Original Title: Modelos organizativos en el tratamiento del dolor oncológico

Authors' objectives: 1. To report on the effectiveness of organisational models of care services in cancer pain management. 2. To identify the main characteristics of health care structures to meet the needs of patients with cancer pain in Spain, to identify improvement deficiencies and opportunities from the perspective of patients, caregivers and health professionals.

Authors' results and conclusions: RESULTS: - Review of quantitative studies: The literature search provided a systematic review published in 2008, including 12 studies, to determine the effectiveness of different organizational models to address cancer pain (the search covered studies published between 1986 and 2006). The organizational models identified were classified into three categories of increasing complexity: 1) the most basic model, called "institutionalization", based on the development and systematic application of standardized patterns of activities applied throughout the day, 2) the clinical pathways, and 3) the pain clinics. Process and outcome indicators to report on the effectiveness of these three models of management for patients with cancer pain wereselected. Among the outcome measures, the measurement of pain intensity and pain relief, the patient satisfaction with the pain management model received and the cost-effectiveness of the model were selected. Among process measures, the fulfillment of the recommendations for pain assessment, the analgesics administration, the avoidance of the use of drugs’ intramuscular administration, and the pain intensity recording were included. Overall, improvements of some secondary indicators were obtained for the three previous organizational models. Specifically, constant improvements of patient satisfaction, incorporation of tools for pain assessment and their continuous use were observed. However, the robustness of this systematic review is limited by the medium-low quality of the included studies. No subsequent quantitative studies that provide information on the comparative effectiveness of different organizational models for the treatment of patients with cancer pain were found. However, we have considered some studies comparing specific interventions that could set in different contexts or changes in the care organization in the same setting (hospitals, local health centers or homes). These studies provided additional information on the results of the three models. - Review of qualitative studies: From a total of 331 references initially identified, only six studies could be included according to the selection criteria previously established. No organizational model of health services to meet the needs of no terminally-ill patients with cancer pain was accurately assessed in any of the included studies. However, they explore perceptions, attitudes and beliefs of patients, their caregivers and healthcare professionals involved in their care, providing valuable information to plan and manage organizational models adapted to the needs of all of them. All stakeholders agreed in emphasizing important aspects that must be present in the ideal model, including the multifactorial and interprofessional approach, adapted to patients’ circumstances, continued, and with informed shared decision making. Some factors specifically recognized by health professionals were: the warranty of accessibility and continuity of care, the improvements in communication and information through the professional-patient interaction and the availability of additional supporting documentation. They also require further efforts on the identification of appropriate measure scales to simplify evaluation and monitoring tasks by patients and professionals,making possible at the same time results’ comparison in both clinical practice and research activities. - Qualitative study about the perceptions of patients, caregivers and professionals on organizational models for the control of cancer pain in Spain: The main findings from patients and caregivers’ perspective were: their main source of information about pain were nurses; most health professionals spend little time to provide information about pain and its control; health professionals do not usually take into account patients opinions and preferences; a more human, accessible, comprehensive and continuous care is received in palliative care units compared to other types of services (oncology services or pain clinics); overall patients are satisfied with their treatment effectiveness regardless of the treating center. The main findings from the health professional perspectives were that: patients need to be individually assessed and classified according to their complexity, to be referred to already existing resources of increasing complexity and costs; continuity of care for most patients must be warranted from Primary Care, including pain assessment and monitoring with treatment adjustment; it is necessary to supplement drug therapy with psychological support for night pain which patient lives in a more distressing way; primary care physicians, nurses and anesthesiologists believe that palliative care units are the most appropriate organizational structures, among those commonly available in Spain, to meet overall needs of patients with cancer pain; coordination between primary and secondary care and also among the different specialized services must be improved; patients with highly complex pain may exceed the capacity of palliative care units and therefore require the activation of specialized hospital services (anesthesiology, or more dramatically, oncology); the development planning of services and the type of organizational model adopted is scarcely based on scientific evidence; non-compliance issues are more frequent in those cases which are not properly informed about the possible side effects of therapies; information and communication technologies are not present to improve access, continuity of care and efficiency for these types of services. CONCLUSIONS: The available scientific evidence of effectiveness and cost effectiveness are not sufficient to guide the development of care services for patients with cancer pain who are not in the final stage of life. Existing scientific evidence suggest that, whatever the available healthcare facilities responsible for the management of cancer pain are, the systematic incorporation and implementation of protocols, CPG or clinical pathways based on the best scientific knowledge can improve overall quality of their processes and results. A basic step to improve pain management and control is to incorporate procedures systematically used for the continuous assessment of pain with valid and standardized tools, followed by the design of treatment plans tailored to patients’ needs. The palliative care units are highly valued in the Spanish context both by patients and their caregivers as well as by health professionals, however. Health authorities should promote comparative research studies, focused on costs and effects, to make informed decisions about how and where to organize the care units for complex cancer pain resistant to conventional therapy should be preferably located.

Authors' methods: To address the first objective of the present study, a systematic review of published scientific literature from 1990 was conducted. MEDLINE, EMBASE, CINAHL, PSYCHOINFO and the COCHRANE Library were searched (search date: August 2010). Two different search strategies to retrieve qualitative and quantitative research methodology studies were developed, using specific search filters for each type of study. Original studies published from 1990 in English or Spanish that assessed the effectiveness of organisational models in pain management of patients with any type of cancer were selected. All identified interventions aimed at treating patients with cancer pain, either specific or stably structured, under a particular organizational model were included. Studies focusing on terminal patients assisted in palliative care units or exclusively on children were excluded. For the review of quantitative studies, systematic reviews, clinical trials, quasiexperimental studies and interrupted time series design which reported on the effectiveness of organizational models compared at least with the usual organization of health care were selected. For the review of qualitative studies, studies with qualitative design and method of analysis that assess the implementation of different organizational models for cancer pain management or variations of the same model including patients, caregivers and/or health professionals and exploring the beliefs, feelings, values, experiences and perceptions were included. The assessment of methodological quality of the included studies was conducted using the CASP Appraisal Tool for each of these two types of studies. Data are presented through narrative synthesis. The meta-ethnographic methodology rather than synthetic methods based on the simple aggregation of studies was used for synthesising qualitative research. To address the second objective of the present study, qualitative research techniques for gathering and analyzing information were used. Specifically, in-depth interviews in four Spanish regions were conducted: Canary Islands, Catalonia, Extremadura and Madrid. Interviews were conducted with: 1) Patients receiving treatment for cancer pain, 2) Caregivers, and 3) Nurses (palliative care), oncologists, primary care physicians, anesthesiologists and other professionals involved in pain management units.

Project Status: Completed

Year Published: 2012

URL for published report: https://sescs.es/modelos-organizativos-en-el-tratamiento-del-dolor-oncologico/

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Canary Health Service

Contact Address: Dirección del Servicio. Servicio Canario de la Salud, Camino Candelaria 44, 1ª planta, 38109 El Rosario, Santa Cruz de Tenerife

Contact Name: sescs@sescs.es

Contact Email: sescs@sescs.es