A team of scientists have studied the impact of an algorithm-based pain management tool on the pain of cancer patients in a number of different cancer units in the UK. The scientists were based at the University of Edinburgh Institute of Genetics and Molecular Medicine, the Edinburgh Cancer Research Centre, scientists from the Institute of Population Health Sciences and Informatics in Edinburgh, and from the University of Oxford. The study was published in the American journal; Journal of Clinical Oncology and is available to read on an open access basis.
Around 50% of cancer patients can suffer from pain. Although they are offered pain relief, often the pain is not managed effectively. Problems with pain management can include treatment guidelines that do not use an explicit algorithm to assess pain, a lack of systematic monitoring of adverse effects or outcomes and no structured assessment of the pain experienced by the patient.
The scientists aimed to compare the usual care offered to cancer patients with pain at cancer units with a policy that added a clinician-delivered bedside assessment and management tool, known as the Edinburgh Pain Assessment and Management Tool (EPAT). They recruited 19 out of 40 cancer centres in the UK, and then randomly assigned the centres to either EPAT or the usual care. The patients’ ages ranged from 20 years to 90 years, which gave a mean average of 60 years. The care centres were chosen if they did not have an existing bedside pain management system, were able to recruit 100 patients within the required timescale and were not expecting to implement organisational changes that could affect pain management policies. Participants were expected to be over the age of 18, with active cancer and cancer-related pain, which had been assessed at 4 or above on a scale of 0-10, within the past 24 hours.
The health professionals who were asked to deliver the pain management were senior oncologists, oncology trainee doctors, oncology nurses and nursing care assistants. In centres where the usual care was exercised, the health team managed patients’ pain, using their clinical judgement and according to the guidelines given by the local authority. For centres using EPAT, the staff were given the EPAT data supplement and offered 1 hour training in using it. EPAT required the healthcare staff to assess a patient’s pain systematically by use of simple questions that should not be changed, by following linked treatment algorithms and the instructions on opioid prescribing and to ensure regular reassessment of pain and opioid adverse effects.
The EPAT care system is included on the bedside chart of the patient. The level of pain experienced by a patient was assessed every time the patient’s vital signs were checked. Patients were asked to rate their worst pain since the last assessment on a scale of 0-10, 0 being no pain and 10 being the worst pain they had experienced. Their responses were colour-coded: 0-2 (grey), 3-4 (yellow), 5-10 (blue). Yellow or blue scores indicated that the clinician should proceed to step 2, checking the location and nature of the pain, what made it worse or better, and checking on the symptoms that could be caused by opioid drugs. The clinician followed the right algorithm, based on the responses, to guide prescribing. One hour after medication, the chart prompted reassessment of the patient’s pain.
Introducing EPAT to the cancer centres affected pain outcomes. Patients had a clinically significant improvement in pain in those centres which used the algorithm. In usual care centres, the numbers of patients with a clinically significant improvement in pain, decreased. Whether patients were assessed by phone after being discharged or assessed as inpatients made no difference to the results. Two centres were unable to implement EPAT because they had unexpected organisational changes. The numbers of patients who had an improvement decreased in these centres. When these centres were excluded from the results, the percentage difference between usual care centres and EPAT centres increased.
Secondary outcomes included the EPAT centres offering better improvements in prescribing according to good practice. Patients who were involved in EPAT scored high satisfaction with the management of their pain and the nurses scored moderate satisfaction with the ease of using the algorithm. The study showed that EPAT could improve pain outcomes for severe or moderate cancer related pain. Adverse opioid effects did not increase in these centres and analgesics were prescribed appropriately. However the numbers of patients with controlled pain, the severity of distress caused by pain and the interference with activities that the pain caused were similar in both groups studied. The study ran for a year, but this was not long enough to change this outcome.
The scientists noted that it was difficult to implement EPAT when there were organisation and leadership changes happening. The scientists felt that this highlighted the importance of taking note of leadership and organisation factors as well as educating health staff when aiming to improve patient care. This study included a good number of UK cancer centres which were spread throughout the country. The scientists conducting the study felt that this was the first large randomised study of integrating pain and management when caring for cancer patients. They suggested that the results add to the evidence that supports implementing such systems for the benefit of the patients.
Fallon, M., et al., Pain Management in Cancer Center Inpatients: A Cluster Randomised Trial to Evaluate a Systematic Integrated Approach - The Edinburgh Pain Assessment and Management Tool, Journal of Clinical Oncology, 2018