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A Cost-Analysis of an Interdisciplinary Pediatric Chronic Pain Clinic
Abstract
Chronic pain is characterized by high rates of functional impairment, health care utilization, and associated costs. Research supports the use of comprehensive, interdisciplinary treatment approaches. However, many hospitals hesitate to offer this full range of services, especially to Medi-Cal/Medicaid patients whose services are reimbursed at low rates. This cost analysis examines the effect on hospital and insurance costs of patients' enrollment in an interdisciplinary pediatric pain clinic, which includes medication management, psychotherapy, biofeedback, acupuncture, and massage. Retrospective hospital billing data (inpatient/emergency department/outpatient visits, and associated costs/reimbursement) from 191 consecutively enrolled Medi-Cal/Medicaid pediatric patients with chronic pain were used to compare 1-year costs before initiating pain clinic services with costs 1 year after. Pain clinic patients had significantly fewer emergency department visits, fewer inpatient stays, and lower associated billing, compared with the year before without interdisciplinary pain management services. Cost savings to the hospital of 11,482 per patient per year were found even after pain clinic service billing was included. Analyses of pre-pain clinic costs indicate that these cost reductions were likely because of clinic participation. Findings provide economic support for the use of interdisciplinary care to treat pediatric chronic pain on an outpatient basis from a hospital and insurance perspective.
Perspective
This article presents a cost analysis of an interdisciplinary pediatric pain outpatient clinic. Findings support the incorporation of a comprehensive treatment approach that can reduce costs from a hospital and insurance perspective over the course of just 1 year.
... 11 IM has also been shown to reduce ED visits, inpatient hospitalization, and overall costs. 12 Patients incorporating IM alongside medication management and psychotherapy also exhibited a lower likelihood of ED visits compared with those who did not receive supplementary IM. 13 Economic models can assess the cost impact of these modalities on reducing overall health care costs, accounting for the upfront investment required to deliver these services. Specifically, a budget impact model estimates the cost savings associated with implementing a given intervention or service, typically due to reduced healthcare utilization and improved clinical outcomes, minus the cost of delivery. ...
... Previous work reporting on the reduction of hospitalizations and ED visits preintegrative and postintegrative medicine implementation was used to estimate these metrics. 12 The per-day costs for hospitalizations and ED visits were then applied to the total number of hospital days preintervention and postintervention to standardize the estimated cost savings associated with the utilization of these services. We therefore estimated a preintervention hospitalization cost of $134,415 (range: $87,875 to 210,451) and ED costs of $928 (range: $761 to 1143). ...
... Probabilities of adverse events (ED visits and hospitalizations) were derived from previous papers analyzing the impact of IM services on ED visits and hospitalizations. 12,13 Because these previous papers do not report on the probability of an ED visit or hospitalization, but rather on the total number of ED visits and hospitalization days on a per-patient basis in the 1-year preintervention/postintervention, the probability of an adverse event was calculated by standardizing the number of ED visits (hospitalization days) to 365 days in a year. ...
Objectives
Chronic pain is a leading cause of morbidity in children and adolescents globally but can be managed with a combination of traditional Western medicine and integrative medicine (IM) practices. This combination has improved various critical health outcomes, such as quality-of-life, sleep, pain, anxiety, and healthcare utilization. These IM practices include acupuncture, yoga, biofeedback, massage, mindfulness, or any combination of these modalities. The current manuscript developed a budget impact model to estimate the institutional costs of implementing these practices among adolescents.
Methods
A decision tree was used to estimate the reduction in hospitalizations and emergency department (ED) use based on a previously published retrospective analysis of children receiving IM practices comparing utilization rates 1-year pre-and post-implementation of IM services (Figure 1). Costs associated with the implementation of each modality were based on hourly compensation rates for licensed professionals administering each service and equipment associated with delivery (e.g. acupuncture needles, biofeedback equipment, and sensors). The cost of each hospitalization and ED visit was derived from the literature. In addition, cost-savings were estimated based on government- and commercial-contracted reimbursement rates for each service.
Results
Cost-savings were approximated to range from 3439 per patient, with even greater cost-savings of up to 4,132 when accounting for governmental and commercial payer reimbursement, respectively.
Discussion
IM leads to improved pain relief when combined with traditional medicine and yields significant cost-savings, thus supporting the routine implementation of IM alongside traditional medicine in healthcare settings.
... All EEs included outpatient services and all but one study 49 included inpatient services. Other cost components considered in the analyses were medication, 12,49-51,53,55 community services, 50 physical and occupational therapy, 12,47,48,[50][51][52][53]55 and OOP expenses. 12,[48][49][50][51] Five studies additionally considered indirect costs, such as parents' lost work time, 12,[47][48][49][50] opportunity costs for informal care, [48][49][50] reduced efficiency at work, 49 lost school hours, 48,49 and reduced efficiency at school. ...
... 50 Complementary integrative medicine, that is, biofeedback, acupuncture, and massage were evaluated in a further study. 55 Five studies [48][49][50]52,55 analyzed an outpatient treatment, 3 studies 12,51,53 an inpatient treatment, and 1 study 47 analyzed a mix of both. A further study did not report if the treatment was inpatient or outpatient. ...
... All studies reported a reduction in costs related to the respective intervention. Four studies [47][48][49]52 included the costs for the respective intervention, which ranged between PPP-USD 200 for an I-CBT in Sweden 49 and PPP-USD 36,725 for an inpatient and outpatient intensive pain rehabilitation program in the United States. 47 ...
Objectives
Chronic pain in children and adolescents (CPCA) is widespread with an increasing prevalence. It is associated with a decreased quality of life and an increased parental work loss. Accordingly, CPCA may pose a substantial economic burden for patients, healthcare payers, and society. Therefore, this systematic review aims to synthesize (1) the results of existing cost-of-illness studies (COIs) for CPCA and (2) the evidence of economic evaluations (EEs) of interventions for CPCA.
Methods
The systematic literature search was conducted in EMBASE, MEDLINE, PsycINFO, NHS EED, and HTA Database until February 2023. Title, abstract and full-text screening were conducted by two researchers. Original articles reporting costs related to CPCA published in English or German were included. Study characteristics, cost components, and costs were extracted. The quality of studies was assessed using standardized tools. All costs were adjusted to 2020 purchasing power parity US dollars (PPP-USD).
Results
Fifteen COIs and 10 EEs were included. Mean annual direct costs of CPCA ranged from PPP-USD 603 to PPP-USD 16,271, with outpatient services accounting for the largest share. Mean annual indirect costs ranged from PPP-USD 92 to PPP-USD 12,721. All EEs reported a decrease of overall costs in treated patients.
Discussion
The methodology across studies was heterogeneous limiting the comparability. However, it is to conclude that CPCA is associated with high overall costs, which were reduced in all EEs. From a health economic perspective, efforts should address the prevention and early detection of CPCA followed by a specialized pain treatment.
... As predicted, PCS-C scores showed a significant reduction at discharge and 3-month follow up compared to baseline. Previously established clinical reference points for PCS-C severity include low (<15), medium (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25), and high (>25), with each reference point being associated with clinically significant differences in functional disability, depressive symptoms, and anxiety [36]. Our results indicate a shift from a high level of catastrophizing (mean: 27) to a more moderate level at IIPT discharge (21.3) and 3-month follow-up (19.8), suggesting clinically significant associations across multiple dimensions of wellness. ...
... However, it is also possible that gender is not associated with IIPT outcomes for other reasons-previous research on the same cohort in a broader sample including multi-modal therapy found that gender was not associated with pain interference during treatment [54]. While a previous systematic review on children and adolescents (ages [5][6][7][8][9][10][11][12][13][14][15][16][17][18] showed that girls experience more chronic pain than boys [1], another systematic review on young adults (aged [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] showed an equal prevalence of chronic pain between sexes [55]. Additional research is therefore needed to clarify gender differences in adolescents with chronic pain. ...
... However, it is also possible that gender is not associated with IIPT outcomes for other reasons-previous research on the same cohort in a broader sample including multi-modal therapy found that gender was not associated with pain interference during treatment [54]. While a previous systematic review on children and adolescents (ages [5][6][7][8][9][10][11][12][13][14][15][16][17][18] showed that girls experience more chronic pain than boys [1], another systematic review on young adults (aged [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] showed an equal prevalence of chronic pain between sexes [55]. Additional research is therefore needed to clarify gender differences in adolescents with chronic pain. ...
Background: More could be known about baseline factors related to desirable Intensive Interdisciplinary Pain Treatment (IIPT) outcomes. This study examined how baseline characteristics (age, gender, child pain catastrophizing (PCS-C), pain interference, pain intensity, anxiety, depression, paediatric health-related quality of life (PedsQLTM), and parent catastrophizing (PCS-P)) were associated with discharge and 3-month follow-up scores of PCS-C, pain intensity, and pain interference. Methods: PCS-C, pain intensity, and pain interference T-scores were acquired in 45 IIPT patients aged 12–18 at intake (baseline), discharge, and 3-month follow-up. Using available and imputed data, linear mixed models were developed to explore associations between PCS-C, pain intensity, and pain interference aggregated scores at discharge and follow-up with baseline demographics and a priori selected baseline measures of pain, depression, anxiety, and PCS-C/P. Results: PCS-C and pain interference scores decreased over time compared to baseline. Pain intensity did not change significantly. Baseline PCS-C, pain interference, anxiety, depression, and PedsQLTM were associated with discharge/follow-up PCS-C (available and imputed data) and pain interference scores (available data). Only baseline pain intensity was significantly associated with itself at discharge/follow-up. Conclusions: Participants who completed the IIPT program presented with reduced PCS-C and pain interference over time. Interventions that target pre-treatment anxiety and depression may optimize IIPT outcomes.
... [3][4][5] Studies have been conducted internationally examining health care utilization and costs for pediatric patients with chronic pain. 2,[5][6][7][8][9][10][11][12][13] Many such studies have demonstrated a significant reduction in utilization of health care resources and costs following pain management provided by interdisciplinary chronic pain centers. [6][7][8]10,12,13 Campbell et al. showed a significant reduction in physician remuneration claims across various health care service departments within the first year of treatment by an outpatient interdisciplinary chronic pain management program, with further decreases over the subsequent 5 years. ...
... 2,[5][6][7][8][9][10][11][12][13] Many such studies have demonstrated a significant reduction in utilization of health care resources and costs following pain management provided by interdisciplinary chronic pain centers. [6][7][8]10,12,13 Campbell et al. showed a significant reduction in physician remuneration claims across various health care service departments within the first year of treatment by an outpatient interdisciplinary chronic pain management program, with further decreases over the subsequent 5 years. 6 A study by Mahrer et al. found a significant decrease in ED consultations and in hospital and insurance cost savings, even when taking into account costs of pain clinic services, within the year following chronic pain management program admission. ...
... 6 A study by Mahrer et al. found a significant decrease in ED consultations and in hospital and insurance cost savings, even when taking into account costs of pain clinic services, within the year following chronic pain management program admission. 10 Inpatient, intensive interdisciplinary pain treatment programs have also been associated with significant decreases in health care utilization and costs. 7,8,11,13 Evans et al. noted an overall decrease in health care utilization but did not find a statistically significant reduction in ED usage, 7 whereas Ruhe et al. found a decrease in health care utilization but no statistically significant difference in health care costs. ...
Background:
There is limited information regarding the effects of pediatric chronic pain management on the number and cost of chronic pain-related emergency department (ED) consultations.
Aim:
This retrospective study aimed to evaluate the number and costs of chronic pain-related ED consultations of children and adolescents with chronic pain conditions at the Montreal Children's Hospital (MCH).
Methods:
Charts of patients followed by the Edwards Family Interdisciplinary Center for Complex Pain (CCP) of the MCH between April 2017 and December 2018 were reviewed. ED consultations, specialist consultations, medication prescriptions, hospital admissions, and outpatient consultation referrals were assessed for the period of 1 year before and after the patients' first consultation with the CCP. Associated costs were also calculated.
Results:
One-hundred sixty-eight patients were included in the analysis. Fifty-one percent consulted the ED and had 151 chronic pain-related ED consultations within 1 year before their initial CCP consultation. In the year following their first CCP consultation, 52 patients (31%) consulted the ED, of which 24 consultations were chronic pain-related (84% reduction). There was an 81% reduction in the costs associated with chronic pain-related ED consultations within 1 year after CCP management. In addition, there was a significant reduction in ED interventions within 1 year after CCP management, though there was no change in medication prescriptions, hospital admissions, or subspecialist consultations.
Conclusion:
Children and adolescents with chronic pain conditions had fewer chronic pain-related ED consultations within 1 year after the first evaluation by an interdisciplinary center for complex pain, contributing to reduced ED costs.
... Evans et al. (2016) observed similar cost-effectiveness of their intensive 3-week integrated inpatient/day-hospital program for chronic pediatric pain, showing reduced healthcare costs, healthcare utilization, and decreased parental work absenteeism over the course of a year (Evans, Benore, & Banez, 2016). Most recently, a cost-analysis was conducted examining cost savings related to participation in an outpatient integrated pediatric pain clinic (Mahrer, Gold, Luu, & Herman, 2018). The outpatient integrated pediatric pain clinic serves children and adolescents with Medi-Cal/Medicaid insurance, which is characteristically a more diverse, lower socioeconomic (at or below 138% of federal poverty level), and higher-need population. ...
... All patients presented with chronic pain, either a primary pain condition or pain secondary to a medical condition (e.g., rheumatological, orthopedic, hematological/oncological diseases), and often had a co-morbid psychiatric condition (e.g., anxiety, depression). See Mahrer, Gold, Luu, and Herman (2018) study for further details about patient population demographics and details about the pain clinic. ...
... Costs of hospital services use were captured by two types of billing; hospital and physician, across three types of services; inpatient, emergency department (ED), and outpatient. Given that Mahrer et al. (2018) found cost savings for inpatient and ED services across both hospital and physician billing, the current study included only these variables to further analyze how type of pain clinic service related to health care cost savings. See Mahrer, Gold, Luu, and Herman (2018) study for further details about how these costs were derived and incurred. ...
Youth with chronic pain have high healthcare utilization and associated costs. Research supports integrated treatment; though, it’s unclear which treatments are used and cost-effective. This study expands on work that found reduced service use and cost savings following participation in an outpatient integrated pediatric pain clinic. We explored which services were commonly used and which individual (psychotherapy, medication management, acupuncture, massage, biofeedback) and/or combinations of services were associated with service use reduction and cost savings. Medication management and psychotherapy were more common than complementary integrative medicine (CIM) services. Massage services were associated with reduced inpatient costs. There were trends of fewer emergency department visits for participants who received CIM services in addition to medication management and psychotherapy, and more visits for those with biofeedback. Findings suggest that a more detailed examination of service utilization is needed to better understand cost outcomes related to the integrated treatment of pediatric chronic pain.
... These outpatient clinics emphasize an interdisciplinary approach to pain care and have demonstrated success in improving pain and functional outcomes, as well as decreasing ED and inpatient visits. 13,15 However, there is little understanding of how these health care utilization patterns may vary among different types of pediatric patients who have sought specialized pain treatment. Therefore, the purpose of this study was twofold: (1) to identify changes in the health care utilization patterns of pediatric patients with chronic pain after seeking treatment at a specialized pediatric pain clinic, and (2) to determine if there were differences in health care utilization patterns by the patient's primary pain diagnosis and sociodemographic characteristics. ...
... These findings are consistent with previous research and lend support to specialized outpatient pain clinics being an effective way to reduce the higher costs associated with emergency and inpatient services. 15 Increases in outpatient visits also aligned with prior research in that ongoing outpatient service utilization is likely once patients initiate specialized pain care. 15 While we did not account for the types of visits that occurred after the initial pain clinic visit, previous authors have asserted that an increase in outpatient care is suggestive of patients being engaged in more regularly scheduled, routine appointments to manage their pain symptoms. ...
... 15 Increases in outpatient visits also aligned with prior research in that ongoing outpatient service utilization is likely once patients initiate specialized pain care. 15 While we did not account for the types of visits that occurred after the initial pain clinic visit, previous authors have asserted that an increase in outpatient care is suggestive of patients being engaged in more regularly scheduled, routine appointments to manage their pain symptoms. 15 While there were significant changes in utilization rates overall, these patterns were not consistent within all groups. ...
Introduction:
Pediatric pain clinics may be the most efficacious way to manage chronic and recurrent pain in children and adolescents, but families often rely heavily on nonspecialized care, such as the emergency department (ED). Health care utilization patterns for pediatric chronic pain have not been fully explored, particularly the patient-level factors that may contribute to underutilization or overutilization of certain services.
Objectives:
To identify health care utilization patterns before and after treatment at a pediatric pain clinic and the associations by primary diagnosis and patient sociodemographics.
Methods:
Data were obtained for all pediatric patients with an initial visit at an outpatient pediatric pain clinic between 2005 and 2009. Individual-level data included patient demographics, insurance type, and diagnosis at first pain clinic visit. Rate of health care system utilization 3 months before and after the initial pain clinic visit was quantified. Health care utilization rates before and after the initial visit to the pain clinic were compared using Wilcoxon signed-rank test.
Results:
Eight hundred twenty-six pediatric pain clinic patients were included. Overall, there were significant decreases in ED utilization (P < 0.001) and increases in outpatient service utilization (P < 0.001) after the initial pain clinic visit. Similar patterns were noted for patients by diagnosis (headache, musculoskeletal, or abdominal pain diagnoses) and among those who were female, white, 15 to 18 years old, privately insured, middle- or high-income (P < 0.05).
Conclusions:
Visits to an outpatient pediatric pain clinic were associated with shifts in health care utilization patterns. Important changes were an overall decrease in emergency visits and an increase in outpatient visits.
... [20][21][22] Interdisciplinary outpatient clinics are also a cost-effective approach for treating pediatric chronic pain. 23 Unfortunately, interdisciplinary pediatric chronic pain treatment programs are limited in number, and emerging research suggests inequities in access to these services. According to childpain.org, ...
... 25 An outpatient interdisciplinary pain clinic within a large West Coast children's hospital reported serving approximately 350 patients annually. 23 Given that this study was conducted in a comparatively smaller children's hospital, our high referral volume is notable. Additional research is needed to examine referral patterns for interdisciplinary pain programs, including the potential influence of contextual factors such as hospital size and catchment area, pain management approaches provided through other services, and variation between individual providers. ...
Purpose
We examine referral sources and clinical characteristics for youth presenting to an outpatient interdisciplinary pediatric chronic pain program.
Patients and Methods
Referral data were extracted from the electronic health record. PROMIS Pediatric Anxiety and Pain Interference Scales were administered at an initial evaluation visit.
Results
The program received 1488 referrals between 2016 and 2019, representing 1338 patients, with increasing volume of referrals over time. Referrals were primarily from orthopedics (19.6%), physical medicine and rehabilitation (18.8%), neurology (14.4%), and rheumatology (12.6%). Patients referred were primarily female (75.4%), White (80.1%), English-speaking (98.4%) adolescents (median=15.0 years). Of those referred, 732 (54.7%) attended an interdisciplinary evaluation (ie, with ≥2 disciplines). Adolescent anxiety was within the expected range by self-report (N=327, MT-score=55.67) and parent proxy-report (N=354, MT-score=57.70). Pain interference was moderately elevated by self-report (N=323, MT-score=61.52) and parent proxy-report (N=356, MT-score=64.02). There were no differences between patients referred who attended versus did not attend an interdisciplinary evaluation based on age, sex, ethnicity, or language. A smaller than expected proportion of referred Black patients (44%, P=0.02) and patients referred from orthopedics (40%) or pulmonology (11%) attended an evaluation, whereas a larger than expected proportion of those referred from physical medicine and rehabilitation (78%) were evaluated (P<0.001).
Conclusion
Results highlight the demand for outpatient interdisciplinary pediatric chronic pain treatment. Findings can inform decisions related to staffing and service design for pediatric hospitals that aim to establish or grow outpatient pediatric chronic pain programs.
... However, the economic effects of IIPT on healthcare utilization and costs in chronic paediatric pain patients have rarely been analysed. Most of the few existing studies were conducted in the United States (Evans et al., 2016;Mahrer et al., 2018). So far, one German study showed that healthcare costs and utilization did not decrease significantly in the year after receiving IIPT compared to 1 year before IIPT (Ruhe et al., 2017). ...
... Inpatient treatments drive high healthcare expenditures; hospitalizations account for half of total healthcare expenditures. Nevertheless, the current analysis indicates significantly fewer hospital admissions after IIPT, consistent with previous studies (Evans et al., 2016;Mahrer et al., 2018;Ruhe et al., 2017). In addition, several studies report problematic medication use in chronic paediatric pain patients, such as polypharmacy and opioid misuse (Gmuca et al., 2019;Guite et al., 2018). ...
Objective
Chronic pain in children and adolescents gives rise to high health care costs. Successful treatment is supposed to reduce the economic burden. The objective of this study was to determine the changes in health care utilization and expenditures from one year before (Pre) intensive interdisciplinary pain treatment (IIPT) to the first (Post 1) and second (Post 2) years after discharge in a sample of pediatric chronic pain patients.
Methods
Claims data from one statutory health insurance company were analyzed for 119 children and adolescents (mean age = 15.3, 68.9% female) who sought IIPT at the German Pediatric Pain Centre. Costs incurred for inpatient treatment, outpatient treatment, medication, remedies and aids were compared before treatment and two years after discharge. Health care utilization was compared using Wilcoxon signed-rank test, and expenditures using trimmed means and the Yuen’s t-test.
Results
Overall costs were significantly lower in the two years after IIPT compared to before IIPT (Pre: 3543€, Post 1: 2681€, Post 2: 1937€ (trimmed means)). Health care utilization changed significantly; hospitalizations decreased in the years after discharge, while psychotherapies stayed stable in the year after discharge but lessened in the second year.
Conclusion
The results of this study support prior findings on the high economic burden of pediatric chronic pain. IIPT may contribute to a transition in health care utilization from somatic-focused treatments to more psychological treatments. Overall costs were reduced as soon as the first year after discharge and decreased even further in the second year.
... A recent study conducted a cost-analysis of an interdisciplinary pediatric pain clinic by retrospectively reviewing billing data for inpatient admissions, emergency department, and outpatient visits and associated costs and reimbursements [120]. Data examined included healthcare costs for patients 1 year prior to initiating interdisciplinary services with costs 1 year after initiating services. ...
... Cost-analyses of pre-pain clinic costs found cost reductions 1 year post clinic participation (up to $36,228 to the hospital and $11,482 to insurance, per patient, per year), providing economic support for interdisciplinary intervention for children with chronic pain [120]. ...
Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.
... This reduction in total health care costs corresponded with significant decreases in direct non-medical costs and indirect costs. Prior, uncontrolled cohort studies of interdisciplinary pain clinics 18,25 and an intensive pain rehabilitation program 10 (where patients received psychological treatment along with physical therapy and medication management) have also demonstrated significant reductions over time in health care costs. ...
... Second, it is possible that more time may be needed to determine the impact of the adjunctive I-CBT program on health care costs. Among the handful of published studies that have evaluated change over time in health care costs among youth with chronic pain, all have been limited by the use of only two time points and none have examined trajectories beyond a 12-month follow-up period 10,17,18,25,32 . It is possible that realization of reductions in health care costs require a longer follow-up period (e.g., 3-5 years or more). ...
The economic burden of pediatric chronic pain is high, with an estimated annual cost of $19.5 billion. Little is known about whether psychological treatment for pediatric chronic pain can alter health care utilization for youth. The primary aim of this secondary data analysis was to evaluate the effect of adjunctive internet cognitive-behavioral therapy intervention (I-CBT) or adjunctive internet education (I-EDU) on health care-related economic costs in a cohort of adolescents with chronic pain recruited from interdisciplinary pain clinics across the United States. For the full sample, health care expenditures significantly decreased from the year prior to intervention to the year following intervention. Results indicated that the rate of change in health care costs over time was not significantly different between the I-CBT and I-EDU groups. Further research is needed to replicate these findings and determine patterns and drivers of health care costs for youth with chronic pain evaluated in interdisciplinary pain clinics and whether psychological treatments can alter these patterns. This trial was registered at clinicaltrials.gov (identifier NCT13165471).
Perspective
Health care expenditures significantly decreased in youth with chronic pain from the year prior to initiating treatment to the following year in both intervention conditions, adjunctive internet cognitive-behavioral therapy and adjunctive internet education. Contrary to our hypothesis, the rate of change in health care costs over time was not significantly different between intervention conditions.
... Comprehensive pain care strategies include not only implementation of effective modalities 17 but aim to maximize their benefit through optimal combinations and bundling of care. 77,78 Yoga and acupuncture therapy have inherent similarities. Both provide patients with counsel on self-care, e.g., breathing techniques to mitigate pain. ...
Background
Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care.
Objective
To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings.
Methods
This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3 rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up.
Results
93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic.
Conclusions
Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.
... There are limited data about the costs to the health care system and society on adolescents living with chronic pain: the Committee on Advancing Pain Research, Care, and Education & Institute of Medicine ( Institute of Medicine [US] Committee on Advancing Pain Research, 2011 ) suggested this could be in the billions of dollars. Preliminary studies in the United States and the United Kingdom also estimate the economic costs of adolescents living with chronic pain to be in the billions of dollars ( Groenewald et al., 2014 ;Mahrer et al., 2018 ). In addition, there are societal costs that come with these adolescents' chronic pain, such as missing education and negative mental health effects. ...
Background:
Primary chronic pain (PCP), a relatively new classification, characterizes pain that is not a secondary response to an underlying primary condition such as trauma or cancer. This study explored the lived experience of adolescents with a diagnosis of PCP.
Method:
A qualitative methodology, Interpretative Description (ID), was used to guide our study. ID uses a constructivist approach and allows for clinician experience to guide a theoretical scaffold of inquiry, which can be refined as the data collection progresses. We interviewed fifteen adolescents (n = 15) living with PCP.
Results:
All participants in this sample reported struggling with diagnostic uncertainty, depression, and anxiety. Adding to their distress was the fact that our participants perceived that health care professionals did not believe them when they described their pain and its intensity.
Conclusions:
While significant research is being conducted on PCP, participants believe there is a lack of knowledge about PCP as a diagnosis and thus there are limited resources and a lack of empathy and understanding for these adolescents.
... Chronic pain is not only a source of human suffering 6 but also a leading cause for patients to ask for medical services. 12,17,18 Furthermore, chronic pain is a major contributor to the global burden of disease, causing a high number of years lived with disability worldwide. 9 Subsequently, chronic pain is associated with increased likelihood of using specialty healthcare services 21,26 and imposes a substantial burden on the healthcare system. ...
The International Classification of Diseases (ICD) is applied worldwide for public health data collection among other use cases. However, the current version of the ICD (ICD-10), to which the reimbursement system is linked in many countries, does not represent chronic pain properly. This study aims to compare the ICD-10 with the ICD-11 in hospitalized patients in terms of specificity, clinical utility, and reimbursement for pain management. The medical records of hospitalized patients consulted for pain management at Siriraj Hospital, Thailand, were reviewed, and all pain-related diagnoses were coded into ICD-10 and ICD-11. The data of 397 patients showed unspecified pain was coded 78% in the ICD-10 and only 0.5% in the ICD-11 version. The difference gap in the proportion of unspecified pain between the 2 versions is wider than in the outpatient setting. The 3 most common codes for ICD-10 were other chronic pain, low back pain, and pain in limb. The 3 most common codes for ICD-11 were chronic cancer pain, chronic peripheral neuropathic pain, and chronic secondary musculoskeletal pain. As in many other countries, no pain-related ICD-10 codes were coded for routine reimbursement. The simulated reimbursement fee remained the same when adding 397 pain-related codings, even if the cost of pain management, such as cost of labor, existed. Compared with the ICD-10 version, the ICD-11 is more specific and makes pain diagnoses more visible. Thus, shifting from ICD-10 to ICD-11 has the potential to improve both the quality of care and the reimbursement for pain management.
... Families report a lack of understanding or validation from their providers, at times feeling the need to prove their pain as real, 63 growing social isolation, 19,69 and overall decrements to family functioning and quality of life. 39,58 Improving team effectiveness may be a direct way to alleviate some familial burden in the context of disjointed care where families must independently seek out the necessary components of treatment that may contribute to higher use of inappropriate services (eg, Emergency Department) and an underutilization of services that have a more positive impact on long-term pain (eg, multidisciplinary treatment 19,26,53 ). ...
... [8][9][10][11] Owing to the costly nature of pediatric chronic pain, there is growing evidence about adopting comprehensive interdisciplinary treatment approaches that include pharmacologic therapies, psychological therapies, lifestyle changes, and nonpharmacologic approaches such as Integrative Medicine (IM) therapies. 12,13 Besides economic benefit, many pediatric pain clinics that utilize these approaches are also effective in addressing pain-related disabilities, school attendance, pain levels, and psychological distress. [14][15][16] However, many hospitals and health systems that care for children hesitate to offer the full range of these services, especially to patients receiving Medicaid whose services are reimbursed at low rates. ...
Purpose: Chronic pain experienced by children and adolescents represents a significant burden in terms of health, quality of life, and economic costs to U.S. families. In 2015, the Boston Medical Center (BMC) Interdisciplinary Pain Clinic initiated an Integrative Medicine (IM) team model to address chronic pain in children. Team members included a pediatrician, child psychologist, physical therapist, acupuncturist, and massage therapist. Children were referred to the pain clinic from primary care and specialty services within BMC, the largest safety-net hospital in the northeastern United States. For this observational assessment, consent and assent were obtained from parents and pediatric patients. Individualized treatment plans were recommended by the IM team. Methods: Self-reported survey and electronic medical record data were collected about socioeconomic demographics, pain, use of medical and IM services, and quality of life. The authors compared health and quality of life indicators and costs of care for each participant from the year before entering the project with these same indicators for the subsequent year. Results: Eighty-three participants were enrolled. Participants ranged in age from 4 to 22 years (mean 14.7 years). Eighty percent of the group were females. Forty-two percent of the sample were white, 30% were Hispanic/Latinx, and 28% were African American. Primary types of pain were abdominal (52%), headache (23%), musculoskeletal (18%), and other (7%). Quality of life indicators improved (p = 0.049) and pain interference decreased (Wilcoxon p = 0.040). Major economic drivers of cost were emergency department (ED) visits, inpatient hospitalizations, and consultations with medical specialists. For the 46 participants who completed the project, the following total cost savings were noted: 17,638 (ED visits), 42,843 (specialist consults). No adverse events were reported. Conclusion: The authors' experience demonstrated that the use of IM approaches in an interdisciplinary team approach is safe, feasible, and acceptable to families. Considerable cost savings were observed in the area of surgical procedures, hospitalizations, and consultations with specialists.
... See Connelly and colleagues [12] and Parsons and colleagues [13] for expanded reviews outlining the use of HAD to advance social science. Mahrer et al. demonstrated how HAD can be leveraged to conduct cost analyses of interdisciplinary chronic pain treatment [14]. ...
Telehealth has emerged as a promising healthcare delivery modality due to its ability to ameliorate traditional access-level barriers to treatment. In response to the onset of the novel coronavirus (COVID-19) pandemic, multidisciplinary pain clinics either rapidly built telehealth infrastructure from the ground up or ramped up existing services. As the use of telehealth increases, it is critical to develop data collection frameworks that guide implementation. This applied review provides a theoretically-based approach to capitalize on existing data sources and collect novel data to inform virtually delivered care in the context of pediatric pain care. Reviewed multisource data are (1) healthcare administrative data; (2) electronic chart review; (3) clinical health registries; and (4) stakeholder feedback. Preliminary telehealth data from an interdisciplinary pediatric chronic pain management clinic (PPMC) serving youth ages 8–17 years are presented to illustrate how relevant implementation outcomes can be extracted from multisource data. Multiple implementation outcomes were assessed, including telehealth adoption rates, patient clinical symptoms, and mixed-method patient-report telehealth satisfaction. This manuscript provides an applied roadmap to leverage existing data sources and incorporate stakeholder feedback to guide the implementation of telehealth in pediatric chronic pain settings through and beyond COVID-19. Strengths and limitations of the modeled data collection approach are discussed within the broader context of implementation science.
... The therapeutic approach to chronic non-cancer pain in adolescents should be based on the biopsychosocial model, using a multimodal (pharmacological and non-pharmacological) and interdisciplinary strategy, integrating several professionals (physicians of different specialties, nurses, psychologists, physical therapists, occupational therapists, and social workers) contributing and sharing treatment objectives. [12,[53][54][55] Initially, a plan of care is outlined with the active participation of the patient, both in the definition of the goals to reach, and in the acquisition and application of coping strategies (ideally active), in which the physician plays the role of a mentor. [56,57] The goal of the treatment is to have an effective control of the pain, although frequently functional recovery (physical activity, regular sleep, school attendance, and social life) usually comes first. ...
Introduction
Chronic pain is defined as a pain lasting more than 3–6 months. It is estimated that 25% of the pediatric population may experience some kind of pain in this context. Adolescence, corresponding to a particular period of development, seems to present the ideal territory for the appearance of maladaptive mechanisms that can trigger episodes of persistent or recurrent pain.
Methods
A narrative review, in the PubMed/Medline database, in order to synthetize the available evidence in the approach to chronic pain in adolescents, highlighting its etiology, pathophysiology, diagnosis, and treatment.
Results
Pain is seen as a result from the interaction of biological, psychological, individual, social, and environmental factors. Headache, abdominal pain, and musculoskeletal pain are frequent causes of chronic pain in adolescents. Pain not only has implications on adolescents, but also on family, society, and how they interact. It has implications on daily activities, physical capacity, school performance, and sleep, and is associated with psychiatric comorbidities, such as anxiety and depression. The therapeutic approach of pain must be multimodal and multidisciplinary, involving adolescents, their families and environment, using pharmacological and non-pharmacological strategies.
Discussion and conclusion
: The acknowledgment, prevention, diagnosis, and treatment of chronic pain in adolescent patients seem not to be ideal. The development of evidence-based forms of treatment, and the training of health professionals at all levels of care are essential for the diagnosis, treatment, and early referral of these patients.
... Comprehensive pain care strategies include not only implementation of effective modalities but also aim to maximize their benefit through optimal combinations and bundling of care. 15,[68][69][70] Access to nonpharmacologic pain care is minimal in low-resource medical centers; medical providers are seeking effective pain care options in light of the opioid crisis and welcome the ability to refer for effective nonpharmacologic care. Acupuncture therapy in our previous trial was highly acceptable to patient participants as well as medical providers who referred patients. ...
Chronic pain is prevalent in the United States, with impact on physical and psychological functioning as well as lost work productivity. Minority and lower socioeconomic populations have increased prevalence of chronic pain with less access to pain care, poorer outcomes, and higher risk of fatal opioid overdose. Acupuncture therapy is effective in treating chronic pain conditions including chronic low back pain, neck pain, shoulder pain, and knee pain from osteoarthritis. Acupuncture therapy, including group acupuncture, is feasible and effective, and specifically so for underserved and diverse populations at risk for health outcome disparities. Acupuncture therapy also encourages patient engagement and activation. As chronic pain improves, there is a natural progression to want and need to increase activity and movement recovery. Diverse movement approaches are important for improving range of motion, maintaining gains, strengthening, and promoting patient engagement and activation. Yoga therapy is an active therapy with proven benefit in musculoskeletal pain disorders and pain associated disability. The aim of this quasi-experimental pilot feasibility trial is to test the bundling of these 2 effective care options for chronic pain, to inform both the design for a larger randomized pragmatic effectiveness trial as well as implementation strategies across underserved settings.
... Intensive residential care is not a realistic model for all patients, 38 given the high costs to individuals and/or third parties. 39 However, combinations of these integrated approaches are likely necessary to achieve similar outcomes. 40,41 Further research is needed to help determine which treatments, at what intensities, and for what durations, are necessary to achieve satisfactory outcomes in terms of chronic pain and co-occurring mood and substance use to expand access and reduce costs and life disruption associated with treatment. ...
Purpose
The objective is to report outcomes of an interdisciplinary group-based residential chronic pain recovery program (CPRC), located in a private non-profit psychiatric hospital. The chronic pain program was aimed at treatment and engagement in self-care of both pain and co-occurring disorders in a residential facility that also offered treatment for specific psychiatric disorders.
Patients and Methods
A retrospective chart review was conducted that included a convenience sample of 131 patients admitted from March 2012 through August 2017 who completed treatment. An interdisciplinary team of professionals provided psycho-behavioral therapy, movement therapies and medication management. Patients completed a battery of psycho-social and demographic questionnaires on admission and before discharge of the program.
Results
Significant differences were noted in pain severity, pain interference, depression and anxiety (p<.01) between admission and discharge, and the Chronic Pain Coping Inventory demonstrated significant differences in guarding (p <.001), asking (p =.018), exercise (p <.001), relaxation (p <.001), and pacing (p=.024). Of patients using opioids on admission, at discharge, 37% had tapered and remained off all opioids, 43% were using buprenorphine for opioid use disorder, and 20% continued on analgesic opioids.
Conclusion
Treatment was associated with reductions in pain severity and interference, in anxiety and in depression as well as improvements in pain coping. Additionally, there was a reduction in reliance on opioids for pain relief.
... La prise en charge doit englober tous les aspects de la douleur. Les programmes de gestion de la douleur (PGD) se sont montrés efficaces dans cette approche [5,6] ...
La douleur chronique touche 20 % des Européens. Une prise en charge interdisciplinaire apparaît nécessaire en raison des facteurs cognitifs et affectivomotivationnels qui deviennent prédominants sur les facteurs sensoridiscriminatifs. Dans les programmes de gestion de la douleur, différentes disciplines interagissent de façon à aider le patient à atteindre un objectif fonctionnel qu’il s’est fixé. Le patient sera encouragé à faire des activités en dehors du centre afin de rendre pérenne son changement de comportement.
... 1,2 Additionally, recent studies have shown decreased health care utilization, including emergency department visits, following treatment of chronic pain. [20][21][22] Maximizing clinic attendance and ensuring that chronic pain is being appropriately treated is therefore important for improving quality of life, management of chronic pain symptoms, and overall patient outcomes. Future studies should focus on identifying additional family and socioeconomic factors that may influence treatment initiation in order to address potential barriers to care. ...
Initial clinic evaluation among referred patients and factors limiting treatment initiation are not well characterized. We conducted a retrospective review of referrals to our outpatient pain clinic to identify intake visits and factors associated with treatment initiation among adolescents with chronic pain. We identified adolescents aged 13 to 18 years at the time of referral to clinic (2010-2016). Factors associated with completion of visits were evaluated using logistic regression. Patients who completed visits more frequently had private insurance than public or no insurance (P = .053). The most common reasons for caregiver decision not to attend the pain clinic included use of another pain clinic, that services were not wanted or no longer needed, and that their child was undergoing further testing. The current study demonstrated that patients with head pain were more likely to complete an intake visit, while there was a trend showing that lack of private insurance decreased this likelihood.
... Additionally, providers may consider close monitoring of patients with complex presentations and/or comorbidities who display difficulty initiating and establishing care in therapy to identify additional supports that may be needed to help patients and families engage in multidisciplinary treatments. Drawing from programs that are already established for pediatrics 46 and adults with chronic pain, 47 incorporating CBT into a comprehensive pain program designed for pediatric chronic SCD pain may offer more efficacious and cost-effective treatment relative to conventional medical treatment alone. ...
Objectives
Evaluate the implementation of cognitive-behavioral therapy (CBT) for chronic pain in a clinical setting by comparing youth with sickle cell disease (SCD) who initiated or did not initiate CBT.
Design
Youth with SCD (ages 6–18; n = 101) referred for CBT for chronic pain were compared based on therapy attendance: Established Care; Early Termination; or Comparison (i.e., did not initiate CBT).
Setting
Outpatient pediatric psychology and comprehensive SCD clinics in 3 locations at a southeastern children’s hospital.
Interventions
CBT delivery was standardized. Treatment plans were tailored to meet individualized needs.
Main Outcome Measures: Healthcare utilization included pain-related inpatient admissions, total inpatient days, and emergency department reliance (EDR) at 12-months pre-post CBT. Patient-reported outcomes (PROs) included typical pain intensity, functional disability, and coping efficacy pre-post treatment.
Results
Adjusting for age, genotype, and hydroxyurea, early terminators of CBT had increased rates of admissions and hospital days over time relative to comparisons; those who established care had faster reduction in admissions and hospital days over time relative to comparisons. EDR decreased by 0.08 over time for Established Care and reduced by 0.01 for every 1 completed session. Patients who completed pre- and post-treatment PROs reported decreases in typical pain intensity, functional disability, and improved coping efficacy.
Conclusions
Establishing CBT care may support reductions in admissions for pain, length of stay, and EDR for youth with chronic SCD pain, which may be partially supported by patient-reported improvements in functioning, coping, and lower pain intensity following CBT. Enhancing clinical implementation of multidisciplinary treatments may optimize the health of these youth.
... Additionally, providers may consider close monitoring of patients with complex presentations and/or comorbidities who display difficulty initiating and establishing care in therapy to identify additional supports that may be needed to help patients and families engage in multidisciplinary treatments. Drawing from programs that are already established for pediatrics 46 and adults with chronic pain, 47 incorporating CBT into a comprehensive pain program designed for pediatric chronic SCD pain may offer more efficacious and cost-effective treatment relative to conventional medical treatment alone. ...
Introduction: Chronic pain in sickle cell disease (SCD) is a multifactorial complication that can contribute to high healthcare utilization. Multidisciplinary treatments going beyond medication alone are needed for the most effective chronic pain management. Cognitive-behavioral therapy (CBT) is effective for youth with chronic pain and focuses on improving daily functioning and coping, but the clinical effectiveness for chronic SCD pain has not been evaluated. This study examined changes in healthcare use over time for youth with chronic SCD pain who participated in CBT compared to controls with chronic SCD pain who never initiated CBT.
Methods: Youth receiving care at comprehensive SCD clinics at three tertiary care locations at Children's Healthcare of Atlanta were included if they were aged 6-18 years, any SCD genotype, and referred to a pediatric psychology outpatient clinic for chronic pain management from November 2014-March 2018. Youth were excluded if they received bone marrow transplantation during the study period, had ongoing CBT past the study period, or were not actively followed for ≥1 year of medical care pre- or post-CBT. Patients were grouped based on therapy attendance: Established Care (i.e., attended ≥3 CBT sessions within 3 consecutive months); Early Termination (i.e., attended <3 CBT sessions within 3 consecutive months); or Control (i.e., did not attend any CBT visits). Patient-reported outcomes included typical pain intensity, functional disability, and coping efficacy at pre- and post-treatment. Healthcare utilization outcomes were abstracted from electronic medical records including: number of inpatient admissions for pain, total inpatient days for pain, and emergency department dependency ratio (EDR; ratio of ED visits to sum of ED and outpatient visits). For the treatment groups, utilization outcomes were calculated from 12-months prior to the first CBT visit, and from 12-months following the last CBT visit. For the control group, outcomes were calculated for 12-months prior to the referral date, and from 12-months following the average duration of CBT for treatment groups (i.e., 3.5 months) to account for passage of time. Changes over time in inpatient admissions, hospital days, and EDR were evaluated separately using linear mixed effect models with a random effect for person-specific intercepts and slopes, which were retained based on model contribution determined by Bayesian Information Criterion. Time, patient characteristics, SCD-modifying treatments, therapy attendance, number of CBT sessions, and interaction effects were initially included in the models; the most parsimonious models were chosen based on backward selection.
Results: At time of referral, youth (n=101) were on average (M) 13.4 years old (SD=2.92), 56.4% female, 68.1% HbSS or HbSβ0, 63.9% prescribed hydroxyurea, and 12.6% received chronic transfusions. The Control (n=44) and Treatment Groups (n=57) did not significantly differ by age, sex, genotype, or treatment with hydroxyurea or chronic transfusion. Based on therapy attendance, 36.1% Established Care, 21.8% were Early Termination, and 42% Controls. Adjusting for age, genotype, and hydroxyurea, patients who terminated CBT early had increased admissions and total hospital days over time compared to controls; those who established care had a reduction in admissions and hospital days over time compared to controls (F's=3.27-3.61, p's<.05). EDR decreased by 0.1 over time for Established Care; for every 1 completed CBT session, EDR was further reduced by 0.01 (p<.05). Patients who completed CBT (n=18) reported decreases in typical pain intensity (Mpre= 5.47, SD=2.24; Mpost=3.76, SD=2.84; p<.01), functional disability (Mpre=26.24, SD=8.45; Mpost=15.18, SD=10.85; p<.001), and improved coping efficacy (Mpre=8.0, SD=2.21; Mpost=9.65, SD=2.94; p<.05) from pre- to post-treatment.
Conclusions: Establishing care in CBT may support reductions in admissions for pain, length of stay, and ED dependency for youth with chronic SCD pain beyond the potential effects of age, genotype, and SCD-modifying treatments. Reductions in utilization may be partially supported by patient-reported improvements in functioning, coping, and lower pain intensity following CBT. Reducing barriers to access and enhancing clinical implementation of multidisciplinary treatments may optimize the health of youth with chronic SCD pain.
Disclosures
Lane: NHLBI: Research Funding; CDC: Research Funding; GA Dept: Other: Contract for newborn screeninjg follow-up services services; Bio Products Laboratory: Other: Sickle Cell Advisory Board; FORMA Therapeutics: Other: Clinical Advisory Board. Dampier:Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Micelle BioPharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Global Blood Therapeutics: Consultancy; Epizyme: Consultancy; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Katz Foundation: Research Funding; Modus Therapeutics: Consultancy; NIH: Research Funding; Merck: Research Funding.
... The beneficial effects of MPM include reduced pain intensity, improved functioning and improved HRQoL (Becker et al., 2000;Dysvik, Kvaløy, Stokkeland, & Natvig, 2010;Heiskanen, Roine, & Kalso, 2012;Jensen, Turner, & Romano, 2007;Kamper et al., 2015). In pediatric patients, MPM has also been shown to reduce hospital visits and related costs (Mahrer, Gold, Luu, & Herman, 2018). However, many original studies and reviews have shown efficacy in selected patient groups only, and the quality of evidence is moderate at best (Kamper et al., 2015;Scascighini et al., 2008). ...
Background
Multidisciplinary pain management (MPM) is a generally‐accepted method for treating chronic pain, but heterogeneous outcome measures provide only limited conclusions concerning its effectiveness. Therefore, further studies on the effectiveness of MPM are needed to identify subgroups of patients who benefit, or do not benefit, from these interventions. Our aim was to analyze health‐related quality of life (HRQoL) changes after MPM and to identify factors associated with treatment outcomes.
Methods
We carried out a real‐world observational follow‐up study of chronic pain patients referred to a tertiary multidisciplinary outpatient pain clinic to describe, using the validated HRQoL instrument 15D, the HRQoL change after MPM, and to identify factors associated with this change. 1043 patients responded to the 15D HRQoL questionnaire at baseline and 12 months after the start of treatment. Background data were collected from the pre‐admission questionnaire of the pain clinic.
Results
53% of the patients reported a clinically important improvement and, of these, 81% had a major improvement. 35% reported a clinically important deterioration, and 12% had no change in HRQoL. Binary logistic regression analysis revealed that major improvement was positively associated with shorter duration of pain (<3 years), worse baseline HRQoL, higher education levels, and being employed.
Conclusions
The majority of the patients reported significant HRQoL improvement after multidisciplinary pain management. Better understanding of the factors associated with treatment outcomes is needed to meet the needs of those who had unfavourable outcomes.
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... 118 In a follow-up study of Washington state insured patients with back pain, fibromyalgia and menopause symptoms, users of nonpharmacologic therapy providers had lower insurance expenditures than those who did not use them. 119 Finally, a cost-analysis of an interdisciplinary pediatric pain clinic found interdisciplinary treatment that included acupuncture, biofeedback, psychotherapy and massage with medication management reduced inpatient and emergency department visits and resulted in hospital cost savings of $36,228/patient/year and in insurance cost savings of $11,482/patient/year. 456 The findings of the current cost analysis support that over the course of just one year, participation in an outpatient individually tailored interdisciplinary pain clinic can significantly reduce costs by more than the cost of the intervention itself. ...
Medical pain management is in crisis: from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care has prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC.
There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in post-surgical pain with opioid sparing, acute nonsurgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components, and self-care/self-efficacy strategies.
Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability.
The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short and long term therapeutic and economic impact of comprehensive care practices.
... 118 In a follow-up study of WA state insured patients with back pain, fibromyalgia and menopause symptoms, users of nonpharmacologic therapy providers had lower insurance expenditures than those who did not use them. 119 Finally, a cost-analysis of an interdisciplinary pediatric pain clinic found interdisciplinary treatment that included acupuncture, biofeedback, psychotherapy and massage with medication management reduced inpatient and emergency department visits and resulted in hospital cost savings of $36,228/patient/year and in insurance cost savings of $11,482/patient/year. 456 The findings of the current cost analysis supports that over the course of just one year, participation in an outpatient individually-tailored interdisciplinary pain clinic can significantly reduce costs by more than the cost of the intervention itself. ...
Medical pain management is in crisis: from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care has prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC.
There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in post-surgical pain with opioid sparing, acute nonsurgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components, and self-care/self-efficacy strategies.
Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability.
The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short and long term therapeutic and economic impact of comprehensive care practices.
Graded exposure treatment (GET) is a theory-driven pain treatment that aims to improve functioning by exposing patients to activities previously feared and avoided. Combining key elements of GET with acceptance-based exposure, GET Living (GL) was developed for adolescents with chronic pain (GL). Based on robust treatment effects observed in our single-case experimental design pilot trial of GL (NCT01974791), we conducted a 2-arm randomized clinical trial comparing GL with multidisciplinary pain management (MPM) comprised of cognitive behavioral therapy and physical therapy for pain management (NCT03699007). A cohort of 68 youth with chronic musculoskeletal pain (M age 14.2 years; 81% female) were randomized to GL or MPM. Owing to COVID-19 restrictions, 54% of participants received zoom video delivered care. Assessments were collected at baseline, discharge, as well as at 3-month and 6-month follow-up. Primary outcomes were self-reported pain-related fear and avoidance. Secondary outcomes were child functional disability and parent protective responses to child pain. As hypothesized, GL improved in primary and secondary outcomes at 3-month follow-up. Contrary to our superiority hypothesis, there was no significant difference between GL and MPM. Patients reported both GL and MPM (in person and video) as credible and were highly satisfied with the treatment experience. Next steps will involve examining the single-case experimental design data embedded in this trial to facilitate an understanding of individual differences in treatment responses (eg, when effects occurred, what processes changed during treatment within the treatment arm). The current findings support GET Living and MPM for youth with chronic pain.
Chronic pain is often elusive because of its specific diagnosis and complex presentation, making it challenging for healthcare providers to develop safe and effective treatment plans. Experts recommend a multifaceted approach to managing chronic pain that requires interdisciplinary communication and coordination. Studies have found that patients with a complete problem list receive better follow-up care. This study aimed to determine the factors associated with chronic pain documentation in the problem list. This study included 126 clinics and 12,803 patients 18 years or older with a chronic pain diagnosis within 6 months before or during the study period. The findings revealed that 46.4% of the participants were older than 60 years, 68.3% were female, and 52.1% had chronic pain documented on their problem list. Chi-square tests revealed significant differences in demographics between those who did and did not have chronic pain documented on their problem list, with 55.2% of individuals younger than 60 years having chronic pain documented on their problem list, 55.0% of female patients, 60.3% of Black non-Hispanic people, and 64.8% of migraine sufferers. Logistic regression analysis revealed that age, sex, race/ethnicity, diagnosis type, and opioid prescriptions were significant predictors of chronic pain documentation on the problem list.
Chronic pain in children is a relatively prevalent cause of functional disability. Contributing factors to this pain are best viewed through the biopsychosocial model. Although evidence is lacking for individual aspects of treatment, interdisciplinary care is considered the best treatment approach for children with chronic pain. Interdisciplinary care can include medication management with daily and as-needed medications, physical and occupational therapy focusing on function and movement, and psychological treatment with cognitive-behavioral therapy and acceptance focused treatment. In children with severe pain and disability, intensive interdisciplinary pain treatment may be needed to improve pain and function.
The development of medical cannabis clinics has emerged in recent years to meet needs from patients and healthcare practitioners amid changing medical cannabis regulations. As more countries are approving the use of cannabinoids for medical purposes, demand for access has increased but has not yet matched medical cannabis training. In countries where robust medical cannabis programs exist, patients are still utilizing illegal markets without adequate medical supervision, and physicians still report reluctance or barriers to prescription. The clinical use of cannabinoid-based treatments requires specific training, to support the careful assessment of patients; appropriate choice of product and chemovar; precise, personalized initiation and titration process; patient education; and continuous monitoring. Consequently, a well-trained multidisciplinary team is necessary to provide best clinical practice. A leading medical cannabis clinic in North America has created a unique model of care where clinical practice interacts with cannabinoid research development. At the clinic, coordinated patient education across physicians, nurses, pharmacists, and support staff plays a pivotal role to improve patient outcomes. Additionally, the unique, high-quality clinical experience has initiated the development of continuing medical education programs and partnership with recognized academic institutions. In a multidisciplinary environment, the creation of medical cannabis educational material and resources for healthcare practitioners and patients is supported by a peer review from the team of experts. Encouraging clinicians to be more engaged, or even to provide direct medical supervision, raises the awareness about cannabinoid potential risks and benefits and builds interest for further training. A focused medical cannabis practice or clinic allows for accelerated learning and experience, as diversity of patient cases is available at a high volume. Similarly, the unique setting allows for comprehensive data collection and the development of robust clinical research programs.
Functional gastrointestinal disorders (FGIDs) compose more than half of new pediatric gastroenterology clinic visits and can lead to functional disability, impaired quality of life, and a cost burden on healthcare. They can be associated with motility disturbances, visceral hypersensitivity, altered mucosal and immune function, gut microbiota, and central nervous system processing; however, general evidence of tissue damage is lacking. To fully understand the pathophysiology of FGIDs, it is important to comprehend the biopsychosocial model, which differs from the biomedical model. It focuses on understanding and treating illness and the patient’s subjective sense of suffering, rather than confining the diagnostic effort to finding disease. Medical tests are not necessary to make a diagnosis of an FGID. The Rome diagnostic criteria, developed through evidence-based research and clinical consensus, provide symptom-based diagnoses for neonatal, toddler, child, and adolescent FGIDs. The clinical interview of children or adolescents with FGID relies heavily on education, effective reassurance, and an individualized treatment plan tailoring to the patient and their family. This chapter highlights conceptual groundwork and concrete suggestions for recognizing and managing patients with FGIDs.
Background
Increasing access to non-pharmacologic pain management modalities, including acupuncture, has the potential to reduce opioid overuse. A lack of insurance coverage for acupuncture could present a barrier for both patients and providers. The objective of this scoping review was to assess the existing literature on acupuncture insurance coverage in the United States and to identify knowledge gaps and research priorities.
Methods
We utilized the Arksey and O’Malley framework to guide our scoping review methodology. We followed a pre-determined study protocol for the level-one abstract and level-two full text screenings. We synthesized information into subject-area domains and identified knowledge gaps.
Results
We found a lack of published data on acupuncture coverage in 44 states, especially in the Midwest and the South. Where data were available, a large proportion of acupuncture users did not have insurance coverage. Consumer demand, state mandates, and efforts to reduce opioid use were motivations to cover acupuncture. Licensed acupuncturists were less likely to be reimbursed and were reimbursed at lower rates compared to physicians. Reported barriers encountered when implementing coverage included a lack of providers, challenges determining when to offer non-pharmacologic treatments, and a lack of evidence for clinical efficacy and cost-effectiveness.
Conclusion
We found a lack of recent publications and data comparing regional coverage in the United States. A key challenge is that commercial insurance plan data are not in the public domain. Further research should assess insurance coverage implementation for acupuncture and measure the impact of policy changes on acupuncture utilization and rates of opioid overuse.
Purpose:
Chronic pain is a growing problem among children and adolescents, and is more prevalent in low-income families. This observational study was conducted to describe the demographics and various descriptors, complementary medicine therapy (CMT) use, and lifestyle factors (i.e., food habits and supplement use) of pediatric patients with chronic pain.
Methods:
Boston Medical Center's Interdisciplinary Pediatric Pain Clinic provides patient education and unique treatment plans, tailored with medical and nonpharmacologic interventions for managing complex and chronic pain. Patient data were obtained through electronic medical chart review and self-reported surveys, and were completed by participants and parents at enrollment.
Results:
Of the 83 participants, the average age was 15.4 ± 4.3, and 80% were female. Referrals to the clinic were due to abdominal pain (52%), headache (23%), and musculoskeletal or other pain (25%). Thirty-one percent were on food assistance programs, with only 24% of patients currently using CMTs and 85% using pain medications. More than half of all participants (63%) missed up to 5 days of school in the past year, while 26% missed more than 6 days. School or academics (77%) were the most frequently self-reported stressor, followed by social/peer issues (39%), bullying (18%), and parental stress (18%). A very small proportion of patients had sufficient intake of dairy (12%), water (23%), vegetables (1%), and fruits (22%).
Conclusion:
Chronic pain can significantly affect lifestyle factors, stress, and child development. Patients evaluated at the clinic had poor diets and report having stressors regarding school, social/peer issues, parental stress, and bullying.
Pain in pediatric inpatients is prevalent, under-recognized, and undertreated. Proper pain management in the pediatric inpatient setting is essential to improving short- and long-term clinical outcomes including maximum pain intensity, physical functioning, frequency of pain medication, and reduce healthcare utilization and costs such as mean number of medical visits and patient and parent ratings of satisfaction and pain experience. Pediatric inpatient pain management has evolved to consist of multimodal analgesia including traditional analgesic medications, physical therapy and exercise, psychotherapy, proper sleep hygiene techniques, stabilization of life stressors and other less traditional, non-pharmacological approaches. Inpatient pediatric pain management is now more opioid-sparing, with more of an emphasis on multidisciplinary therapy. Despite advancements in pain assessment and multimodal pain treatment options, management of pain can still be challenging due to the subjective nature of pain which can be challenging to monitor (especially in pediatric patients with limited communication abilities), the safety profiles and variable responses of pain medications in pediatric patients, environmental and psychosocial factors, and the limited number of clinical trials conducted. In this chapter, we review aspects of comprehensive pain management in pediatric inpatients including differential diagnosis, assessment, treatment, and management of pain in the hospital and at discharge.
Objective
A person’s concept of pain can be defined as how they understand what pain actually is, what function it serves and what biological processes are thought to underpin it. This study aimed to explore the concept of pain in children with and without persistent pain.
Design
In-depth, face-to-face interviews with drawing tasks were conducted with 16 children (aged 8–12 years) in New South Wales, Australia. Thematic analysis was used to analyse and synthesise the data.
Setting
Children with persistent pain were identified from a pain clinic waiting list in Australia, and children without pain were identified through advertising flyers and email bulletins at a university and hospital.
Participants
Eight children had persistent pain and eight children were pain free.
Results
Four themes emerged from the data: ‘my pain-related knowledge’, ‘pain in the world around me’, ‘pain in me’ and ‘communicating my concept of pain’. A conceptual framework of the potential interactions between the themes resulting from the analysis is proposed. The concept of pain of Australian children aged 8–12 years varied depending on their knowledge, experiences and literacy levels. For example, when undertaking a drawing task, children with persistent pain tended to draw emotional elements to describe pain, whereas children who were pain free did not.
Conclusions
Gaining an in-depth understanding of a child’s previous pain-related experiences and knowledge is important to facilitate clear and meaningful pain science education. The use of age-appropriate language, in combination with appropriate assessment and education tasks such as drawing and discussing vignettes, allowed children to communicate their individual concept of pain.
Purpose of Review
Chronic pain is a prevalent, disabling, and expensive pediatric condition. Specific treatment options have limited evidence and are often extrapolated from adult care. This review evaluates pain outcome measures, psychological treatment, pharmacologic management, multidisciplinary treatment models, and emerging topics in pediatric pain medicine.
Recent Findings
Multimodal cognitive behavioral therapy and intensive interdisciplinary pain treatment have the strongest evidence for improving pain and function while decreasing healthcare utilization. There is emerging evidence that parental involvement in care is an important factor in pediatric outcomes. While there is increased interest in emerging topics such as use of marijuana-derived products, acupuncture, and virtual reality, the evidence behind such interventions remains limited.
Summary
Pediatric chronic pain treatment centers on the biopsychosocial model of pain and multidisciplinary treatment. Recent research shows that intensive interdisciplinary pain treatment can improve pain, function, and healthcare utilization. Long-term benefits and risks of emerging treatments in pediatric chronic pain remain poorly understood.
Objectives:
To retrospectively characterize the rate of referrals to an outpatient chronic pain clinic among adolescents with chronic pain, and to identify factors associated with referral.
Methods:
Adolescents 13-18 years of age seen in 2010-2015 at outpatient clinics associated with Nationwide Children's Hospital (NCH) and diagnosed with chronic pain were included if they lived near NCH and had not been previously referred to the NCH outpatient chronic pain clinic. Subsequent referrals to the pain clinic were tracked through December 2017 using a quality improvement database. Factors predicting referral were assessed at the initial encounter in another outpatient clinic, and analyzed using multivariable logistic regression.
Results:
The analysis included 778 patients (569 female; median age 15▒y), of whom 96 (12%) were subsequently referred to the chronic pain clinic, after a median period of 3 months. Generalized chronic pain (adjusted odds ratio [aOR]=1.8; 95% confidence interval [CI]: 1.1, 3.1; P=0.023) and regional pain syndromes (aOR=3.1; 95% CI: 1.5, 6.7; P=0.003) were associated with increased likelihood of referral. Referral was also more likely among female patients and among patients with a mental health comorbidity or recent surgery or hospitalization.
Discussion:
Referrals to our chronic pain clinic were more likely for adolescents with generalized chronic pain, regional pain syndromes, and patients with mental health comorbidities. Recent hospitalization or surgery, but not recent emergency department visits, were associated with pain clinic referral. Multivariable analysis did not find disparities in referral by race or socioeconomic status.
Purpose of review
We review the prevalence of pediatric chronic musculoskeletal pain, the clinical need, the evidence for pharmacological, psychological, physical and, complementary approaches to pain management, and the possible future development of interdisciplinary and distance care.
Recent findings
We summarize the Cochrane Systematic Reviews on pharmacological interventions, which show a lack of evidence to support or refute the use of all classes of medication for the management of pain. The trials for NSAIDs did not show any superiority over comparators, nor did those of anti-depressants, and there are no trials for paracetamol, or of opioid medications. There are studies of psychological interventions which show promise and increasing support for physical therapy. The optimal approach remains an intensive interdisciplinary programmatic treatment, although this service is not available to most.
Summary
1. Given the absence of evidence, a program of trials is now urgently required to establish the evidence base for analgesics that are widely prescribed for children and adolescents with chronic musculoskeletal pain. 2. Until that evidence becomes available, medicine review is an essential task in this population. 3. We need more examples and efficacy evaluations of intensive interdisciplinary interventions for chronic pain management, described in detail so that researchers and clinicians can unpack possible active treatment components. 4. Online treatments are likely to be critical in the future. We need to determine which aspects of treatment for which children and adolescents can be effectively delivered in this way, which will help reduce the burden of the large number of patients needing support from a small number of experts.
The population prevalence of pediatric chronic pain is not well characterized, in part because of a lack of nationally representative data. Previous research suggests that pediatric chronic pain prolongs inpatient stay and increases costs, but the population-level association between pediatric chronic pain and health care utilization is unclear. We use the 2016 National Survey of Children's Health to describe the prevalence of pediatric chronic pain, and compare health care utilization among children ages 0 to 17 years according to the presence of chronic pain. Using a sample of 43,712 children, we estimate the population prevalence of chronic pain to be 6%. In multivariable analysis, chronic pain was not associated with increased odds of primary care or mental health care use, but was associated with greater odds of using other specialty care (odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.62-2.47; P < .001), complementary and alternative medicine (OR = 2.32, 95% CI = 1.79-3.03; P < .001), and emergency care (OR = 1.62, 95% CI = 1.29-2.02; P < .001). In this population-based survey, children with chronic pain were more likely to use specialty care but not mental health care. The higher likelihood of emergency care use in this group raises the question of whether better management of pediatric chronic pain could reduce emergency department use.
Perspective:
Among children with chronic pain, we show high rates of use of emergency care but limited use of mental health care, which may suggest opportunities to increase multidisciplinary treatment of chronic pain.
Objective:
Examine the cost-effectiveness of a 3-week interdisciplinary pediatric chronic pain rehabilitation program. METHODS: Self-reported health care utilization and parent missed work of youth with chronic pain (n = 127) at admission and 1-year follow-up were compared. Financials were calculated from program revenue and established national costs for health care and wages.
Results:
Data indicate significant reductions in days hospitalized, physician office visits, physical/occupational therapy services, psychotherapy visits, and parental missed work. Estimated health care expenses were 14,189 in the year after admission (-12,229 in the year prior and 11,039). CONCLUSIONS: Comparing estimated expenses before (15,378) minus program costs (27,119 per family in the year following admission. These findings extend the benefit of the program beyond clinical improvement, to outcomes important to both families and insurers.
Pediatric debilitating chronic pain is a severe health problem, often requiring complex interventions such as intensive interdisciplinary pain treatment (IIPT). Research is lacking regarding the effectiveness of IIPT for children. The objective was to systematically review studies evaluating the effects of IIPT.
Cochrane, Medline/Ovid, PsycInfo/OVID, PubMed, PubPsych, and Web of Science were searched. Studies were included if (1) treatment was coordinated by ≥3 health professionals, (2) treatment occurred within an inpatient/day hospital setting, (3) patients were <22 years, (4) patients experienced debilitating chronic pain, (5) the study was published in English, and (6) the study had ≥10 participants at posttreatment. The child's pain condition, characteristics of the IIPT, and 5 outcome domains (pain intensity, disability, school functioning, anxiety, depressive symptoms) were extracted at baseline, posttreatment, and follow-up.
One randomized controlled trial and 9 nonrandomized treatment studies were identified and a meta-analysis was conducted separately on pain intensity, disability, and depressive symptoms revealing positive treatment effects. At posttreatment, there were large improvements for disability, and small to moderate improvements for pain intensity and depressive symptoms. The positive effects were maintained at short-term follow-up. Findings demonstrated extreme heterogeneity.
Effects in nonrandomized treatment studies cannot be attributed to IIPT alone. Because of substantial heterogeneity in measures for school functioning and anxiety, meta-analyses could not be computed. There is preliminary evidence for positive treatment effects of IIPT, but the small number of studies and their methodological weaknesses suggest a need for more research on IIPTs for children.
Copyright © 2015 by the American Academy of Pediatrics.
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The aim of this study was to assess the economic cost of chronic pain among adolescents receiving interdisciplinary pain treatment. Information was gathered from 149 adolescents (ages 10-17) presenting for evaluation and treatment at interdisciplinary pain clinics in the United States. Parents completed a validated measure of family economic attributes, the Client Service Receipt Inventory, to report on health service use and productivity losses due to their child's chronic pain retrospectively over 12 months. Health care costs were calculated by multiplying reported utilization estimates by unit visit costs from the 2010 Medical Expenditure Panel Survey. The estimated mean and median costs per participant were 6,770, respectively. Costs were concentrated in a small group of participants; the top 5% of those patients incurring the highest costs accounted for 30% of total costs, whereas the lower 75% of participants accounted for only 34% of costs. Total costs to society for adolescents with moderate to severe chronic pain were extrapolated to $19.5 billion annually in the United States. The cost of adolescent chronic pain presents a substantial economic burden to families and society. Future research should focus on predictors of increased health services use and costs in adolescents with chronic pain.
Perspective:
This cost of illness study comprehensively estimates the economic costs of chronic pain in a cohort of treatment-seeking adolescents. The primary driver of costs was direct medical costs followed by productivity losses. Because of its economic impact, policy makers should invest resources in the prevention, diagnosis, and treatment of chronic pediatric pain.
A comprehensive systematic review of economic evaluations of complementary and integrative medicine (CIM) to establish the value of these therapies to health reform efforts.
PubMed, CINAHL, AMED, PsychInfo, Web of Science and EMBASE were searched from inception through 2010. In addition, bibliographies of found articles and reviews were searched, and key researchers were contacted. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies of CIM were identified using criteria based on those of the Cochrane complementary and alternative medicine group. All studies of CIM reporting economic outcomes were included. STUDY APPRAISAL METHODS: All recent (and likely most cost-relevant) full economic evaluations published 2001-2010 were subjected to several measures of quality. Detailed results of higher-quality studies are reported.
A total of 338 economic evaluations of CIM were identified, of which 204, covering a wide variety of CIM for different populations, were published 2001-2010. A total of 114 of these were full economic evaluations. And 90% of these articles covered studies of single CIM therapies and only one compared usual care to usual care plus access to multiple licensed CIM practitioners. Of the recent full evaluations, 31 (27%) met five study-quality criteria, and 22 of these also met the minimum criterion for study transferability ('generalisability'). Of the 56 comparisons made in the higher-quality studies, 16 (29%) show a health improvement with cost savings for the CIM therapy versus usual care. Study quality of the cost-utility analyses (CUAs) of CIM was generally comparable to that seen in CUAs across all medicine according to several measures, and the quality of the cost-saving studies was slightly, but not significantly, lower than those showing cost increases (85% vs 88%, p=0.460).
This comprehensive review identified many CIM economic evaluations missed by previous reviews and emerging evidence of cost-effectiveness and possible cost savings in at least a few clinical populations. Recommendations are made for future studies.
Chronic and recurrent pain not associated with a disease is very common in childhood and adolescence, but studies of pain prevalence have yielded inconsistent findings. This systematic review examined studies of chronic and recurrent pain prevalence to provide updated aggregated prevalence rates. The review also examined correlates of chronic and recurrent pain such as age, sex, and psychosocial functioning. Studies of pain prevalence rates in children and adolescents published in English or French between 1991 and 2009 were identified using EMBASE, Medline, CINAHL, and PsycINFO databases. Of 185 published papers yielded by the search, 58 met inclusion criteria and were reviewed, and 41 were included in the review. Two independent reviewers screened papers for inclusion, extracted data, and assessed the quality of studies. Prevalence rates ranged substantially, and were as follows: headache: 8-83%; abdominal pain: 4-53%; back pain: 14-24%; musculoskeletal pain: 4-40%; multiple pains: 4-49%; other pains: 5-88%. Pain prevalence rates were generally higher in girls and increased with age for most pain types. Lower socioeconomic status was associated with higher pain prevalence especially for headache. Most studies did not meet quality criteria.
Pain is the most common reason people visit emergency rooms. Pain does not discriminate on the basis of gender, race or age. The state of pain management in the emergency department (ED) is disturbing. ED physicians often do not provide adequate analgesia to their patients, do not meet patients' expectations in treating their pain, and struggle to change their practice regarding analgesia. A review of multiple publications has identified the following causes of poor management of painful conditions in the ED: failure to acknowledge pain, failure to assess initial pain, failure to have pain management guidelines in ED, failure to document pain and to assess treatment adequacy, and failure to meet patient's expectations. The barriers that preclude emergency physicians from proper pain management include ethnic and racial bias, gender bias, age bias, inadequate knowledge and formal training in acute pain management, opiophobia, the ED, and the ED culture. ED physicians must realize that pain is a true emergency and treat it as such.
A few studies of long-term outcomes for pediatric functional abdominal pain (FAP) have assessed acute non-abdominal pain at follow-up, but none has assessed chronic pain. We followed a cohort of pediatric patients with FAP (n=155) and a well control group (n=45) prospectively for up to 15 years. Participants ranged in age from 18 to 32 years at a follow-up telephone interview. FAP patients were classified as Resolved (n=101) versus Unresolved (n=54) at follow-up, based on whether they reported symptoms consistent with the adult Rome III criteria for a functional gastrointestinal disorder. Headache symptoms and reports of chronic non-abdominal pain also were assessed at follow-up. In the Unresolved group, 48.1% reported one or more sites of chronic non-abdominal pain at follow-up, compared to 24.7% in the Resolved group and 13.3% in the control group, p<0.01. More than half (57.4%) of the Unresolved group endorsed symptoms consistent with International Headache Society criteria for headache, compared to 44.6% of the Resolved group and 31% of controls, p<0.05. One-third of the Unresolved group reported both headache and one or more sites of chronic non-abdominal pain at follow-up, compared to 17.8% of the Resolved group and 4.4% of controls. Youth with FAP that persists into adulthood may be at increased risk for chronic pain and headache. Examination of central mechanisms that are common across chronic pain disorders may enhance understanding of this subgroup of FAP.
The author reviewed the current status of research on the impact of recurrent and chronic pain on everyday functioning of children and families and organized the research findings around the specific life contexts (e.g., school, peers) that may be affected by pain. Although findings demonstrate that many different aspects of child and family life are affected by pain, the prevalence and severity of children's functional limitations associated with pain remain unknown. Few treatment studies for pediatric recurrent and chronic pain have focused on enhancing children's functioning. It has been shown, however, that functional outcomes can be improved by cognitive-behavioral interventions. Recommendations for research on functional outcomes and implications for clinical practice are discussed.
The effects of chronic pain, chronic illness, and physical disability in adolescence are diverse, often influencing every facet of an adolescent's life. The biopsychosocialspiritual model provides a framework within which to conceptualize the experience of the adolescent with chronic pain and can be very helpful in guiding clinical care including creating comprehensive interdisciplinary treatment plans. Literature on chronic pain often focuses on pediatric or adult populations and does not lend information on how to provide evidence-based treatment for the adolescent in chronic pain. The study of chronic pain in adolescence has been largely limited by small samples, cross-sectional and observational designs, and studies that intertwine findings with pediatric and adult populations. Herein, we review the literature on the biopsychosocialspiritual experience of the adolescent with chronic pain.
Pediatric chronic pain, which can result in deleterious effects for the child, bears the risk of aggravation into adulthood. Intensive interdisciplinary pain treatment (IIPT) might be an effective treatment, given the advantage of consulting with multiple professionals on a daily basis. Evidence for the effectiveness of IIPT is scarce. Here, we investigated the efficacy of an IIPT within a randomized controlled trial by comparing an intervention group (IG) (n=52) to a waiting-list control group (WCG) (n=52). We made assessments before (PRE), immediately after treatment (POST), as well as at short-term (POST6MONTHS) and long-term (POST12MONTHS) follow-up. We determined a combined endpoint, "improvement" (pain intensity, disability, school absence) [16,21], and investigated three additional outcome domains (anxiety, depression, catastrophizing). We also investigated changes in economic parameters (healthcare use, parental work absenteeism, subjective financial burden) and their relationship to the child's improvement. Results at POST showed that significantly more children in the IG than in the WCG were assigned to improvement (55% compared to 14%; Fisher p<.001; 95% CI for incidence difference: 0.21%-0.60%). While immediate effects were achieved for disability, school absence, depression and catastrophizing, pain intensity and anxiety did not change until short-term follow-up. More than 60% of the children in both groups were improved long-term. The parents reported significant reductions in all economic parameters. The results from the present study support the efficacy of the IIPT. Future research is warranted to investigate differences in treatment response and to understand the changes in economic parameters in nonimproved children.
Objectives:
Although pediatric patients with chronic pain often turn to complementary therapies, little is known about patients who seek academic integrative pediatric care.
Design:
The study design comprised abstraction of intake forms and physician records from new patients whose primary concern was pain.
Setting/location:
The study setting was an academic pediatric clinic between January 2010 and December 2011.
Subjects:
Of the 110 new patients, 49 (45%) had a primary concern about headache (20), abdominal pain (18), or musculoskeletal pain (11).
Results:
The average age was 13±4 years, and 37% were male. Patients reported an average pain level of 6±3 on a 10-point scale, and most reported more than one kind of pain; parents had an average of 7±3 health concerns per child, including fatigue (47%), mood or anxiety (45%), constipation/diarrhea (41%), and/or sleep problems (35%). Most patients (57%) were referred by specialists; 71% were taking prescription medications; and 53% were taking one or more dietary supplements at intake. Of those tested, most (61%) had suboptimal vitamin D levels. All families wanted additional counseling about diet (76%), exercise (66%), sleep (58%), and/or stress management (81%). In addition to encouraging continued medical care (100%) and referral to other medical specialists (16%), frequent advice included continuing or initiating dietary supplements such as vitamins/minerals (80%), omega-3 fatty acids (67%), and probiotics (31%). Stress-reducing recommendations included biofeedback (33%), gratitude journals (16%), and yoga/t'ai chi (8%). Other referrals included acupuncture (24%) and massage (20%).
Discussion:
Patients who have chronic pain and who present to an integrative clinic frequently have complex conditions and care. They are interested in promoting a healthy lifestyle, reducing stress, and using selected complementary therapies.
Conclusion:
Patients with chronic pain who seek integrative care may benefit from the kind of coordinated, integrated, comprehensive care provided in a medical home.
Objectives: Chronic pain is associated with substantial direct and indirect costs in adulthood. Chronic pain problems are also common in childhood, but little is known about the costs of pediatric chronic pain and its treatment. The objectives of this study were to examine and describe healthcare utilization and indirect burden among pediatric chronic pain patients and their families. Methods: Participants were parents of 75 pediatric patients with daily or almost daily pain for at least three months, seen at a multidisciplinary pediatric pain outpatient clinic. Information about healthcare use and indirect familial burden was obtained during a semi-structured interview at the patients* first visit to the pain clinic. A financial analyst extracted cost data regarding hospital charges. To assess change over time, the same information was gathered from parents and the hospital financial analyst six months after their initial visit. Results: Parents reported numerous healthcare visits related to their child's pain condition [e.g., visits to specialists, physical therapy visits], high financial costs [e.g., charges for outpatient visits], and substantial indirect burden [e.g., time spent in medical appointments and missed workdays]. Parents reported lower healthcare utilization and decreased burden on families at the six-month follow-up assessment. Conclusions: Our results suggest that pediatric chronic pain is associated with considerable direct financial costs and indirect familial costs. Preliminary evidence suggests that involvement in a multidisciplinary program may be associated with decreased health care use and indirect burden.
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In 2008, according to the Medical Expenditure Panel Survey (MEPS), about 100 million adults in the United States were affected by chronic pain, including joint pain or arthritis. Pain is costly to the nation because it requires medical treatment and complicates treatment for other ailments. Also, pain lowers worker productivity. Using the 2008 MEPS, we estimated 1) the portion of total U.S. health care costs attributable to pain; and 2) the annual costs of pain associated with lower worker productivity. We found that the total costs ranged from 635 billion in 2010 dollars. The additional health care costs due to pain ranged from 300 billion. This represents an increase in annual per person health care costs ranging from 300 compared to a base of about 299 to 309 billion), cancer (188 billion). Our estimates are conservative because they do not include costs associated with pain for nursing home residents, children, military personnel, and persons who are incarcerated.
Perspective:
This study estimates that the national cost of pain ranges from 635 billion, larger than the cost of the nation's priority health conditions. Because of its economic toll on society, the nation should invest in research, education, and training to advocate the successful treatment, management, and prevention of pain.
Statistics is a subject of many uses and surprisingly few effective practitioners. The traditional road to statistical knowledge is blocked, for most, by a formidable wall of mathematics. The approach in An Introduction to the Bootstrap avoids that wall. It arms scientists and engineers, as well as statisticians, with the computational techniques they need to analyze and understand complicated data sets.
Chronic pain and fatigue are common physical complaints among children and adolescents. Both symptoms can interfere considerably with daily life by affecting sleep and eating habits, engagement in physical and social activities, and school participation. The aim of this study was to examine the potential mediational role of fatigue in the relationship between pain and children's school functioning and overall health-related quality of life (HRQOL).
Children seeking outpatient pain management services at two urban children's hospitals were recruited for this study. The combined sample includes 80 children and adolescents between the ages of 8 and 18 years (M=13.89, SD=2.57), 72.5% female, and their caregivers. The Pediatric Quality of Life Inventory (PedsQL 4.0) was used to assess HRQOL and the related PedsQL Multidimensional Fatigue Scale provided a comprehensive measure of fatigue.
On the basis of Preacher and Hayes' mediation model (2004), fatigue functioned as a mediator between pain and overall HRQOL on the basis of both self and caregiver proxy reports. Fatigue functioned as a mediator between pain and school functioning on the basis of the caregiver proxy report only. Additionally, moderate relationships were found between self and caregiver proxy reports of HRQOL and fatigue, although children self-reported less fatigue, better school functioning, and greater quality of life than did their caregivers.
Findings demonstrated that fatigue is a significant problem for many youth with chronic pain and may be an important target for clinical intervention.
Emotional and social factors contribute to the outcome of medical treatment of pediatric patients with chronic illness, especially when associated with disability. They are also important in the management of psychosomatic illnesses, chronic pain syndromes, and specific chronic illnesses. In this era of preoccupation with the cost of health care, there is no consensus about the clinical necessity and cost effectiveness of pediatric hospital psychosocial care programs. The validity of psychosocial care as a clinically effective and cost-effective approach to pediatric care, however, can be established only from carefully controlled, well-designed scientific studies. Optimally, these studies should be randomized, prospective, controlled trials that include the reliable identification of specific psychosocial problems and the subsequent validation of treatment approaches. Currently, such controlled studies of the effectiveness of pediatric hospital psychosocial care programs are lacking.
Little is known about the epidemiology of pain in children. We studied the prevalence of pain in Dutch children aged from 0 to 18 years in the open population, and the relationship with age, gender and pain parameters. A random sample of 1300 children aged 0-3 years was taken from the register of population in Rotterdam, The Netherlands. In the Rotterdam area, 27 primary schools and 14 secondary schools were selected to obtain a representative sample of 5336 children aged 4-18 years. Depending on the age of the child, a questionnaire was either mailed to the parents (0-3 years) or distributed at school (4-18 years). Of 6636 children surveyed, 5424 (82%) responded; response rates ranged from 64 to 92%, depending on the subject age and who completed the questionnaire. Of the respondents, 54% had experienced pain within the previous 3 months. Overall, a quarter of the respondents reported chronic pain (recurrent or continuous pain for more than 3 months). The prevalence of chronic pain increased with age, and was significantly higher for girls (P<0.001). In girls, a marked increase occurred in reporting chronic pain between 12 and 14 years of age. The most common types of pain in children were limb pain, headache and abdominal pain. Half of the respondents who had experienced pain reported to have multiple pain, and one-third of the chronic pain sufferers experienced frequent and intense pain. These multiple pains and severe pains were more often reported by girls (P<0.001). The intensity of pain was higher in the case of chronic pain (P<0. 001) and multiple pains (P<0.001), and for chronic pain the intensity was higher for girls (P<0.001). These findings indicate that chronic pain is a common complaint in childhood and adolescence. In particular, the high prevalence of severe chronic pain and multiple pain in girls aged 12 years and over calls for follow-up investigations documenting the various bio-psycho-social factors related to this pain.
Health economic evaluations are now more commonly being included in pragmatic randomized trials. However a variety of methods are being used for the presentation and analysis of the resulting cost data, and in many cases the approaches taken are inappropriate. In order to inform health care policy decisions, analysis needs to focus on arithmetic mean costs, since these will reflect the total cost of treating all patients with the disease. Thus, despite the often highly skewed distribution of cost data, standard non-parametric methods or use of normalizing transformations are not appropriate. Although standard parametric methods of comparing arithmetic means may be robust to non-normality for some data sets, this is not guaranteed. While the randomization test can be used to overcome assumptions of normality, its use for comparing means is still restricted by the need for similarly shaped distributions in the two groups. In this paper we show how the non-parametric bootstrap provides a more flexible alternative for comparing arithmetic mean costs between randomized groups, avoiding the assumptions which limit other methods. Details of several bootstrap methods for hypothesis tests and confidence intervals are described and applied to cost data from two randomized trials. The preferred bootstrap approaches are the bootstrap-t or variance stabilized bootstrap-t and the bias corrected and accelerated percentile methods. We conclude that such bootstrap techniques can be recommended either as a check on the robustness of standard parametric methods, or to provide the primary statistical analysis when making inferences about arithmetic means for moderately sized samples of highly skewed data such as costs.
The utilization of health care services in children and adolescents with chronic benign pain was studied in a Dutch population sample of 254 chronic pain sufferers aged 0-18 years. Children and adolescents who had reported chronic pain (continuous or recurrent pain >3 months) in our previous prevalence study were asked to keep a 3-week diary on their pain and to fill out questionnaires on background factors, health care use and the impact of pain. Parent ratings were used for children aged 0-11 years, self-report was used in adolescents (12-18 years). In a 3-month period, in 53.4% of the cases medication was used for pain, and general practitioners and specialists were consulted for pain in 31.1% and 13.9% of subjects, respectively. Physiotherapists, psychologists and alternative health providers were visited by 11.5, 2.8, and 4.0%, respectively. In the preceding year, 6.4% had been hospitalized due to pain. The most important factors linked to utilizing medical services were gender, various pain characteristics, school absenteeism and disability. Although consulters reported to be less physically fit and less satisfied with health, their parents were better adapted to the pain, by talking and sharing, mutual support, normalization of the child and heightened self-esteem, than non-consulters. Prospective studies are needed to test causality of coping on care-seeking behavior.
Numerous studies have documented a strong association between chronic pain and psychopathology. Previous research has shown that chronic pain is most often associated with depressive disorders, anxiety disorders, somatoform disorders, substance use disorders, and personality disorders. The primary objective of this review article is to describe the nature of the relationship between chronic pain and each of these types of psychopathology. In addition, this article will explore how each of these disorders are expressed within the context of chronic pain, with a consideration of both diagnostic and treatment issues.
Medline and PsychLit searches of the chronic pain/psychopathology literature from 1980 through 2000 were conducted using the keywords chronic pain, psychopathology, psychiatric disorders, and psychological disorders.
The relationship between chronic pain and psychopathology has generated substantial empirical and theoretical interest, with depressive disorders receiving much of the attention.
Although no single theoretical model can fully explain the causal relationship between chronic pain and psychopathology, a diathesis-stress model is emerging as the dominant overarching theoretical perspective. In this model, diatheses are conceptualized as preexisting, semidormant characteristics of the individual before the onset of chronic pain that are then activated and exacerbated by the stress of this chronic condition, eventually resulting in diagnosable psychopathology.
Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome.
To evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.
Ninety-five patients with headaches who consulted 1 of the authors in 1983 were previously studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standardized interview protocol was used.
Sixty (78%) of 77 patients responded (60 of the 95 of the original cohort). At 20-year follow-up, 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, and 14 (23%) had migraine and tension-type headaches. Having more than 1 headache type was more prevalent than at diagnosis or initial follow-up (P<.001), and headache type varied across time. Of those with headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although an improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to remit (P<.04). Headache severity at diagnosis was predictive of headache outcome at 20 years. During the month before follow-up, nonprescription medications were used by 31 (70%) of those with ongoing headaches, and prescription medications were used by 6 (14%). However, 20 (45%) believed that nonpharmacological methods were most effective. Medication use increased during the 10 years since last follow-up. No patient used selective serotonin receptor agonists (triptans).
Twenty years after diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changes across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically.
There is very little general evidence to support the clinical management, particularly diagnosis, of medically unexplained chronic pain (UCP) in children.
We sought to assess in children with UCP if clinical characteristics held important by general pediatricians help to accurately diagnose psychiatric morbidity and, alternatively, if the same can be achieved using dedicated questionnaires.
We used a cross-sectional diagnostic study in a pediatric outpatient clinic of a university hospital. Our participants were 134 patients, aged 8 to 18 years, who were referred for UCP. Performed were (1) diagnostic test reflecting the pediatricians' choice of clinical characteristics and (2) selected questionnaires. Classification was performed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, by a child psychiatrist using the Diagnostic Interview Schedule for Children-Parent Version IV and the Semi-structured Clinical Interview for Children and Adolescents. Results were analyzed by logistic regression.
Psychiatric morbidity was present in 80 of the children. A minority had a medical explanation for the pain (15% definite, 17% probable). The clinical diagnostic model included age, social-problem indicators, family structure, parental somatization, and school problems. In the quintile of children in whom this model predicted the highest risk, 93% indeed had psychiatric morbidity at reference testing. In the quintile with the lowest predicted risk, indeed only 27% had psychiatric morbidity. The Dutch Personality Inventory for Youth and the Child Behavior Checklist matched the pediatricians' choice of clinical characteristics. In the quintile of children with the highest predicted risk based on these questionnaires, 89% had psychiatric morbidity. In the quintile with the lowest predicted risk, only 15% had psychiatric morbidity.
A pediatrician-chosen set of clinical characteristics of children with UCP proves useful in diagnosing psychiatric morbidity. Using selected questionnaire screening yields similar results.
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Chronic pain is one of the most prevalent and costly problems in the United States today. Traditional medical treatments for it, though, have not been consistently efficacious or cost-effective. In contrast, more recent comprehensive pain programs (CPPs) have been shown to be both therapeutically efficacious and cost-effective. The present study reviews available evidence demonstrating the therapeutic efficacy and cost-effectiveness of CPPs, relative to conventional medical treatment. Searches of the chronic pain treatment literature during the past decade were conducted for this purpose, using MEDLINE and PSYCHLIT. Studies reporting treatment outcome results for patients with chronic pain were selected, and data on the major outcome variables of self-reported pain, function, healthcare utilization and cost, medication use, work factors, and insurance claims were evaluated. When available, conventional medical treatments were used as the benchmark against which CPPs were evaluated. This review clearly demonstrates that CPPs offer the most efficacious and cost-effective, evidence-based treatment for persons with chronic pain. Unfortunately, such programs are not being taken advantage of because of short-sighted cost-containment policies of third-party payers.
Perspective:
A comprehensive review was conducted of all studies in the scientific literature reporting treatment outcomes for patients with chronic pain. This review clearly revealed that CPPs offer the most efficacious and cost-effective treatment for persons with chronic pain, relative to a host of widely used conventional medical treatment.
Recurrent pains are a complex set of conditions that cause great discomfort and impairment in children and adults. The objectives of this study were to (a) describe the frequency of headache, stomachache, and backache in a representative Canadian adolescent sample and (b) determine whether a set of psychosocial factors, including background factors (i.e., sex, pubertal status, parent chronic pain), external events (i.e., injury, illness/hospitalization, stressful-life events), and emotional factors (i.e., anxiety/depression, self-esteem) were predictive of these types of recurrent pain. Statistics Canada's National Longitudinal Survey of Children and Youth was used to assess a cohort of 2488 10- to 11-year-old adolescents up to five times, every 2 years. Results showed that, across 12-19 years of age, weekly or more frequent rates ranged from 26.1%-31.8% for headache, 13.5-22.2% for stomachache, and 17.6-25.8% for backache. Chi-square tests indicated that girls had higher rates of pain than boys for all types of pain, at all time points. Structural equation modeling using latent growth curves showed that sex and anxiety/depression at age 10-11 years was predictive of the start- and end-point intercepts (i.e., trajectories that indicated high levels of pain across time) and/or slopes (i.e., trajectories of pain that increased over time) for all three types of pain. Although there were also other factors that predicted only certain pain types or certain trajectory types, overall the results of this study suggest that adolescent recurrent pain is very common and that psychosocial factors can predict trajectories of recurrent pain over time across adolescence.
Multidisciplinary programs for management of acute and chronic pain in children
- Berde
Berde CB, Solodiuk J. Multidisciplinary programs for management of acute and chronic pain
in children. In: Schechter NL, Berde CB, Yaster M (Eds). Pain in Infants, Children and
Adolescents. Philadelphia: Lippincott Williams & Wilkins: 471-86, 2003.
Assessment and management of children with chronic pain: A position statement from the American Pain Society
- T Palermo
- C Eccleston
- K Goldschneider
- K Mcginn
- N Sethna
- N Schechter
- H Turner
Palermo T, Eccleston C, Goldschneider K, McGinn K, Sethna N, Schechter N, Turner H.
Assessment and management of children with chronic pain: A position statement from
the American Pain Society, 2013.