The Incidence and Risk Factors of Persistent Opioid Use After Surgery­a Retrospective Secondary Data Analysis.

BACKGROUND: The risk of persistent postoperative opioid use (PPOU) and its association with the type of surgery are still unclear in Germany. METHODS: We conducted a nationwide retrospective cohort study on the basis of claims data from BARMER, a statutory health insurance carrier in Germany. Opioid-naive adults who did not have cancer and who underwent inpatient surgery in 2018 were included in the study. The operations were divided into 103 categories. PPOU was defined as the prescribing of opioids between postoperative days 1 and 90 and also between postoperative days 91 and 180 after hospital discharge. Patient-associated risk factors in the 12 months before surgery were investigated. RESULTS: 203 327 patients were included. 1.4% had PPOU (95% confidence interval [1.4; 1.5]). There were major differences between operation groups: major amputations and orthopedic procedures carried the greatest risk for the development of PPOU. The type of surgery had a larger effect on the risk of PPOU than pre-existing risk factors (explained variance 22.3% vs. 14.3%). Among such factors, alcohol abuse and pre-existing treatment with antidepressant drugs were associated with the highest risk for PPOU (odds ratios [OR] 1.515 [1.277; 1.797] and 2.131 [1.943; 2.336]). CONCLUSION: The incidence of PPOU in Germany is low (1.4%). The type of surgery plays an important role in its development.

[Interdisciplinary multimodal pain therapy: does the dose make a difference? : A comparison from routine clinical care]. / Interdisziplinäre multimodale Schmerztherapie: Macht die Dosis einen Unterschied? : Ein Vergleich aus der klinischen Routineversorgung.

BACKGROUND: Interdisciplinary multimodal pain therapy (IMPT) is an established treatment for patients with severe chronic pain. Little evidence is available on the role of treatment dosage and, in particular, on the association between the duration of IMPT and treatment outcome. AIM: The aim of this retrospective study was to compare the medium-term treatment success of a short inpatient (SIT, 1 week) and a long outpatient (LOT, 4 weeks) IMPT with a comparable treatment concept and comparable therapy intensity (20 h/week) in patients with severe chronic pain. METHODS: Patients in both groups completed the German Pain Questionnaire at the beginning and end of IMPT as well as after 3 months. Primary outcome measures included pain-related impairment and average pain intensity at follow-up in patients of comparable sex, age as well as pain intensity and impairment at the beginning of the therapy. RESULTS: While both groups initially showed significant treatment effects in pain-related impairment and average pain intensity, LOT patients (n = 32) reported significantly better values in both variables at 3­month follow-up compared with SIT patients (n = 32). This was due to sustained positive effects in LOT patients and worsening in the SIT group. CONCLUSION: The results indicate that initial treatment effects can be observed in both treatment settings, but a longer duration of therapy seems to favour the long-term stability of treatment effects.

[What determines the overall quality of postoperative pain management? A question of perspective]. / Was ist ausschlaggebend für die Gesamtqualität der postoperativen Schmerztherapie? Eine Frage der Perspektive.

BACKGROUND: The outcome domains pain intensity, pain-related interference, side effects, (treatment) information, participation and personal interaction have all been identified as relevant factors in the management of perioperative pain. However, it is not yet clear which of these are particularly significant for the subjectively perceived overall quality of postoperative pain management. AIM: A newly developed questionnaire was used in this cross-sectional study to assess the relevance of these domains for patients and compare the relevance to healthcare professionals (HCP). METHODS: The patient survey (n = 40) was conducted on the first postoperative day at Jena University Hospital, Germany. In order to investigate group differences, 63 HCP (disciplines: n = 15 anaesthesiology, n = 17 surgery, n = 31 nursing) were recruited. The questionnaire primarily included all pairwise comparisons between the domains with regard to the overall quality of postoperative pain management. The resulting sum scores for each domain were the primary outcome measure, which were analysed using generalized estimating equations. RESULTS: Within the group of patients, there were significant differences in the prioritization of the six outcome domains, with personal interaction followed by intensity and interference having received the highest ratings. There were also significant differences within the domains between the perspectives of patients and HCP, as well as between the HCP themselves. CONCLUSIONS: The study demonstrates that personal interaction and the reduction of pain intensity and interference are three key factors that are significant for patients' experience of postoperative pain management. However, the extent to which the harmonisation of these three factors with those given prominence by HCP would positively impact postoperative pain management remains unclear and should be investigated further.

Understanding Kinesiophobia: Predictors and Influence on Early Functional Outcomes in Patients with Total Knee Arthroplasty.

This observational study aimed to identify predictors of kinesiophobia and examine its correlation with early functional outcomes in TKA recipients. On the first and fifth postoperative days (POD1 and POD5), we evaluated pain using the International Pain Outcomes Questionnaire (IPO-Q) and created multidimensional pain composite scores (PCSs). The Total Pain Composite Score (PCStotal) assesses the overall impact of pain, taking into account outcomes of pain intensity, pain-related interference with function, and emotions and side effects. Functional status on POD 5 was determined by the Barthel index, 6 min walking test, and knee range of motion. Kinesiophobia was assessed on POD5 using the Tampa Scale for Kinesiophobia (TSK). Among 75 TKA patients, 27% exhibited kinesiophobia. The final regression model highlighted PCStotal on POD5 (OR = 6.2, CI = 1.9-19.9), PCStotal (OR = 2.1, CI = 1.2-3.8) on POD1, and the intensity of chronic pain before surgery (OR = 1.4, CI = 1.1-2.1) as significant kinesiophobia predictors. On POD5, those with kinesiophobia showed increased dependency, slower gait, and poorer knee extension recovery. This study emphasizes the need to identify and address kinesiophobia in TKA patients for better functional outcomes and recovery. Additionally, it is vital to assess different domains of pain, not just pain intensity, as it can lead to kinesiophobia development.

Perceptions of Quality of Interprofessional Collaboration, Staff Well-Being and Nonbeneficial Treatment: A Comparison between Nurses and Physicians in Intensive and Palliative Care.

This study assessed differences in interprofessional collaboration, perception of nonbeneficial care, and staff well-being between critical care and palliative care teams. In six German hospitals, a staff survey was conducted between December 2013 and March 2015 among nurses and physicians in intensive and palliative care units. To allow comparability between unit types, a matching was performed for demographic characteristics of staff. N = 313 critical care and 79 palliative care staff participated, of which 72 each were successfully matched. Critical care nurses perceived the poorest overall quality of collaboration compared with critical care physicians and palliative care physicians and nurses. They also reported less inclusive leadership from attendings and head nurses, and the least collaboration on care decisions with physicians. They were most likely to perceive nonbeneficial care, and they reported the lowest levels of job satisfaction and the highest intention to leave the job. In partial correlations, aspects of high-quality collaboration were associated with less perceived nonbeneficial care and higher staff well-being for both critical care and palliative care staff. Our findings indicate that critical care teams could improve collaboration and enhance well-being, particularly among nurses, by adopting principles of collaborative work culture as established in palliative care.

Operation-specific risk of postoperative nausea: a cross-sectional study comparing 72 procedures.

OBJECTIVES: Determination of the procedure-specific, risk-adjusted probability of nausea. DESIGN: Cross-sectional analysis of clinical and patient-reported outcome data. We used a logistic regression model with type of operation, age, sex, preoperative opioids, antiemetic prophylaxis, regional anaesthesia, and perioperative opioids as predictors of postoperative nausea. SETTING: Data from 152 German and Austrian hospitals collected in the Quality Improvement in Postoperative Pain Treatment (QUIPS) registry from 2013 to 2022. Participants completed a validated outcome questionnaire on the first postoperative day. Operations were categorised into groups of at least 100 cases. PARTICIPANTS: We included 78 231 of the 293 947 participants from the QUIPS registry. They were 18 years or older, willing and able to participate and could be assigned to exactly one operation group. MAIN OUTCOME MEASURES: Adjusted absolute risk of nausea on the first postoperative day for 72 types of operation. RESULTS: The adjusted absolute risk of nausea ranged from 6.2% to 36.2% depending on the type of operation. The highest risks were found for laparoscopic bariatric operations (36.2%), open hysterectomy (30.4%), enterostoma relocation (29.8%), open radical prostatectomy (28.8%), laparoscopic colon resection (28.6%) and open sigmoidectomy (28%). In a logistic regression model, male sex (OR: 0.39, 95% CI 0.37 to 0.41, p<0.0001), perioperative nausea and vomiting prophylaxis (0.73, 0.7 to 0.76, p<0.0001), intraoperative regional anaesthesia (0.88, 0.83 to 0.93, p<0.0001) and preoperative opioids for chronic pain (0.74, 0.68 to 0.81, p<0.0001) reduced the risk of nausea. Perioperative opioid use increased the OR up to 2.38 (2.17 to 2.61, p<0.0001). CONCLUSIONS: The risk of postoperative nausea varies considerably between surgical procedures. Patients undergoing certain types of operation should receive special attention and targeted prevention strategies. Adding these findings to known predictive tools may raise awareness of the still unacceptably high incidence of nausea in certain patient groups. This may help to further reduce the prevalence of nausea. TRIAL REGISTRATION NUMBER: DRKS00006153; German Clinical Trials Register; https://drks.de/search/de/trial/DRKS00006153.

Chronic postsurgical pain: A European survey.

BACKGROUND: Chronic postsurgical pain (CPSP) is a clinical problem, and large prospective studies are needed to determine its incidence, characteristics, and risk factors. OBJECTIVE: To find predictive factors for CPSP in an international survey. DESIGN: Observational study. SETTING: Multicentre European prospective observational trial. PATIENTS: Patients undergoing breast cancer surgery, sternotomy, endometriosis surgery, or total knee arthroplasty (TKA). METHOD: Standardised questionnaires were completed by the patients at 1, 3, and 7 days, and at 1, 3, and 6 months after surgery, with follow-up via E-mail, telephone, or interview. MAIN OUTCOME MEASURE: The primary goal of NIT-1 was to propose a scoring system to predict those patient likely to have CPSP at 6 months after surgery. RESULTS: A total of 3297 patients were included from 18 hospitals across Europe and 2494 patients were followed-up for 6 months. The mean incidence of CPSP at 6 months was 10.5%, with variations depending on the type of surgery: sternotomy 6.9%, breast surgery 7.4%, TKA 12.9%, endometriosis 16.2%. At 6 months, neuropathic characteristics were frequent for all types of surgery: sternotomy 33.3%, breast surgery 67.6%, TKA 42.4%, endometriosis 41.4%. One-third of patients experienced CPSP at both 3 and 6 months. Pre-operative pain was frequent for TKA (leg pain) and endometriosis (abdomen) and its frequency and intensity were reduced after surgery. Severe CPSP and a neuropathic pain component decreased psychological and functional wellbeing as well as quality of life. No overarching CPSP risk factors were identified. CONCLUSION: Unfortunately, our findings do not offer a new CPSP predictive score. However, we present reliable new data on the incidence, characteristics, and consequences of CPSP from a large European survey. Interesting new data on the time course of CPSP, its neuropathic pain component, and CPSP after endometriosis surgery generate new hypotheses but need to be confirmed by further research. TRIAL REGISTRATION: clinicaltrials.gov ID: NCT03834922.

Trajectories of pain and opioid use up to one year after surgery: analysis of a European registry.

BACKGROUND: Long-term opioid use after surgery is a crucial healthcare problem in North America. Data from European hospitals are scarce and differentiation of chronic pain has rarely been considered. METHODS: In a mixed surgical cohort of the PAIN OUT registry, opioid use and chronic pain were evaluated before surgery, and 6 and 12 months after surgery (M6/M12). Subgroups with or without opioid medication and pre-existing chronic pain were analysed. M12-chronic pain was categorised as chronic postsurgical pain (CPSP) meeting the ICD-11 definition, chronic pain related to surgery not meeting the ICD-11 definition, and chronic pain unrelated to surgery. Primary endpoint was the rate of M12 opioid users. Variables associated with M12 opioid use and patient-reported outcomes were evaluated. RESULTS: Of 2326 patients, 5.5% were preoperative opioid users; 4.4% and 3.5% took opioids at M6 and M12 (P<0.001). Chronic pain before operation and at M6/M12 was reported by 41.2%, 41.8%, and 34.7% of patients, respectively (P<0.001). The rate of M12 opioid users was highest in group unrelated (22.3%; related 8.3%, CPSP 1.5%; P<0.001). New opioid users were 1.1% (unrelated 7.1%, related 2.3%, CPSP 0.7%; P<0.001). M12 opioid users reported more pain, pain-related physical and affective interference, and needed more opioids than non-users. The predominant variable associated with M12 opioids was preoperative opioid use (estimated odds ratio [95% confidence interval]: 28.3 [14.1-56.7], P<0.001). CONCLUSIONS: Opioid use was low in patients with CPSP, and more problematic in patients with chronic pain unrelated to surgery. A detailed assessment of chronic pain unrelated or related to surgery or CPSP is necessary. CLINICAL TRIAL REGISTRATION: NCT02083835.

Numeric rating scale for pain should be used in an ordinal but not interval manner. A retrospective analysis of 346,892 patient reports of the quality improvement in postoperative pain treatment registry.

ABSTRACT: To assess postoperative pain intensity in adults, the numeric rating scale (NRS) is used. This scale has shown acceptable psychometric features, although its scale properties need further examination. We aimed to evaluate scale properties of the NRS using an item response theory (IRT) approach. Data from an international postoperative pain registry (QUIPS) was analyzed retrospectively. Overall, 346,892 adult patients (age groups: 18-20 years: 1.6%, 21-30 years: 6.7%, 31-40 years: 8.3%, 41-50 years: 13.2%, 51-60 years: 17.1%, 61-70 years: 17.3%, 71-80 years: 16.4%, 81-90 years: 3.9%, >90: 0.2%) were included. Among the patients, 55.7% are female and 38% had preoperative pain. Three pain items (movement pain, worst pain, least pain) were analyzed using 4 different IRT models: partial credit model (PCM), generalized partial credit model (GPCM), rating scale model (RSM), and graded response model (GRM). Fit indices were compared to decide the best fitting model (lower fit indices indicate a better model fit). Subgroup analyses were done for sex and age groups. After collapsing the highest and the second highest response category, the GRM outperformed other models (lowest Bayesian information criterion) in all subgroups. Overlapping categories were found in category boundary curves for worst and minimum pain and particularly for higher pain ratings. Response category widths differed depending on pain intensity. For female, male, and age groups, similar results were obtained. Response categories on the NRS are ordered but have different widths. The interval scale properties of the NRS should be questioned. In dealing with missing linearity in pain intensity ratings using the NRS, IRT methods may be helpful.

Responsiveness of multiple patient-reported outcome measures for acute postsurgical pain: primary results from the international multi-centre PROMPT NIT-1 study.

BACKGROUND: Postsurgical outcome measures are crucial to define the efficacy of perioperative pain management; however, it is unclear which are most appropriate. We conducted a prospective study aiming to assess sensitivity-to-change of patient-reported outcome measures assessing the core outcome set of domains pain intensity (at rest/during activity), physical function, adverse events, and self-efficacy. METHODS: Patient-reported outcome measures were assessed preoperatively, on day 1 (d1), d3, and d7 after four surgical procedures (total knee replacement, breast surgery, endometriosis-related surgery, and sternotomy). Primary outcomes were sensitivity-to-change of patient-reported outcome measures analysed by correlating their changes (d1-d3) with patients' global impression of change and patients' specific impression of change items as anchor criteria. Secondary outcomes included identification of baseline and patient characteristic variables explaining variance in change for each of the scales and descriptive analysis of various patient-reported outcome measures from different domains and after different surgeries. RESULTS: Of 3322 patients included (18 hospitals, 10 countries), data from 2661 patients were analysed. All patient-reported outcome measures improved on average over time; the median calculated sensitivity-to-change for all patient-reported outcome measures (overall surgeries) was 0.22 (range: 0.07-0.31, scale: 0-10); all changes were independent of baseline data or patient characteristics and similar between different procedures. CONCLUSIONS: Pain-related patient-reported outcome measures have low to moderate sensitivity-to-change; those showing higher sensitivity-to-change from the same domain should be considered for inclusion in a core outcome set of patient-reported outcome measures to assess the effectiveness and efficacy of perioperative pain management.

Pain After Outpatient Surgical Procedures.

BACKGROUND: Approximately 8.1 million outpatient surgical procedures were performed in Germany in 2021. Little is known about the quality of postoperative pain treatment in the outpatient sector. METHODS: The AQS1 project comprises a combined survey of patients and staff in the framework of quality control for ambulatory surgery. The primary endpoint of this study was the prevalence of relevant incisional pain (≥ 4/10 on the numerical rating scale) up to postoperative day 3. Secondary endpoints included prognostic variables for pain and pain-associated outcomes, based on the AQS1 patient questionnaire. Moreover, mixed regression models were used to analyze potential prognostic variables and associations of pain with other outcomes (study registration number DRKS00028052). RESULTS: Data from 330 008 patients were evaluated (from 1 July 2001 to 31 December 2021). The overall prevalence of relevant incisional pain up to postoperative day 3 was 22.5%, with major differences between different types of procedure (3.2%-51.2%). Pain was most common after hemorrhoid surgery (51.2%) and the laparoscopic lysis of large and small bowel adhesions (45.4%). The main associations of relevant pain were with younger age (odds ratio [OR] 1.87, 95% confidence interval [1.82; 1.91]), early postoperative pain (1.34, [1.30; 1.39]), inadequate provision of analgesics (2.90, [2.71; 3.09]), and surgical wound infections (2.60, [2.43; 2.78]). Patients with pain reported lower overall satisfaction with the procedure and a longer inability to work. CONCLUSION: These data have not been tested for representativeness. They can serve as a point of departure for the optimization of individualized perioperative pain therapy and for the planning of prospective studies.

Developing consensus on core outcome sets of domains for acute, the transition from acute to chronic, recurrent/episodic, and chronic pain: results of the INTEGRATE-pain Delphi process.

Background: Pain is the leading cause of disability worldwide among adults and effective treatment options remain elusive. Data harmonization efforts, such as through core outcome sets (COS), could improve care by highlighting cross-cutting pain mechanisms and treatments. Existing pain-related COS often focus on specific conditions, which can hamper data harmonization across various pain states. Methods: Our objective was to develop four overarching COS of domains/subdomains (i.e., what to measure) that transcend pain conditions within different pain categories. We hosted a meeting to assess the need for these four COS in pain research and clinical practice. Potential COS domains/subdomains were identified via a systematic literature review (SLR), meeting attendees, and Delphi participants. We conducted an online, three step Delphi process to reach a consensus on domains to be included in the four final COS. Survey respondents were identified from the SLR and pain-related social networks, including multidisciplinary health care professionals, researchers, and people with lived experience (PWLE) of pain. Advisory boards consisting of COS experts and PWLE provided advice throughout the process. Findings: Domains in final COS were generally related to aspects of pain, quality of life, and physical function/activity limitations, with some differences among pain categories. This effort was the first to generate four separate, overarching COS to encourage international data harmonization within and across different pain categories. Interpretation: The adoption of the COS in research and clinical practice will facilitate comparisons and data integration around the world and across pain studies to optimize resources, expedite therapeutic discovery, and improve pain care. Funding: Innovative Medicines Initiative 2 Join Undertaking; European Union Horizon 2020 research innovation program, European Federation of Pharmaceutical Industries and Associations (EFPIA) provided funding for IMI-PainCare. RDT acknowledges grants from Esteve and TEVA.

Risk Factors for Severe Pain and Impairment of Daily Life Activities after Cesarean Section-A Prospective Multi-Center Study of 11,932 Patients.

Cesarean section (CS) is the most widely performed and one of the most painful surgeries. This study investigated postoperative pain after CS using patient-related outcomes (PROs) to identify risk factors for severe pain. The secondary outcome was to evaluate the influence of surgery indication (primary CS (PCS) vs. urgent CS (UCS)). This multi-center, prospective cohort study included data submitted to the pain registry "quality improvement in postoperative pain treatment" (QUIPS) between 2010 and 2020. In total, 11,932 patients were evaluated. Median of maximal pain was 7.0 (numeric rating scale (NRS) 0 to 10); 53.9% suffered from severe pain (NRS ≥ 7), this being related to impairment of mood, ambulation, deep breathing and sleep, as well as more vertigo, nausea and tiredness (p < 0.001). Distraction, relaxation, mobilization, having conversations, patient-controlled analgesia (PCA) and pain monitoring were shown to be protective for severe pain (p < 0.001). Maximal pain in PCS and UCS was similar, but UCS obtained more analgesics (p < 0.001), and experienced more impairment of ambulation (p < 0.001) and deep breathing (p < 0.05). Severe pain has a major effect on daily-life activities and recovery after CS, and depends on modifiable factors. More effort is needed to improve the quality of care after CS.

Structural characteristics and contractual terms of specialist palliative homecare in Germany.

BACKGROUND: Multi-professional specialist palliative homecare (SPHC) teams care for palliative patients with complex symptoms. In Germany, the SPHC directive regulates care provision, but model contracts for each federal state are heterogeneous regarding staff requirements, cooperation with other healthcare providers, and financial reimbursement. The structural characteristics of SPHC teams also vary. AIM: We provide a structured overview of the existing model contracts, as well as a nationwide assessment of SPHC teams and their structural characteristics. Furthermore, we explore whether these characteristics serve to find specifc patterns of SPHC team models, based on empirical data. METHODS: This study is part of the multi-methods research project "SAVOIR", funded by the German Innovations Fund. Most model contracts are publicly available. Structural characteristics (e.g. number, professions, and affiliations of team members, and external cooperation) were assessed via an online database ("Wegweiser Hospiz- und Palliativversorgung") based on voluntary information obtained from SPHC teams. All the data were updated by phone during the assessment process. Data were descriptively analysed regarding staff, cooperation requirements, and reimbursement schemes, while latent class analysis (LCA) was used to identify structural team models. RESULTS: Model contracts have heterogeneous contract partners and terms related to staff requirements (number and qualifications) and cooperation with other services. Fourteen reimbursement schemes were available, all combining different payment models. Of the 283 SPHC teams, 196 provided structural characteristics. Teams reported between one and 298 members (mean: 30.3, median: 18), mainly nurses and physicians, while 37.8% had a psychosocial professional as a team member. Most teams were composed of nurses and physicians employed in different settings; for example, staff was employed by the team, in private practices/nursing services, or in hospitals. Latent class analysis identified four structural team models, based on the team size, team members' affiliation, and care organisation. CONCLUSION: Both the contractual terms and teams' structural characteristics vary substantially, and this must be considered when analysing patient data from SPHC. The identified patterns of team models can form a starting point from which to analyse different forms of care provision and their impact on care quality.

Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study.

Introduction: The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery. Materials and methods: The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis. Results: The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines. Conclusion: The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines.

The Perioperative Pain Management Bundle is Feasible: Findings From the PAIN OUT Registry.

OBJECTIVES: The quality of postoperative pain management is often poor. A "bundle," a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a "Perioperative Pain Management Bundle" and whether this would be associated with improved multidimensional pain-related patient-reported outcomes (PROs). METHODS: "PAIN OUT," a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the "Perioperative Pain Management Bundle" into the clinical routine and collected another round of data. The bundle consists of 4 treatment elements: (1) a full daily dose of 1 to 2 nonopioid analgesics (eg, paracetamol and/or nonsteroidal anti-inflammatory drugs), (2) at least 1 type of local/regional anesthesia, (3) pain assessment by staff, and (4) offering patients information about pain management. The primary endpoint was a multidimensional pain composite score (PCS), evaluating pain intensity, interference, and side effects that was compared between patients who received the full bundle versus not. RESULTS: Implementation of the complete bundle was associated with a significant reduction in the PCS ( P < 0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, nonopioid analgesics were associated with a higher PCS (ie, poorer outcome, and negligible ES), and the other elements were associated with a lower PCS (all negligible small ES). Individual PROs were consistently better in patients receiving the full bundle compared with 0 to 3 elements. The PCS was not associated with the surgical discipline. DISCUSSION: We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.

[Identifying patients with risk for severe pain after ophthalmological surgery]. / Wie erkennt man Risikopatienten für starke Schmerzen nach Augeneingriffen?

Modern ophthalmology includes a wide range of surgical options and, accordingly, also requires appropriate pain management. There are established risk factors for severe postoperative pain that should be identified and considered in the perioperative management. The main risk factors and existing recommendations are presented in this article. Patients at risk should be identified before surgery. It is important that perioperative pain management is implemented in the treatment plan as part of an interdisciplinary cooperation to identify and address the risks as early as possible.

Association between preoperative serum C-reactive protein level and leukocyte count and postoperative pain after otolaryngological surgery.

PURPOSE: To determine whether the preoperative inflammatory serum C-reactive protein (CRP) and leukocyte count (LEUK) are associated with postoperative pain and complaints after otolaryngological surgery. METHODS: Retrospective evaluation of 680 patients (33% female, median age 50 years) receiving otolaryngological surgery between November 2008 and March 2017 in a tertiary university hospital. Postoperative pain on the first postoperative day was assessed using the validated questionnaire of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale for assessment of postoperative pain (NRS, 0-10). The influence of preoperative parameters including CRP and LEUK on patients' postoperative pain was estimated. RESULTS: Mean CRP value was 15.6 ± 34.6 mg/l and mean LEUK value 7.8 ± 3.2 Gpt/l. Patients with pharyngeal surgery had the highest CRP values (34.6 ± 52.9 mg/l), highest LEUK values (9.2 ± 4.2 Gpt/l) and the highest pain levels (3.1 ± 2.4 NRS) compared to all other surgical procedures (all p < 0.05). Higher postoperative pain was associated with LEUK values > 11.3 Gpt/l (r = 0.093, p = 0.016) and higher preoperative chronic pain (r = 0.127, p = 0.001). Multivariate analysis confirmed younger age, female gender, duration of surgery, preoperative chronic pain, type of surgery, and higher LEUK values > 11.3 as independent factors for postoperative pain. Perioperative antibiotics had no effect on the postoperative pain. CONCLUSION: Beyond known factors, preoperative LEUK as inflammation marker is an independent predictor for pain on the first postoperative day.

[Utilization of palliative care at the end of life in Germany: temporal trend (2016-2019) and regional variability]. / Inanspruchnahme von Palliativversorgung am Lebensende in Deutschland: zeitlicher Verlauf (2016­2019) und regionale Variabilität.

BACKGROUND: In Germany, palliative care (PC) is provided on a homecare, inpatient, general, and specialized basis. Since little is currently known about the temporal course and regional differences in the forms of care, the present study was aimed to investigate this. METHOD: In a retrospective routine data study with 417,405 BARMER-insured persons who died between 2016 and 2019, we determined the utilization rates of primary PC (PPC), specially qualified and coordinated palliative homecare (PPC+), specialized palliative homecare (SPHC), inpatient PC, and hospice care on the basis of services billed at least once in the last year of life. We calculated time trends and regional variability and controlled for needs-related patient characteristics and access-related county of community characteristics. RESULTS: From 2016 to 2019, total PC increased from 33.8 to 36.2%, SPHC from 13.3 to 16.0% (max: Rhineland-Palatinate), and inpatient PC from 8.9 to 9.9% (max: Thuringia). PPC decreased from 25.8 to 23.9% (min: Brandenburg) and PPC+ came in at 4.4% (max: Saarland) in 2019. Hospice care remained constant at 3.4%. Regional variability in utilization rates remained high, increased for PPC and inpatient PC from 2016 to 2019, and decreased for SPHC and hospice care. The regional differences were also evident after adjustment. CONCLUSION: Increasingly more SPHC, less PPC, and high regional variability, which cannot be explained by demand- or access-related characteristics, indicate that the use of PC forms is oriented less to demand than to regionally available care capacities. In view of the growing need for palliative care due to demographic factors and decreasing personnel resources, this development must be viewed critically.