Abstract
Background: Pain in people with cancer is common but often under-recognized and under-treated. Guidelines can improve the quality of pain care, but need targeted strategies to support implementation. Aim: To test the feasibility of two service-level strategies for supporting guideline implementation: a screening system and medical record audit. Design: Multimethods. Setting: One oncology outpatient service, and one palliative care outpatient and inpatient service. Participants: Patients with advanced cancer. Methods: Patients were screened in the waiting room with a modified version of the Edmonton Symptom Assessment System-revised either electronically or in paper-based format. Feasibility indicated the percentage of patients successfully screened from the total number attending the services. An audit assessed adherence to key indicators of pain assessment and management. Feasibility thresholds were set at 75% incidence for screening and a median of 30 minutes per patient for audit. Results: Of 452 patient visits, 95% (n = 429) were successfully screened, 34% (n = 155) electronically and 61% (n = 274) paper-based. Electronic pain screening was technically challenging and time-intensive for nurses. Thirty-one patients consented to have their records audited. The median audit time was 37.5 minutes (range 10-120 minutes). Variability arose from the number and type of record (outpatient or inpatient). Adherence to indicators varied from 63% (pain assessment at first presentation) to 94% (regular pain assessment and medication prescribed at regular intervals). Conclusions: This study confirmed the need to implement evidence-based guidelines for cancer pain and generated useful insights into the feasibility of pain screening and audit.
Highlights
Pain is experienced by more than half of people with cancer and can have serious impacts on everyday functioning and quality of life (Breivik et al, 2009; van den Beuken-van Everdingen, Hochstenbach, Joosten, Tjan-Heijnen, & Janssen, 2016)
The results add to previous research that has highlighted shortcomings in cancer pain care, thereby underlining the need for improving evidence-based practice
The barriers encountered with electronic screening in the current study contrast somewhat with previous evidence for feasibility, which have been reported mostly in oncology settings (Kotronoulas et al, 2014)
Summary
Pain is experienced by more than half of people with cancer and can have serious impacts on everyday functioning and quality of life (Breivik et al, 2009; van den Beuken-van Everdingen, Hochstenbach, Joosten, Tjan-Heijnen, & Janssen, 2016). Multidisciplinary management of cancer pain is essential to ensure comprehensive assessment and patient education, and to optimize nonpharmacologic and pharmacologic intervention (Peng, Wu, Sun, Chen, & Huang, 2006). Barriers to cancer pain care exist at the levels of the healthcare system (e.g. lack of coordination), service (e.g. confusion regarding multidisciplinary roles), clinician (e.g. lack of knowledge and time) and patient (e.g. reluctance to report pain) (Fazeny et al, 2000; Jacobsen et al, 2009; Oldenmenger, Sillevis Smitt, van Dooren, Stoter, & van der Rijt, 2009). Clinical practice guidelines can improve both the processes and outcomes of care for cancer pain Guidelines are unlikely to be implemented without targeted strategies to incentivise use and overcome barriers (Grimshaw et al, 2004). The MRC’s Framework for Complex Interventions was used as a guide, using the four phases of development, feasibility and piloting, evaluation, and implementation
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