Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation.

OBJECTIVES: With ever increasing mandates to reduce costs and increase the quality of pain management, health care institutions are faced with the challenge of adopting innovative technologies and shifting workflows to provide value-based care. Transaction cost economic analysis can provide comparative evaluation of the consequences of these changes in the delivery of care. The aim of this study was to establish proof-of-concept using transaction cost analysis to examine chronic pain management in-clinic and through telehealth. METHODS: Participating health care providers were asked to identify and describe two comparable completed transactions for patients with chronic pain: one consultation between patient and specialist in-clinic and the other a telehealth presentation of a patient's case by the primary care provider to a team of pain medicine specialists. Each provider completed two on-site interviews. Focus was on the time, value of time, and labor costs per transaction. Number of steps, time, and costs for providers and patients were identified. RESULTS: Forty-six discrete steps were taken for the in-clinic transaction, and 27 steps were taken for the telehealth transaction. Although similar in costs per patient ($332.89 in-clinic vs. $376.48 telehealth), the costs accrued over 153 business days in-clinic and 4 business days for telehealth. Time elapsed between referral and completion of initial consultation was 72 days in-clinic, 4 days for telehealth. CONCLUSIONS: U.S. health care is moving toward the use of more technologies and practices, and the information provided by transaction cost analyses of care delivery for pain management will be important to determine actual cost savings and benefits.

Redesigning delivery of opioids to optimize pain management, improve outcomes, and contain costs.

INTRODUCTION: Chronic pain is a public health concern, and in the last decade, there has been a dramatic increase in the use and abuse of prescription opioids for chronic non-cancer pain. METHODS: We present an overview of a five-component model of pain management implemented at the University of Washington Division of Pain Medicine designed to facilitate recent state guidelines to reduce the risks associated with long-term use of prescription opioids. RESULTS: Central to the model described are guidelines for best clinical practice, a collaborative care approach, telehealth solutions, comprehensive prescription-monitoring, and measurement-based care. DISCUSSION: The model presented is a patient-centered, efficient, and cost-effective approach to the management of chronic pain.

Effects of nefopam on early postoperative hyperalgesia after cardiac surgery.

OBJECTIVE: The purpose of this randomized, double-blind placebo-controlled study was to evaluate the effect of nefopam, a centrally acting antinociceptive compound, on the development of hyperalgesia after sternotomy. Preventive strategy giving nefopam from the early stage of anesthesia was compared with a postoperative strategy only and placebo. DESIGN: This study was double-blinded and randomized. SETTING: It was conducted in a single university hospital. PARTICIPANTS: Ninety American Society of Anesthesiologists II to III patients scheduled for elective cardiac surgery. INTERVENTIONS: Patients were assigned randomly to receive a 0.3-mg/kg bolus of nefopam at the induction of anesthesia followed by a continuous infusion of 0.065 mg/kg/h for 48 hours (G1), a 0.3-mg/kg bolus of nefopam at the end of surgery followed by a continuous infusion of 0.065 mg/kg/h for 48 hours (G2), or a placebo (G3). Postoperative analgesia was based on morphine patient-controlled analgesia and rescue analgesia when necessary. Postoperative hyperalgesia, pain scores, morphine consumption, and postoperative cognitive dysfunction were assessed for the first 48 hours and thereafter on postoperative days 4 and 7. MEASUREMENTS AND MAIN RESULTS: The postoperative extent of dynamic hyperalgesia and the decrease of the nociceptive threshold evaluated by von Frey filaments at the sternal midline were smaller in group 1 and group 2 compared with the placebo group at the 24th hour. The primary objective was the extent of hyperalgesia at the midline given as the mean (standard deviation [SD]) (4.4 [2.5] cm for G1, 4.1 [2.7] for G2, and 6.1 [2.7] cm for G3. The punctuate is given as mean (SD) (64 [43] g for G1, 68 [40.8] g for G2, and 32 [27] g for G3; with p < 0.05 for the comparisons of extent and punctuate hyperalgesia between G1 and G3 and G2 and G3). The extent of hyperalgesia was not significantly different among the 3 groups on days 2, 4, and 7 after surgery. There were no significant differences in pain scores, morphine consumption, or postoperative cognitive dysfunctions. CONCLUSIONS: Nefopam administered during the perioperative period slightly reduced acute hyperalgesia after cardiac surgery, but this was not associated with improved analgesic efficacy.

Treatment of chronic non-cancer pain.

Chronic pain is a pervasive problem that affects the patient, their significant others, and society in many ways. The past decade has seen advances in our understanding of the mechanisms underlying pain and in the availability of technically advanced diagnostic procedures; however, the most notable therapeutic changes have not been the development of novel evidenced-based methods, but rather changing trends in applications and practices within the available clinical armamentarium. We provide a general overview of empirical evidence for the most commonly used interventions in the management of chronic non-cancer pain, including pharmacological, interventional, physical, psychological, rehabilitative, and alternative modalities. Overall, currently available treatments provide modest improvements in pain and minimum improvements in physical and emotional functioning. The quality of evidence is mediocre and has not improved substantially during the past decade. There is a crucial need for assessment of combination treatments, identification of indicators of treatment response, and assessment of the benefit of matching of treatments to patient characteristics.

Target-controlled dosing of remifentanil during cardiac surgery reduces postoperative hyperalgesia.

OBJECTIVE: One of the strategies to attenuate opioid-induced hyperalgesia (OIH) may be to decrease intraoperative doses of opioids by using target-controlled infusion (TCI). DESIGN: Double-blind and randomized study. SETTING: A single university hospital. PARTICIPANTS: Forty American Society of Anesthesiologists II to III patients scheduled for elective cardiac surgery. INTERVENTIONS: patients were randomized to 1 of the 2 groups: 1 group received an infusion of intraoperative remifentanil using TCI (target: 7 ng/mL), and the 2nd one was given an intraoperative continuous infusion (CI) (0.3 µg/kg/min). The anesthestic protocol and postoperative pain management were the same in both groups. The extent of mechanical dynamic hyperalgesia on the middle line perpendicular to the wound was considered the primary endpoint. The secondary endpoints were other results of dynamic and punctuate hyperalgesia until postoperative day 7, visual analog scale (VAS) and verbal rating scale (VRS) scores, and total morphine consumption until postoperative day 2. MEASUREMENTS AND MAIN RESULTS: Morphometric and demographic characteristics and duration of surgery were comparable in both groups. Intraoperative remifentanil consumption was greater in CI than in TCI group (5,329 [1,833] v 3,662 [1,160] µg, p = 0.003). During the first 44 hours, there were no differences in morphine consumption, VAS, and VRS. The extent of hyperalgesia was significantly lower on postoperative days 1, 2, and 4 in the TCI group than in the CI group on the 3 evaluated lines (p < 0.05). Punctuate hyperalgesia evaluating 3 different points was lower in the TCI than in the CI group from postoperative day 1 until postoperative day 7 (p < 0.05). CONCLUSIONS: The intraoperative decrease of opioid consumption when comparing the CI versus TCI mode of administration of remifentanil led to less OIH after cardiac surgery.

Ethical decision-making: do anesthesiologists, surgeons, nurse anesthetists, and surgical nurses reason similarly?

BACKGROUND: Principle-based ethical theory is currently available to guide health care professionals in clinical decision-making when they face ethical dilemmas. These principles include respect for autonomy (RA), nonmaleficence (NM), beneficence (B), and distributive justice. It is, however,unknown which principles, if any, guide physicians and nurses in this decision-making. The goal of our study was to explore how anesthesiologists, surgeons, nurses, and nurse anesthetists reason in the face of a moral dilemma. METHODS: By an anonymous survey we asked: Would you give a blood transfusion to a young, ASA I, Jehovah's Witness who clearly refused transfusion, in a case of a life-threatening bleeding? What ethical principle did you apply in your decision?We presented this question before and after a 1-hour ethical tutorial about these principles. RESULTS: Twenty-nine anesthesiologists, 41 surgeons, 21 surgical nurses, and 33 nurse anesthetists participated in our survey. We found that 59%, 30%, 29%, and 36% of anesthesiologists, surgeons,surgical nurses, and nurse anesthetists, respectively, would give a blood transfusion despite the patient's demand. Nurses used B, surgeons NM, and anesthesiologists B and NM to justify transfusion. However, two among 11 anesthesiologists and five among 12 surgeons did not explain their choice. Those who tend to withhold blood transfusion overwhelmingly used RA as the principle behind this decision. Nine participants changed their view before and after the tutorial. There was no correlation between gender, age, and professional experience with the choice of principle. The average interest score for the tutorial was 74/100 for all participants after this ethical course. CONCLUSIONS: Anesthesiologists tend to transfuse Jehovah's Witness patients more than did the others. Together with surgeons, they explicitly justify their decision-making less frequently when compared with nurses and nurse anesthetists. Further education in ethical theory is appreciated and needed.

Percutaneous pulsed radiofrequency reduces mechanical allodynia in a neuropathic pain model.

BACKGROUND: Neuropathic pain is a result of a primary lesion or dysfunction of the peripheral or central nervous system, and its treatment is challenging. Animal models have been helpful in understanding mechanisms of neuropathic pain and in developing new treatment strategies. In this study, we examined the effect of percutaneous pulsed radiofrequency (PRF), which is a minimally invasive pain treatment method, on mechanical allodynia in a neuropathic pain rat model. METHODS: Neuropathic pain was achieved in a peripheral nerve pain model by performing L5-6 spinal nerve ligation. On the 14th postoperative day, percutaneous PRF was applied to the plantar side of the left rear paw. Animals were evaluated for mechanical allodynia with both dynamic plantar aesthesiometer (DPA) (weight and paw withdrawal time) and von Frey filaments (VF) on the 14th postoperative day and 1, 3, 5, 7, 10, and 14 days after PRF treatment. Experiments were conducted in six groups: Sham-operated+placebo PRF 6 min, sham-operated+PRF 6 min, neuropathic (NP)+2 min placebo PRF, NP+2 min PRF, NP+6 min placebo PRF, and NP+6 min PRF. RESULTS: Allodynia developed in all animals in the NP groups compared to sham-operated animals (P=0.0001). DPA and VF showed that PRF application for 2 min significantly improved allodynia on 1-14th post-PRF day, compared to placebo PRF (P=0.0001). Although DPA (both weight and paw withdrawal time) did not show any therapeutic effect from 6 min PRF application on 1-14th post-PRF days (P=1.00), VF demonstrated transient improvement for the first week, which disappeared on later evaluations of the 6 min PRF group. CONCLUSIONS: Percutaneous PRF is an effective treatment option in the NP pain model, and further studies are needed to clarify its underlying mechanisms of action.

Voluntary informed consent in research and clinical care: an update.

Informed consent is important: in research, it allows subjects to make an informed and voluntary choice to participate--or refuse to participate--in a project where they will be asked to take risks for the benefit of others. In both research and clinical care, informed consent represents a permission to intervene on a person's private sphere. The elements of informed consent are usually described as disclosure, understanding, decision-making capacity, and voluntariness. Each poses distinct difficulties, and can be amenable to improvements. However, research on the quality of informed consent and on strategies intended to improve it have only become the object of research relatively recently. In this article, we describe some results of this research, and outline how they can be relevant to informed consent in research and clinical care. Although much of the data suffers from limitations, it does suggest that disclosure has improved, but is still uneven, comprehension is often poor, for both patients and research subjects. Moreover, trust is a motivating factor for research participation, and thus we run risks if we allow false expectations and prove ourselves unworthy of this trust. Although improving consent forms does not have a clear effect on understanding, improving the consent process may help. Finally, better information may decrease anxiety and seems to have at most a small negative effect on research recruitment.

Attitudes and beliefs regarding the role of interventional pain management at the end-of-life among caregivers: a 4-year perspective.

Intrathecal and epidural opioid analgesia represents a major advance in the management of cancer pain, adding a new dimension to opioid therapy by allowing prolonged analgesia through the use of significantly lower doses than those required for systemic administration. However, myths, misconceptions, and apprehension continue to serve as major barriers to effective cancer pain management, and concerns regarding safety, efficacy, and relative ease of utilization still prevail. This, in turn, results in unnecessary suffering, depression, diminished cognitive function, sleep disturbance, functional disability, and compromised quality of life. We conducted a survey to systematically explore medical and paramedical attitudes prior to and 4 years after the introduction an interventional pain program and attempted to qualitatively analyze what appeared as main facilities or difficulties following end-of-life clinical experiences. In general we found that all caregivers were satisfied from using interventional pain relief techniques at the end-of-life; more so among caregivers directly involved in patient care. Although nearly half of the responders initially found "technical manipulations" moderately difficult to difficult, after a simple hands-on instruction all found these techniques to be "helpful, simple and feasible." "When all went well," caregivers found implantable devices as a useful tool to relieve pain, to increase the ability of patients to complete personal endeavors, notably mobilization, but also noted an increased patient anxiety at the end-of-life. "When all went wrong," caregivers evoked the paradoxical attitude of patients to having a "high-tech" treatment at the end-of-life, causing them eventually to have "false hope," as well as the phenomenon of "interdisciplinary hyperactivity," creating what was referred to as therapeutic futility. In summary, this study suggests the importance on insisting to introduce novel techniques into practice despite initial apprehension, however, quality improvement by detecting and overcoming attitudinal barriers remain primordial and requires narrative research.

Ethical and epistemological problems when applying evidence-based medicine to pain management.

Epistemology, or the theory of knowledge, is a branch in philosophy concerned with the definitions of knowledge and evidence. Although evidence-based medicine (EBM) has a strong ethical imperative behind it, rooted in the concern to do no harm, to do one's best for one's patients, and by doing so--eliminating waste, it still harbors within it serious epistemological limits. These include methodological and ethical limits to perform randomized controlled trials, the idea of "hierarchy of evidence" which may provide conclusions well short of medical knowledge, and the unique use of a single particular theory of statistical inference which is far from consensual. In this article, we review these difficulties and suggest that EBM is at best a methodological solution to some clinical phenomena, but remains blind to mechanisms of explanation and causation needed, in order to advance our knowledge. Further research in the theory of evidence and inference, causation and correlation, clinical judgment and collective knowledge, the structure of medical theory, and the nature of clinical effectiveness are needed.

Percutaneous vertebroplasty in octogenarians: results and follow-up.

OBJECTIVES: To determine pain relief, performance status, morbidity, and mortality associated with percutaneous vertebroplasty for spinal pain in patients aged 80 years and older. DESIGN: Prospective, descriptive, third-party independent interview, clinical audit. SETTING: University Hospital, Geneva, Switzerland. PARTICIPANTS: Patients aged 80 years and older who underwent vertebroplasty between August 1997 and August 2004 because of vertebral fractures from osteoporotic or malignant etiologies. METHODS: Primary outcome measures were verbal rating scale (VRS) (0--no pain, 5--intolerable) and Eastern Cooperative Oncology Group (ECOG) performance status scale (0--normal activity, 4--unable to get out of bed) before and after procedure. Patients were interviewed 8 to 35 months post treatment (mean 25), independently assessed for pain relief, analgesic consumption, and overall satisfaction by using the American Society of Anesthesiologists (ASA) Outcome Measures questionnaire. RESULTS: Mean VRS scores significantly decreased from 4.86 +/- 0.64 to 2.39 +/- 1.14 (P < 0.05), and mean ECOG performance scores improved from 1.87 +/- 0.97 to 1.29 +/- 1.06 (P < 0.05) after treatment. When patients were analyzed by etiology (group 1--cancer; group 2--osteoporosis), both groups significantly reduced their VRS (P < 0.05); however, only group I significantly improved their performance (P < 0.05; P = 0.334, respectively). Nine patients answered the ASA questionnaire (18 deceased, 1 demented, 1 lost to follow-up) and reported an improvement in their ability to perform daily tasks. No early or late complications were observed; none of the deaths were procedure-related. CONCLUSIONS: Percutaneous vertebroplasty is a safe, minimally invasive, well-tolerated analgesic procedure among octogenarians suffering from spinal pain, permitting increased activities of daily living. Pain reduction is significant regardless of the etiology; performance scores are significantly improved in cancer pain.

Acute differential modulation of synaptic transmission and cell survival during exposure to pulsed and continuous radiofrequency energy.

Pulsed radiofrequency, in which short bursts of radiofrequency energy are applied to nervous tissue, has been recently described as an alternative technique devoid of nerve injury, a subsequent side effect of thermal lesions created by continuous radiofrequency lesioning. Yet the mechanism of this effect remains unclear. In this study we compared the acute effects of pulsed versus continuous radiofrequency energy on impulse propagation and synaptic transmission in hippocampal slice cultures and on cell survival in cortical cultures. A differential effect was observed on both systems, with pulsed radiofrequency producing a transient and continuous radiofrequency a lasting inhibition of evoked synaptic activity. In addition, although both continuous radiofrequency and pulsed radiofrequency treatments induced a distance-dependent tissue destruction under the stimulating needle, the effect was more pronounced in the continuous radiofrequency group. These findings suggest that the acute effects of pulsed radiofrequency are more reversible and less destructive in nature than the classic continuous radiofrequency mode, even in normothermal conditions. This model might help elucidate the importance of various parameters for the clinical application of radiofrequency lesioning and might open new horizons for the role of pulsed radiofrequency lesioning in cases of neuropathic pain.

Pain medicine versus pain management: ethical dilemmas created by contemporary medicine and business.

The world of health care and the world of business have fundamentally different ethical standards. In the past decades, business principles have progressively invaded medical territories, leading to often unanticipated consequences for both patients and providers. Multidisciplinary pain management has been shown to be more effective than all other forms of health care for chronic pain patients; yet, fewer and fewer multidisciplinary pain management facilities are available in the United States. The amazing increase in interventional procedures and opioid prescriptions has not led to a lessening of the burden of chronic pain patients. Ethical dilemmas abound in the treatment of chronic pain patients: many are not even thought about by providers, administrators, insurance companies, or patients. We call for increased pain educational experiences for all types of health care providers and the separation of business concepts from pain-related health care.

What does it mean to call chronic pain a brain disease?

UNLABELLED: Multiple investigators have recently asked whether neuroimaging has shown that chronic pain is a brain disease. We review the clinical implications of seeing chronic pain as a brain disease. Abnormalities noted on imaging of peripheral structures have previously misled the clinical care of patients with chronic pain. We also cannot assume that the changes associated with chronic pain on neuroimaging are causal. When considering the significance of neuroimaging results, it is important to remember that "disease" is a concept that arises out of clinical medicine, not laboratory science. Following Canguilhem, we believe that disease is best defined as a structural or functional change that causes disvalue to the whole organism. It is important to be cautious in our assertions about chronic pain as a brain disease because these may have negative effects on 1) the therapeutic dialogue between clinicians and patients; 2) the social dialogue about reimbursement for pain treatments and disability due to pain; and 3) the chronic pain research agenda. Considered scientifically, we may be looking for the cause of chronic pain through neuroimaging, but considered clinically, we are in fact often looking to validate pain complaints. We should not yield to the temptation to validate pain with the magnetic resonance imaging scanner (structural or functional). We should not see pain as caused by the brain alone. Pain is not felt by the brain, but by the person. PERSPECTIVE: Neuroimaging investigators have argued that brain imaging may demonstrate that chronic pain is a brain disease. We argue that "disease" is a clinical concept and that conceiving of chronic pain as a brain disease can have negative consequences for research and clinical care of patients with chronic pain.