Pain management organization models in adult cancer patients

Medical and Medicine

Evidence-Based Nursing

Brink-Huis, A., van Achterberg, T., & Schoonhoven, L. (2008). Pain management: A review of organisation models with integrated processes for the management of pain in adult cancer patients. Journal of Clinical Nursing, 17(15), 1986-2000. doi:10.1111/j.1365-2702.2007.02228.x

Systematic Review: Are the results of the review valid?

Because the studies were heterogeneous a meta-analysis could not be performed. Consequently, the study resulted in a narrative review that identified three organization models of pain management that contain integrated processes.

It is unclear if the results of the review are valid because none of the questions below are answered affirmatively as follows: (a) a clear research question was not stated, (b) relevant studies were likely missed and (c) the results were dissimilar from study to study.

#1What question (PICO) did the systematic review address?

What is best? The main question being addressed should be clearly stated.

This paper: Yes ( No ( Unclear (

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Comment:

A research question was not explicitly stated, but from the study's aim a question can be deduced and written as follows: What organization models exist in cancer pain management that contain integrated care processes that lead to reduced pain in cancer patients?

The research question should address the PICO acronym: Population, Intervention, Comparison, and Outcome (Stevens, 2009), and does. The population consisted of patients with cancer. The intervention consisted of integrated care processes. The comparison existed across the different organization models and the outcome was the reduction of pain.

#2 Is it unlikely that important, relevant studies were missed?

What is best?

The search included four major databases (Medline, CINAHL, Cochrane and Clinical Evidence), and the reference lists from the retrieved studies were also looked at.

This paper: Yes ( No ( xx Unclear (

Comment:

It is likely the search missed important and relevant studies. Four databases were used, but additional studies may have been retrieved if the DARE, DynaMed, and Joanna Briggs Institute had also been searched.

#3Were the criteria used to select articles for inclusion appropriate?

What is best?

This paper: Yes ( xx No ( Unclear (

Comment:

Inclusion and exclusion criteria were predetermined by two authors (Anita Brink-Huis and Theo van Achterberg). Retrieved studies were assessed and included if all of the inclusion criteria were met. The complete search strategy resulted in 20 studies. Two studies were discarded because full text was not available. The full text of the remaining 18 studies was examined in more detail. Five studies were excluded because no intervention related to pain management took place and one study was excluded because it concerned an implementation report.

#4 Were the included studies sufficiently valid for the type of question asked?

What were the results?

The paper resulted in a narrative review because meta-analysis could not be performed. The results for all models indicate that they are beneficial to the management of pain in cancer patients. The authors identified the fact that the level of evidence is limited, as there are no strong methodological trials. They explained that it was nearly impossible to meet all methodological quality criteria when conducting a trial in the field of (advanced) cancer pain. For clinical practice they recommended the development of policies for referrals to a pain consultation service. These policies could be integrated within a clinical pathway. Further research for testing the effectiveness of a clinical pathway in combination with a pain consultation service is needed.

A clinical pathway can be seen as a comprehensive institutionalization model. It pays more attention to other integrated processes such as an interdisciplinary approach and continuity of care and follows the patient through all stages of care. A pain consultation service seems to be a 'stand-alone' model, concentrating on complex pain management issues and available on demand. Consultation on demand can be problematic: the effectiveness of the service depends on the willingness of other professionals to ask for help.

The authors also recommend standardization of the outcome measures in order to evaluate the effectiveness of pain management models. Evaluation of the quality of pain management should involve measurements of both patient outcomes and process outcomes.

How are the results presented?

The results were presented as a narrative discussion; no statistics, other than those from each study, were described. Meta-analysis was not possible.