A suite of implementation strategies did not provide sufficient improvement in pain-related outcomes for patients with cancer in the outpatient setting compared with usual care. A team of researchers suggest oncology ambulatory centers may be lacking adequate resources for routine pain screening, patient and staff education, and quality improvement. These findings were published in JAMA Network Open.

The researchers conducted a stepped wedge, cluster-randomized, non-blinded clinical trial at 6 cancer centers in Australia to gauge the effectiveness of 3 cancer pain guideline implementation strategies. They enrolled 544 adult outpatients with advanced cancer who reported a worst pain severity of 2 or more on a numeric rating scale (NRS) of 0 to 10.

The primary outcome was the percentage of patients with moderate to severe pain who reported a clinically important improvement of 30% or more 1 week after their initial screening. Secondary outcomes such as fidelity to the intervention, mean average pain, patient empowerment, and quality of life, were measured at weeks 1, 2, and 4.


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As part of the intervention, a clinical champion provided an overview of the pain guidelines and implementation resources for center clinicians, and a system was established to make sure the clinicians saw the screening results to help with their consultations. Each center was randomly allocated to control or intervention phase in an order determined by a computer algorithm.

Patients were asked to complete an NRS for their worst pain and average pain during the past 24 hours at each visit to the cancer center. They were assigned to the control or intervention based on the status of the center when they were first screened and reported having a worst pain rated as 2 or more on the NRS.

Study results showed that guideline implementation strategies at the center, healthcare professional, and patient levels did not achieve a 30% or greater improvement in patients’ pain compared with usual care.

“For the primary outcome, namely a reduction in the pain score by 30% among those with a score of 5 or more on the NRS on worst pain at week 1, there was no significant difference between the control group and the prevention group,” the researchers reported. Fidelity to the intervention also was lower than anticipated.

A lack of dedicated resources at the cancer centers could be partially responsible for the limited intervention uptake. Adequate resources, including sufficient nurse staffing in ambulatory care, could improve outcomes, as the nurses could perform rapid assessments of patients and provide the optimal patient education.

Limitations for this study included an inability to blind the research team and center staff, which may have introduced some bias into the patient selection and outcome data collection. Poor participation also affected secondary outcomes at the week 1 mark, as many of the participants didn’t receive the necessary documents by mail in time.  

Disclosures: One author declared affiliation with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

Lovell MR, Phillips JL, Luckett T, et al. Effect of cancer pain guideline implementation on pain outcomes among adult outpatients with cancer-related pain: a stepped wedge cluster randomized trial. JAMA Netw Open. 2022;5(2):e220060. doi:10.1001/jamanetworkopen.2022.0060