Pain represents a growing patient concern and a flourishing service line for healthcare. Hospitals are creating pain management centers with a focus on chronic and acute pain, relying on interventional and multidisciplinary procedures targeting long-term pain.
This article appears in the September issue of HealthLeaders magazine.
Physical pain is beginning to define America. Back pain. Knee pain. Spinal disorders. Headaches. Arthritis. Shingles. Migraines. Pain can be here today, gone tomorrow, or a constant presence, gnawing, clawing, endless. Whether sporadic or chronic, pain prompts patients to move from physician to physician, hospital to hospital, seeking the elixir, the magic cure, the one last surgery, even for some tentative relief.
In fact, pain is the most common reason patients visit doctors, hospitals, and health systems. The pain condition is so ingrained that it is dubbed the fifth vital sign by medical professionals.
As such, pain represents a flourishing patient market for healthcare. Hospitals are creating pain management centers with a focus on chronic and acute pain, relying on interventional and multidisciplinary procedures targeting long-term pain.
Pain impacts more Americans than diabetes, heart disease, and cancer combined, and costs the nation up to $635 billion each year in medical treatment and lost productivity, according to a 2011 Institute of Medicine report brief. Hospitals are responding to the booming pain market by focusing on various aspects of care. For hospitals, a key strategy is structuring their pain programs, from evaluating acute and chronic pain, to providing psychological evaluation if needed and patient education.
Hospitals also recognize the need to improve pain management outcomes to improve patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. The HCAHPS survey, which is linked to CMS payments, asks patients about pain management.
Patient pain management is a "big part of patient satisfaction," says Thomas A. Mathew, MD, an internal medicine physician and hospitalist at the 1,100-licensed-bed Christiana Care Health System in Wilmington, Del., which has seen significant growth the past two years in pain management.
For years, its pain management program was part of its palliative care program, but the growth in patients who presented with pain as a complaint prompted the system to create a multidisciplinary team specializing in pain care, including anesthesiologists and interventional radiologists, Mathew says. Over time, pain management has overtaken palliative care.
The 1,158-licensed-bed Barnes-Jewish Hospital in St. Louis expanded the size of its Washington University Pain Management Center from 5,000 to 10,000 square feet to accommodate a growing patient population. In the meantime, it restructured its pain program into two areas, concentrating on chronic and cancer pain in the one area and acute perioperative pain in the other. The Pain Management Center is part of the hospital's Center for Advanced Medicine, and it includes outpatient and inpatient programs.
"We recently moved to a larger facility because of a growing need, with more and more patients to be seen and procedures to be done. You compare year-to-year and month-to-month, and those numbers are going up steadily," says Michael Bottros, MD, director of acute pain service at Barnes-Jewish Hospital and assistant professor of anesthesiology at the Washington University Pain Management Center. "We are seeing a variety of patients, from those with head and neck pain to low back pain to postsurgical pain."
The organization intends to offer pain care for a multitude of service lines. "If you improve patient management, you also indirectly improve everything else," Bottros says. "It has a rippling effect. With service lines such as oncology or surgery, pain is a factor in all of them. It's a common underlying feature. We are ensuring that appropriate pain care paths are developed for the patient based on the condition and the type of surgery they've had."
At the 907-bed Massachusetts General Hospital in Boston, the number of pain patients has increased steadily, from 600 per month in 2007 to more than 1,000 this year. At least 70% are seeking treatment for spine-related pain: chronic low back pain, spinal stenosis, and herniated disks, says Chris Gilligan, MD, MBA, director of the center for pain medicine at MGH. As many as 30% of the patients are treated for other pain conditions, such as musculoskeletal pain, arthritis, shingles, and cancer-related conditions.
With increasing numbers of patients needing pain care, MGH has tried to make treatment more efficient, Gilligan says. For instance, back pain patients are admitted to the hospital's emergency department observation unit instead of an inpatient floor, as had been done previously. Consequently, patient length of stay in the hospital has been reduced, he adds.
"In the observation unit, we perform pain service consults in a very timely fashion," Gilligan says. "If we need imaging and/or injection, they happen quickly and we can reduce length of stay substantially compared to regular hospital admission."
Hospital pain treatment centers are becoming more prominent, especially since many general practitioners are reluctant to become involved in pain management because of their concerns about increased law enforcement scrutiny and widespread misuse of prescription drugs, says Tiffany Meert, chief operating officer of the Northern Nevada Medical Center, a 55-staffed-bed facility in Sparks, Nev. Those concerns have prompted the hospital to become involved in a partnership with a physician group to oversee pain management, she says.
Accidental drug overdoses that result in deaths have been rampant across the country. "It's a huge problem," says Gilligan of MGH
Mathew, the Christiana Care physician, says it is essential for healthcare leadership to overcome obstacles like potential drug overdoses to improve pain management. Pain care itself is "one of the biggest opportunities for improvement in medicine in healthcare, and the place where we just don't have adequate rules in the game because everybody's perception of pain is different and what the
Success key No. 1: Dealing with prescription drugs
Arnold Feldman, MD, a longtime interventional pain specialist in Baton Rouge, La., didn't want to be associated with the word pain. Indeed, he removed the word from his practice sign several years ago and replaced it simply with "The Feldman Institute." While he continues to treat patients afflicted with pain, specializing in interventional pain management outpatient procedures, he wants to distance his practice from less scrupulous providers.
Law enforcement, especially the U.S. Drug Enforcement Administration, is increasingly scrutinizing physicians because of so-called drug or pill mills, physician practices that overprescribe powerful drugs that are linked to the abuse of painkillers. Opioid analgesics—including morphine, oxycodone, and methadone—are among the prescription drugs most often linked to abuse.
Drug overdose death rates in the United States have more than tripled since 1990, "and have never been higher," according to the Centers for Disease Control and Prevention. Nearly three in four prescription drug overdoses are caused by opioid pain relievers, the CDC states. The misuse and abuse of prescription painkillers was responsible for more than 475,000 ED visits in 2009, a number that nearly doubled in five years.
"[Law enforcement] are scrutinizing doctors like crazy," Feldman says. "We don't want to be associated with drug or narcotics mills." Law enforcement's focus has prompted many primary care physicians to shy away from prescribing pain pills at all. "Family doctors used to treat people with pain," he explains. "They will not anymore. One of the reasons is poor education about opioids and the fear of government scrutiny and prosecution."
Hospitals, too, are specifically organizing pain treatment programs not only to relieve pain but also to coordinate care that thwarts potential abuses. The American Medical Association has called for a multidisciplinary clinical approach to the treatment of chronic pain with a focus on responsible prescribing of opioids. Physicians, hospitals, and health systems also are touting nondrug therapies and integrative approaches to treat pain without narcotics.
The government has taken steps to assist hospitals in overcoming problems with opioids. The Joint Commission, for instance, issued a Sentinel Event Alert that urges hospitals to take specific steps to prevent serious complications or even deaths from opioids. A growing number of states are enacting policies that promote the delivery of effective pain management, according to an American Cancer Society Action Network report.
Pain treatment programs are focusing on medication reconciliation as a key element in helping to improve treatment of patients and combat overprescribing of drugs. Such programs are often linked to sophisticated electronic medical records that keep tabs on patient usage of drugs and physician prescribing.
"We have made a huge effort in our center the past several years to have our medication reconciliation be more effective," says Gilligan of MGH. Under the protocol, patients are evaluated and educated about the impact of their medications. The dosages and the responses are registered in medical records. The medical record indicates what medication is appropriate and what interventions are needed.
"Every single time, someone goes over what medications [patients] are taking, what those medications do, and this is done even before the doctor sees them, and [the doctor] again goes over it all," Gilligan says. As they leave the hospital, patients review a summary report. The physicians are monitored, too. If a physician makes a mistake related to the dosage ordered, "the EMR triggers a response. It isn't perfect, but it greatly reduces the chances for errors."
General practitioners and nurses aren't the only team members involved in medication reconciliation, Gilligan says. "If a patient has behavioral or mental health issues, and not just the chronic pain, there are people on staff to deal with that—psychologists and psychiatrists. The psychiatrists have additional training in pain and substance abuse." Neurologists also are included in the pain unit, he says.
Barnes-Jewish Hospital routinely updates prescribers, interns, residents, and nurse practitioners in the hospital about patients' medications, especially for those patients transferred from one area of the hospital to another. With its medical record, the hospital's pain management center coordinates medication the patients take in the home and hospital.
Barnes-Jewish Hospital also implemented the Pasero Opioid-induced Sedation Scale to improve assessment of opioid medication administration in non-ICU inpatient nursing units. "A lot of us are moving away from opioids as a frontline therapy," says Bottros. "We have a system-based approach."
Physicians in pain management programs are increasingly striking a balance between ordering proper medications and trying to ward off potential drug abuses, the American Cancer Society Action Network has found.
"Keeping the patients' perspective and needs in focus is extremely important in prescribing painkillers," says David Woodmansee, associate director for state and local campaigns for the American Cancer Society Cancer Action Network. "That is the essence of balance."
Success key No. 2: Treating children's pain
While many hospitals are launching programs primarily to help adult patients cope with pain, others are focusing on children, especially cancer patients. A major concern is that younger children may have trouble communicating the extent of their pain, making diagnosis and treatment difficult. And, too often, physicians and hospitals lack expertise in providing proper medication and integrative or nonpharmacological therapies for children in pain, says Stefan Friedrichsdorf, MD, medical director of pain medicine, palliative care, and integrative medicine at the 381-staffed-bed Children's Hospitals and Clinics of Minnesota in Minneapolis.
An independent, not-for-profit healthcare system, Children's of Minnesota provides care through more than 12,000 children inpatient visits and more than 300,000 emergency room and other outpatient clinic visits every year. By establishing a specific pain management program, the hospital
has added protocols that have resulted in improved outcomes and reduced length of stay for its patients, says Friedrichsdorf. The multidisciplinary team includes physicians, nurses, social workers, psychologists, and massage therapists. The pain management program has increased its volume of patients in each of the past several years, from a total of 1,117 children seen in 2008 to 1,440 in 2012.
Focusing on patient management has resulted in savings and reduced lengths of stay. One of the most significant efforts was establishing an advanced analgesia-sedation protocol for babies and children who had undergone open heart surgery. In pediatric circles, it is known that pediatric sedation requires a balance between risk and procedures. Studies have shown that the demand for procedural sedation for diagnostic and therapeutic procedures is increasing.
Hospitals must establish proper protocols to provide safe and high-quality sedation. The Minneapolis analgesia-sedation protocol has resulted in reduced length of stay from eight to seven days, and it intubated children four hours earlier, despite the fact that the children were considered generally "sicker" from their cardio scores, according to Friedrichsdorf.
In the cardiovascular ICU, process improvements also meant workflow changes, he adds. Adjustments were made to team roundings, such as the requirement that twice each day—from 7 a.m. to 8 a.m. and again from 4:30 p.m. to 5:30 p.m.—a team nurse, respiratory therapist, intensivist, cardiologist, cardiac surgeon, pharmacist, and pain physician round on every patient. If a rounding occurs at a cardiac ICU, a cardiac intensivist is involved.
The hospital's readmission rate within seven days, for any condition, was as low as 3.5% from January to December of 2012, which is notable when compared to 24 other children's hospitals, the lowest of which had a readmission rate of 4.1%, according to the Pediatric Health Information System, a database operated by the Alexandria, Va.–based Children's Hospital Association. Generally, Children's of Minnesota has "sent their patients home faster and that drives up satisfaction for the patients and their parents," Friedrichsdorf says.
Managing children's pain at hospitals across the country has been erratic, in part because of uncertainty among physicians in providing proper doses of medication for pain, says Friedrichsdorf. By not incorporating multidisciplinary teams to focus on children's pain needs, hospitals are coming up short for children, especially for those with acute chronic pain, he adds.
"Most children's hospitals are not even implementing the basic principles of acute or chronic pain management," he says. Among the places where these principles should be applied are in children with acute pain, postoperative pain, and cancer pain, after open-heart surgery and orthopedic procedures, and for chronic pain, such as abdominal and musculoskeletal pain.
"Children with cancer pain, they probably receive too little medication, and pediatric patients with chronic pain and headaches probably get too much," Friedrichsdorf says. "It's quite easy to prescribe strong medication and say, 'I'll see you in two weeks.' These kids need physical therapy and normalized lives. We extubate the children when they are admitted to our hospital and they receive advanced pain management. This is a business model that hospital leadership can get behind."
Success key No. 3: Comanaging pain
A pain management specialist looked around the Nevada desert and noticed it lacked more than water: There weren't many pain doctors around.
"Over the past few years, there has been only one pain management doctor for every 10,000 patients who come in for pain treatment," observes Denis Patterson, DO, now medical director of Northern Nevada Medical Center's Pain Management Center. "There's definitely a need for pain management, a huge need really, and pain management is very much underutilized in the community."
Patterson and his physician group were eager to establish protocols in a niche market, especially for patients who were clamoring for lower back pain care. The doctors reached a comanagement agreement with Northern Nevada Medical Center. Both physicians and hospital representatives comprise the leadership team that oversees pain management programs at the hospital's Pain Management Center.
"At the Pain Management Center, our goal is to return patients to a maximum level of functioning and independence by identifying the source pain and using advanced techniques to reduce the level of pain and suffering," says Patterson.
For the Northern Nevada Medical Center, teaming up with the physicians group was a good fit. The hospital was known in the community for its orthopedics program and had launched an outpatient rehabilitation and sports medicine unit, "which has been a fast-growing program," explains Meert, the hospital's COO. "Opening a pain management center was a natural fit for our continuum of care and for the population we serve," she says.
The comanagement program allows the hospital to have "highly respected, fellowship-trained pain management physicians at Nevada Advanced Pain Specialist to comanage quality outcomes and indicators as well as program enhancement and efficiency," Meert says. The hospital "invested capital" in the pain management program, especially with added imaging equipment and surgical staff. Within a year, the hospital began to recoup its investment by especially focusing on patients with lower back pain, she says, adding that "so many patients were in need." It was important that the hospital focus on "enhanced quality," Meert says. "It's a constant state of education."
More than 50% of patients report having knee pain, and when combining that statistic with those reporting low back and neck pain, that represents 85% of patients, according to Patterson. The hospital's pain management program is comanaged by the Northern Nevada Medical Center and a physicians group, the Reno-based Nevada Advanced Pain Specialists, which specializes in stroke, knee replacement, hip replacement, and spine surgery. The program received the Joint Commission's Gold Seal of Approval for low back pain.
At the Pain Management Center, patients undergo an evaluation that may include x-rays, magnetic resonance imaging scans, or nerve studies to find the specific disk, nerve root, joint, or tendon causing pain. After a physician identifies the source of pain, he or she may use image-guided techniques to deliver steroids, burn nerve endings, or perform other targeted therapies at the precise area causing pain.
The physicians group initiated the working relationship with the hospital after seeing the great need for pain care in the Sparks and Reno area of Nevada, say Meert and Patterson. Too often, primary care physicians lack knowledge about pain management, Patterson says. "Part of what we do is educating primary care doctors what patient management is, and that what we are trying to do is in the best interest of the patient."
With the comanagement arrangement, the hospital expanded staff, particularly surgery and imaging. Like other pain management programs, the staff includes therapists and acupuncturists. Physicians have increased referrals for patient care, Patterson says. The message to physicians is: "If it hurts, send them." Once patients are examined, "that allows us to triage them, work up a program, and see what's happening."
For both the hospital and the physicians, it's a good working relationship that allows for more patients into the program and reciprocal incentives for the medical group, Patterson says. The hospital reduces overhead costs for physicians, who bring patients to the facility. "It's nice," he says. "It lowers my overhead and they have a center where we can see patients. In return, we do a lot of cases at the hospital, and the hospital gets a facility fee. They make a profit in the end, and they have supplies for us."
The comanagement program involves leadership from both the physicians group and the hospital, Patterson says. It includes the physician partners and the hospital's CFO and CEO. "It's a win-win situation in the sense [that this is] an underutilized field," he says.
Success key No. 4: Pain management satisfaction
At Massachusetts General Hospital, daily meetings include physicians and administrative staff who review data and results from HCAHPS surveys, which score how patients say the hospital managed their pain. How often was the patient's pain well controlled during the hospital stay? Did the staff do everything they could to help patients with their pain?
MGH officials believe the hospital hasn't scored quite as well as it should, says Gilligan, the pain management director, even though the patients' perception about the hospital's level of care surrounding pain issues is consistently at or above the state average. "I think we score consistently low on that," he says. Most recently, in a survey of 300 patients from 2011 to 2012, 72% of patients reported that the pain was well controlled, which is comparable to the state average of 72%, and above the national average of 71%, according to Hospital Compare.
Gilligan says the hospital would score much higher if it weren't "very conservative with using narcotics for noncancer pain." Some patients say the hospital "doesn't listen to me" when they ask for more powerful drugs, he says. Still, the hospital's pain management center maintains its conservative approach.
Other hospital officials acknowledge that they, too, would get better satisfaction scores if they catered more to patients' requests for more drugs to relieve their pain. "To get great patient outcome scores, a lot of patients might say, 'Give me more drugs,' right?" notes Patterson of the Northern Nevada Medical Center. "It's a juggling act. I want to make sure the patients who are coming in are not just doctor shopping or trying to get drugs," he adds.
"That's a hard part of pain management. Could I get better patient satisfaction scores if I gave more opioids?" Patterson asks, perhaps rhetorically. "But after all, at the end of the day, I've got to do what's medically appropriate; I've got to sleep at night."
At the hospital, Patterson says, "I think we have a reputation as the strictest in town. The 'drug-seeking patients,' they'll come in for easy meds. They say, 'No offense, you're too strict. I'll go somewhere else.' " He tells the patients, "Hey, good luck. Let me help you out the door."
Hospital procedures themselves cause pain. Each year, hospitals perform about 10 million inpatient surgeries and 17 million outpatient surgeries, all of which require pain management.
So how does a hospital improve its patient satisfaction scores when it comes to pain management? Within the past year, Barnes-Jewish Hospital has made inroads in patient satisfaction score improvements through changed protocols, especially involving anesthesiologists in a revised process of care, says Bottros.
It is important that pain management is developed for the appropriate pain condition and the type of surgery a patient has had. The hospital has made "simple" rather than drastic changes to improve patient satisfaction scores, Bottros says. Barnes-Jewish Hospital has anesthesiologists in a leadership role in pain management, which has been important for postoperative care and postoperative pain control.
"There's a growing trend for anesthesiologists to show their worth as perioperative physicians, not just in the operating room but in preoperative assessment and planning. It is using anesthesiologists in a more robust fashion," Bottros says.
The hospital focuses on consistent pain management, implementing a multidisciplinary team focus, with an emphasis on communication and proper protocols. For instance, the team consistently paces the use of epidurals for pain associated with surgeries, and acetaminophen is used, not just the
narcotics. It's important that the nursing staff consistently communicates with patients about their pain, and that message is directed to physicians.
The Barnes-Jewish Hospital has found ways to improve patient satisfaction scores dealing with pain. "In a very short time, the scores have increased robustly," Bottros says. In scores from patients who had gynecological surgery, patient satisfaction scores improved from 67% to 85% in two months in early 2013, he says.
Bottros noted that pain is sometimes difficult to control following surgery in orthopedics cases, such as knee replacement or hip pain. Yet those patient satisfaction scores also increased, from 55% to 83% for knee surgery, and 78% to 94% for hip surgery from September 2012 to April 2013.
Among colorectal surgical patients, for instance, patient satisfaction scores increased from 66% to 83.3% within the same six-month period, he says. "The only thing we changed is that we made sure the care path includes epidurals for perioperative pain, as well as other adjutant therapies."
In another area, knee replacement—where hospitals often have had difficulty achieving good scores among patients following surgery—the hospital's pain satisfaction scores jumped significantly from 55.4% to 83.3% from September 2012 to April 2013.
Because the reported improved patient satisfaction scores covered only a short period of time, Bottros concedes it's not a large, long-term sample. But he says the increased scores reflect the hospital's inroads into pain management and relief for patients.
"We try to ensure that we don't just stick to one particular technique," especially for postoperative pain management, he says. "For some surgeries, like abdominal, we use epidurals in combination with adjuvant medications such as IV acetaminophen or ketorolac, a nonsteroid anti-inflammatory drug," he adds. "For other surgeries, we use IV PCA [intravenous patient-controlled analgesia] in combination with adjuvant medications such as acetaminophen."
Patient attitudes about how hospitals control their pain is impacted by their perception of how the staff listens to them and cares about how they feel, with communication a key, Bottros says.
"I think in today's society, patients are a little less stoic than they might have been in the 1950s. Today people are more open to discussing their pain. Today patients are a lot more vocal about their problems and more vocal about their complaints," he says.
"If you improve pain management, you are also indirectly improving other aspects of patient satisfaction," Bottros says. "If a patient is happy with pain control, it does impact other scores as well."
Years ago, physicians were taught that pain control was "a symptom of some underlying disease, and as pain becomes more and more prevalent, and more chronic, that pain becomes a disease in itself," Bottros says. "We have started thinking outside the box a little bit, stopped trying to search for that elusive Pandora's Box, and now we're trying to accommodate patients."
This article appears in the September issue of HealthLeaders magazine.