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Systems Approach Can Improve Cancer Pain Management

Based on research by Barbara A. Murphy, MD



A systems approach to pain and symptom management can boost the overall well-being of patients with cancer, according to Barbara A. Murphy, MD, a medical oncologist who works with a multidisciplinary healthcare team to improve patients' quality of life (QOL) and ensure coordinated care. Speaking at the Scripps Cancer Center's 29th annual conference on clinical hematology and oncology, she said it is "a moral imperative" to alleviate suffering in cancer patients. Murphy is director of the Pain and Symptom Management Program, Cancer Supportive Care Program; director of the Head and Neck Research Program; associate professor of medicine (hematology/oncology) and VICC member, Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, Tennessee. She told the audience it would require planning on their part to launch an assertive, proactive communication program and to manage dose requirements of opioids.

Improving QOL
The holistic program used in her practice is committed to improving the patients' QOL by addressing not only their physical cancer issues, but their emotional and spiritual issues as well. "I'm not just talking about drugs," she said. "Pain is a problem, and we have had the tools to deal with that part of the problem."

The purpose of Murphy's oncology supportive care program, she said, is to:
  • Improve patients' overall wellbeing and thus the QOL
  • Enhance symptom control and functional outcome
  • Modify health behaviors.
The global construct, Murphy said, includes patients' perceptions of wellbeing, as influenced by their experiences, points of view, expectations, and beliefs.1 She reminded clinicians that healthrelated issues are only one factor when considering QOL. Commonly assessed QOL domains include well-being on several fronts: physical, functional, social, emotional, spiritual, and financial.

Patients underreport psychological distress
Murphy said numerous studies use self-report questionnaires to conclude that cancer patients do not have a lower QOL than healthy people. Murphy quoted the work of Breetvelt and Van Dam2 who wrote about the so-called response shift: "Under the influence of a highly significant life event, such as getting a life-threatening disease…there will be a concurrent change in the internalized standard on which the patient bases their perceptions."

In other words, patients in these studies were underreporting their psychological distress; on their own, they had made the decision to move the bar. Breetvelt and Van Dam warned that the true nature of cancer and the resulting decrease in QOL could be "obscured totally." They said these "I'm OK" studies were in contrast with other research that documented the de rigueur experience of treating physicians, nurses, and other caretakers. They advised physicians not to put a lot of stock in questionnaires.

Education of patients, physicians, and their staffs: what works?
Murphy said patient education can help overcome barriers to improved QOL. "But patient education by itself will not improve their outcome," she said. Barrier reduction can have more of an effect on the outcome if it focuses on such end points as knowledge, attitudes, practice patterns, and pain control, but, in studies, it has not been sufficient by itself.

"We hoped education would improve patient outcome, but you can change knowledge and attitude and that has not made a significant difference in the outcome," said Murphy. A study by Wells and associates found that a pain education program could improve knowledge and beliefs of the patient and their primary caregiver, but that continued access to pain-related information did not affect long-term pain outcomes.3

Moving beyond education "We need to move beyond education—but where next?" asked Murphy. "More interventions are needed that can be easily adopted by clinicians in various settings." She suggested a "pain hotline" where patients could communicate their pain to their providers. "This had been used in a postoperative setting where it was found to be effective, but when studied in the oncology setting, it was not."

Murphy suggested that a model for adequate pain control would include patient reporting of pain levels, an assessment titration communication, and the physician's cooperation. Patients, she suggested, could keep a pain diary and a brief pain index. She noted her current investigation of a nurse-managed narcotic-titration drugorder sheet,4 as a way to improve pain control. This phase 3 study is sponsored by the National Cancer Institute.

Critical steps for adequate pain outcome
Murphy listed the critical steps that should be considered for adequate pain outcome:
  1. Patient report of pain (and medical staff recognition of problem)
  2. Assessment of pain by the provider
  3. Pain treatment plan
  4. Review of plan with patient
  5. Document assessment and plan
  6. Patient follows treatment plan.
To elucidate the critical steps in a specific plan, Murphy discussed a study by Cleeland and colleagues, who examined a computerized telephone monitoring and alert system (with an interactive voice-response system) that alerted clinic staff via e-mail when cancer patient pain levels exceeded a specified threshold.5 Telephone calls primarily reinforced the patient's use of prescribed medication, provided information for the management of symptoms, or addressed the need for and arranged a change of medication. The researchers found that this method reduced symptom severity and lowered symptomrelated interference for the monitored group compared with the control group. "The e-mail alert would go to a nurse, and she could react; we found this phone call intervention worked really well," said Murphy.

VHA study
An earlier report by Cleeland and associates described a joint collaborative (Veterans Health Administration [VHA] and Institute for Healthcare Improvement) that used a rapid-cycle improvement model to improve pain management within the VHA Health System. Each patient–healthcare pro vider dyad worked within a system to affect a better outcome.6

The study's goals were to improve delivery of pain management to VHA patients and to compare team process and patient report data on key goals from selected study units; 70 teams from 22 Veterans Integrated Service Networks participated.

Findings were that the number of patients experiencing moderate or severe pain on study units dropped from 24% to 17% while pain assessment increased from 75% to 85%; pain-care plans for patients with mild pain increased from 58% to 78%; and the number of patients provided pain education increased from 35% to 62%. "This study highlights the critical issue of patients needing a plan of care," said Murphy.

IT could address complex problem
Murphy said that combining electronic medical records with a systems approach gives data at a glance. The two basic components of a systems approach—elements and processes—can be applied in the medical records setting.

She explained it this way: In a car, the dashboard gives the driver a glimpse of all the information needed to make decisions while operating the vehicle. Dashboards in IT are essentially the same. "You can look at the display and say, 'What am I doing well, or not well?' It allows you to search databases and identify outcome issues at the patient level, the clinic level, and the provider level," said Murphy, who pointed out that, based on the patient's report of pain, the provider could match the level of pain to the regimen prescribed. She said that a lot of data could be organized with this system so that providers could offer adequate pain control for the many stakeholders. She added, "Pain control is complex, but using information systems and technology may hold the key to this complex problem."

References
  1. Murphy BA, Gilbert J, Cmelak A, Ridner SH. Symptom control issues and supportive care of patients with head and neck cancers. Clin Adv Hematol Oncol. 2007;5:807-822.
  2. Breetvelt IS, Van Dam FS. Underreporting by cancer patients: the case of response-shift. Soc Sci Med. 1991;32:981-987.
  3. Wells N, Hepworth JT, Murphy BA, et al. Improving cancer pain management through patient and family education. J Pain Symptom Manage. 2003;25:344-356.
  4. Kane MN, Hamlin ER 2nd, Hawkins WE. Measuring preparedness to address patient preferences at the end of life. Am J Hosp Palliat Care. 2004;21:267-274.
  5. Cleeland CS, Vaporcian A, Shi Q, et al. A computerized telephone monitoring and alert system to reduce postoperative symptoms: a randomized trial. J Clin Oncol. 2008;26(15S): Abstract 9536.
  6. Cleeland CS, Reyes-Gibby CC, Schall M, et al. Rapid improvement in pain management: the Veterans Health Administration and the Institute for Healthcare Improvement collaborative. Clin J Pain. 2003;19:298-305.