What Are the Barriers and Facilitators for the Self-Management of Chronic Pain with and without Neuropathic Characteristics?

Chronic pain requires affected individuals to self-manage their health. This study compared barriers and facilitators of self-management in two groups of people with chronic pain: those with and without neuropathic characteristics. A cross-sectional survey study of community-dwelling Canadians was conducted. The sample (n = 710) included randomly selected participants who reported chronic pain. The Self-Report Leeds Assessment of Neuropathic Symptoms and Signs was used to screen for neuropathic characteristics. Barriers and facilitators of self-management included self-efficacy (Pain Self-Efficacy Questionnaire), depression (Patient Health Questionnaire 9), social support and relationship with health care provider (Chronic Illness Resources Survey), and pain intensity (numeric rating scale). Participants were asked which factors they felt made pain management easier or harder. Statistical analyses included frequency, percent, relative risk (RR), and 95% confidence intervals (CI). Self-confidence to manage pain was the most commonly perceived self-management barrier/facilitator by both groups; however, participants with neuropathic characteristics (n = 188) were more likely to report low self-efficacy than those without neuropathic characteristics (n = 522) (RR = 2.1, CI = 1.62-2.72, ref = high self-efficacy). Participants with neuropathic characteristics were also more likely to screen positive for depression (RR = 2.30, CI = 1.73-3.06, ref = no/mild depression). There were no group differences in social support and relationship with health professional, but 40.8% felt they were not involved as equal partners in decision making and goal setting related to their care. Health professionals should consider collaborative decision making when seeking to support self-management abilities. Addressing low self-efficacy and depression may be especially important for supporting self-management by individuals with neuropathic characteristics.

Validity of the Child Facial Coding System for the Assessment of Acute Pain in Children With Cerebral Palsy.

The purpose of the current study was to examine the concurrent and discriminant validity of the Child Facial Coding System for children with cerebral palsy. Eighty-five children (mean = 8.35 years, SD = 4.72 years) were videotaped during a passive joint stretch with their physiotherapist and during 3 time segments: baseline, passive joint stretch, and recovery. Children's pain responses were rated from videotape using the Numerical Rating Scale and Child Facial Coding System. Results indicated that Child Facial Coding System scores during the passive joint stretch significantly correlated with Numerical Rating Scale scores (r = .72, P < .01). Child Facial Coding System scores were also significantly higher during the passive joint stretch than the baseline and recovery segments (P < .001). Facial activity was not significantly correlated with the developmental measures. These findings suggest that the Child Facial Coding System is a valid method of identifying pain in children with cerebral palsy.

The Canadian STOP-PAIN project: the burden of chronic pain-does sex really matter?

OBJECTIVES: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain (CP) in individuals on waitlists of Canadian multidisciplinary pain treatment facilities. This article focuses on sex differences. Objectives were to (1) determine the pain characteristics and related biopsychosocial factors that best differentiated women and men with CP; and (2) examine whether public and private costs associated with CP differed according to sex. MATERIALS AND METHODS: Sample consisted of 441 women and 287 men who were evaluated using self-administered questionnaires and a structured interview protocol. A subsample (233 women and 137 men) recorded all pain-related expenditures in a comprehensive diary over 3 months. RESULTS: Results revealed that the burden of illness associated with CP was comparable in both sexes for average and worst pain intensity, pain impact on daily living, quality of life, and psychological well-being. The same was true for pain-related costs. The results of a hierarchical logistic regression analysis, in which sex was treated as the dependent variable, showed that factors that differentiated men and women were: work status, certain circumstances surrounding pain onset, present pain intensity, intake of particular types of pain medication, use of certain pain management strategies, pain beliefs, and utilization of particular health care resources. DISCUSSION: This study suggests that women and men who are referred to multidisciplinary pain treatment facilities do not differ significantly in terms of their pain-related experience. However, the aspects that differ may warrant further clinical attention when assessing and managing pain.

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.

Cost of illness for chronic stable angina patients enrolled in a self-management education trial.

BACKGROUND: Chronic stable angina (CSA) is a major debilitating health problem in Canada. A paucity of relevant cardiovascular data sets has precluded a detailed examination of the impact of interventions on CSA-related costs and its broader economic burden. OBJECTIVES: As part of a larger clinical trial, the authors sought to determine the short-term impact of a standardized self-management training program on CSA-related costs. A secondary objective was to estimate the total annualized cost of CSA per patient from a societal perspective. METHODS: Pre- and three-month post-test cost data were collected on 117 participants using the Ambulatory Home Care Record. Mean annualized direct, indirect and system-related CSA costs (2003 to 2005) were estimated; total per-patient CSA costs from a societal perspective were calculated as the sum of these costs. RESULTS: The mean (+/- SD) age of participants was 68+/-11 years; 80% were male. The program did not impact costs in the short-term. Direct annual out-of-pocket costs, including money paid for health care, travel to appointments, medication, equipment and home support totaled $3,267. Indirect costs, reflecting the value of all unpaid time spent by those engaged in angina-related care, were $12,963. System costs, including costs paid by public and private insurers, were $2,979. Total estimated annual CSA costs from a societal perspective were $19,209 per patient. CONCLUSIONS: These data suggest that CSA imposes a major economic burden, comparable with other prevalent conditions such as chronic noncancer pain. Advancements in self-management training research are needed to help reduce the economic burden of CSA in Canada.

A responsive evaluation of an Aboriginal nursing education access program.

Nursing education access programs have been introduced in a number of countries to address the shortage of healthcare providers of Aboriginal descent. An evaluation study of a nursing education access program in Labrador, Canada, was undertaken using a Responsive Evaluation approach. Interviews and focus groups with program stakeholders were conducted. Program effectiveness was influenced by culturally relevant curriculum, experiential and authentic learning opportunities, academic and social support, and the need for partnership building between stakeholders. The authors report key findings resulting from the Responsive Evaluation.

Challenges in accessing multidisciplinary pain treatment facilities in Canada.

PURPOSE: The objective of this survey was to examine the services offered by multidisciplinary pain treatment facilities (MPTFs) across Canada and to compare access to care at these MPTFs. METHODS: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain, having a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital and rehabilitation centre administrators in Canada, the Insurance Bureau of Canada, the Workplace Safety and Insurance Board or similar body in each province. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list for each province. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire regarding their MPTF infrastructure, clinical, research, teaching and administrative activities. RESULTS: Completed survey forms were received from 102 MPTFs (response rate 85%) with 80% concentrated in major cities, and none in Prince Edward Island and the Territories. The MPTFs offer a wide variety of treatments including non-pharmacological modalities such as interventional, physical and psychological therapy. The median wait time for a first appointment in public MPTFs is six months, which is approximately 12 times longer than non-public MPTFs. Eighteen pain fellowship programs exist in Canadian MPTFs and 64% engage in some form of research activities CONCLUSION: Canadian MPTFs are unable to meet clinical demands of patients suffering from chronic pain, both in terms of regional accessibility and reasonable wait time for patients' first appointment.

The impact of organizational culture on clinical managers' organizational commitment and turnover intentions.

OBJECTIVES: The purpose was to investigate managers' perceptions of organizational culture and attitudinal and behavioral reactions during and after restructuring, and to test a model linking culture to outcome. BACKGROUND: Healthcare reform has altered the work environment, but few studies have documented the impact of system changes on managers responsible for clinical services. METHODS: Survey data were collected from clinical managers (N = 104; 99) employed by 3 institutional boards in Newfoundland and Labrador in 2000 and 2002. Response rates were 57.6% and 47.7%, respectively. RESULTS: For both periods, most variable ratings were in the low range and depicted moderately, positive intercorrelations. Select culture variables, trust, and job satisfaction emerged as significant predictors of commitment. Although culture and trust exerted inconsistent effects on intent, satisfaction remained a predictor over time. CONCLUSION: The findings support the negative impact of reform on clinical managers, and the strong link between positive ratings of culture, trust, and satisfaction, and greater commitment and intent to stay. Greater attention should focus on promoting more positive cultures and work-related attitudes, and less turnover intentions.

Attitudes and perceptions of registered nurses during and shortly after acute care restructuring in Newfoundland and Labrador.

OBJECTIVES: To monitor changes in registered nurses' perceptions of the impact of seven years of health care restructuring in Newfoundland and Labrador (NL) and to measure the attitudinal and behavioural reactions over four years comparing the St John's region, where hospital aggregation occurred, to other regions of the province. METHODS: Data were collected on acute care nurses' personal characteristics and perceptions of the importance of reform and its impact on workplace conditions and health care quality in 1995, 1999, 2000 and 2002. Nurses' attitudes and intentions were monitored across three time periods (i.e. 1999, 2000 and 2002). RESULTS: Perceived workplace conditions and health care quality, as well as attitudes and behaviours were generally negative. However, there was some improvement over time. The temporal sequence of scores suggests that restructuring had an adverse impact on nurses' attitudes. Few significant regional differences were observed. CONCLUSIONS: Although health services restructuring had an adverse impact on nurses' attitudes, aggregation of hospitals in St John's region was achieved without further deterioration. Provincial wide initiatives are needed to promote more positive work environments and increase the organizational effectiveness.

Telehomecare: a comparison of three Canadian models.

The delivery of health care is often segmented into sectors. In Canada, hospital care has traditionally been distinct from community care, and thus the transition of patients across sectors has been challenging. This paper focuses on the systematic development of an integrated model of care for children, for the purpose of smoothing the transition from hospital to home. The new service model uses emerging telecommunications technology to link hospital care providers to patients at home and is termed "telehomecare" (THC). Independent models of THC were developed for three sites across Canada through semistructured interviews and focus groups. Participants included health care providers and administrators from the hospital and community, and patient families. The resulting models were compared using content analysis to determine whether there was a core model of THC that was generalisable across Canada. A core model of THC was identified that includes the use of videoconferencing to enable the integration of hospital- and community-based care to support patients during the initial stages of the transition to home. Each site also articulated unique characteristics in their service model that were related to the nature of their health care delivery system and patient population. This paper describes the core model of transitional care, presents a synopsis of each of the three models, and compares the models. THC provides opportunities to address limitations in the current system and to improve upon equity of access to quality care for children making the transition from hospital to home.