David H. Goldstein

A systematic review of the effect of waiting for treatment for chronic pain.

&NA; In many countries timely access to care is a growing problem. As medical costs escalate health care resources must be prioritized. In this context there is an increasing need for benchmarks and best practices in wait‐time management. The Canadian Pain Society struck a Task Force in December 2005 to identify benchmarks for acceptable wait‐times for treatment of chronic pain. As part of the mandate a systematic review of the literature regarding the relationship between waiting times, health status and health outcomes for patients awaiting treatment for chronic pain was undertaken. Twenty‐four studies met the inclusion criteria for the review. The current review supports that patients experience a significant deterioration in health related quality of life and psychological well being while waiting for treatment for chronic pain during the 6 months from the time of referral to treatment. It is unknown at what point this deterioration begins as results from the 14 trials involving wait‐times of 10 weeks or less yielded mixed results with wait‐times amounting to as little as 5 weeks, associated with deterioration. It was concluded that wait‐times for chronic pain treatment of 6 months or longer are medically unacceptable. Further study is necessary to determine at what stage the deterioration begins from the onset of pain to treatment and the impact of waiting on treatment outcomes. Most important is the need to improve access to appropriate care for patients with chronic pain, an escalating public health care problem with significant human and economic costs.

Definitions of "respiratory depression" with intrathecal morphine postoperative analgesia: a review of the literature.

PurposeTo review the postoperative intrathecal morphine (ITM) analgesia literature for their definitions of “respiratory depression” (RD).SourceMedline (1966 — June Week 5 2001) and reference lists were searched for original studies involving bolus-dose ITM for postoperative analgesia, which used “respiratory depression” or similar terms.Principal findingsThe search identified 209 studies. These were included if ITM use was appropriate (bolus dose, postoperative analgesia) and the term “respiratory depression” was used, which left 96 studies remaining. Forty-four (46%) did not define “RD” despite using this term. A further 24 (25%) defined RD with respiratory rate (RR) alone. Only 28 (29%) defined RD with more than RR alone. There was no statistically significant association between the presence of a definition for RD with study design, study size or publication period. Also, no significant association existed between rigorousness of RD definitions and the above factors.ConclusionThe term “respiratory depression” has no clear definition from a review of the literature on ITM use for postoperative analgesia. While defining RD with bradypnea is superior to having no definition, this is still inadequate. In future research, the consistent use of terms with specific meanings will facilitate understanding the true incidence of ITM’s respiratory effects. If “respiratory depression” is used, then an explicit definition of its meaning should be provided. Future research must also address what is clinically significant respiratory impairment from intrathecal opioids, and how to optimally monitor for this. Further delineating their risksvs benefits will allow for more optimal dosing.RésuméObjectifPasser en revue les documents sur l’analgésie postopératoire, réalisée avec la morphine intrathécale (MIT), quant à leurs définitions de la “dépression respiratoire” (DR).SourceLa base Medline (1966 — Semaine 5, juin 2001) et les listes de lectures de référence ont été fouillées à la recherche d’études originales sur des bolus de MIT administrés comme analgésie postopératoire, et dans lesquelles on retrouve le terme “dépression respiratoire” ou des termes similaires.Constatations principalesLa recherche nous a fourni 209 études. Les études (96) comportant un usage approprié de la MIT (dose en bolus, analgésie postopératoire) et l’utilisation du terme “dépression respiratoire” ont été retenues. Malgré l’utilisation du terme “DR”, 44 études (46 %) ne la définissaient pas. D’autres études, 24 (25 %), n’utilisaient que le terme “fréquence respiratoire” (FR) pour définir la DR. Seulement 28 (29 %) études en donnaient une définition plus large. Il n’y avait pas d’association significative entre la présence d’une définition de la DR et le devis de l’étude, sa taille ou sa date de publication. Aussi, aucune association significative n’a été trouvée entre la rigueur des définitions de la DR et les facteurs susmentionnés.ConclusionLe terme “dépression respiratoire” n’a pas de définition claire dans les documents examinés sur l’usage de la MIT comme analgésie postopératoire. Il est préférable de définir la DR par la bradypnée que de ne pas la définir, mais cela demeure incomplet. À l’avenir, l’usage uniforme de termes et de leurs définitions spécifiques facilitera la compréhension de la véritable incidence des effets respiratoires de la MIT. Le terme “dépression respiratoire” doit être accompagné d’une définition explicite. Les recherches à venir doivent traiter des affections respiratoires cliniques significatives causées par les opioïdes intrathécaux et de la façon de les déceler le plus efficacement. En déterminant davantage leurs risques et leurs bienfaits, nous pourrons en établir une posologie optimale.

Impact of perioperative pain intensity, pain qualities, and opioid use on chronic pain after surgery: a prospective cohort study.

Background and Objectives A better understanding of the pathogenesis of chronic postsurgical pain is needed in order to develop effective prevention and treatment interventions. The objective of this study was to evaluate the incidence and risk factors for chronic postsurgical pain in women undergoing gynecologic surgery. Methods Pain characteristics, opioid consumption, and psychologic factors were captured before and 6 months after surgery. Analyses included univariate statistics, relative risks (RRs) and 95% confidence intervals (95% CIs), and modified Poisson regression for binary data. Results Pain and pain interference 6 months after surgery was reported by 14% (n = 60/433) and 12% (n = 54/433), respectively. Chronic postsurgical pain was reported by 23% (n = 39/172) with preoperative pelvic pain, 17% (n = 9/54) with preoperative remote pain, and 5.1% (n = 10/197) with no preoperative pain. Preoperative state anxiety (RR = 1.8; 95% CI, 1.1–2.8), preoperative pain (pelvic RR = 3.7; 95% CI, 1.9–7.2; remote RR = 3.0; 95% CI, 1.3–6.9), and moderate/severe in-hospital pain (RR = 3.0; 95% CI, 1.0–9.4) independently predicted chronic postsurgical pain. The same 3 factors predicted pain-interference at 6 months. Participants describing preoperative pelvic pain as “miserable” and “shooting” were 2.8 (range, 1.3–6.4) and 2.1 (range, 1.1–4.0) times more likely to report chronic postsurgical pain, respectively. Women taking preoperative opioids were 2.0 (range, 1.2–3.3) times more likely to report chronic postsurgical pain than those not taking opioids. Women with preoperative pelvic pain who took preoperative opioids were 30% (RR = 1.3; 95% CI, 0.8–1.9) more likely to report chronic postsurgical pain than those with preoperative pelvic pain not taking opioids. Conclusions Preoperative pain, state anxiety, pain quality descriptors, opioid consumption, and early postoperative pain may be important predictors of chronic postsurgical pain, which require further investigation.

Using a personal digital assistant enhances gathering of patient data on an acute pain management service: a pilot study

PurposeHandheld computer technology provides a unique opportunity for health care professionals to access real time or near real time patient information and evidence-based resources at the point-of-care. The purpose of this study was to assess one physician’s experience using acute pain assessment software on a personal digital assistant (PDA) to assess patients on an acute pain management service (APMS).MethodsUsing a historical control and a “time and motion” study design, comparisons were made on acute pain assessment time and comprehensiveness when patient assessments are documented on a PDA vs the current paper-based method.ResultsThe study physician (a PDA-user) reported feeling comfortable with the assessment software after five patient assessments. PDA assessments were more likely to contain documentation regarding pain and side effects (e.g., nausea, pruritus, hypotension) than the paper assessments. The median time of the “assessment only” component of the patient encounter was 53 sec longer using the PDA compared to paper (P < 0.00), however, the median “total encounter” (chart review, assessment, documentation) time was 74 sec shorter using the PDA vs paper (P < 0.00).DiscussionThe findings of this preliminary study suggest that the PDA is a reliable tool that meets the data management requirements within an APMS setting. This study found that patient assessments documented using acute pain software developed for use on a PDA were as efficient and content-rich as paper assessments. The PDA may even enhance the efficiency of the patient assessment process through the provision of more comprehensive digital data for research, clinical, and administrative needs.RésuméObjectifLordinateur nomade offre une chance unique aux professionnels de la santé d’accéder en temps réel ou presque à des renseignements sur le patient et à des ressources cliniques sur place. Notre objectif était d’estimer l’expérience d’un médecin qui utilise le logiciel d’évaluation de la douleur aiguë sur un assistant numérique personnel (ANP) pour examiner les patients d’un service de traitement de la douleur aiguë (STDA).MéthodeDans notre étude de type contrôle historique et tempsmouvement, nous avons comparé le temps et la représentativité de l’évaluation de la douleur aiguë pour des études de patients documentées sur ANP vs la méthode courante sur papier.RésultatsLe médecin (un utilisateur d’ANP) s’est dit à l’aise avec le logiciel après cinq évaluations. Les examens avec l’ANP ont plus de chance de contenir de la documentation sur la douleur et les effets secondaires (comme les nausées, le prurit, l’hypotension) que celles sur papier. Le temps moyen de la partie ‘évaluation seule’ de la rencontre avec le patient a été plus longue de 53 sec avec l’ANP, comparé au papier (P < 0,00), mais le temps moyen de ‘l’entrevue complète’ (revue du dossier, évaluation, documentation) a été plus court de 74 sec avec l’ANP vs le papier (P < 0,00).DiscussionLes résultats de cette étude préliminaire indiquent que l’ANP est un outil fiable qui répond aux exigences de gestion des données dans le cadre d’un STDA. Les évaluations de patients documentées à l’aide du logiciel sur la douleur aiguë, mis au point pour un usage sur ANP, ont été aussi efficaces et riches de contenu que les évaluations sur papier. L’ANP peut même améliorer le procédé d’évaluation du patient en fournissant plus de données numériques détaillées pour la recherche, les besoins cliniques et administratifs.

A comparison of paper with electronic patient-completed questionnaires in a preoperative clinic

In this unblinded randomized control trial we compared electronic self-administered Pre-Admission Adult Anesthetic Questionnaires (PAAQ) using touchscreen technology with pen and paper. Patients were recruited in the Preassessment Clinic if they had completed a PAAQ in the surgeon’s office. Patients were randomized to study PAAQ using paper, hand-held computer (PDA), touchscreen desktop computer (kiosk), or tablet. Patients also completed a preference and satisfaction survey. The main outcome measures were percent agreement between the prestudy and study PAAQ and time to completion. Only six of the 366 patients approached refused to participate. The median time to completion of the PAAQ was shortest on the kiosk (2.3 min) and longest on the PDA (3.2 min) (&khgr;2 = 14.5; P = 0.002). The mean agreement between the prestudy and the study PAAQ was approximately 94% across all study arms. The proportion of participants expressing comfort before and after completing the PAAQ increased from 10% to 97% on the computerized arms and from 60% to 64% on the paper arm. Touchscreen computer technology is an accurate, efficient platform for patient-administered PAAQ. Patients expressed comfort using the technology and preference for computerized versus paper for future questionnaires.

In Canada, anesthesiologists are less likely to respond to an electronic, compared to a paper questionnaire

PurposeA randomized unblinded controlled trial was used to assess the utility of electronic questionnaires in a survey of Canadian anesthesiologists.MethodsPostal or electronic questionnaires were sent between November 2001 and March 2002 to 1,333 anesthesiologists registered with the Canadian Anesthesiologists’ Society. The primary outcome measure was the difference in response rates between electronic and postal questionnaires. Secondary outcome measures included a comparison of demographic characteristics, cost, and knowledge and practice regarding prophylactic perioperative beta blockade.ResultsThe overall response rate was 52%. E-mail participants were half as likely as postal participants to respond to the questionnaire (35% vs 69%, relative risk = 0.51, 95% confidence interval 0.45–0.58). Respondents who provided an e-mail address were younger and more likely to be affiliated with an academic institution. There were no significant differences in responses to knowledge and practice questions. The electronic arm was faster than the postal arm and the cost per reply was one-third the cost of the postal arm (

The impact of sampling and measurement on the prevalence of self-reported pain in Canada

2.50 vs

The relationship between movement-evoked versus spontaneous pain and peak expiratory flow after abdominal hysterectomy

8.02).ConclusionsElectronic surveys are a means of acquiring information from a large number of individuals in a rapid, efficient and cost-effective manner. This methodology may be particularly valid and useful in surveys of participants with similar backgrounds and internet access. However the lower response rates achieved as compared with postal surveys indicates a need to use vigilance when generalizing results to a broader population.RésuméObjectifNous avons utilisé une épreuve randomisée, contrôlée et ouverte pour évaluer l’utilité de questionnaires électroniques lors d’une enquête auprès des anesthésiologistes canadiens.MéthodeDes questionnaires postaux et électroniques ont été envoyés entre novembre 2001 et mars 2002 à 1 333 anesthésiologistes membres de la Société canadienne des anesthésiologistes. La principale mesure a été la différence du taux de réponses aux envois postaux et électroniques. La seconde comprenait une comparaison des caractéristiques individuelles, du coût, et des connaissances et de la pratique en regard du bêta blocage périopératoire préventif.RésultatsLe taux de réponse général a été de 52 %. Les participants par courriel ont été deux fois moins nombreux que par la poste à répondre au questionnaire (35 % vs 69%, le risque relatif a été de 0,51, l’intervalle de confiance de 95 % 0,45–0,58). Les répondants par courriel étaient plus jeunes et plus souvent affiliés à une institution universitaire. Il n’y a pas eu de différence significative de réponses sur les connaissances et la pratique. Le groupe du courriel a répondu plus rapidement que le groupe de la poste et le coût par réponse a été le tiers du coût postal (2,50

Acute pain management services have progressed, albeit insufficiently in Canadian academic hospitals.

vs 8,02

Antidepressant drugs for prevention of acute and chronic postsurgical pain early evidence and recommended future directions

).ConclusionLes enquêtes électroniques permettent d’obtenir de l’information d’un grand nombre de personnes d’une manière rapide, efficace et économique. Cette méthodologie peut être particulièrement valide et utile auprès de participants dont les connaissances sont comparables et qui ont accès à Internet. Cependant, les taux de réponses plus bas obtenus en comparaison avec les enquêtes postales indiquent la nécessité d’être vigilant au moment de généraliser les résultats pour une importante population.