Doctors must lead efforts to reduce waste and variation in practiceBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3668 (Published 06 June 2013) Cite this as: BMJ 2013;346:f3668
All rapid responses
Chris Ham’s opinion that doctors must lead the efforts to reduce waste and variation in practice should be a wake up call for all clinicians working in musculoskeletal pain services (MSK) .1 I will refer to recent journal publications to support my response.
One in three primary care consultations are due to musculoskeletal pain complaints. While large numbers of patients respond to management in primary care, a few continue to experience disability and a disproportionately high NHS costs are incurred in their care. The research evidence available for clinicians, to predict likelihood of treatment effectiveness, is limited. The resultant provision, by default, of marginally beneficial treatments and revolving door access to care is wasteful and risks causing iatrogenic harm.
The pain problems are invariably linked with distress and sufferers perceive a poorer emotional and functional quality in their lives. The standard approach that targets physical pain first and later addresses emotional factors, as an afterthought, is clearly not working. In fact, depression is four times more prevalent among chronic pain sufferers and pain is quoted as depression’s most common bedfellow.2 Expressing opinion on the relative value of psychological or psychiatric care for this group is not the purpose of this comment. However, in practice, it must be noted that psychological therapies are the mainstay of treatment for emotional adversity in secondary care.
In an article on opiates for treatment of chronic non-malignant pain, authors presented a clear analysis of the indications, effects and risks.3 Despite the extensive use of opiates for non-malignant pain, long-term benefits to patients have never been demonstrated. A higher prevalence of death observed in those who received opiates from physicians compared to illicit users in the USA is a worrying trend. Although they described clinical observation, opiate contract and monitoring, a planned structure for objective monitoring was not proposed. There is clearly a need for developing a structure to prevent similar harm in the UK.
In general, the world now is increasingly reliant on IT (information technology) as the main enabler in life and it is increasingly implemented in healthcare. Opinions that PROMs (patient reported outcome measurements) could be used to plan “real value” healthcare to patients are also often published. An International consensus guideline for the measurement of chronic pain was proposed in 2003 (www.immpact.org).4 It is reasonable to assume that measuring functional adversity, using generic health related quality of life questionnaire (for example SF36), may assist clinicians to improve value.5
A recent volume of an anaesthetic journal was devoted to the topics relating to the Map of medicine pain pathways. A chapter dealt with “comprehensive assessment of chronic pain patients” recommends the use of holistic evaluation with questionnaires to enrich clinical information. 6 A wider adoption of pathways and compliance will however, depend on the ease of use and whether users perceive improved functional benefits to their patients.
Now, consider the case of “problem pain patients” leaving primary care to access secondary or community MSK services. For some, this started their revolving door journey within the system punctuated with specialists’ attention and treatments, yet with no “real benefit” of improved function. The question is whether PROMs based IT supported, service incorporating routine objective functional assessment may prompt clinicians to function differently?
Perhaps clinicians armed with the report may exercise caution in escalating physical treatments if emotional functions are progressively worsening. They may refrain from escalating pain-directed physical treatments in the presence of major depression. Everyone knows that injection for pain is not a treatment for co-morbid depression.
Again a clinician who observes an absence of functional improvement (emotional and physical) may refrain from escalating opiates to chase pain relief.
Exploring emotional issues, perceived as stigmatizing, with patients presenting with predominantly physical symptoms is always difficult. The availability of a PROMs report provides a platform to base difficult negotiations during an emotionally charged consultation. The routine use of PROMs has been evaluated in a Denmark pain service and was proven feasible.7
I considered writing this letter after reading a pain specialist’s comments at his retirement.8
He said; “I am leaving pain medicine a somewhat disappointed man.
What I hoped was that skillful treatments would mean that we could make lots of people better; unfortunately that has not been my experience nor is it of many pain doctors. Yet we are reluctant to admit as much, even to ourselves”.
He then despaired on the futility of injections practiced and continues: “For some of us in the independent sector, they are a lucrative source of income too. We have seen the vigour with which some of these interventions have been defended by pain physicians as a whole, despite the lack of evidence that will persuade our commissioners”.
He then rightly questions, “If these procedures were not so prominent in independent practice, they would have been investigated better and defended with less vigour.”
For that he says, “Pain doctors of my vintage owe the specialty an apology, because we knew all this but did nothing to gather the evidence and I apologise for my part in this”.
We currently provide 21st century care within a structure designed for the mid 20th century. Perhaps incorporating PROMs with an IT structure and clinicians’ commitment to objectively measure what we are doing may transform the service. Clinicians are best placed to respond to the challenge. May be then, some of us could reflect on our pain specialist job as a job well done! We may even wonder how we managed the service before we started objective measurements.
“We can only be sure to improve what we can actually measure” (Quality care for the 21st century- Lord Darzi 2008).
1) C. Ham. Doctors must lead efforts to reduce wasteful practice. BMJ 2013; 346: 27.
2) Godlee F. Editor’s choice BMJ 2012; 345: e6851.
3) Freynhagen R, Geisslinger G, Schung S A. Opioids for chronic non cancer pain. BMJ 2013; 346: 38-41.
4) Turk DC, Dworkin RH, Allen RR, Bellamy N, Brandenburg N, Carr DB et al. Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain 2003; 106(3):337-345.
5) Contopoulos-Ioannidis DG, Karvouni A, Kouri I, Ioannidis JP. Reporting and interpretation of SF-36 outcomes in randomised trials: systematic review. BMJ 2009; 338:a3006.
6) Dansie E J, Turk D C. Assessment of patients with chronic pain. British Journal of Anaesthesia 2013; 111(1): 19-25.
7) Becker N, Bondegaard, Thomsen A, Olsen AL Sjogrean P, Bech P, Eriksen J. Pain epidemiology and HRQOL in chronic non-malignant pain patients referred to a Danish multidisciplinary pain centre. Pain 1997;73(3): 393-400.
8) Skinner A. Thoughts of member: Home run-- A personal valediction. Pain news 2013; 11 (1): 23-24.
Competing interests: No competing interests
The OECD lists the US as topping the worldwide cost of providing healthcare at 17.6% of GDP, or $8,233 per person. How much progress have the medical leaders at Kaiser made towards providing the more efficient healthcare offered by the NHS for $3,433 or 9.6% of GDP?
Competing interests: No competing interests