Improve pain management through managed care
Putting teeth’ into institutional QA
A $2 million initiative by the Fallon Healthcare System and HMO in Worcester, MA, will test strategies aimed at persuading physicians and other health professionals in the HMO’s primary care clinics to adopt the cancer pain guideline issued in 1994 by the federal Agency for Health Care Policy and Research (AHCPR). That massively researched pain guideline is a landmark in the history of cancer pain advocacy, lending federal legitimacy to the same philosophy of pain control practiced by hospices.
"But promulgation of a guideline, in and of itself, almost never makes a difference" in clinicians’ habitual behavior especially with a problem as entrenched and multifaceted as inadequate pain management, observes Mildred Z. Solomon, EdD, director of the Center for Applied Ethics and Professional Practice at the Education Development Center in Newton, MA. Solomon is coordinating the Fallon program, which was funded by AHCPR and the National Cancer Institute to shed light on the barriers to implementing guidelines and more effective strategies for overcoming those barriers.
The Fallon project will use a randomized controlled trial. Staff at four Fallon primary care clinics will receive copies of the cancer pain guideline, while four other clinics will receive an intensive, two-tiered intervention.
One component focuses on individual behaviors, including face-to-face dissemination of information and mentoring by consultant pain experts from Massachusetts General Hospital in Boston, Solomon says. The other component focuses on organizational issues, using protocols to make pain more visible and its assessment and follow-up routine and habitual.
In addition to the pain and regulatory barriers project already described, the Robert Wood Johnson Foundation was expected in August to announce a three-year, $1.6 million initiative for pain experts at the University of Wisconsin, Madison, to work with the Joint Commission on Accreditation of Healthcare Organizations and Medicare peer review organizations on developing standards to make pain assessment and treatment part of the accreditation process.
Institutional barriers the most formidable
"Many of us have concluded that while we may be able to do a lot to educate doctors and patients, in reality the systemic barriers may the most formidable," explains June Dahl, PhD, professor of pharmacology at University of Wisconsin-Madison, and director of the Resource Center for State Cancer Pain Initiatives.
"Pain [management] is not a priority, there are no institutional rewards for doing it well, and other forces in the institution conspire against it. All of us are challenged by the question: How do we change clinical practice?" Dahl says.
Accreditation and other quality improvement processes "with teeth" can be very powerful ways to bring about changes in clinical practice. "It is now too easy for professionals to ignore pain and to buy into the perspective that pain isn’t significant. The science of pain control continues to improve, while a variety of outmoded clinical practices prevent application of what we know," she explains.
"We also want to work with the National Committee for Quality Assurance [NCQA]," the Washington, DC-based organization formed to accredit HMOs. Currently there is little related to quality of care, especially about pain management, in the standards, although NCQA’s HEDIS (Health Employer Data Information Set) 3.0 is beginning to address other quality of care issues, Dahl says.
Barry Scholl, NCQA public relations spokesman, confirms Dahl’s statement, but adds, "NCQA sees HEDIS as an ever-evolving measurement system. In the last few weeks, we’ve also started launching new measurement advisory panels [MAPs]," which will identify areas needing quality measures, and then test and develop them.
"I think NCQA would be the first to acknowledge that there are numerous areas in need of desperate attention and measures to address them," Scholl says. "I can’t say with any certainty how pain [management] will move forward. Perhaps it will be looked at by the new geriatric MAP." Other MAPS will address general areas of pediatrics, behavioral health/chemical dependency, cardiovascular, asthma, and women’s health.
[There are a number of valuable resources that hospices can use to aid them in advocating for better pain management, both in their agencies and in their communities.
The Mayday Pain Resource Center at the City of Hope National Medical Center has a comprehensive set of pain tools and resources available over the Internet. Contact the Center at 1500 E. Duarte Rd., Duarte, CA 91010. Telephone: (818) 359-8111, Ext. 3829. Fax: (818) 301-8941. E-mail: mayday_ [email protected].
Contact the Resource Center for State Cancer Pain Initiatives at 1300 University Ave., #4720, Madison, WI 53706. Telephone: (608) 265-4013. Fax: (608) 265-4014. E-mail: www.wisc.edu.wcpi.
The Mayday PainLink at Education Development Center in Newton, MA, also has Internet resources available at: www.edc.org/CAI/PainLink.]
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