Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
-
Daniel W. Wheeler
,
Sara Kinna
Abstract
Background and aims
Hospitalization as a result of acute exacerbation of complex chronic pain is a largely hidden problem, as patients are often admitted to hospital under a variety of specialities, and there is frequently no overarching inpatient chronic pain service dedicated to their management. Our institution had established an inpatient acute pain service overseen by pain physicians and staffed by specialist nurses that was intended to focus on the management of perioperative pain. We soon observed an increasing number of nurse-to-nurse referrals of non-surgical inpatients admitted with chronic pain. Some of these patients had seemingly intractable and highly complex pain problems, and consequently we initiated twice-weekly attending physician-led inpatient pain rounds to coordinate their management. From these referrals, we identified a cohort of 20 patients who were frequently hospitalized for long periods with exacerbations of chronic pain. We sought to establish whether the introduction of the physician-led inpatient pain ward round reduced the number and duration of hospitalizations, and costs of treatment.
Methods
We undertook a retrospective, observational, intervention cohort study. We recorded acute Emergency Department (ED) attendances, hospital admissions, and duration and costs of hospitalization of the cohort of 20 patients in the year before and year after introduction of the inpatient pain service.
Results
The patients’ mean age was 38.2 years (±standard deviation 13.8 years, range 18-68 years); 13 were women (65.0%). The mode number of ED attendances was 4 (range 2–15) pre-intervention, and 3 (range 0–9) afterwards (p = 0.116). The mode bed occupancy was 32 days (range 9–170 days) pre-intervention and 19 days (range 0–115 days) afterwards (p = 0.215). The total cost of treating the cohort over the 2-year study period was £733,010 (US$1.12m), comprising £429,479 (US$656,291) of bed costs and £303,531 (US$463,828) of investigation costs. The intervention did not achieve significant improvements in the total costs, bed costs or investigation costs.
Conclusions
Despite our attending physician-led intervention, the frequency, duration and very substantial costs of hospitalization of the cohort were not significantly reduced, suggesting that other strategies need to be identified to help these complex and vulnerable patients.
Implications
Frequent hospitalization with acute exacerbation of chronic pain is a largely hidden problem that has very substantial implications for patients, their carers and healthcare providers. Chronic pain services tend to focus on outpatient management. Breaking the cycle of frequent and recurrent hospitalization using multidisciplinary chronic pain management techniques has the potential to improvepatients’ quality of life and reduce hospital costs. Nonetheless, the complexity of these patients’chronic pain problems should not be underestimated and in some cases are very challenging totreat.
1 Introduction
There is a strong focus on reducing the need for emergency hospital admission and the duration of hospitalization in most global healthcare systems. Uncontrolled acute pain is one of the most common symptoms causing emergency hospital admission. In general, pain alerts healthcare professionals to a clinical problem that can then be treated appropriately.
Chronic pain persists beyond the normal, expected healing time and therefore is thought not to have an acute warning function [1]. Nevertheless, when chronic pain is severe and disabling, it may lead to unplanned hospital admission. In a proportion of patients with chronic pain, the cause of pain cannot ultimately be identified, even after repeated admissions under a variety of specialties.
Most healthcare professionals will have met patients who present to primary or secondary care frequently with a variety of recurrent clinical problems [2]. Many attend with acute exacerbations of what has become a chronic pain problem. In some of these patients the diagnosis is clear, but in a substantial proportion a diagnosis is not made, despite multiple and often repeated investigations [3]. In others, the intensity of pain experienced by the patient is thought to be out of proportion to that expected.
In our institution, a team of specialist inpatient nurses was established to manage perioperative pain, and supervise patient controlled and epidural analgesia regimes on the wards. The remit of the team quickly evolved to include the management of non- surgical patients with acute and chronic pain problems. It became clear that there was a cohort of approximately 20 patients who were being admitted frequently under one or more specialties with acute uncontrolled exacerbations of chronic pain. It was also clear that an acute hospital was not the ideal environment in which to address these patients’ needs.
Having recognized the complexity of many of these pain syndromes, we sought to reduce the frequency of unplanned admissions to hospital and improve the symptoms and experiences of this vulnerable group of patients.
To do so, we instituted regular inpatient pain rounds under the supervision of a pain physician, with a view to refining, reducing or replacing analgesia regimes, offering interventions (if appropriate), introducing chronic pain management strategies and enlisting the support and input of allied health professionals (such as physical and occupational therapists, psychologists, mental health professionals and rehabilitation physicians).
The objectives of this retrospective observational intervention study were to understand the burden on patients and our institution of frequent or lengthy episodes of hospitalization for acute-on-chronic pain exacerbation, and to establish whether an intensive physician-led programme could reduce this burden. We sought to establish the number, duration, and costs of hospital admissions, investigations and therapy of the 20 patients with acute-on-chronic pain exacerbation who spent the longest periods as inpatients in our hospital, a 1,000-bed university hospital, over 1 year. We compared these with a second 1-year period immediately afterwards, when regular physician-led inpatient pain rounds had been fully established, allowing us to judge the impact of this strategy on patient outcomes.
2 Materials and methods
2.1 Study design and approval
This was a retrospective, interventional cohort study. It was registered and approved as a service evaluation with our institution’s audit office.
2.2 Identification of patient cohort
We used written and electronic pain service records to identify the 20 adults known to the inpatient pain team who spent the most days as hospital inpatients at Addenbrooke’s Hospital, Cambridge, United Kingdom, between April 30, 2008 and April 30, 2009. We retrospectively reviewed all Emergency Department (ED) attendances and episodes of acute hospitalization to identify the nature of the admission and whether the primary symptom was acute- on-chronic pain, or where control of chronic pain symptoms had complicated or prolonged admissions for other clinical reasons. We excluded children (≤17 years), and adults admitted due to trauma, for planned surgery unrelated to the axis of chronic pain or exacerbations of medical co-morbidities in which pain management was not a feature of the hospital stay.
2.3 Parameters measured
For each patient, and for each episode of hospitalization, we recorded the source of admission (self-referral to the ED, primary care referral to hospital speciality or planned elective admission), inpatient ward (general medical, general surgical, orthopaedic, neurosurgery, gynaecology, critical care), primary axis of pain and length of any subsequent hospitalization. We also recorded investigations undertaken for each admission, including biochemistry, haematology, blood transfusion, microbiology, imaging, nuclear medicine, cardiology and endoscopy. Finally, we recorded requests for liaison psychiatry review, and for physiotherapy, occupational therapy and psychologic assessment. The costs of hospital accommodation, investigations and therapy were obtained from our institution’s finance department, and the total cost of each admission was calculated.
2.4 Intervention
From May 2009 to May 2010 a regular attending physician-led inpatient pain service ward round was initiated, to complement the work of the inpatient specialist nurse team. This took place twice weekly, and focused on patients with acute exacerbation of chronic pain, to improve symptoms, minimize repetition of unnecessary investigations, facilitate discharge from hospital and subsequent outpatient management, and reduce the risk of readmission. Patients with acute exacerbation of chronic pain who attended the ED during a round were assessed by the team with a view to avoiding the need for hospitalization. We therefore examined the admissions of the same cohort of 20 patients between May 1, 2009 and May 1, 2010 to establish the effect of this intervention.
2.5 Statistical analysis
All data were anonymized before analysis. Parameters are presented as the mean ± standard deviation (SD), mode (range) or the number (proportion, %), as appropriate. Costs are shown in US Dollars (with Pounds Sterling, £, in parentheses), and were converted using the exchange rate on the last day of the study (£1.00 = US$1.528; May 1, 2010). The distribution of data was assessed using the Shapiro-Wilk test, and the paired t-test or Wilcoxon signed rank test used to compare outcomes in the pre- and post-intervention years for non-normally distributed data per patient and for the entire cohort, respectively. The chi-squared test was used to compare ED admission rates. All statistical analyses were undertaken with the R statistics programme (version 3.4.0; R Foundation for Statistical Computing, Vienna, Austria) [4].
3 Results
3.1 Patient cohort
Of the cohort of 20 patients, 13 were women (65.0%). The patients’ mean age on April 30, 2008 was 38.2 years (±SD 13.8 years, range 18–68 years). The principle axis of chronic pain was the abdomen in 10 patients (50.0%), the musculoskeletal system in five patients (25.0%), the pelvis in three patients (15.0%) and the chest in one patient (5.0%). The remaining patient (5.0%) had chronic widespread pain syndrome.
3.2 Contact with acute hospital services pre-intervention
In the year before the initiation of the physician-led inpatient ward round, the cohort of 20 patients had 111 contacts with acute hospital services: either ED attendances with or without subsequent hospital admission, or primary care referral for immediate assessment or planned elective admission. We excluded two of these episodes from our analysis: one emergency admission via the ED following a road traffic collision and the same patient’s subsequent elective admission for removal of a distal fracture fixation locking plate.
Of the remaining 109 acute contacts, 107 (98.1%) were selfreferrals to the ED; the primary clinical problem in each case was an acute exacerbation of chronic pain symptoms. The remaining two episodes (1.9%) were elective admissions for inpatient investigation of chronic pain. During the first year, none of the patients were referred to hospital by their primary care physician. The mode number of ED attendances was 4 (range 2–15). As a result of these attendances, patients were hospitalized 83 times (77.6% of ED attendances) and discharged from the ED on 24 occasions (22.4% of ED attendances). As a consequence, the cohort spent 1,101 days occupying acute hospital beds, the mode bed occupancy was 32 days (range 9–170 days). The specialties under which the cohort was admitted are shown in Table 1.
Specialty under which the cohort was hospitalized, pre- and post-intervention.
 |
3.3 Contact with acute hospital services post-intervention
In the year after the initiation of the physician-led inpatient ward round, the cohort of 20 patients had 89 contacts with acute hospital services, either ED attendances with or without subsequent hospital admission, primary care referral for immediate assessment or planned elective admission. We excluded five of these episodes from our analysis: one admission with diltiazem-induced bradycardia, one admission for an exchange of an intra-medullary nail and three admissions relating to elective breast augmentation (elective admission for the procedure, an emergency admission for the management ofwound infection and elective admission for refashioning of the incision).
Of the remaining 84 acute contacts, 79 (94.0%) were selfreferrals to the ED; the primary diagnosis in each case was an acute flare of chronic pain symptoms. The remaining five episodes comprised four elective admissions for inpatient investigation of pain and one referral by a primary care physician for an acute pain flare- up. The mode of ED attendances post-intervention was 3 (range 0–9). Two patients in the cohort did not present to our institution in the post-intervention year, but the difference in number of acute presentations to hospital pre- and post-intervention for the whole cohort was not statistically significant (p = 0.116).
As a result of these attendances, patients were admitted 65 times (82.2% of ED attendances) and discharged on 14 occasions (17.8%); the proportion of patients admitted from the ED was not significantly different from the pre-intervention year (p = 0.431). As a consequence, the cohort occupied inpatient acute hospital beds for 803 days post-intervention; the mode bed occupancy was 19 days (range 0–115 days, p = 0.215 compared with the pre-intervention year; Fig. 1).
Box-and-whisker plot showing the cohort’s bed occupancy before and after physician-led intervention.
3.4 Costs of hospitalization pre- and post-intervention
The total cost to our institution of treating the 20-patient cohort over the 2-year study period was US$1.12m (£733,010), comprising US$656,291 (£429,479) of bed costs and US$463,828 (£303,531) of investigation and therapy costs. A comparison of the costs of hospitalization of the cohort before and after intervention is shown in Table 2. Despite the intervention, and the absence of any costs for the two patients who did not present to our institution in the postintervention year, there were no significant differences in the total costs, bed costs or investigation and therapy costs for the cohort or per patient (Table 2, Fig. 2).
Costs of treating the patient cohort pre- and post-intervention.
| Pre-intervention year | Post-intervention year | p value | |
|---|---|---|---|
| Bed costs for cohort | US$378,273 (£247,543) | US$278,018 (£181,936) | 0.330 |
| Investigation and therapy costs for cohort | US$228,946 (£149,823) | US$234,883 (£153,708) | 0.596 |
| Total costs for cohort | US$607,219 (£397,366) | US$512,901 (£335,644) | 0.430 |
| Bed costs per patient | US$18,886 (£12,359) | US$13,901 (£9,097) | 0.218 |
| Investigation and therapy costs per patient | US$11,447 (£7,491) | US$11,744 (£7,685) | 0.930 |
| Total costs per patient | US$30,333 (£19,850) | US$25,645 (£16,782) | 0.496 |
-
Costs were converted from Pounds Sterling (£) into US Dollars (US$) using the exchange rate on the last day of the study(£1.00 = US$1.528; May 1, 2010) and rounded to the nearest unit. Data are presented as the mean
Box-and-whisker plot showing the total, bed and investigation costs of treating the cohort before and after physician-led intervention.
4 Discussion
The burden of acute exacerbation of chronic pain in this relatively young cohort of 20 patients was very substantial. We were struck not only by the high financial costs of caring for these patients, but especially by the obvious impact that frequent and recurrent hospitalizations had on patients’ quality of life. The total number of unplanned hospital attendances over the 2-year study period was 193, leading to 148 hospitalizations for a total duration of 1,904 days. The extent of the disruption that this caused to patients’ family, work and social lives was very evident, although we did not seek to quantify this in this study. In some cases, repeated and/or lengthy hospitalization became self-defeating; even with careful discharge planning and outpatient follow-up, some vulnerable patients were unable to cope at home, and readmission was almost inevitable.
The problem of recurrent or repeated hospitalizations due to acute exacerbation of chronic pain was also largely hidden in our institution. As pain is a symptom and not a diagnosis, the reasons for hospital admission recorded varied widely, and the patients were not detected by hospital-wide databases or electronic records. This problem was exacerbated by admissions under a variety of (sometimes different) specialties, and it is notable that a substantial proportion of patients were admitted under non-surgical specialties. Indeed, our chronic pain team generally became aware of patients in our cohort due to referrals by ward nurses to our specialist pain nurses. Our specialist nurses’ outreach activities had spread awareness of the chronic pain team’s capabilities beyond the surgical wards and beyond their originally intended remit of the management of acute perioperative pain. Few of our referrals came from physicians, who perceived that chronic pain services were only offered to outpatients. None of the 20 patients in the cohort had been known to outpatient chronic pain services at their first admission.
Our interventions aimed to reduce the number of hospital attendances, reduce the proportion of attendances that led to hospital admission, reduce the number of investigations, and reduce length of hospital stay. To achieve this, we introduced a comprehensive multidisciplinary approach to inpatients that is part of routine clinical practice for outpatients. This included support from patients’ primary care physicians, attending physicians, allied health professionals such as physical and occupational therapists, and specialist pain psychologists. We drew up ED attendance plans [5], and sought to rationalize, refine, reduce and replace strong analgesics wherever possible, with a strong emphasis on opioid replacement or dose reduction. Indeed, the two patients in the cohort who were not hospitalized at all in the second year were successfully treated for opioid-induced constipation.
Although our intervention appeared to save 298 bed-days and US$94,318 (£61,722), we are mindful that there were no statistically significant differences in the frequency of the cohort’s ED attendances, the proportion admitted from the ED, bed occupancy or total costs between the pre- and post-intervention years. Nevertheless, our intervention was highly clinically significant for the two patients who did not return to hospital in the post-intervention year, and many of the other patients were hospitalized less often and for fewer days. Not all patients benefited from our strategy, however, and our findings suggest that it requires further refinement and improvement. The clinical challenges posed by these complex patients should not be underestimated [5].
Our study had several limitations. First, it was limited to a single cohort in one institution in a publically-funded healthcare system. Our university hospital is a tertiary referral centre for several specialties, so our findings may not be generalizable to other hospitals operating under different healthcare systems and serving different populations. Second, we did not undertake long-term follow-up, so cannot be sure that improvements were maintained, or were simply a result of the relapsing and remitting nature of chronic pain. Third, we cannot tell whether patients began attending other local hospitals instead of ours, whether they chose to ‘suffer in silence’ at home instead of coming to hospital, or whether our intervention led to broader improvements in their quality of life. However, by liaising with colleagues in primary care we were able to establish that the two patients who ceased to attend our institution did not begin to attend elsewhere. Finally, we did not take into account the costs of outpatient care, or changes to patients’ drug regimes.
In conclusion, we found that a single cohort of patients frequently admitted to our institution with acute exacerbation of chronic pain were frequently hospitalized for long periods, and incurred substantial treatment and investigation costs. Importantly, the frequency and length of their hospitalization would also make living a normal life almost impossible, which in turn makes outpatient treatment more challenging. Although two patients did not present to acute hospital again after our attending physician- led intervention, the length and costs of hospitalization of the entire cohort were not significantly reduced. This suggests that other strategies need to be identified to help this highly complex and vulnerable group of patients.
Highlights
Hospitalization with acute exacerbation of complex chronic pain is a hidden problem.
Chronic pain services typically focus on outpatients rather than inpatients.
We started a physician-led pain round to address complex pain issues in inpatients.
We identified 20 patients frequently hospitalized by chronic pain for long periods.
The intervention was successful in some patients, but not in the cohort as a whole.
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Ethical issues: The study was registered and approved as a service evaluation with our institution’s audit office. No identifiable patient details are included in the manuscript or the database used for analysis.
-
Conflicts of interest: None of the authors has a potential conflict of interest to declare, including any financial, personal or other relationships with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence, or be perceived to influence, this work.
-
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
We are grateful to Drs Mark Abrahams, David Hughes, Rokas Tamosauskas and Evan Weeks, and Sr Maria Gloag, for their assistance with the inpatient pain ward rounds.
References
[1] Classification of Chronic Pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl 1986;3:S1–226.Search in Google Scholar
[2] Patel S, Kai J, Atha C, Avery A, Guo B, James M, Malins S, Sampson C, Stubley M, Morriss R. Clinical characteristics of persistent frequent attenders in primary care: case-control study. Fam Pract 2015;32:624–30.Search in Google Scholar
[3] Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. BMJ 2001;322:767.Search in Google Scholar
[4] R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing Website; 2017. Available at: https://www.R-project.org [accessed July 27].Search in Google Scholar
[5] Jacob R, Wong ML, Hayhurst C, Watson P, Morrison C. Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design. Clin Med (Lond) 2016;16:325–9.Search in Google Scholar
© 2017 Scandinavian Association for the Study of Pain
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- A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
- Clinical pain research
- PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
- Clinical pain research
- Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
- Editorial comment
- Towards a structured examination of contextual flexibility in persistent pain
- Clinical pain research
- Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
- Editorial comment
- Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
- Editorial comment
- Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
- Editorial comment
- A glimpse into a neglected population – Emerging adults
- Observational study
- Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
- Clinical pain research
- Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
- Clinical pain research
- Prevalence and characteristics of chronic pain: Experience of Niger
- Observational study
- The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
- Original experimental
- Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
- Original experimental
- Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
- Clinical pain research
- The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
- Clinical pain research
- Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
- Topical review
- Targeting cytokines for treatment of neuropathic pain
- Original experimental
- What constitutes back pain flare? A cross sectional survey of individuals with low back pain
- Original experimental
- Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
- Clinical pain research
- Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
- Original experimental
- The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
- Educational case report
- Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
- Original experimental
- Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
- Observational study
- Predictors of chronic neuropathic pain after scoliosis surgery in children
- Clinical pain research
- Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
- Clinical pain research
- A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
- Clinical pain research
- Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
- Original experimental
- Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
- Original experimental
- Initial validation of the exercise chronic pain acceptance questionnaire
- Clinical pain research
- Exploring patient experiences of a pain management centre: A qualitative study
- Clinical pain research
- Narratives of life with long-term low back pain: A follow up interview study
- Observational study
- Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
- Clinical pain research
- Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
- Original experimental
- Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
- Observational study
- Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
- Clinical pain research
- Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
- Original experimental
- Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
- Topical review
- Psychoneuroimmunological approach to gastrointestinal related pain
- Letter to the Editor
- Do we need an updated definition of pain?
- Narrative review
- Is acetaminophen safe in pregnancy?
- Book Review
- Physical Diagnosis of Pain
- Book Review
- Advances in Anesthesia
- Book Review
- Atlas of Pain Management Injection Techniques
- Book Review
- Sedation: A Guide to Patient Management
- Book Review
- Basics of Anesthesia
