Stratified Pain Management Counseling and Implementation Improving Patient Satisfaction: A Prospective, Pilot Study
Introduction Acute post-operative pain is a significant concern for patients undergoing surgery, as it not only causes discomfort but also negatively impacts surgical recovery and overall quality of life. Despite the widespread use of peri-operative multimodal analgesia, its efficacy remains suboptimal, with more than 50% of patients in the USA and China still experiencing moderate-to-severe post-operative pain. This highlights the urgent need for improved pain management strategies that address the individual needs of patients while minimizing opioid consumption and associated risks.
The concept of individualized pain management has gained traction in recent years, as it aims to bridge the gap between patients’ analgesic needs and clinicians’ perceptions of those needs. To achieve this, it is crucial to identify pre-operative characteristics that render patients susceptible to severe and prolonged post-operative pain. Additionally, addressing patients’ misconceptions about the potential adverse effects of analgesic medications is essential for ensuring optimal pain management outcomes.
The development of a stratified analgesic model based on risk assessment offers a promising approach to improving peri-operative pain management. By identifying patients at higher risk of post-operative pain and tailoring analgesic techniques and medications accordingly, this model has the potential to enhance analgesic efficacy, patient satisfaction, and recovery quality while minimizing healthcare costs.
Methods This prospective, controlled, pilot study was conducted at a single university hospital and included 361 patients who underwent elective surgery between January 2017 and September 2018. Patients were recruited from various surgical departments, including gynecology, general surgery, orthopedic surgery, plastic surgery, thoracic surgery, breast surgery, and urological surgery.
The study population was divided into two groups: the stratified analgesia group (n = 187) and the conventional analgesia group (n = 174). Patients in the stratified analgesia group received peri-operative pain risk assessment and stratified analgesia counseling, while those in the conventional group received conventional multimodal analgesia.
Pain risk assessment was performed using the pre-validated Peri-Operative Pain Risk Scale (PPRS)-CYMZ 2.0, which evaluates seven key factors: type of surgery, minimally invasive status, estimated duration of surgery, pre-operative chronic pain at surgical sites, ASA grade, risk factors for chronic post-operative pain, and malignancy status. Based on their total PPRS-CYMZ 2.0 score, patients were stratified into low (1-3), intermediate (4-7), or high (8-14) risk groups.
Stratified analgesia counseling involved a comprehensive explanation of the patient’s risk of developing acute moderate-to-severe post-operative pain and the planned pain management protocol. This counseling was conducted by anesthesiologists specializing in pre-operative evaluation and aimed to address patients’ misconceptions and concerns regarding analgesic medications.
The implementation of stratified analgesia involved a multidisciplinary team of anesthesiologists, surgeons, and nursing staff. The stratified analgesia algorithm included pre-operative preventive analgesia, intra-operative analgesia, and post-operative analgesia based on pain risk stratification. Patients at higher risk of pain received more potent analgesic techniques and medications, such as patient-controlled analgesia (PCA) and local wound infiltration combined with nerve blocks.
Outcome assessments included post-operative pain intensity at rest and during motion, rescue analgesia administration, quality of recovery as measured by the Quality of Recovery 40 (QoR-40) questionnaire, total dosage of peri-operative opioids, analgesic satisfaction, and analgesic costs. These assessments were performed at various time points during the post-operative period, with follow-up continuing until hospital discharge.
Results The study found that the stratified analgesia group reported significantly lower pain intensity during motion at 24 hours post-operatively compared to the conventional group (P = 0.03). Additionally, the stratified group required lower dosages of rescue analgesia (P = 0.03) and had a lower cumulative number of rescue analgesia episodes (31 vs. 68, P < 0.01).
In terms of recovery quality, the stratified analgesia group demonstrated significantly better scores on the QoR-40 questionnaire, particularly in the domains of physical wellbeing and pain (P = 0.04). Patients in the stratified group also reported higher levels of analgesic satisfaction (P = 0.03) and received lower total dosages of opioids (P = 0.03).
From a cost perspective, the stratified analgesia protocol proved to be more economical, with lower direct analgesic costs, analgesia-related costs, and total analgesic costs compared to conventional analgesia (P = 0.04). The cost-effective ratio (CER) was 62 in the stratified group versus 109 in the conventional group, indicating that each patient in the stratified group saved 47 RMB for every one point increase in analgesic satisfaction.
Discussion The findings of this pilot study demonstrate that stratified pain management counseling and implementation can significantly improve post-operative analgesia, patient satisfaction, and recovery quality while reducing healthcare costs. By incorporating a comprehensive risk assessment and tailored analgesic approach, the stratified protocol addresses several key challenges in peri-operative pain management.
One of the primary advantages of the stratified analgesia protocol is its ability to balance patients’ expectations with their actual pain management needs. The pre-operative counseling component helps patients understand their risk of post-operative pain and the rationale behind their individualized pain management plan. This not only increases patient compliance but also encourages more open communication about pain levels and treatment effectiveness.
The risk stratification process itself is a critical component of the protocol’s success. By identifying patients at higher risk of severe post-operative pain, clinicians can implement more aggressive analgesic strategies, such as PCA and nerve blocks, at an earlier stage. This proactive approach reduces the need for rescue analgesia and minimizes the risk of uncontrolled pain, which can negatively impact recovery and patient satisfaction.
The study’s findings regarding opioid consumption are particularly noteworthy, given the ongoing global concerns about opioid misuse and addiction. The stratified protocol’s ability to reduce total opioid dosages while maintaining or improving pain control represents a significant advancement in peri-operative pain management. This is especially important for patients with a history of chronic pain or those who may be at higher risk of developing opioid dependence.
The cost-effectiveness of the stratified analgesia protocol is another important consideration. By reducing the need for rescue analgesia and minimizing the occurrence of analgesia-related adverse events, the protocol not only improves patient outcomes but also lowers overall healthcare costs. This is particularly relevant in the context of increasing healthcare expenditures and the need for more efficient resource allocation.
The study’s limitations should be acknowledged, including its open-label design and potential for selection bias. Additionally, the risk scale used in this study was developed and validated in a single tertiary medical center, which may limit its generalizability to other healthcare settings. Future research should focus on multi-center trials to further validate the effectiveness of stratified analgesia protocols and explore additional methods for opioid-sparing peri-operative pain management.
Conclusion This pilot study demonstrates that stratified pain management based on surgical pain risk assessment and counseling can significantly improve post-operative analgesia, patient satisfaction, and recovery quality while reducing healthcare costs. The protocol’s emphasis on individualized pain management, proactive analgesic strategies, and comprehensive patient education represents a significant step forward in peri-operative pain management.
The findings of this study have important implications for clinical practice, as they provide a framework for implementing more effective and efficient pain management strategies. By incorporating risk assessment, tailored analgesic approaches, and patient education into routine peri-operative care, healthcare providers can better meet the needs of surgical patients while addressing the ongoing challenges associated with opioid use and healthcare costs.
As the field of peri-operative pain management continues to evolve, the development and implementation of stratified analgesia protocols offer a promising avenue for improving patient outcomes and optimizing resource utilization. Future research should focus on refining risk assessment tools, exploring novel analgesic techniques, and evaluating the long-term impact of stratified pain management on patient recovery and satisfaction.
doi.org/10.1097/CM9.0000000000000540
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