Wheeler Daniel W, Kinna Sara, Bell Andrew, Featherstone Peter J, Sapsford David J, Bass Sam P
University Division of Anaesthesia, University of Cambridge, Box 93, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom; Department of Anaesthetics, Box 93, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom; Department of Anaesthetics, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, United Kingdom.
Department of Anaesthetics, Box 93, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom.
Scand J Pain. 2017 Oct;17:345-349. doi: 10.1016/j.sjpain.2017.09.006. Epub 2017 Oct 6.
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.
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.
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.
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.
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 improve patients' 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 to treat.
因复杂慢性疼痛急性加重而住院是一个在很大程度上被忽视的问题，因为患者常因各种专科疾病入院，且通常没有专门的住院慢性疼痛服务来管理他们。我们机构设立了一个由疼痛科医生监督、专科护士配备的住院急性疼痛服务，旨在专注于围手术期疼痛管理。我们很快注意到，因慢性疼痛入院的非手术住院患者由护士转护士的转诊数量不断增加。其中一些患者似乎存在难以治疗且高度复杂的疼痛问题，因此我们启动了每周两次由主治医生主导的住院疼痛查房，以协调他们的管理。从这些转诊患者中，我们确定了一组20名因慢性疼痛加重而频繁长期住院的患者。我们试图确定由医生主导的住院疼痛病房查房的引入是否减少了住院次数、住院时长及治疗费用。
我们进行了一项回顾性、观察性、干预队列研究。我们记录了这20名患者在引入住院疼痛服务前一年和后一年的急性急诊科就诊情况、住院情况以及住院时长和费用。
患者的平均年龄为38.2岁（标准差±13.8岁，范围18 - 68岁）；13名是女性（65.0%）。干预前急诊科就诊次数的众数为4次（范围2 - 15次），干预后为3次（范围0 - 9次）（p = 0.116）。干预前床位占用天数的众数为32天（范围九 - 170天），干预后为19天（范围0 - 115天）（p = 0.215）。在为期2年的研究期间，治疗该队列患者的总费用为733,010英镑（112万美元），包括床位费用429,479英镑（656,291美元）和检查费用303,531英镑（463,828美元）。该干预在总费用、床位费用或检查费用方面未取得显著改善。
尽管有我们主治医生主导的干预措施，但该队列患者的住院频率、住院时长以及极高的费用并未显著降低，这表明需要确定其他策略来帮助这些病情复杂且脆弱的患者。
因慢性疼痛急性加重而频繁住院是一个在很大程度上被忽视的问题，对患者、其护理人员和医疗服务提供者都有重大影响。慢性疼痛服务往往侧重于门诊管理。采用多学科慢性疼痛管理技术打破频繁反复住院的循环，有可能改善患者的生活质量并降低医院成本。尽管如此，这些患者慢性疼痛问题的复杂性不应被低估，在某些情况下治疗极具挑战性。
