Abstract
PurposePain is suboptimally managed in patients with cancer. We aimed to compare the effect of a policy of adding a clinician-delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes.Patients and MethodsIn a two-arm, parallel group, cluster randomized (1:1) trial, we observed pain outcomes in 19 cancer centers in the United Kingdom and then randomly assigned the centers to either implement EPAT or to continue UC. The primary outcome was change in the percentage of study participants in each center with a clinically significant (≥ 2 point) improvement in worst pain (using the Brief Pain Inventory Short Form) from admission to 3 to 5 days after admission. Secondary outcomes included quality of analgesic prescribing and opioid-related adverse effects.ResultsTen centers were randomly assigned to EPAT, and nine were assigned to UC. We enrolled 1,921 patients and obtained outcome data from 93% (n = 1,795). Participants (mean age, 60 years; 49% women) had a variety of cancer types. For centers randomly assigned to EPAT, the percentage of participants with a clinically significant improvement in worst pain increased from 47.7% to 54.1%, and for those randomly assigned to continue UC, this percentage decreased from 50.6% to 46.4%. The absolute difference was 10.7% (95% CI, 0.2% to 21.1%; P = .046) and it increased to 15.4% (95% CI, 5.8% to 25.0%; P = .004) when two centers that failed to implement EPAT were excluded. EPAT centers had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC.ConclusionA systematic integrated approach improves pain outcomes for inpatients in cancer centers without increasing opioid adverse effects.
Highlights
We aimed to compare the effect of a policy of adding a clinician-delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes
Ten centers were randomly assigned to EPAT, and nine were assigned to UC
For centers randomly assigned to EPAT, the percentage of participants with a clinically significant improvement in worst pain increased from 47.7% to 54.1%, and for those randomly assigned to continue UC, this percentage decreased from 50.6% to 46.4%
Summary
Half of patients with cancer suffer from pain.[1,2,3] Despite the availability of pain management guidelines, poor outcomes are common.[4,5,6,7,8,9,10] Common shortcomings in pain management include unstructured assessment, use of treatment guidelines that lack explicit algorithms and do not address clinicians’ concerns about prescribing opioids, and lack of systematic monitoring of outcomes, including adverse effects.[11,12]. We developed a simple clinician-administered bedside tool—the Edinburgh Pain Assessment and management Tool (EPAT)—that builds on the concept of pain as the fifth vital sign.[13,14,15,16] EPAT aims to change routine practice by directing a systematic assessment of cancer-related pain, guiding treatment
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