Abstract
Background
Cancer pain continues to be undertreated, despite the availability of evidence-based guidelines. The Australian National Pain Strategy identified establishment of systems and guidelines to adequately manage cancer pain as a high priority.
Objectives
This study aimed to identify barriers and facilitators to adult cancer pain assessment and management as perceived by Australian health professionals; establish the perceived need for new Australian guidelines and implementation strategies; identify which guidelines are used; and identify barriers and facilitators to guideline use. This article focuses on the perceptions of responding palliative care physicians.
Design
A cross-sectional survey was administered online.
Participants
Invitations were circulated via peak bodies and clinical leaders. Comments were coded independently by two researchers.
Results
Ninety-two palliative care physicians responded to the survey; 39% of the national total. The majority reported barriers to pain management, including insufficient access to nonpharmacologic interventions, poor coordination between services, and management challenges posed by comorbidities. Forty-five percent reported using pain guidelines, most commonly the Australian Therapeutic Guidelines—Palliative Care. Respondents were largely supportive of the development of new Australian guidelines and implementation strategies, in particular any offering advice on specific cases of cancer pain (e.g., neuropathic), patient self-management resources, assessment of patient priorities, and disciplinary roles.
Conclusion
Barriers to evidence-based practice identified by our survey might be addressed via strategies to support decision making and coordination of care (e.g., a clinical pathway). Particular attention should be paid to promoting access to nonpharmacologic interventions and patient education, and improving referral and care coordination.
Introduction
Pain is experienced by up to 75% of people with cancer yet remains undertreated across the world.1–5 Failure to manage pain is due to barriers at all levels—patient, caregiver, health professional, and health care system.6–17 Research suggests that implementation of evidence-based clinical practice guidelines for cancer pain can improve the processes of care and patient outcomes.11 A systematic review has identified three models that have demonstrated efficacy to some degree: (1) institutional models, which provide policies and procedures for regular pain assessment and standardization of pain treatment; (2) clinical pathways, which provide step-by-step guidance on optimal sequencing and timing of assessment and management; and (3) expert consultation.11
In Australia, pain in people with cancer has been identified as an important area for improvement by both the National Institute of Clinical Studies (NICS) and the Cancer Institute New South Wales (NSW).18,19 The recently launched Australian National Pain Strategy has six major goals including, “timely access to best-practice, evidence-based assessment and care.”20 The Pain Strategy was developed in 2010 at a National Pain Summit and included input from a Cancer Pain and Palliative Care Working Group. This group concluded that a primary objective should be the promotion of guidelines and systems to ensure adequate assessment and management of cancer pain, improve communication between patients and health care providers, and facilitate coordination between providers. However, more data are needed to guide selection of appropriate strategies. To date, Australian studies examining barriers to cancer pain assessment and management have focused on the perceptions of patients and caregivers.21–24 These surveys identified patient and caregiver barriers in the form of misconceptions about opioids, perceived lack of control, poor management expertise, and barriers to communication. A better understanding of barriers and facilitators from the perspectives of Australian health professionals is needed to inform promotion of evidence-based practice.
The aims of the current study were to:
Inform understanding of barriers and facilitators to adult cancer pain assessment and management in various Australian clinical practice settings from the perspectives of different disciplines.
Establish the level of support for new Australian guidelines and associated implementation strategy.
Find out which guidelines for adult cancer pain are used.
Inform understanding of barriers and facilitators to adult cancer pain guideline use.
We were especially interested in the views of motivated clinicians most likely to drive change.25
Methods
The methods have been described in detail elsewhere.26 Briefly, the study used a cross-sectional online survey design. Participants were health professionals of any discipline involved in caring for adults with cancer pain in Australia. This article focuses on responses from participants who self-reported their discipline as palliative care physician. Palliative care physicians are generally considered experts in pain management and provide clinical care for people with advanced cancer who are experiencing symptoms, especially as they approach the end of life. Understanding their current practice and attitudes is therefore critical for any efforts aimed at improving pain assessment and management.
Participants were recruited via e-mail invitations and newsletters sent out by peak bodies and other organizations (see Table 1 for those that circulated to palliative care physicians). We also asked Australian clinical leaders in cancer pain to circulate the invitation via their networks.
Table 1.
Peak Bodies that Circulated Survey to Palliative Care Physicians
| ANZ Society of Palliative Medicine (ANZSPM) |
| Australasian Chapter of Palliative Medicine |
| Australian Pain Society |
| CanNET NT |
| CareSearch |
| Clinical Oncological Society of Australia |
| Grampian Integrated Cancer Service |
| Painaustralia |
| Palliative Care Australia |
| Primary Care Collaborative Cancer Clinical Trials Group (PC4) |
| WA Centre for Cancer & Palliative Care |
An open online survey was administered via a secure online platform, SurveyMonkey® (www.surveymonkey.com/). Open online surveys are subject to selection bias because participants self-select, leading to a volunteer effect.27 In the current study, an overrepresentation of motivated respondents with experience of, and interest in, guideline use were considered to be supportive of, rather than disabling to, our aims.
The survey “went live” on August 30, 2011 and closed on April 30, 2012. Information about respondents requested in the survey included discipline and primary workplace location (state/territory, postcode), sector, and outreach status. Respondents were asked how routinely their primary workplace implemented each of a list of evidence-based practices identified by Dy et al.28 and the Clinical Indicators for Pain Project funded by the Victorian Department of Health.29 Further questions related to access to specialist palliative care and pain services; use of and familiarity with guidelines for assessment and management of cancer pain; the need for new Australian guidelines and implementation strategies; and perceptions of barriers and facilitators to best practice and use of guidelines.
Item response options included yes/no, verbal rating scales (e.g., strongly agree, agree, disagree, strongly disagree) and comment boxes after every item. Comments were independently coded by two authors (M.L. and T.L.) who then met to reach consensus.
Results
Ninety-two palliative care physicians were recruited to the survey. This represents 39% of the total 236 palliative medicine specialists registered with the Australian Health Practitioner Regulation Agency.30 Ten participants self-identified as holding dual specialty roles as oncologists, four as registrars/trainees, three as geriatricians, two as general practitioners, two as pain specialists, and one as registered nurse. The geographic spread of respondents roughly corresponded to that of the general population,31 with all states and territories represented except the Northern Territory (Table 2). Thirty-five percent of respondents provided an outreach clinic to a regional or remote area from a metropolitan hospital. Only 7% were in private practice.
Table 2.
Sample Characteristics
| State/territory (% Australian general populationa) | (n=92)% |
|---|---|
| VIC (24.9) | 28% |
| NSW (32.3) | 27% |
| QLD (20.2) | 20% |
| WA (10.4) | 8% |
| SA (7.3) | 3% |
| TAS (2.3) | 7% |
| ACT (1.6) | 2% |
| NT (1.0) | 0% |
| Sector | |
| Public hospital | 43% |
| Public practice | 40% |
| Private practice | 4% |
| Private hospital | 3% |
| Community care | 3% |
| Does the physician run an outreach clinic | |
| Yes | 35% |
Based on demographic data from the Australian Bureau of Statistics.1
Palliative care physicians self-report close adherence to current recommendations in cancer pain assessment and management, despite many barriers identified. The most prevalent of these appears to relate to lack of access to services to provide nonpharmacologic management of cancer pain. These include: psychologists providing cognitive behavioral therapy (CBT) for which there exists Level 1 evidence for efficacy in cancer pain management; and physiotherapists who provide therapy for musculoskeletal pain. Many of the free text comments described health professionals' lack of knowledge about opioids and their use. The next most prevalent barrier identified was a lack of coordination across multiple providers.
Availability of more patient and caregiver education was most frequently nominated as being likely to improve cancer pain assessment and management at the physician's primary workplace (Table 3).
Table 3.
Responses to Questions on Current Practice in Assessment and Management of Cancer Pain
| How routinely does each of these practices takes place at your primary workplace? (Most of the time/always or nearly always) | (n=77)% |
| Use of breakthrough opioids in cancer patients receiving long-acting opioids | 99% |
| Use of bowel regimens in cancer patients receiving opioids | 96% |
| Follow-up of pain management for cancer patients | 97% |
| Scheduled pain medication for severe pain | 95% |
| Continuity of opioid doses across health care settings | 92% |
| Regular pain assessment in cancer patients | 91% |
| Routine assessment of pain in new cancer patients | 91% |
| Routine pain education for cancer patients | 83% |
| Use of a validated pain scale to assess cancer pain | 71% |
| How much of a barrier is each of the following at your primary workplace? (somewhat of a barrier/very substantial barrier) | (n=76)% |
| Difficulty accessing services that enable nonpharmacologic management of cancer pain | 83% |
| Lack of coordination across multiple providers | 78% |
| Challenges posed by comorbidities | 76% |
| Difficulty accessing interventional pain services | 71% |
| Impact of distance on ability to access pain-related services for patients | 62% |
| Inability to access ongoing data on pain and quality of life to monitor progress and outcomes | 62% |
| Lack of regular case reviews to critically discuss and evaluate pain assessment and management | 58% |
| Difficulty keeping abreast of advances from research | 58% |
| Inadequate remuneration for time spent (e.g., on multidisciplinary meetings) | 54% |
| Lack of benchmarks to assess improvement in quality of pain management over time | 54% |
| Difficulty accessing transport services for patients requiring management for cancer pain | 47% |
| Difficulty accessing acute pain services | 47% |
| Limited expertise in the assessment and management of cancer pain | 30% |
| Difficulty accessing palliative care services | 11% |
| What would improve cancer pain assessment and management at your primary workplace? (Check as many as apply) | (n=77)% |
| More patient education | 64% |
| More caregiver education | 62% |
| More training and access to information on pain assessment and management | 57% |
| Increase in dedicated clinician time | 55% |
| One or more clinical champion(s) | 42% |
| A more multidisciplinary approach | 39% |
| New mechanisms for evaluating outcomes | 18% |
| Policy changes | 10% |
| Unsure | 5% |
Lack of available specialist pain services and long waiting times for these services were identified as causing delayed referral to those services by 62% of 29 responding palliative care physicians. Access to a pain service was of acceptable speed and ease for only 44% of 81 respondents (Table 4).
Table 4.
Responses to Questions Regarding Specialist Pain Service Involvement in Cancer Pain Assessment and Management
| Question (Response) | (n=77)% |
|---|---|
| What proportion of patients with cancer pain would benefit from referral to a specialist pain service for assessment and management? (Most/all or nearly all) | 19% |
| (n=81)% | |
| In your area health service, how quickly and easily can a specialist pain service typically be accessed for assessment and management of cancer pain? (Access is of acceptable speed and ease) | 44% |
| How often is referral to a specialist pain service for assessment and management of cancer pain delayed for the following reasons? (Most of the time/always or nearly always) | (n=29)% |
| Lack of available specialist services | 62% |
| Long waiting time | 62% |
| Need for patients to travel to tertiary centers | 31% |
| Difficult/complex referral processes | 24% |
| Lack of coordination between services | 21% |
| Difficulty accessing patient transport | 17% |
| Lack of knowledge of available services | 14% |
| Difficulty selecting which patients should be referred | 7% |
| Delays are due to patients themselves (e.g., because they fear perceived side effects or addictiveness of treatment) | 3% |
Only 68% of palliative care physicians felt that all or nearly all people with cancer pain should be seen by palliative care services indicating that 32% felt that palliative care services should be used for only a select group of patients who could not be managed adequately by oncologists or general practitioners. Only eight respondents answered the question about delayed referrals to palliative care services possible because the options given in the questions were not barriers for other respondents (Table 5).
Table 5.
Responses to Questions Regarding Specialist Palliative Care Service Involvement in Cancer Pain Assessment and Management
| Question (Response) | (n=76)% |
|---|---|
| What proportion of patients with cancer pain would benefit from referral to a specialist palliative care service for assessment and management? (Most/all or nearly all) | 68% |
| (n=75)% | |
| In your area health service, how quickly and easily can a specialist palliative care service typically be accessed for assessment and management of cancer pain? (Access is of acceptable speed and ease) | 87% |
| How often is referral to a specialist palliative care service for assessment and management of cancer pain delayed for the following reasons? (Most of the time/always or nearly always) | (n=8)% |
| Lack of knowledge of available services | 13% |
| Difficulty selecting which patients should be referred | 13% |
| Lack of coordination between services | 13% |
| Delays are due to patients themselves (e.g., because they fear perceived side effects or addictiveness of treatment) | 0% |
| Long waiting time | 0% |
| Difficult/complex referral processes | 0% |
| Difficulty accessing patient transport | 0% |
| Need for patients to travel to tertiary centers | 0% |
Guideline use
More than 90% of 77 responding palliative care physicians supported the need for guidelines and an implementation strategy for those guidelines. A guideline was already in routine use in the practice of 45% of 87 respondents. The (Australian) Therapeutic Guidelines—Palliative Care was the most commonly used guideline used by 22 respondents (Table 6).
Table 6.
Responses to Questions on Guidelines for Assessing and Managing Cancer Pain
| Question (Response) | |
|---|---|
| What level of need do you think there is for the following? (Some need/urgent need) | (n=77)% |
| An Australian guideline for nonpharmacologic management of cancer pain | 92% |
| An Australian guideline for pharmacologic management of cancer pain | 90% |
| Implementation strategy to inform use of existing guidelines in and across different service settings | 90% |
| An Australian guideline for assessing cancer pain | 90% |
| In a new Australian implementation strategy for guidelines on cancer pain, how useful would the following be? (Somewhat/very useful) | (n=77)% |
| Advice on best practice for specific cases of cancer pain (e.g., nociceptive) | 96% |
| Inclusion of patient 'action plans' to aid self-management | 95% |
| Guidance on assessing patient-identified priorities | 92% |
| Guidance on roles for each discipline | 90% |
| Templates for taking case histories and identifying patient-identified priorities | 84% |
| Patient version of implementation strategy | 79% |
| Inclusion of key performance indicators | 74% |
| One or more guideline routinely used in primary workplace? | (n=87)% |
| Yes | 45% |
| Which specific guideline(s) used routinely in primary workplace | (n=32)% |
| (Australian) Palliative Care Expert Group (2010): Therapeutic Guidelines— Palliative Care. Version 3 | 66% |
| Institutional or departmental guideline(s) | 31% |
| NHMRC (2006): Guidelines for a palliative approach in residential aged care | 16% |
| European Association for Palliative Care (2001): Morphine and alternative opioids in cancer pain; the EAPC recommendations | 13% |
| American Pain Society (2005): Guidelines for the management of cancer pain in adults and children | 9% |
| European Society for Medical Oncology (2007): Minimum clinical recommendations for the management of cancer pain | 3% |
| National Comprehensive Cancer Network (2010): Clinical practice guidelines in Oncology - adult cancer pain | 3% |
| National Institutes of Health (2002): Symptom management in cancer: pain, depression and fatigue | 3% |
| Palliative Care in Paediatric Oncology | 3% |
| APSOC Guidelines for the management of neuropathic pain (APSOC—Management in pain in residential aged care facilities) | 3% |
| Therapeutic guidelines | 9% |
| Palliative Care Formulary 3rd Edition Twycross & Wilcock | 3% |
| Twycross Therapeutics in Terminal Cancer | 3% |
| Cancer Institute EVIQ | 3% |
| Internal guidelines and policies are used regarding analgesia and analgesics | 3% |
| Burst Ketamine Guidelines Methadone Guidelines (Perth) | 3% |
| Paediatric Palliative Care references | 3% |
| Own silver chain guidelines, developed from looking at other published info | 3% |
| Peter Mac Cancer Pain Management Guidelines | 3% |
| Peter MacCallum Guidelines Western Health Victoria Guidelines | 3% |
| Victorian Eastern Metropolitan Regional Palliative Care Consortia Opioid Conversion Guidelines | 3% |
| We have developed our own guidelines for the management of uncontrolled cancer pain | 3% |
| NHMRC Acute Pain Guidelines | 3% |
| Analgesics Therapeutic Guidelines—Palliative Care | 3% |
| Perceptions about guideline use (Agree/strongly agree)—completed by | (n=32)% |
| One or more guideline working well | 100% |
| Use of pain guideline(s) at my primary workplace influence(s) patient outcomes | 78% |
| There are adequate resources at my primary workplace to provide care according to one or more pain guideline(s) | 78% |
| My service endorses use of one or more particular pain guideline(s) | 78% |
| Clinical staff at my primary workplace adhere to the same pain guideline(s) | 72% |
Discussion
This was the first study to explore Australian palliative care physicians' perceptions of ways to improve cancer pain assessment and management. Palliative care physicians responding to our online survey were strongly supportive of the need for new Australian cancer pain assessment and management guidelines and an implementation strategy. When asked about barriers to provision of pain management, respondents identified a lack of access to nonpharmacologic pain management strategies, lack of coordination between providers, and patient comorbidities. Other barriers included lack of consensus and knowledge about pain management and lack of resources to teach.
The most commonly identified barrier, lack of access to nonpharmacologic pain management strategies, has also been identified as a barrier in other countries.32 Nonpharmacologic pain management strategies are recommended briefly in many international guidelines33,34 and could be included in more detail in an Australian guideline. Inclusion of such strategies in a national guideline may influence providers and administrators to increase access to services enabling nonpharmacologic pain management, including physiotherapy, occupational therapy, and psychology. Psychology, in particular, while increasingly available in oncology departments, remains uncommon in Australian specialist palliative care services. A problem with access to medicines, in particular items not subsidized by the Pharmaceutical Benefits Scheme such as gabapentin for pain management was also identified by respondents.
The second most commonly identified barrier, lack of coordination across multiple providers, confirms the priority placed on the need for improvement in this area by the National Pain Summit.18 Respondents reported that poor coordination resulted in medications being omitted either by accident or intentionally by providers who are reluctant to prescribe opioids. Increased collaboration between specialties through joint clinics, ward rounds and dual training of registrars between palliative care and pain medicine or palliative care and oncology may help to improve care coordination.
A guideline and implementation strategy can take the form of a clinical pathway. On the basis of the perceived need and identified evidence-practice gap, the authors are currently developing such a clinical pathway based on international guidelines and a consensus process involving Australian experts in cancer pain management (http://wiki.cancer.org.au/australia/Guidelines:Cancer_pain_management). It will include patient screening with self-report measures, health professional education, and a patient-held version of the pathway. It will be patient-centered, evidence-based and updated, and include opioid conversion information. It will act as an education tool about opioids for consumers and health professionals and address many of the commonly held misconceptions about opioids.
Further strategies used by the clinical pathway for cancer pain will include recommendations for a link between pain assessment and evidence-based management being incorporated into hospital accreditation, regular prompts to use the guidelines, and measures designed to foster good organizational support. While concern has been expressed35,36 that clinical guidelines create a barrier to critical thinking, the main aim of guidelines and pathways is to ensure that essential elements of comprehensive pain assessment and management are not omitted by those who lack specialist knowledge.
Limitations to the survey reported here include the fact that only 39% of Australian palliative care physicians responded and some questions were answered by a small proportion of respondents only as seen in the tables. Participants may not have answered questions pertaining to areas which were not seen as important or relevant in their practice but as the reasons are not given, it is difficult to draw conclusions for individual items with a low response rate. The methods used to recruit participants and administer the survey are likely to have resulted in a volunteer effect. The results are likely to reflect the views of “clinical champions” who would support implementation of strategies for improving pain assessment and management, but it would also be informative to collect data on the opinions of less proactive physicians. There are no data to support the high reported adherence to evidence-based practice. There is evidence that pain is undertreated across a range of settings, which would suggest that there is scope for practice improvement.
Conclusion
Australian palliative care physicians support an implementation strategy for cancer pain management guidelines. An example of a guideline and implementation strategy is a clinical pathway which can standardize pain management recommendations and be a valuable tool for health professional education in a wide variety of settings and for improving communication about pain assessment and management. Increased awareness of the gaps in availability of evidence-based strategies may also influence policy makers.
Acknowledgments
We would like to acknowledge staff and postgraduate students at the Faculty of Health at UTS for comments on draft versions of the survey reported in this article. We would also like to acknowledge Alex Brando from the Peter MacCallum Cancer Centre for sharing information about the Clinical Indicators for Pain Project funded by the Victorian Department of Health. Finally, we would like to thank the peak bodies and clinical experts referred to in the Methods section for assisting with recruitment to the survey.
Author Disclosure Statement
Melanie Lovell has received a peer-reviewed Cancer Research Grant from Pfizer.
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