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Study Shows Best Performing Hospitals Manage Pain Best


NEW YORK (Reuters Health) - Hospital differences in pain management are tied to different patient-reported pain scores after colorectal resection, according to a study from the Michigan Surgical Quality Collaborative (MSQC).

"The best-performing hospitals achieved superior pain control through the use of analgesia regimens that more often used local anesthesia blocks in the operating room,non-steroidal anti-inflammatory drugs, and patient-controlled analgesia rather than intermittent narcotics," said Dr. Scott E. Regenbogen from the University of Michigan, Ann Arbor.

"This suggests that efforts to implement multimodal analgesia regimens may improve pain control in the immediate postoperative period," he told Reuters Health by email.

Despite increasing attention to postoperative pain management, most patients continue to experience severe pain after major surgery, Dr. Regenbogen and colleagues note in Annals of Surgery, online January 7.

The researchers used MSQC data from 52 hospitals to evaluate the extent to which multimodal pain management practices are used after major surgery and how hospitals' perioperative practices might affect patient-reported pain levels in real-world surgical practice. Their study included 7,221 patients who underwent colorectal resection between 2012 and 2014.

Nine hospitals had average adjusted pain scores significantly worse and eight hospitals had average adjusted pain scores significantly better than the overall average. The "best" hospitals were somewhat larger and had higher annual volumes of colorectal resection than the "worst" hospitals.

Patients in hospitals with best pain scores were significantly more likely to receive local anesthesia and epidural anesthesia during the operation and to have patient-controlled analgesia (PCA), nonsteroidal anti-inflammatory drugs (NSAIDs), or a combination of PCA and NSAIDs and significantly less likely to receive intermittent postoperative narcotics, compared with patients in hospitals with worst pain scores.

Hospitals with the lowest pain scores had a significantly higher proportion of operations with a minimally invasive approach than did hospitals with the highest pain scores.

Patients whose operations took place in hospitals in the lowest quartile of pain scores had significantly shorter mean postoperative length of stay and were significantly less likely to have a postoperative complication, emergency department visit, or readmission.

Patient factors contributing to worse pain scores included being younger than 50 (versus age over 75), a woman, black (versus white), a smoker, and uninsured or insured by Medicaid (versus Medicare or privately insured).

"Most likely," the researchers note, "both pain scores and clinical outcomes reflect more global features of the quality of care in hospitals' surgical performance. Thus, hospitals with the most streamlined, high-quality perioperative care pathways experience the best pain scores, as well as improved clinical outcomes."

"Early postoperative analgesia regimens are an essential component of efforts to improve the efficiency and quality of postoperative recovery," Dr. Regenbogen said."Effective pain control, even in the first postoperative day, is associated with reduced postoperative length of stay and fewer major complications and readmissions. Thus, effective multimodal analgesia is an essential component of high-value perioperative care around colorectal surgery."

"This study is hopefully just one example of a growing emphasis on patient-reported outcomes in surgery," Dr.Regenbogen said. "Within a statewide quality collaborative, we have begun to prioritize engagement of patients, in addition to our partnering surgeons, hospitals, and mayors, in efforts to improve surgical care in Michigan. In this study, we used patient-reported pain measures to evaluate quality of care. In the near future, we will elicit patient-reported measures of functional recovery, psychosocial support, and other outcomes to validate the perioperative outcomes we have relied on traditionally. We hope this study will serve as a model for those novel areas of investigation."

Dr. Antoni Sabate from Hospital Universitari de Bellvitge in Barcelona, Spain, who has researched postoperative analgesia told Reuters Health by email, "Pain is largely influenced by magnitude of the surgical procedure, surgical technique (minimally invasive), analgesia protocol (the use of local anesthetic infiltration in open and laparoscopic, the use of epidural in open procedures, implementation of PCA and NSAID in both laparoscopic and open procedures."

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