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The American Journal of Managed Care November 2018
A Randomized, Pragmatic, Pharmacist-Led Intervention Reduced Opioids Following Orthopedic Surgery
David H. Smith, PhD, RPh; Jennifer L. Kuntz, PhD; Lynn L. DeBar, PhD, MPH; Jill Mesa; Xiuhai Yang, MS; Jennifer Schneider, MPH; Amanda Petrik, MS; Katherine Reese, PharmD; Lou Ann Thorsness, RPh; David Boardman, MD; and Eric S. Johnson, PhD
Understanding and Improving Value Frameworks With Real-World Patient Outcomes
Anupam B. Jena, MD, PhD; Jacquelyn W. Chou, MPP, MPL; Lara Yoon, MPH; Wade M. Aubry, MD; Jan Berger, MD, MJ; Wayne Burton, MD; A. Mark Fendrick, MD; Donna M. Fick, RN, PhD; David Franklin, BA; Rebecca Killion, MA; Darius N. Lakdawalla, PhD; Peter J. Neumann, ScD; Kavita Patel, MD, MSHS; John Yee, MD, MPH; Brian Sakurada, PharmD; and Kristina Yu-Isenberg, PhD, MPH, RPh
From the Editorial Board: Glen D. Stettin, MD
Glen D. Stettin, MD
A Narrow View of Choosing Wisely
Daniel B. Wolfson, MHSA, Executive Vice President and COO, ABIM Foundation
Cost of Pharmacotherapy for Opioid Use Disorders Following Inpatient Detoxification
Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
Overdose Risk for Veterans Receiving Opioids From Multiple Sources
Guneet K. Jasuja, PhD; Omid Ameli, MD, MPH; Donald R. Miller, ScD; Thomas Land, PhD; Dana Bernson, MPH; Adam J. Rose, MD, MSc; Dan R. Berlowitz, MD, MPH; and David A. Smelson, PsyD
Effects of a Community-Based Care Management Model for Super-Utilizers
Purvi Sevak, PhD; Cara N. Stepanczuk, MPP; Katharine W.V. Bradley, PhD; Tim Day, MSPH; Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Keith Kranker, PhD; Kate Stewart, PhD; and Lorenzo Moreno, PhD
Predicting 30-Day Emergency Department Revisits
Kelly Gao; Gene Pellerin, MD; and Laurence Kaminsky, PhD
Patients' Adoption of and Feature Access Within Electronic Patient Portals
Jennifer Elston Lafata, PhD; Carrie A. Miller, PhD, MPH; Deirdre A. Shires, PhD; Karen Dyer, PhD; Scott M. Ratliff, MS; and Michelle Schreiber, MD
Impact of Dementia on Costs of Modifiable Comorbid Conditions
Patricia R. Salber, MD, MBA; Christobel E. Selecky, MA; Dirk Soenksen, MS, MBA; and Thomas Wilson, PhD, DrPH
Currently Reading
Hospital Cancer Pain Management by Electronic Health Record–Based Automatic Screening
Jinyoung Shin, MD, PhD; Hyeonyoung Ko, MD, MPH; Jeong Ah Kim, BS; Yun-Mi Song, MD, PhD; Jin Seok Ahn, MD, PhD; Seok Jin Nam, MD, PhD; and Jungkwon Lee, MD, PhD

Hospital Cancer Pain Management by Electronic Health Record–Based Automatic Screening

Jinyoung Shin, MD, PhD; Hyeonyoung Ko, MD, MPH; Jeong Ah Kim, BS; Yun-Mi Song, MD, PhD; Jin Seok Ahn, MD, PhD; Seok Jin Nam, MD, PhD; and Jungkwon Lee, MD, PhD
A cancer pain control program for inpatients based on electronic health record–based automatic screening provided effective pain relief and achieved high satisfaction among patients and physicians.

Objectives: A cancer pain clinic (CPC) service is a thorough, comprehensive consultation service for patients with uncontrolled cancer pain. The aim of this study was to determine the success of a new CPC service with enrollment via electronic health record–based automatic screening at 1 cancer center in Korea.

Study Design: A case-control study and a satisfaction survey.

Methods: The intervention group (n = 158) was enrolled in the CPC service, whereas the control group (n = 158), which was matched using propensity scores, did not participate in the service. The pain scores of participants were compared using an independent t test. Thirty-nine patients and 20 physicians completed a self-administered survey on instructions for pain-relief medications, effective usage of long-acting and short-acting opioids, perceptions of or barriers to CPC services, knowledge of opioid use, and overall satisfaction.

Results: Although the baseline pain score of the intervention group was significantly higher than that of the control group (P = .013), the difference in the decrease of pain between the groups was significant at days 1 (P = .001) and 2 (P = .039). Although the difference in pain scores disappeared on day 3, total pain score was significantly lower in the intervention group than in the control group (P = .012). When comparing pain relief events (<4 points on a 0-10 numeric rating scale that measured pain daily), the intervention group experienced more relief events than did controls (P = .017). Patients were satisfied with their physicians giving clear instructions and considering their opinions about pain-relief medications. The oncology residents expressed satisfaction with the management of patients with opioid-naïve or intractable pain.

Conclusions: The new CPC service seems to provide effective pain relief and users seem to be highly satisfied with it. These results support the importance of an integrated and specialized approach to cancer-related pain management.

Am J Manag Care. 2018;24(11):e338-e343
Takeaway Points
  • A new cancer pain control program based on electronic health record–based automatic screening can efficiently select patients with uncontrolled pain and serve as a specialized and comprehensive consultation.
  • We confirmed the quality of cancer pain clinic services via reduced pain scores in the early phase of treatment and reports of satisfaction among patients and physicians.
The all-cancer incidence rate in Korea started to decrease after 2012 (2012-2014, –6.6%), and overall cancer mortality has decreased 2.7% annually since 2002.1 Nonetheless, pain remains among the most prevalent and distressing problems in patients with cancer. Optimal pain management contributes to improved survival and better quality of life.2,3 Therefore, pain management is a vital part of routine cancer care and has been advocated for by a multitude of professional organizations and institutions.4 Nevertheless, the undertreatment rate of cancer pain has been estimated at 43% globally5 and at up to 74% for Korean patients with cancer.6 Various factors contribute to pain undertreatment, including those related to patients, physicians, family, institutions, and society.7,8

A cancer pain clinic (CPC) was first implemented in 2014 to improve the quality of cancer pain management in 1 cancer center in Korea. The mission of the CPC is comprehensive control of cancer pain during a patient’s entire treatment period. For inpatients, an automatic screening system selects patients with uncontrolled cancer- or treatment-related pain. The CPC consists of 3 steps, designed according to the National Comprehensive Cancer Network guideline: assessment, management, and reassessment.3 This includes time-based assessment, pain-relief medication modifications, emotional support, patient education, assessment of drug adherence, and identification of adverse events during an initial face-to-face interview and follow-up visits (Table 1). Moreover, the CPC provides physician education concerning opioid prescriptions. All steps are recorded in the electronic health record (EHR) and shared with the attending oncologist. Considering the effects of cancer on patients and their families, the CPC also features the comprehensive care of patients and families. The CPC team consists of 3 family physicians with more than 3 years of experience treating patients with cancer and 1 oncology nurse practitioner.

Although this CPC service has been operating for 2 years, its effectiveness in managing cancer pain has not been formally examined. The aim of this study is to determine the success of the new CPC service at 1 cancer center in Korea.


This research involved a case-control study and a satisfaction survey of physicians and patients using a self-administered questionnaire. This study was approved by the institutional review board of Samsung Medical Center. The board waived the need for informed consent for the retrospective analysis of existing administrative and clinical data that do not include any identifiable personal information. All prospectively recruited subjects provided written informed consent.

Case-Control Study

Retrospective chart review of inpatients was conducted between October 2015 and June 2016. Pain assessment was based on an 11-point numeric rating scale (NRS) with 0 indicating no pain and 10 indicating the worst pain imaginable. The data were from EHR notes written by nurse practitioners 3 times each day. Patients whose pain was undertreated were defined by their meeting 1 or more of the following criteria: (1) moderate to severe pain (NRS score of 4-10) during the previous 24 hours despite pain medication, (2) severe pain (NRS score of 7-10) during the previous 24 hours, and (3) additional rescue medicine administered more than 3 times a day. When a patient met 1 or more of these criteria, the resident physician received an automatic notice requiring CPC consultation on their EHR screen. If the resident physician agreed to consult the CPC, the patient’s information was automatically transmitted to the CPC team. If a patient received multiple consultations, we counted only 1 event.

Sample size was estimated based on the results of a pilot study, in which the intervention group took less than 0.32 days (less than 8 hours) to achieve diminished pain intensity to a score of less than 4 on the NRS using an independent t test with a type I error of .05 and a type II error of .20. The necessary sample size was estimated at 158 people per group. We selected 1 patient and 1 control using a propensity score for age (<40, 40-49, 50-59, 60-69, and >70 years), cancer site, and purpose of hospitalization, such as operation or medical treatment. The intervention group (n = 158) was defined as patients who followed the guidance of the pain management consultation. Controls (n = 158) were selected from patients with cancer who were hospitalized for the same purpose during the same period; they had not followed the guidance of CPC consultation, although pain intervention was indicated in this screening. The final analysis included 316 patients (18.4% of total screened patients). All patients were 18 years or older and had been admitted for cancer-related treatment, such as surgery, chemotherapy, radiotherapy, or supportive care.

NRS-ranked pain scores were collected by the EHR from the day of consultation (day 0) and the 4 following days (days 1, 2, 3, and 4). Pain assessment was performed 3 times a day. Therefore, each value or mean daily pain score was used in this analysis. Information on age, sex, diagnosis, treatment, purpose of hospitalization, and pain intensity was obtained via EHR review by the nurse practitioner.

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