO Ontario Chronic Pain and Opioid Stewardship ("ECHO") is a CME telementoring program that aims to increase capacity and access for primary care providers (PCPs) who manage patients with chronic pain. Objective This study uses chart reviews to evaluate ECHO's impact on PCP performance and to discuss the feasibility of performing chart reviews for evaluation purposes as per Moore's framework. Study Design Retrospective chart review Setting The practices of 12 primary care providers across Ontario who attended ECHO between June 2014 to August 2018. The inclusion criteria for PCPs was 1) attended a minimum of four ECHO sessions, and 2) clinic site must be approving of a site visit for chart reviews. Population Studied 47 patient charts were included. For each patient chart reviewed, PCPs were asked to choose patients in their practice on whom they had used ECHO-taught knowledge. Inclusion criteria for patients was 1) have chronic pain and be managed by the ECHO-participating PCP, 2) was prescribed opioids during the time frame of the study, and 3) not presented during ECHO sessions. Informed consent was obtained prior to each site visit. 1) Increased use of ECHO-taught pain and opioid management strategies 2) Feasibility of using chart reviews to evaluate PCP performance following a CME activity Results 25 (53%) patients were male and the average age was 59 (± 14) years. 24 (51%) patients had two or more pain diagnoses at baseline, with musculoskeletal pain being the most prevalent at 81%. 26 (55%) patients had comorbid mental health conditions and 13 (28%) had sleep disorders. Trends in results showed marginal, but non-significant, improvements in PCP performance after ECHO as indicated by increased use of pain and opioid management strategies. Conclusions Conducting chart reviews was a challenging method to assess provider performance. Future work to assess provider performance should include a qualitative component (in-depth interviews or focus groups) in order to complement the quantitative data and provide context for care and management decisions.

Promoting an interprofessional approach to chronic pain management in primary care using Project ECHO.

Chronic pain is a complex multidimensional condition that requires management with multiple professions' expertise. Healthcare training programs tend to adhere to curricula within their own profession with very few interactions with other groups. Project ECHO (Extension for Community Healthcare Outcomes) Chronic Pain and Opioid Stewardship is a model for interprofessional education, using tele-mentoring, case-base discussions and clinically focused presentations. The goal is to improve competency and confidence in managing complex cases in primary care. This qualitative study engaged twenty healthcare practitioners from multiple professions who had participated in ECHO in focus group discussions about managing patients with chronic pain, about their reasons for and the effect of participating in Project ECHO Ontario Chronic Pain/Opioid Stewardship, and about their perspectives on interprofessional care. The results show that participating in ECHO resulted in personal and professional benefit, and increased understanding about their own roles and limitations, as well as other healthcare professionals' roles. The participants described changes in their attitudes toward patients with chronic pain, and their colleagues from other professions. Non-physician participants were more likely to approach physicians to discuss their assessment and diagnosis as well as prescriptions. The interprofessional nature of the program was seen as positive and contributed to perceived changes in practice collaboration. These results show that healthcare professionals from multiple professions expressed mainly positive views of ECHO's emphasis on interprofessional care, with different professions appreciating different aspects of that approach.

Project ECHO Telementoring Intervention for Managing Chronic Pain in Primary Care: Insights from a Qualitative Study.

Objective: Family physicians in Canada receive little training in chronic pain management; concomitantly, they face increasing pressure to reduce their prescribing of opioids. Project ECHO Ontario Chronic Pain/Opioid Stewardship (ECHO) is a telementoring intervention for primary care practitioners that enhances their pain management skills. This qualitative study reports participants' experiences and assessment of ECHO. Design: An opportunistic sample of multidisciplinary primary care providers attending one of three residential weekend workshops participated in focus group discussions. Setting: University or hospital facilities in Toronto, Thunder Bay, and Kingston, Ontario, Canada. Subjects: Seventeen physicians and 20 allied health professionals. Methods: Six focus group discussions were conducted at three different sites during 2014 and 2015. Transcripts were analyzed using a qualitative-descriptive approach involving analytic immersion in the data, reflection, and achieving consensus around themes discerned from transcribed discussions. Results: Findings resolved into five main themes: 1) challenges of managing chronic pain in primary care; 2) ECHO participation and improvement in patient-provider interaction and participant knowledge; 3) the diffusion of knowledge gained through ECHO to participants' colleagues and patients; 4) ECHO participation generating a sense of community; and 5) disadvantages associated with participating in ECHO. Conclusions: Managing patients with chronic pain in primary care can be difficult, particularly in remote or underserved practices. Project ECHO offers guidance to primary care practitioners for their most challenging patients, promotes knowledge acquisition and diffusion, and stimulates the development of a "community of practice."

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

No 164 - Directive clinique de consensus pour la prise en charge de la douleur pelvienne chronique.

OBJECTIF: Améliorer La compréhension de la douleur pelvienne chronique (DPC) et fournir des directives cliniques factuelles qui bénéficieront aux fournisseurs de soins de santé primaires, aux obstétriciens-gynécologues et aux spécialistes de la douleur chronique. FARDEAU DE LA SOUFFRANCE: La DPC est une pathologie débilitante courante qui affecte les femmes. Elle est à l'origine d'importantes souffrances personnelles et de dépenses de santé considérables associées aux interventions, dont de multiples consultations et un grand nombre de traitements médicaux et chirurgicaux. Puisque la pathophysiologie sous-jacente de cet état pathologique complexe est mal comprise, ces traitements n'ont obtenu que des taux de réussite variables. ISSUES: Efficacité des options diagnostiques et thérapeutiques (y compris l'évaluation du dysfonctionnement myofascial); soins multidisciplinaires; un modèle de réadaptation mettant l'accent sur l'obtention d'un fonctionnement supérieur malgré la présence d'une certaine douleur (plutôt que de chercher à obtenir une guérison totale); et utilisation appropriée des opiacés pour le soulagement de la douleur chronique. PREUVES: Des recherches ont été menées dans Medline et la base de données Cochrane en vue d'en tirer les articles de langue anglaise, publiés entre 1982 et 2004, portant sur des sujets liés à la DPC, dont la gestion des soins actifs, le dysfonctionnement myofascial et les options thérapeutiques médicales et chirurgicales. Les membres du comité ont analysé la littérature pertinente, ainsi que les données disponibles tirées d'une évaluation des besoins des personnes présentant une DPC; ils ont fait appel à une approche de consensus pour l'élaboration des recommandations. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur l'examen médical périodique. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport (Tableau 1). RECOMMANDATIONS: Les recommandations visent ce qui suit : (a) compréhension des besoins des femmes présentant une DPC ; (b) évaluation clinique générale ; (c) évaluation pratique des niveaux de douleur ; (d) douleur myofasciale ; (e) médicaments et interventions chirurgicales ; (f) principes de la gestion des opiacés; (g) utilisation accrue de l'imagerie par résonance magnétique (IRM) ; (h) documentation de l'étendue de La maladie constatée au moyen de la chirurgie ; (i) thérapies non conventionnelles; (j) accès à des modèles de soins multidisciplinaires faisant appel à des composantes de physiothérapie (comme l'exercice et la posture) et de psychologie (comme La thérapie cognitivo- comportementale), conjointement avec d'autres disciplines médicales, telles que La gynécologie et l'anesthésie ; (k) attention accrue portée à La DPC dans La formation des professionnels de La sante ; et (l) attention accrue portée à la DPC dans le domaine des recherches officielles et de haut calibre. Le comité recommande que les ministères provinciaux de La Sante prennent des mesures en faveur de la création d'équipes multidisciplinaires pouvant assurer La prise en charge de cette pathologie. Chapitre 2 : Portee et definition de La douleur pelvienne chronique Chapitre 3 : Anamnese, examen physique et évaluation psychologique Chapitre 4 : Explorations Chapitre 5 : Sources de douleur pelvienne chronique Chapitre 6 : Causes urologiques et gastro-intestinales de La douleur pelvienne chronique Chapitre 7 : Dysfonctionnement myofasclal Chapitre 8 : Therapie medicale - résultats en matiere d'efficacite Chapitre 9 : Chirurgie - résultats en matiere d'efficacite Chapitre 11 : Prise en charge multidisciplinaire de La douleur chronique Chapitre 14 : Orientations futures.

Guideline for primary care management of headache in adults.

OBJECTIVE: To increase the use of evidence-informed approaches to diagnosis, investigation, and treatment of headache for patients in primary care. QUALITY OF EVIDENCE: A comprehensive search was conducted for relevant guidelines and systematic reviews published between January 2000 and May 2011. The guidelines were critically appraised using the AGREE (Appraisal of Guidelines for Research and Evaluation) tool, and the 6 highest-quality guidelines were used as seed guidelines for the guideline adaptation process. MAIN MESSAGE: A multidisciplinary guideline development group of primary care providers and other specialists crafted 91 specific recommendations using a consensus process. The recommendations cover diagnosis, investigation, and management of migraine, tension-type, medication-overuse, and cluster headache. CONCLUSION: A clinical practice guideline for the Canadian health care context was created using a guideline adaptation process to assist multidisciplinary primary care practitioners in providing evidence-informed care for patients with headache.

"Keep trying": a qualitative investigation into what patients with chronic pain gain from Project ECHO.

Objective: The study aims to investigate the patient perspective on the pathway from healthcare practitioners' presentations of their cases at a Project ECHO (Extension for Community Healthcare Outcomes) tele-clinic to the management of those patients' chronic pain. Introduction: Managing patients with chronic and complex pain constitutes a prevalent, stressful challenge in the primary care setting. Primary care physicians typically have received little training in treating such patients and, until recently, have relied heavily on opioid and other pharmaceutical therapies as part of their regimen. Project ECHO Ontario Chronic Pain and Opioid Stewardship is an interprofessional telementoring program connecting pain specialists to primary care practitioners with the aim of supporting them in managing their patients with chronic pain, although the patients concerned do not generally participate in the telementoring sessions. While a number of papers have described the benefits accruing to healthcare professionals through participating in Project ECHO, there has been little exploration concerning patients' perceptions of their care subsequent to case presentation. Methods: Using data from in-depth interviews with 20 patients along with their associated case presentation forms and the recommendations following the presentation, we look at the alignment of patient and practitioner views and inquire about the patient's perceptions of how Project ECHO affects them. Results: Results suggest that the impact on patients is indirect but positive: most respondents express pleasure in contributing to research around chronic pain management, though only two of them identified a direct impact on their own treatment. They also appreciated their practitioner's efforts to bring expert attention to the patient's situation. Conclusions: Patients whose cases are presented to Project ECHO sessions experience positive emotions at being part of the process of research and quality improvement, regardless of changes in their own conditions. This study highlights the importance to patients of their practitioners' commitment to managing their chronic pain.

Evidence-based guideline for neuropathic pain interventional treatments: spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks.

BACKGROUND: The Special Interest Group of the Canadian Pain Society has produced consensus-based guidelines for the pharmacological management of neuropathic pain. The society aimed to generate an additional guideline for other forms of neuropathic pain treatments. OBJECTIVE: To develop evidence-based recommendations for neuropathic pain interventional treatments. METHODS: A task force was created and engaged the Institute of Health Economics in Edmonton, Alberta, to survey the literature pertaining to multiple treatments. Sufficient literature existed on four interventions only: spinal cord stimulation; epidural injections; intravenous infusions; and nerve blocks. A comprehensive search was conducted for systematic reviews, randomized controlled trials and evidence-based clinical practice guidelines; a critical review was generated on each topic. A modified United States Preventive Services Task Force tool was used for quality rating and grading of recommendations. RESULTS: Investigators reviewed four studies of spinal cord stimulation, 19 studies of intravenous infusions, 14 studies of epidural injections and 16 studies of nerve blocks that met the inclusion criteria. The task force chairs rated the quality of evidence and graded the recommendations. Feedback was solicited from the members of the task force. CONCLUSION: There is sufficient evidence to support recommendations for some of these interventions for selected neuropathic pain conditions. This evidence is, at best, moderate and is often limited or conflicting. Pain practitioners are encouraged to explore evidence-based treatment options before considering unproven treatments. Full disclosure of risks and benefits of the available options is necessary for shared decision making and informed consent.

The prevalence of chronic pain in Canada.

BACKGROUND: While chronic pain appears to be relatively common, published population prevalence estimates have been highly variable, partly due to differences in the definition of chronic pain and in survey methodologies. OBJECTIVES: To estimate the prevalence of chronic pain in Canada using clear case definitions and a validated survey instrument. METHODS: A telephone survey was administered to a representative sample of adults from across Canada using the same screening questionnaire that had been used in a recent large, multicountry study conducted in Europe. RESULTS: The prevalence of chronic pain prevalence for adults older than 18 years of age was 18.9%. This was comparable with the overall mean reported using identical survey questions and criteria for chronic pain used in the European study. Chronic pain prevalence was greater in older adults, and females had a higher prevalence at older ages compared with males. Approximately one-half of those with chronic pain reported suffering for more than 10 years. Approximately one-third of those reporting chronic pain rated the intensity in the very severe range. The lower back was the most common site of chronic pain, and arthritis was the most frequently named cause. CONCLUSIONS: A consensus is developing that there is a high prevalence of chronic pain within adult populations living in industrialized nations. Recent studies have formulated survey questions carefully and have used large samples. Unfortunately, a substantial proportion of Canadian adults continue to live with chronic pain that is longstanding and severe.

The Canadian STOP-PAIN project - Part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities?

PURPOSE: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This article presents the patients' bio-psycho-social profile. METHODS: A sample of 728 patients was recruited from waitlists of eight university-affiliated MPTFs across Canada. Subjects completed validated questionnaires to: 1) assess the characteristics and impact of their pain; and 2) evaluate their emotional functioning and quality of life (QoL). Follow-up questionnaires were completed by a subgroup of 271 patients three months later. RESULTS: Close to 2/3 of the participants reported severe pain (> or = 7/10) that interfered substantially with various aspects of their daily living and QoL. Severe or extremely severe levels of depression were common (50.0%) along with suicidal ideation (34.6%). Patients aged > 60 yr were twice as likely to experience severe pain (> or = 7/10) as their younger counterparts (P = 0.002). Patients with frequent sleep problems were more at risk of reporting severe pain (P < or = 0.003). Intense pain was also associated with a greater tendency to catastrophize (P < 0.0001) severe depressive symptoms (P = 0.003) and higher anger levels (P = 0.016). Small but statistically significant changes in pain intensity and emotional distress were observed over a three-month wait time (all P < 0.05). CONCLUSION: This study highlights the severe impairment that patients experience waiting for treatment in MPTFs. Knowing that current facilities cannot meet the clinical demand, it is clear that effective prevention/treatment strategies are needed earlier in primary and secondary care settings to minimize suffering and chronicity.

The Canadian STOP-PAIN project - Part 2: What is the cost of pain for patients on waitlists of multidisciplinary pain treatment facilities?

PURPOSE: The Canadian STOP-PAIN Project was designed to document the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This paper describes the societal costs of their pain. METHODS: A subgroup of 370 patients was selected randomly from The Canadian STOP-PAIN Project. Participants completed a self-administered costing tool (the Ambulatory and Home Care Record) on a daily basis for three months. They provided information about publicly financed resources, such as health care professional consultations and diagnostic tests as well as privately financed costs, including out-of-pocket expenditures and time devoted to seeking, receiving, and providing care. To determine the cost of care, resources were valued using various costing methods, and multivariate linear regression was used to predict total cost. RESULTS: Overall, the median monthly cost of care was $1,462 (CDN) per study participant. Ninety-five percent of the total expenditures were privately financed. The final regression model consisted of the following determinants: educational level, employment status, province, pain duration, depression, and health-related quality of life. This model accounted for 35% of the variance in total expenditure (P < 0.001). CONCLUSION: The economic burden of chronic pain is substantial in patients on waitlists of MPTFs. Consequently, it is essential to consider this burden when making decisions regarding resource allocation and waitlist assignment for a MPTF. Resource allocation decision-making should include the economic implications of having patients wait for an assessment and for care.

Research funding for pain in Canada.

Chronic pain is an escalating public health problem. There are inadequate resources to assist patients suffering with pain in Canada. Therefore, it is important that research examining novel and appropriate treatment for chronic pain is conducted. To determine the current level of research funding for pain in Canada, the Canadian Pain Society conducted a survey. Of 79 active researchers performing pain-related studies, 65 received funding in the past five years amounting to a total of approximately $80.9 million. This is less than 1% of the total funding from the Canadian Institutes of Health Research and 0.25% of the total funding for health research.

Design Process and Utilization of a Novel Clinical Decision Support System for Neuropathic Pain in Primary Care: Mixed Methods Observational Study.

BACKGROUND: Computerized clinical decision support systems (CDSSs) have emerged as an approach to improve compliance of clinicians with clinical practice guidelines (CPGs). Research utilizing CDSS has primarily been conducted in clinical contexts with clear diagnostic criteria such as diabetes and cardiovascular diseases. In contrast, research on CDSS for pain management and more specifically neuropathic pain has been limited. A CDSS for neuropathic pain has the potential to enhance patient care as the challenge of diagnosing and treating neuropathic pain often leads to tension in clinician-patient relationships. OBJECTIVE: The aim of this study was to design and evaluate a CDSS aimed at improving the adherence of interprofessional primary care clinicians to CPG for managing neuropathic pain. METHODS: Recommendations from the Canadian CPGs informed the decision pathways. The development of the CDSS format and function involved participation of multiple stakeholders and end users in needs assessment and usability testing. Clinicians, including family medicine physicians, residents, and nurse practitioners, in three academic teaching clinics were trained in the use of the CDSS. Evaluation over one year included the measurement of utilization of the CDSS; change in reported awareness, agreement, and adoption of CPG recommendations; and change in the observed adherence to CPG recommendations. RESULTS: The usability testing of the CDSS was highly successful in the prototype environment. Deployment in the clinical setting was partially complete by the time of the study, with some limitations in the planned functionality. The study population had a high level of awareness, agreement, and adoption of guideline recommendations before implementation of CDSS. Nevertheless, there was a small and statistically significant improvement in the mean awareness and adoption scores over the year of observation (P=.01 for mean awareness scores at 6 and 12 months compared with baseline, for mean adoption scores at 6 months compared with baseline, and for mean adoption scores at 12 months). Documenting significant findings related to diagnosis of neuropathic pain increased significantly. Clinicians accessed CPG information more frequently than they utilized data entry functions. Nurse practitioners and first year family medicine trainees had higher utilization than physicians. CONCLUSIONS: We observed a small increase in the adherence to CPG recommendations for managing neuropathic pain. Clinicians utilized the CDSS more as a source of knowledge and as a training tool than as an ongoing dynamic decision support.

Evaluation of an innovative tele-education intervention in chronic pain management for primary care clinicians practicing in underserved areas.

INTRODUCTION: Inadequate knowledge and training of healthcare providers are obstacles to effective chronic pain management. ECHO (extension for community healthcare outcomes) uses case-based learning and videoconferencing to connect specialists with providers in underserved areas. ECHO aims to increase capacity in managing complex cases in areas with poor access to specialists. METHODS: A pre-post study was conducted to evaluate the impact of ECHO on healthcare providers' self-efficacy, knowledge and satisfaction. Type of profession, presenting a case, and number of sessions attended were examined as potential factors that may influence the outcomes. RESULTS: From June 2014 to March 2017, 296 primary care healthcare providers attended ECHO, 264 were eligible for the study, 170 (64%) completed the pre-ECHO questionnaire and 119 completed post-ECHO questionnaires. Participants were physicians (34%), nurse practitioners (21%), pharmacists (13%) and allied health professionals (32%). Participants attended a mean of 15 ± 9.19 sessions. There was a significant increase in self-efficacy (p < 0.0001) and knowledge (p < 0.0001). Self-efficacy improvement was significantly higher among physicians, physician assistants and nurse practitioners than the non-prescribers group (p = 0.03). On average, 96% of participants were satisfied with ECHO. Satisfaction was higher among those who presented cases and attended more sessions. DISCUSSION: This study shows that ECHO improved providers' self-efficacy and knowledge. We evaluated outcomes from a multidisciplinary group of providers practicing in Ontario. This diversity supports the generalisability of our findings. Therefore, we suggest that this project may be used as a template for creating other educational programs on other medical topics.

Women's Pain Experience Predicts Future Surgery for Pain Associated With Endometriosis.

OBJECTIVES: A previous randomized controlled trial from 1991 to 1993 comparing excision of endometriosis with sham surgery demonstrated no difference in reported pain after blinding between the excision and sham groups for one year. Overall, when both groups were considered, there was a significant reduction in pain one year postoperatively. This trial was done to determine the predictors of subsequent surgery. METHODS: The time to repeat surgery was the outcome of interest as a marker for significant pain. Survival analysis and log rank tests were performed to determine if the time to repeat surgery differed by group or by age, parity, original level of pain pre-operatively and stage of the disease. RESULTS: Only the reported measurement of pain prior to the initial trial was a significant covariate in the overall prediction of repeat surgery among all subjects. The overall repeat surgical operation rate was 48.3% in the sham surgery group and 51.7% in the excision group. The estimated relative risk for repeat surgery (excision vs. sham) was 1.42 (95% confidence intervals 0.539- 3.75). CONCLUSION: Pain experience preoperatively was found to be an important predictor of subsequent surgical need. In this study, age, stage of disease, and excision of endometriosis were not associated with improvement in pain as measured by the time to repeat surgery.

Creating clinically relevant knowledge from systematic reviews: the challenges of knowledge translation.

RATIONALE AND OBJECTIVE: A research translation strategy for chronic pain was developed that has significant potential to advance the usefulness of systematic reviews (SRs) in clinical practice. METHOD: The strategy used interactive case-based workshops that summarize current evidence on treatments for chronic non-cancer pain. Health technology assessment researchers and clinicians collaborated to translate SR evidence into education aids, but this proved far from straightforward. RESULTS: Sourcing and selecting the SR evidence required maintaining a credible balance between the diametrical concepts of comprehensiveness and efficiency, and relevance and validity. On examination of the collated evidence base, further challenges were encountered in dealing with the lack of consistency among the SRs in the quality of execution, the scales used to rate the quality of the evidence, and the conclusions on common topic areas. Strategies for overcoming these difficulties are discussed. CONCLUSIONS: The key elements for creating clinically relevant knowledge from SRs are: a flexible, consistent and transparent methodology; credible research; involvement of renowned content experts to translate the evidence into clinically meaningful guidance; and an open, trusting relationship among all contributors.

The Alberta Ambassador Program: delivering Health Technology Assessment results to rural practitioners.

BACKGROUND: The purpose of Health Technology Assessment (HTA) is to make the best possible summary of the evidence regarding specific health interventions in order to influence health care and policy decisions. The need for decision makers to find relevant HTA data when it is needed is a barrier to its usefulness. These barriers are highest in rural areas and amongst isolated practitioners. METHODS: A multidisciplinary team developed an interactive case-based instructional strategy on the topic of chronic non-cancer pain (CNCP) management using clinical evidence derived by HTA. The evidence for each of 18 CNCP interventions was distilled into single-sheet summaries. Clinicians and HTA specialists ('Ambassadors') conducted 11 two-hour interactive sessions on CNCP in eight of Alberta's nine health regions. Pre- and post-session evaluations were conducted. RESULTS: The sessions were attended by 130 individuals representing 14 health and administrative disciplines. The ambassador model was well received. The use of content experts as ambassadors was highly rated. The educational strategy was judged to be effective. Awareness of the best evidence in CNCP management was increased. Although some participants reported practice changes as a result of the workshops, the program was not designed to measure changes in patient outcome. CONCLUSION: The ambassador program was successful in increasing awareness of the best evidence in CNCP management, and positively influenced treatment decisions. Its teaching methods were felt to be unique and innovative by participants. Its methods could be applied to other clinical content areas in order to increase the uptake of the results of HTA.

Laparoscopy and reported pain among patients with endometriosis.

OBJECTIVE: To compare the effectiveness of sharp excision of endometriosis with sham surgical excision in alleviating endometriosis-associated pain for up to 1 year following surgery. METHODS: Patients requiring a laparoscopy for severe pelvic pain were eligible. If endometriosis was visually identified at laparoscopy, a biopsy of a representative lesion was taken. The women were then randomized either to have all remaining endometriosis excised with laparoscopic scissors (the excision group) or to have no further surgical treatment (the control group). Patients were asked to complete daily pain scales for 1 month preoperatively and quarterly for 1 year postoperatively. Subjects were blinded to their treatment allocation for 1 year. RESULTS: Twenty-nine women underwent laparoscopy and biopsy and were randomized to have excision or no treatment of endometriosis. The excision and control groups were similar in age, parity, and revised American Society for Reproductive Medicine stage of disease. Sixteen women completed the full year of follow-up: 9 in the excision group, and 7 in the control group. Overall, recorded pain was significantly reduced at 1 year (P < 0.05), with no significant difference between the excision and control groups. CONCLUSION: Laparoscopy with diagnostic biopsy alone is associated with a significant reduction in pain for up to 1 year postoperatively. Although the study lacked sufficient statistical power to exclude an effect of excision, pain relief in each group was similar. These results indicate a potential benefit of sham surgical procedures in assessing novel surgical interventions.

Consensus guidelines for the management of chronic pelvic pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (f) principles of opiate management; (g) increased use of magnetic resonance imaging (MRI); (h) documentation of the surgically observed extent of disease; (i) alternative therapies; (j) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical isciplines, such as gynaecology and anesthesia; (k) increased attention to CPP in the training of health care professionals; and (l) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition. CHAPTER 7: MYOFASCIAL DYSFUNCTION: 1. Health care providers should become more aware of myofascial dysfunction as a cause of chronic pelvic pain (CPP) and the available treatment options (IB). 2. Patients should participate in the management of CPP due to myofascial dysfunction by actively using a home stretching and exercise program (ll-2B). CHAPTER 8: MEDICAL THERAPY--EVIDENCE ON EFFECTIVENESS: 1. Opioid therapy can be considered for pain control under adequate supervision (II-3B). 2. Hormonal treatment of chronic pelvic pain of gynaecologic origin, including oral contraceptives, progestins, danazol, and gonadotropin-releasing hormone agonists, has been studied extensively and should be considered as the first line for many women, especially those with endometriosis (I and II-1A). 3. Adjuvant medications, such as antidepressants and antibiotics, can be of supporting help in specific situations (II-3B). CHAPTER 9: SURGERY-EVIDENCE ON EFFECTIVENESS: 1. The lack of robust clinical trials of the surgical management of chronic pelvic pain should be addressed. The use of alternative epidemiologic models, including case-controlled and cohort-controlled trials, should be considered (III-A). 2. Further delineation of the role of appendectomy and of presacral neurectomy appears warranted in the management of endometriosis-related pain (III-A). CHAPTER 11: MULTIDISCIPLINARY CHRONIC PAIN MANAGEMENT: 1. Multidisciplinary chronic pain management should be available for women with chronic pelvic pain within the publicly funded health care system in each province and territory of Canada (III-B). CHAPTER 14: FUTURE DIRECTIONS: 1. The curriculum for professional development should be expanded to include theory and techniques in the management of myofascial dysfunction (A). 2. Research into CPP should be encouraged, particularly in the areas of the impact of CPP on the use of health services, the pathophysiology of myofascial dysfunction, and gene therapy. Because randomized trials for qualitative outcomes are exceedingly difficult, alternative robust models, such as case-controlled or cohort-controlled trials, should be pursued (A). 3. Methods of improving interaction with patients should be explored. They might include formal contractual approaches to managing pain with opiates and efforts to better appreciate the patient's perceived needs (A).

Consensus guidelines for the management of chronic pelvic pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; (j) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.