The Role of Clinical Practice Guidelines in Improving the Management of Chronic Pain

An Interview with Neil Schechter, MD, FAAP

Neil Schechter, M.D. is an Associate Professor of Anesthesia at Harvard Medical School and is the author of over 90 articles and chapters. He is the senior editor of Pain in Infants, Children and Adolescents, the major textbook in the field of pediatric pain. Dr. Schechter has been a member of numerous scientific and professional committees that have developed guidelines and recommendations for the treatment of pediatric pain—including the World Health Organization, the American Pain Society, and the Institute of Medicine. He now directs the Chronic Pain Clinic at Boston Children’s Hospital. He is also the president of ChildKind, a global initiative to reduce pain in pediatric healthcare institutions.

Wendy Williams, B.S.N., M.Ed.:

Thank you for agreeing to this phone interview with PainEDU.org about the role of clinical practice guidelines in chronic pain management. We are speaking with you as a developer of clinical practice pain management guidelines for organizations like the World Health Organization and the American Pain Society. You have also worked on developing programs that make use of clinical practice guidelines for improved patient outcomes. How do you think clinical practice guidelines can play a role in improving the management of chronic pain?

Neil Schechter, MD, FAAP: Well, in pain management, and in pretty much every other area of medicine, if we merely apply what we know in a uniform manner, care would be much improved. John Bonica, one of the founding fathers of pain management, said as early as the 1990 edition of his textbook: “For nearly thirty years, I have studied the reasons for inadequate management of postoperative pain and they remain the same…inadequate or improper application of available information and therapies is certainly the most important reason for inadequate postoperative pain relief.” 1

The adoption of clinical practice guidelines is a way of assuring a uniform care approach to patients with similar problems; such guidelines can help optimize the care of patients with chronic pain (pediatric or adult). The intention behind clinical practice guidelines is to provide evidence-based guidance to healthcare professionals who serve patients with specific conditions—and ultimately, the goal of these guidelines is to improve patient outcomes.

If guidelines were adopted and applied widely and consistently, we assume that they would improve patient outcomes. But research tells us that no matter how strong the evidence base, clinical practice guidelines often do not seem to affect clinical practice. There are many studies that confirm this finding, including a 1999 JAMA study by Cabana and colleagues.2

 

ED note: The paper referenced concludes: “Despite wide promulgation, guidelines have had limited effect on changing physician behavior. In general, little is known about the process and factors responsible for how physicians change their practice methods when they become aware of a guideline.”

The Cabana study identified a number of barriers to physician adherence of clinical practice guidelines:

  • Lack of awareness or familiarity
  • Lack of agreement
  • Lack of self-efficacy
  • Lack of outcome expectancy
  • Inertia of previous practice
  • External barriers

NS: First, a lack of knowledge or awareness about guidelines makes it impossible to use them. However, there may well be situations where the clinician knows that guidelines exist, but the supporting evidence may be weak or controversial. In the area of chronic pain in particular, there is no gold standard—in fact, there is some disagreement about approaches, even among respected professional societies. Additionally, there may be financial or logistical barriers that limit implementation. There is also the inertia factor that Cabana mentioned. If someone has been doing something the same way for a while and feels that they’re doing a good job, there is no incentive to change to a less familiar approach, even if it’s supposedly “evidence-informed”.

 

WW: Can pain-related patient outcomes be improved using clinical practice guidelines, given the challenges you outline?

NS: Yes—but of course, the problem is implementing the guidelines in a given setting. It may take pressure from an outside source to accomplish that. It would be helpful if practitioners who are interested in changing pain practices could figure out a way to sample the patient experience regarding pain. That might involve a review of existing quality improvement instruments, or the introduction of new ones.

For example, many hospitals use Press Ganey or Picker surveys to gather information on patients’ perceptions of the hospital. Examining pain-related complaints helps make the case for improvement. Alternatively, surveying every room in the hospital—using an instrument such as the American Pain Society Patient Outcome Questionnaire—gives a good sense of how patients perceive the quality of pain management. If those measures suggest that there is concern about the quality of pain management, it’s easier to advocate for the implementation of appropriate guidelines. Ideally, when an institution recognizes that they aren’t providing pain care at sufficient levels, they may be motivated to include patient comfort as a core value within the system, much like we do for patient safety or confidentiality. Patient expectation for comfort and reduced pain should drive the adoption and use of respected clinical guidelines. We typically want to do well by our patients. When they weigh in and tell us how we’re meeting core values, we’ll know if we are hitting the mark.

I’m convinced that institutional or system-wide change is an effective way to reduce patients’ pain, and improve pain management in a sustained way. Adopting clinical guidelines assures a uniform approach to care, which goes a long way toward meeting pain management goals. There are two articles in the journal Pediatrics describing the work that my colleagues and I did in two Connecticut hospitals. We worked to close the gap between what was known about optimal pain management for hospitalized children, and what was actually done. I believe that what we learned about changing practice behavior through systems or culture change can be helpful to anyone looking to improve patient outcomes for pain care.3, 4

A number of strategies seemed to be effective:

  • Beginning with a survey or audit of present practices in selected (clinical) areas. There are benchmarks available so that institutions or systems can compare their outcomes with similar settings.
  • Including physicians, nurses, psychologists, pharmacists, and other healthcare professionals in pain-reduction efforts.
  • Inviting a multidisciplinary group of champions to be part of a pain council that was led by a person with administrative authority to mandate change.
  • Using—and modifying—national guidelines and consensus statements to address local strengths, weaknesses, and customs.
  • Implementing ongoing education initiatives to promote change—and sustain it.
  • Having a continuous, vigilant quality improvement program monitored by members of the pain council.4

WW: In conclusion, could you please share practical suggestions about using clinical guidelines to improve pain management?

NS: If you are looking to learn about your patients’ pain experiences, ask your patients directly. To minimize bias, I would recommend consulting an outside group to conduct a survey using a de-identified, standardized instrument. Patients have been known to hold back the truth of their experience to spare the clinician’s feelings. Let the patients know that you are committed to having patients in your care as comfortable as possible. “How are we doing? Please be honest in your responses.” Deb Gordon and other pain management leaders revised the American Pain Society’s Patient Outcome Questionnaire in 2009 as a starting point for building a survey. The results of this effort could encourage healthcare providers to seek out and use guidelines that make sense for their particular care setting.

If you are ready to identify a set of pain management guidelines to improve your practice, go for it. Don’t let the fact that there is no “gold standard” for pain management get in the way of moving toward the improvement of patient outcomes. Get together with others in your organization who want to ensure patient comfort and reduce pain overall. Identify what pain care guidelines are out there. Make your decision and individualize or localize the guidelines you choose to suit your practice setting. Finally, keep evaluating how your guidelines are working to meet the clinical practice goals and amend as needed.

If you are looking to increase your own self-efficacy, do an audit of your practice and readiness to get to the next level of pain management expertise. Ask yourself: “According to these clinical practice guidelines, how am I doing? Am I where I would like to be? How can I close the gaps in my own pain management practice?” Behavior change has the best shot when it’s based on internal motivation from individuals or whole organizations who aspire to improve.

References

  1. Bonica JJ. The Management of Pain. 2nd ed. Philadelphia, PA: Lea & Febiger; 1990
  2. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines?: a framework for improvement. JAMA. 1999;282(15):1458-1465.
  3. Schechter NL, Blankson V, Pachter LM, Sullivan CM, Costa L. The ouchless place: no pain, children’s gain. Pediatrics. 1997; 99(6):890–894
  4. Schechter NL From the Ouchless Place to Comfort Central: the evolution of a concept. Pediatrics. 2008;122(3), S154 -S160.

Resource

Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for Quality Improvement of Pain Management in Hospitalized Adults: Preliminary Psychometric Evaluation http://www.jpain.org/article/S1526-5900%2810%2900351-2/abstract