The complexity and prevalence of chronic noncancer pain challenges existing models of service delivery. More than 80% of people experiencing chronic noncancer pain do not receive timely pain treatment, and this brings an associated risk of deterioration while waiting.26,40,47The number of people with chronic noncancer pain in Australia is predicted to increase from 3.24 million in 2018 to 5.23 million in 2050.16 Current health care systems struggle to contain the costs of chronic pain, estimated at more than 200 billion Euros in Europe, 150 billion dollars in the United States, and 73.2 billion dollars in Australia per annum.16,57
At public hospital tertiary pain centers in Australia, the traditional model of care has incorporated individual multidisciplinary assessment, followed by individual pain specialist led treatment as the usual pathway, with only select patients entering group treatment programs of varying duration.
The need for service redesign has been recognized worldwide, and various innovations trialed.9,13,22,29,35,36,55 The implementation of short preassessment education group sessions has led to reduction in wait times, early exposure to evidence-informed pain management, and patient familiarization with group-based treatment.6,12,24 Adaptations of this intervention are now commonplace in Australian public hospital pain services. The development of a group-based format for pain assessment with further efficiencies in resource utilization and patient flow was an additional innovation at Hunter Integrated Pain Service (HIPS).50 The group assessment showed resource efficiency in reducing wait times by providing clinicians with the capacity to manage multiple patients simultaneously, and by reducing the impact of patient nonattendance compared with the individual format.
Based on this preliminary work, HIPS embarked on creating a resource-efficient, standardized management pathway that was entirely group-based, linking preassessment education, assessment, and treatment groups.
The content of all groups, from initial education to assessment to active treatment, emphasizes a whole person approach and the implementation of active self-management, rather than passively received treatment strategies.24,39,60 This aims to modify brain interpretation, wind down nervous system sensitization, and reduce pain intensity over time.
This study aims to describe the implementation of a standardized group pathway in terms of content and process. Preliminary outcome data are reported.
Patients included in this cross-sectional study are those adults with chronic noncancer pain who participated in the standardized group pathway in 2016 (January 1, 2016–December 31, 2016), after referral to HIPS. Owing to the continuous nature of patient flow through the service, there were patients active in the pathway in 2016, whose initial engagement occurred the previous year. On the other hand, some patients referred during 2016 did not become active in the pathway until the following year and so were not included in the study.
In carefully selected cases, individual assessment and treatment was offered as a nonstandard option. This included those who were cognitively impaired, elderly (>75 years), severely disabled (eg, quadriplegic), or those identified in the referral as not appropriate for group participation (eg, deaf, blind, or non-English speaking). Patients initially participating in individual treatment could choose to enter the standardized group pathway. Requests from patients in the group pathway to switch to the individual pathway were considered on a case-by-case basis, in view of patient factors such as reports of excessive anxiety in group situations, previously unidentified visual or hearing impairments, or language barriers. The individual pathway outcomes are not reported in this study.
2.2. Data collection processes
The implementation of an Australasian chronic pain database, electronic Persistent Pain Outcomes Collaboration (ePPOC), has been reported previously.54 Study data were primarily drawn from the 2016 ePPOC HIPS annual report. The ePPOC team based at the University of Wollongong collates nonidentifiable patient data submitted electronically by participating pain services across Australia and New Zealand. These data are then analyzed and provided to each service in midyear and annual reports. In 2016, ePPOC included data from 46 specialist pain services in Australia and New Zealand.
Patients are requested to complete the ePPOC entry questionnaire after referral, and this is collected at their first appointment. The questionnaire includes demographic and baseline data for a battery of standardized assessment tools: Brief Pain Inventory, Depression, Anxiety, and Stress Scale (DASS21), Pain Catastrophizing Scale (PCS), and Pain Self-Efficacy Questionnaire (PSEQ).32,38,43,52,53 A brief description of each tool, interpretation of scores, and criteria to determine clinical significance of change in scores is provided in Appendix 1 (available as Supplemental digital content at http://links.lww.com/PR9/A49).18 Patients also received an ePPOC review questionnaire at completion of active treatment and at 3 months after their last clinical interaction with the service.
Data were extracted from the ePPOC database into text files, then imported into SAS (version 9.4; SAS Institute, NC), to be statistically analyzed. This included comparison of clinically significant improvement on each assessment tool from referral to end of active treatment, for HIPS and other services. Reduction in daily opioid use and waiting times from referral to first contact were also compared. For both HIPS and other services, “n” varied depending on whether the questionnaire was returned and if an item was completed or if missing, imputable. For categorical data, the χ2 test was used to test for difference in proportions. For continuous data, the t test was used to test for difference in mean values. P values less than 0.05 were considered statistically significant.
2.5. Missing data
Patients needed to complete a required number of items in the assessment tools for a subscale to be considered valid, with missing items imputed as the average of completed items for the DASS, PCS, and PSEQ subscales (see Appendix 1, available as Supplemental digital content at http://links.lww.com/PR9/A49).
2.6. Ethical approval and consent
Only patients who consented to their data being used for research purposes in the ePPOC entry and review questionnaires were included in this study.
Ethical approval to establish ePPOC and use the deidentified Australian data set for reporting and research purposes has been obtained through the Ethics Committee at University of Wollongong.
2.7. Overview of the group process
The standardized group pathway consisted of 3 sequential steps (Fig. 1). The first step was the education group titled, “Understanding Pain.” This was followed by the second step, which was a group assessment termed, “Assessment and Planning.” The third step was the core treatment group named, “Active Pain Treatment.” Patients were given the option of bringing a support person or carer to the first 2 steps. Patients followed this sequence of steps progressing through the pathway, but could exit at any step, resulting in treatment recommendations being sent to their referrer or general practitioner (GP). After completion of the group pathway, patients could choose further review with the service. The review and subsequent patient outcomes are beyond the scope of this article.
At each step of the pathway, there was an emphasis on expanding and reinforcing key messages from the previous step with supportive interactions between clinicians and patients. Appropriate and effective communication techniques were used, including empathy, validation, and motivational interviewing.1,7,19 An environment conducive to behavior change was created and fostered.15,19
Content of each group reflected current evidence and the requirement to target low health literacy.28,31,45,46,49,59 Cognitive and behavior change targets were identified in a collaborative fashion. At each step, clinicians and patients worked in partnership, towards identification and development of realistic and meaningful targets. These targets included reducing opioids, catastrophizing and pain interference, and increasing physical activity and pain self-efficacy. Patients had an active role in modifying and fine-tuning targets through their journey with the service.
Table 1 summarizes the details of each group of the standardized pathway.
2.8. Understanding Pain
After referral and triaging, most patients were invited to the first step in the standardized group pathway, Understanding Pain, which has been reported previously.24 This preassessment education group ran in the form of an interactive seminar with multimedia presentation and opportunities for questions and comments. Content emphasized current pain neuroscience, neuroplasticity, a whole person approach and the transition from passively received medical treatments to active self-treatment. The content was available in digital format for ease of access to remotely situated patients.27
For those who chose to progress beyond Understanding Pain, a secondary triage process occurred. This was based on any new information contained in the ePPOC referral questionnaire (routinely collected at Understanding Pain) or obtained through direct observation of or conversation with the patient at Understanding Pain. Most patients were invited to attend the next step in the group pathway, a multidisciplinary group pain assessment workshop titled “Assessment and Planning.”
2.9. Assessment and Planning
The resource requirements and content of this workshop have been reported in detail previously.50 Throughout the day, patients were guided to perform their own structured self-assessment and developed a personalized pain recovery plan (Appendix 2, available as Supplemental digital content at http://links.lww.com/PR9/A49). The workshop was interactive and had an emphasis on expanding and reinforcing key messages from Understanding Pain, with supportive interactions between clinicians and patients. Patients also received a manual summarizing the content of the workshop and had the opportunity to collect printed information on topics such as pain-related medication and accessing community psychology services.
Patients identified as taking more than 100 mg of oral morphine equivalent daily dose or taking medications associated with significant health risks were offered a brief individual medication review with the specialist pain medicine physician. The patient's prescription medication was discussed, and a medication plan, which may have included a deprescribing regimen, was negotiated with the patient's active participation. A copy of the pain recovery plan, team report, and medication plan (if applicable) was forwarded to the referrer.
2.10. Active Pain Treatment
The final step in the standardized group pathway was attendance at a core treatment group called “Active Pain Treatment,” with a duration of 21 hours over 6 weeks.
This 6-week group program, conducted 1 day every week, was facilitated by a clinical psychologist, a pain physiotherapist, and a clinical nurse specialist. The core treatment program reinforced a whole person approach, addressing 5 domains of pain management: biomedical, mindbody, connection, activity, and nutrition.25 Implementation of active self-management, with reduced reliance on passive strategies including pain-related medications, was encouraged.41 The Explain Pain model was used to discuss the neuroscience of chronic pain.39 Psychological elements of this program were mainly based on cognitive behavioural therapy with inclusion of mindfulness-based strategies.20,48,56 Components included reframing of dysfunctional cognitions, enabling adaptive behaviors and graded task assignments to enhance functioning. The contribution of social disconnection to pain experience in participants and ways to re-establish connection to people, purpose, and place was explored.51 Gradual grading up of physical activities from baseline, incorporating pacing strategies, and mindful movement were important components of the physical activity domain of pain management.23,42 Participants were also invited to review their diet and anthropometric measures and make healthier food choices to improve overall wellbeing.3,4
A brief outline of the program, including the primary behavioral targets, is outlined in Table 2. Patients were given simple written resources on active treatment strategies developed and updated regularly in line with current evidence regarding pain.
The clinical nurse specialist facilitated sessions on pain-related medications and nutrition. Options of further medication input, in person or over the phone, with the clinical nurse specialist were also offered. Another alternative offered was a phone consultation between the specialist pain medicine physician and the GP.
The importance of regular weekly attendance was emphasized, and limited catch-up options were available for missed sessions. On the final week of the Active Pain Treatment group, patients reviewed and updated their pain recovery plan created at Assessment and Planning.
2.11. Patient–clinician phone interactions
For all groups except Understanding Pain, patients received a preparatory phone call. A staff member checked on patient readiness to attend, current pain medications and answered any questions regarding the group.
After referral, at any step, patients were able to phone for support during working hours. This support included reviewing progress and discussing challenges, including those related to medication deprescribing.
2.12. Staff resource requirements for group interventions
The clinical staff facilitating groups consisted of a mix of specialist pain medicine physicians, pain medicine trainees, clinical nurse specialists, clinical psychologists, and pain physiotherapists. Table 3 details the entire 2016 staffing levels at HIPS, whereas Table 1 includes details of staffing for each step of the group pathway.
3.1. Patient flow through the service
In 2016, 928 patients were actively engaged with HIPS, compared with 15,862 for other services (Table 4). During the same period, HIPS received 1192 patient referrals. The number of patients going through various steps in the group pathway in the same period was 690, 278, and 92 patients for steps 1, 2, and 3, respectively. As previously explained, this was not a cohort due to the continuous nature of patient flow through the service.
Approximately 68.4% of HIPS patients were seen solely through the group format, as compared to 22% of those attending groups with other services. A higher percentage of HIPS patients attended their first clinical contact within 3 months of referral compared with other services (81.4% vs 68.6%, P < 0.001).
3.2. Demographics of patient population
The 2016 ePPOC data showed HIPS patients at referral had a similar patient profile to other services with some important differences, which were clinically and statistically significant (Table 4). More patients attending HIPS identified as being indigenous, needed assistance with communication, took opioids more than twice a week, and had experienced pain for more than 5 years. Hunter Integrated Pain Service patients had a higher proportion of patients who were unemployed due to pain. The average number of associated comorbidities was higher in the HIPS population, and although this difference was statistically significant, it is unlikely to be clinically significant. Only 0.2% of HIPS patients required an interpreter compared with 5.4% for other services. Baseline characteristics including sex, average age, opioid dose, number of drug groups used, and number of sites of pain were similar in both populations.
3.3. Standardized assessment tools at referral
When comparing results from standardized assessment tools at referral, average pain severity was lower in HIPS compared with other services, and this was statistically significant, although unlikely to be clinically significant (6.2 vs 6.4). There was no statistically significant difference between HIPS patients and those attending other services with regards to the other assessment tools (Table 5).
3.4. Patient outcomes
In those patients who scored in the moderate/severe/extremely severe categories of standardized assessment tools (Brief Pain Inventory, DASS21, PCS, and PSEQ) at referral, there were no statistically significant differences in the proportion of patients making clinically significant improvement over time between HIPS and other services (Table 6).
A higher proportion of HIPS patients achieved a 50% or greater than 50% reduction in opioid use at end of treatment compared with other services. The difference in proportions was statistically significant for all patients on opioids as well as the subgroup of patients on 40 mg or more oral morphine equivalent daily dose at referral.
The standardized group pathway aims for the best possible patient outcomes while maximizing efficient utilization of finite staff resources.
Population profile was similar at baseline between HIPS and other services, except for some differing vulnerabilities in the HIPS population (higher indigenous status and communication difficulties and lower need for interpreter). Despite this, clinical outcomes were noninferior, and there were lower wait times. It was also noted that greater opioid reduction was achieved.
Utilization of the HIPS group pathway facilitates exposure of an increased number of patients to group intervention. There is a theoretical risk of poorer pathway outcomes from using group education and assessment, as opposed to individual (due to dilution of personal contact time and reduced emphasis on individual patient selection). However, this study affirms that it is possible to achieve noninferior patient-related outcomes as compared to other services, while facilitating increased numbers of patients through a standardized, short-duration group pathway.
An early invite to the initial large group, Understanding Pain, offers a timely and potentially therapeutic interaction to a high number of patients and their support persons. It minimizes waiting times, introduces patients to a group setting, and allows for the option of an early discharge.12,24
Undertaking assessment in a short-duration group workshop, the second step in the standardized group pathway, is resource-efficient as it can be overbooked, unlike individual assessment.14,50,61 This helps to counter the problem of patient nonattendance, which is well known in most chronic conditions, including pain.21,37,44 The group assessment has shown comparable clinical outcomes with individual assessment.50
There is no consensus within the pain field regarding optimal duration of pain treatment groups. Long-duration groups in Australia are up to 120 hours.5 Typically, such long-duration groups are offered to smaller numbers of more highly selected patients, often with compensable funding status. From a service design perspective, the potentially greater improvement of individuals undertaking a long-duration group is offset by the restrictions in access that necessarily apply.
The duration of 21 hours over 6 weeks was based on clinician and patient feedback obtained after core pain treatment groups of varying durations that HIPS had run in the past. The rationale for this included patient acceptability, effective utilization of clinician time, and adequate time for participants to practice active strategies and problem solve pain-related issues. The HIPS team attempts to reverse the passive passenger role, reinforced through years of traditional health care interactions.8,11,30
Burke et al.5 define the duration of such a program to be low (<30 hours) compared with the Australian average of 68.6 hours. Further research, including analysis of ePPOC data, will enable identification of the “sweet spot” in optimizing the resources required to achieve acceptable clinical results, recognizing that the ideal results to resource ratio may vary across different clinical contexts.
Hunter Integrated Pain Service standardized group pathway is an example of a triaging model of care. Although this study was a cross-sectional study and not a cohort study, the decreased number of patients attending the active treatment stage or final step of group pathway suggests a process of funneling of patients. Those patients most ready to change and needing further support engage in active treatment.30,33,34,58 The resource-efficient design of the model allows for prioritization of finite resources, honors patient decision-making, and values clinician effort.
Low literacy is a wide-reaching problem in health care.2 Communication techniques and educational strategies tailored to behavior change and low literacy are imbedded consistently and deliberately throughout HIPS standardized group pathway. All written material was designed for fifth to sixth grade readability, with educational aids such as tick boxes and incorporating short active sentences.10,17,45,59
Ongoing open line of telephone communication and support between the service and patient/GP was designed to decrease need for frequent in-person consults and also guarded against therapeutic relapse.
There are a number of study limitations. First, the study did not measure outcomes for those patients entering the nonstandard individual pathway which precluded comparison of outcomes with those entering the standardized pathway. Furthermore, outcomes were only measured after Active Pain Treatment, the third step in the standardized group pathway. Measuring outcomes after each step of the pathway would have allowed analysis of any additive therapeutic benefit for each step. Another shortcoming of the study was the inability to differentiate between those who leave the pathway positively because of good therapeutic progress as opposed to those who disengage, without such progress.
It is envisaged that this article will provide a foundation for further exploring models of chronic pain management, with comparison of outcomes from individual and group pathways as an important focus. In addition, analysis of the impact of patient complexity on progression through the group pathway may inform more individually tailored programs. This would be especially important for those identifying as indigenous, to ensure cultural differences are respected and addressed appropriately.
Hunter Integrated Pain Service promotes short-duration groups as the standard intervention for patients experiencing chronic noncancer pain. This is efficient in terms of team resource utilization and exposure of patients to evidence-based care. Outcome data were noninferior for this standardized, sequenced, short-duration group pathway, as compared to other services whose data were typically based on more individualized assessment and treatment and often, longer-duration groups. This model has implications for other pain services that are resource-limited and have lengthy waitlists.
The authors have no conflict of interest to declare.
The authors acknowledge the considerable and enthusiastic contribution of all members of HIPS towards implementation of the model of care reported.
Appendix A. Supplemental digital content
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