System strengthening to support value-based care and healthy ageing for people with chronic pain

1. Chronic pain: an increasing and urgent global burden

Chronic pain imposes the greatest loss of productivity of any health condition, creating a major threat to human capital, to achievement of targets for the sustainable development goals (https://www.un.org/sustainabledevelopment/sustainable-development-goals/), and to healthy ageing.^6,28 Chronic pain disproportionally affects the most vulnerable in low- and middle-income countries (LMICs),^23,25 creating a vicious cycle of poverty from the significant physical, social, psychological, occupational, and financial sequelae of pain. Critically, the burden of pain, particularly musculoskeletal pain, continues to rise globally.^7,23 The pooled prevalence estimate for chronic pain of any origin in adults in the United Kingdom is 43.5%, and about one in 10 live with chronic widespread pain.¹³ Prevalence estimates are associated with older age (eg, up to 62% among individuals >75 years), highlighting important implications for population ageing globally.^6,32 These estimates and trends mirror those from LMICs.²²

2. Addressing chronic pain in health systems

The global relevance of pain and the scale of its burden justify urgent global leadership in driving quality pain care that includes preventive public health and optimizing service delivery for people living with pain. The World Health Organization, IASP, and other political, government, and civil society organizations have the opportunity to drive global system-strengthening initiatives. These system-level initiatives incorporate the fundamental building blocks of health and social care systems: policy and regulation, financing models, workforce planning, information systems, and mechanisms for optimal service delivery. At a population level, these critical building blocks facilitate accessibility, safety, effectiveness, and sustainability of pain care. Such strategies are typically created and operationalized by system-level managers (eg, policy makers) and administrators within health services. Despite the personal and societal impacts of chronic pain, few nations, particularly LMICs,¹⁶ have developed appropriate system-level strategies to address the impact, and to support delivery, of appropriate pain care. This landscape highlights the need for system-level strengthening initiatives that explicitly consider pain,^6,25 and particularly in LMICs.^18,25 Initiatives such as the World Health Organization Rehabilitation 2030 (http://www.who.int/disabilities/care/rehab-2030/en/) and Integrated Care for Older People (https://www.who.int/ageing/health-systems/icope/en/) offer promising levers to integrate pain care into contemporary global system-strengthening approaches.⁴

3. Value-based care for chronic musculoskeletal pain in health systems

Despite the increasing burden of chronic musculoskeletal pain,²³ access to safe and effective care (high-value care) globally remains highly variable. Elshaug et al.¹² define high-value care as “care for which evidence suggests it confers benefit to patients, or probability of benefit exceeds probable harm.” Conversely, low-value care is defined as “care for which evidence suggests it confers no or very little benefit to patients, or risk of harm exceeds probable benefit.”

Although clinical guidelines and Models of Care (system-level frameworks that guide service delivery for specific conditions⁵) recommend high-value options as preventive public health strategies and first-line treatments (eg, exercise and weight loss for osteoarthritis pain), many health systems fail to achieve this: delivering too much low-value pain care and too little high-value pain care. Public health initiatives and care pathways for people with established conditions must be supported by policy and financing models that emphasise first-line, effective interventions, while also respecting patient preferences, cultural and ethnic sensitivities, and capacity for tailoring care. For example, the feasibility of implementing high-value pain care is being assessed in LMICs, such as in Nepal.²⁹

Ironically, citizens of high-income economies can access low-value care options, whereas those in LMICs have limited or no access to appropriate pain care, eg analgesia for pain relief.^25,33 The use of opioids for managing noncancer musculoskeletal pain is widespread and yet, with few exceptions, is discordant with evidence in most situations and has great potential for harm.²⁶ Other low-value care examples commonly delivered for musculoskeletal pain include: routine spinal imaging in the absence of specific indicators and spinal fusion surgery for nonspecific low back pain¹⁵; arthroscopic surgery as primary treatment for knee joint osteoarthritis³⁰; vertebroplasty for osteoporotic vertebral fracture⁹; and overuse of passive therapies, including analgesic medicines and conservative therapies (eg, manual and electrotherapies), in the absence of appropriate active self-management.³ Funding low-value care options can increase risk of harm, restrict opportunities for improvements in health outcomes that may otherwise be achievable with higher-value care options, and limit funding of, and access to, higher-value care options.⁸ High-value care examples for musculoskeletal pain include contemporary education about pain, addressing unhelpful beliefs, providing reassurance, reducing distress, promoting graded functional activities, supporting return to work, and where appropriate, behavioural therapies and nutritional care.² Surgery, medicines, and other interventions may represent high-value care in appropriately selected patients, (eg, total joint replacement surgery, disease-modifying medicines for inflammatory arthritides, opioids for postsurgical pain, and emergency surgery for cauda equina compression). Systems should support timely delivery of these interventions where and when appropriate.

4. Drivers of low-value pain care

Drivers of low-value pain care are complex and interdependent. First, the traditional biomedical model of pain focuses on a target tissue “to be fixed.” This model is discordant with the contemporary biopsychosocial model of pain. The biomedical model fails to capture the multidimensional contributors to each individual’s experience of pain. Clinicians’ belief in this model and system- and service-level support for a biomedical model may drive behaviours that favour low-value therapeutic pathways that may be more heavily marketed, easier to access, and simpler to understand, but less likely to provide long-term benefit for most.

Second, many low-value diagnostic and therapeutic approaches are delivered in a short time frame, at high cost. Depending on the financing models of different health care settings, these approaches can present attractive options that are profitable for clinicians and health facilities (by generating high throughput and high revenue), creating opportunities for subconscious or conscious bias towards low-value care. Although high-value interventions are often less expensive per unit than many low-value approaches, they are often more difficult to access because current funding models limit opportunities to deliver high-value care options at scale. Access may also be constrained by limited clinician training in high-value care approaches, such as psychologically informed care.³¹

Third, commercial entities have exerted undue influence over clinical behaviours and consumer preferences, as well as over regulatory policies. The opioid epidemic in the United States and other nations highlights the ways in which the pharmaceutical industry has partially shaped the discourse on pain management. Pharmaceutical companies were reported to have spent $USD 880 million on political contributions and lobbying efforts from 2006 to 2015, and opioid medicine claims have been associated with benefits received by physicians from industry.^17,20 A confluence of factors, in high-income settings and LMICs,²⁰ has created a perfect low-value care climate: direct marketing to patients in a consumerist society; physician benefits in a landscape of comparatively loose regulations for prescribing; active influence of medical societies to promote widespread use of prescription opioids; and aggressive lobbying to maintain comparatively less stringent regulation in terms of price setting and marketing restrictions.²⁰

5. System strengthening to promote high-value pain care

Governments and health services need to invest in high-value care while concurrently disinvesting in low-value or no-value care, inclusive of preventive public health initiatives. Such a reorientation is likely to produce a major return on investment for national economic development necessary to meet sustainable development goal targets,²⁴ to overcome commercial and economic drivers to low-value pain care,¹² and to support access to affordable and effective pain care. Multiple strategies are required to achieve such reorientation.^7,10,25,27 First, at a system level, development of appropriate policy and regulation are needed to prioritise high-value pain care (eg, National Pain Strategies, such as those developed in Australia¹ and the United States²¹ and pain Models of Care⁵). Regulation must include financing arrangements to defund ineffective and potentially harmful diagnostics and interventions and incentivise high-value, integrated care. The amendment of physician payment schedules instituted in Ontario, Canada, in 2012 to reflect evidence-informed care for low back pain is one such system-level example (http://www.health.gov.on.ca/en/pro/programs/ecfa/action/primary/lower_back.aspx). Although condition-specific strategies may be more feasible in high-income settings, integration of pain care reforms into existing health system infrastructure will be particularly important for LMICs. Supporting integration between health and social care services will be essential to address pain in the context of healthy ageing and chronic condition management.⁴ Policy and financing reform are also essential to develop and implement downstream surveillance systems (eg, pain registries and population pain prevalence monitoring, particularly in LMICs¹⁹), pain care standards, and pathways linked to reimbursement at a service level for public and private health services and insurance schemes. Linking service delivery performance with funding and measuring outcomes will help better inform consumers’ knowledge, drive improved clinical practice behaviours, and reduce variability in delivery of high-value care. A range of models exists for regulation of and/or cooperation with private industry to achieve health gains.¹¹ Engagement with the private sector through appropriately administered and regulated partnerships is essential to develop and implement appropriate policy and regulation for pain care and public health generally.

Second, building capacity in health practitioners’ and emerging practitioners’ knowledge and interprofessional skills of a contemporary understanding of pain science is vital (http://www.iasp-pain.org/GlobalYear). This includes highlighting the need for integration of pain care within and across training curricula, supporting interdisciplinary care consistent with core competencies,¹⁴ and achieving balance between commercial and noncommercial providers of professional development.

Third, building and evaluating pain literacy and awareness of value-based care among consumers and civil society will help to ensure that people can actively and effectively participate in their care decisions, health reform debates, and processes to inform pain care.