Acute pain is a common and anticipated consequence of surgical interventions. It is usually directly associated with tissue damage, is expected to fade with tissue healing, and resolves within days to weeks. Despite being generally self-limited, however, acute pain can profoundly impact the perioperative period and alter patient well-being. In recent decades, numerous insights have been made into the significance of acute pain and its management. During this same period, the economics of healthcare have assumed increasing importance as an ever-growing proportion of US gross domestic product (GDP) is spent on healthcare (essentially doubling since 1980 to approximately 17.8% in 2015).1 The topic of healthcare economics is particularly prominent in the United States, which already spends about 50% more on healthcare than comparable developed countries and is projected to spend 20% of GDP on healthcare by the year 2025.1
Surprisingly, despite compelling interest and importance, our insights into healthcare economics of acute pain medicine remain relatively primitive. Publications specifically concerning the economics of acute pain medicine are particularly scarce. In a comprehensive review of acute pain management, the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine collected the available scientific evidence through August 2014.2 Although the entire analysis by Schug and colleagues yielded more than 750 evidence-based “key messages,” there were only 4 regarding economic considerations (Box 2.1). It is noteworthy that each of these was based on “new” evidence that had become available since publication of these researchers’ previous edition in 2010.
This chapter will attempt to expand on and update previously published summaries and will consider the economics of acute pain medicine primarily in terms of costs and benefits. Rather than concentrate on any specific measures of economic assessment and analysis, the chapter will focus on general concepts that apply to virtually all clinical settings. Details regarding healthcare finances will only be considered indirectly, as they are tremendously situational, rapidly changing, and simply beyond the scope of this discussion.
2. The Modern Focus on Acute Pain
As alluded to in the introduction, the past several decades have witnessed significant improvements in the prevention and treatment of acute postoperative pain. Developments such as patient-controlled analgesia, continuous epidural analgesia, and minimally invasive surgical techniques have led to dramatic breakthroughs in patient care. Through such successes, it has become the standard of care that severe acute postoperative pain can and should be effectively managed.
Around the recent turn of the century, a number of initiatives were introduced that were intended to help close the gap between potential and actual patient care regarding acute pain. Some notable efforts include the following:
1999—Adopting the concept from the American Pain Society, the Veterans Health Administration called for pain to be treated as the “fifth vital sign” and required the use of the Numeric Rating Scale for all clinical encounters.3 This resulted in an organized effort to detect and quantify pain, and included a mandate to treat specific levels of pain (e.g., pain scores of 4 or greater out of 10).
2000—The US Congress designated the 10 years beginning January 1, 2001, as the “Decade of Pain Control and Research.” Although this push was primarily directed toward inadequacies in chronic, irreversible, and palliative pain management, it signaled a new level of federal engagement in pain medicine.4
2001—The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now known simply as the Joint Commission) introduced new pain management standards that required facilities to better assess and treat pain. Notably, an article in the Journal of the American Medical Association that introduced these new standards described poor pain control as “unethical, clinically unsound, and economically wasteful” (italics added).5
2002—Building on the increased focus on pain management, work began on the development of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This survey includes several pointed questions that assess a patient’s experience with pain management. The HCAHPS survey has since become an important metric in patient care and is variously tied to reimbursement.
Along with many others, these milestones were instrumental in substantially raising the profile of acute (and chronic) pain management. Today, the treatment of pain has widely come to be considered a fundamental human right.6 Currently, it can be said that there is a strong mandate for the optimal management of pain.
Despite heightened awareness and clinical advancements, however, contemporary patient surveys suggest that acute pain continues to be inadequately controlled. A recent survey of American patients indicated that there has been little improvement in acute pain control over the past 20 years.7 In this survey of 300 random American adults who had undergone surgery within the past 5 years, 86% reported pain after surgery, with fully 75% of these experiencing moderate to extreme levels of pain (levels that were commonly still present after discharge). These disappointing findings likely indicate deficiencies in compliance with accepted approaches. This concern is supported by indirect evidence indicating that multimodal analgesia (MMA) is not being provided when indicated. Ladha and colleagues looked at the perioperative use of MMA in a large database of appropriate surgical patients and found that only 54.2% had received 2 or more nonopioid analgesics.8 The adoption of “value-based” payment models (e.g., bundled payments) is intended to accelerate the adoption of best practice initiatives such as MMA.
Efforts directed toward discerning the optimal management of acute pain have progressed on many fronts. The American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters (representing the medical specialists most intimately involved in acute pain management) published practice guidelines on acute pain management in the perioperative setting in 2004 and again in 2012.9 Expanding on the ASA guidelines, the American Pain Society (with input from the ASA and American Society of Regional Anesthesia and Pain Medicine) recently published even more current guidelines in 2016.10 In these and other publications, several concepts are emphasized that represent the core of modern acute pain management.
3.1. Multimodal analgesia
Perhaps the most fundamental advance in the management of acute pain in recent years has been the concept of MMA.11 In this paradigm, combinations of analgesic agents are administered to take advantage of additive and possibly synergistic effects while decreasing dose-related side effects. Options may also include physical (e.g., transcutaneous electrical nerve stimulation) and cognitive-behavioral modalities. The multitude of available agents (acetaminophen, nonsteroidal anti-inflammatory drugs, local anesthetics, ketamine, etc.) presents numerous possible combinations of analgesics. Through the use of alternative nonopioid analgesic agents, an opioid-sparing effect is a common goal of the MMA approach.
At this point, the role of opioids for pain control deserves special comment. Opioids have long been appreciated as effective analgesics, particularly for acute pain. It is not surprising, therefore, that an increased reliance on them was the initial response to recent mandates to improve pain control. This approach to acute pain management has proven to be unsatisfactory on several levels. Unfortunately, these drugs are associated with a high incidence of opioid-related adverse drug effects (ORADEs). The increased use of opioids is thereby naturally expected to increase the rate of nausea (and vomiting), increase the frequency of pruritis, and decrease bowel motility. On further analysis, such “minor” ORADEs have been shown to exert significant negative effects on acute perioperative recovery, length of stay, and overall costs of care.12 Furthermore, despite efforts at proper titration, the increased use of opioids has also been associated with increased rates of such major adverse effects as opioid-associated sedation and respiratory depression.13 Last, the recent “opioid epidemic” has raised further concerns regarding opioid prescribing for acute pain management. Recent data indicate that the transition from acute to chronic opioid use is more common in the perioperative period than formerly appreciated.14 These as well as other issues with opiates (e.g., diversion) strongly further support the concept of opioid-sparing MMA.
However, it must be appreciated that in the evolving realm of MMA there are not yet any “gold standards.”15 Nevertheless, current ASA guidelines recommend the use of multimodal pain management therapy “whenever possible.”9
3.2. Pain protocols
Unsurprisingly, the severity and nature of postoperative pain are ultimately dependent on the specific surgical procedure performed. A growing body of evidence also indicates that the effectiveness of analgesics is dependent on the nature of the surgical procedure. These observations form the basis for designing evidence-based, procedure-specific pain management protocols (which can be further refined through the inclusion of patient-specific features such as pediatrics).
The PROSPECT (PROcedure-SPECific Postoperative Pain ManagemenT) initiative is an international effort to develop procedure-specific management recommendations.16 The PROSPECT Working Group consists of an international panel of anesthesiologists and surgeons and has published evidence-based guidelines for a number of procedures (www.postoppain.org).
In a closely related development, the desire to optimize and accelerate recovery for common surgical procedures has resulted in several enhanced recovery after surgery (ERAS) protocols. Although these are not exclusively concerned with pain management, acute pain control is recognized as one of 5 key components of ERAS protocols and is considered a prerequisite for other clinical advantages of ERAS such as early mobility and minimization of hospital-acquired adverse events. Accelerated clinical care, including effective pain management, has been encouraged as a further means to address the opioid epidemic (mentioned in the “Multimodal Analgesia” section of this chapter).17
3.3. Pain management as a service
In the 1980s, the concept of the acute pain service (APS) was developed in response to both humanitarian and pragmatic concerns regarding deficiencies in pain management.18 Although there is still no consensus regarding the optimal structure or function of an APS, its primary purpose remains all-day, everyday accountability for acute pain management within an institution. Essential functions of an APS include (1) the promotion of evidence-based care of pain, (2) the development of pain management protocols and guidelines, and (3) the management of advanced analgesic techniques (e.g., continuous regional anesthesia). The ASA Task Force on Acute Pain Management specifically recommends that “anesthesiologists providing perioperative analgesia services should do so within the framework of an Acute Pain Service.”9
In 2009, a nationwide survey indicated that 74% of hospitals in the United States (and fully 96% of American university/teaching hospitals) had an organized APS.19 With anesthesiology personnel involved in 95% of these services, virtually all American anesthesiology residents will have significant exposure to the organized APS model during residency training.
Each of the 3 key concepts mentioned in this section has been considered from an economic perspective. It should be noted, however, that such studies have often been inconclusive, open to valid criticism, and can certainly be said to illustrate the difficulties inherent in studying in isolation a single element of complex systems.
From its inception, MMA has long been thought of in terms of value.20 Although evidence is limited and studies have a great deal of heterogeneity, it is widely thought that optimal MMA has the potential to decrease healthcare costs (primarily through opioid sparing and a decreased incidence of dose-related adverse drug effects).11
Economic analyses of procedure-specific pain protocols have been nearly uniformly favorable. A recent analysis of a clinical pathway for total knee arthroplasty, for example, noted several patient benefits as well as a reduction in direct costs.21 Similarly, a meta-analysis of enhanced recovery for colorectal surgery concluded that implementation of ERAS pathways optimized utilization of healthcare resources.22 These and other studies robustly support the ERAS concept of accelerating the return of baseline function.23
Studies of the economic impact of the APS have been mixed.24 Systematic reviews of studies published through the first decade of the 2000s are acknowledged as being hampered by poor-quality evidence.25,26 However, a more recent analysis of studies published between 2005 and 2012 concluded that using an APS resulted in 17.4% cost savings (primarily through shorter hospital stays and lower readmission rates).27
4. Fundamentals of Healthcare Economics: The Value Equation
Price is what you pay, value is what you get.
Warren Buffett, American investor
The fee-for-service payment model so commonly encountered in healthcare clearly rewards volume of care, often with little regard for outcomes, complications, or expenditures. In recent years, there have been concerted efforts to promote alternative incentives in healthcare. The result has been termed the value agenda or the transition from volume to value.28 “Value-based” models intend to promote efficient, high-quality care at a lower cost. Ideally, metrics can be developed that will also allow for individualized patient-centered care.
While the concept of value is ultimately in the eye of the beholder (i.e., the consumer—which can include patients, physicians, healthcare systems, payers, and even society as a whole), it is often expressed mathematically as simply:
Value = Benefits/Costs
This definition of value warrants a few comments. First, it should be noted that value is a concept that lacks specific units and is not always monetary. Second, costs can be extremely complex and must be considered from the various perspectives of healthcare stakeholders (patients, for example, often consider the value of lower pain levels [benefit] relative to adverse drug effects such as nausea [cost]).29 Third, while value is certainly increased by providing the same benefit at lower cost or increased benefit at the same cost, relative values remain extremely difficult to compare (e.g., the costs of acute pain management compared with those for cancer treatment or childhood immunizations—in other words, given the reality of limited healthcare resources, is acute pain medicine “worth it”?). Finally, the value of acute pain medicine has proven to be particularly challenging to determine since upfront costs are frequently associated with significant “downstream” benefits (many of which are reflected in an absence of adverse events).
The assessment of value in healthcare can be expressed in many ways (Box 2.2). Although consensus has been reached on definitions, economic terms are frequently used inexactly in the literature. A detailed consideration of these terms can be found in other sources.30 Practitioners should be aware that no single economic assessment measure is considered superior to another.
5. Benefits and Costs of Acute Pain Management
5.1. Benefits of acute pain management
Effective treatment of acute pain has been shown to result in numerous benefits. These can be broadly categorized as follows.
5.1.1. Improved patient experience of care
Improving the individual patient experience of care constitutes one-third of the “triple aim” of modern healthcare, with the other aims being reduction in the costs of care and improved public health.31 Acute postoperative pain has long been known to be a major concern for surgical patients. Although surveys have repeatedly demonstrated substantial patient “willingness to pay” for antiemetic interventions, a comparative survey has shown the prevention of postoperative pain to be valued by patients twice as highly as the prevention of postoperative nausea and vomiting.32
Adequate pain control is clearly associated with patient satisfaction.33 Analysis of HCAHPS surveys demonstrates a high correlation between global satisfaction with care and “always” receiving good pain control (r > .84)34
5.1.2. Systematic efficiency
Despite efforts at cost control, medicine remains an extremely labor- and resource-intensive industry. Any factors that adversely impact the smooth and efficient delivery of surgical care can be anticipated to have a negative economic effect.
A major impact of acute postoperative pain control is in the facilitation of throughput within a facility. Effective pain control, particularly through the use of regional anesthesia, has been shown to facilitate postanesthesia care unit (PACU) bypass, decrease the duration of PACU stay, and promote timely discharge. This may benefit a facility in terms of reducing usage of staff overtime. Although the overall economic impact of these effects is often debatable, they certainly offer the potential to decrease utilization of healthcare personnel (particularly in the ambulatory surgery setting). Perhaps a more tangible example of improved throughput is the opioid-sparing pain management seen in ERAS protocols for colorectal surgery, which improve bowel motility and significantly reduce hospital length of stay.35
In the ambulatory surgery setting, effective pain control can also reduce unanticipated admissions and readmissions. Pain has been shown to be the most common cause for these major inefficiencies, which incur significant costs.36
5.1.3. Fewer acute complications
Minor complications associated with pain and its management are common in the acute postoperative setting. Opioids, effective and having low acquisition costs, are frequently utilized as first-line agents but are associated with a high incidence of economically significant minor adverse effects (e.g., nausea and vomiting) that can accumulate and have a substantial impact on postoperative recovery.37 Optimal pain management, as through MMA, can be expected to reduce the incidence of these minor complications.
Although it may seem intuitive that effective postoperative analgesia should result in a lower incidence of major postoperative complications, efforts to analyze this issue have been constrained by the available evidence (which has often been of low quality) and limitations of existing data and methods.38 The relatively low incidence of major adverse events renders most studies underpowered to detect statistically significant effects. The strongest evidence for a beneficial effect of pain management appears to be a reduction in major pulmonary complications, particularly in elderly patients.39
5.1.4. Less chronic morbidity
Reducing the incidence of the pain-related inability to participate in timely postoperative rehabilitation programs certainly has the potential to result in faster and more complete recovery with less work loss and less reduction in productivity. However, the greatest potential benefit associated with optimal acute pain management may be in difficult-to-measure longer-term benefits.
Perhaps most promising is the potential for optimal acute pain management to prevent persistent postsurgical pain (PPSP). Not surprisingly, chronic pain has been shown to be associated with tremendous economic costs.40 PPSP appears to be much more common than generally appreciated (Table 2.1), and its prevention has been referred to as the “Holy Grail of anesthesiology.”41 While association should not be confused with causation, intense acute postoperative pain has been shown to be one of the most predictive factors in the development of PPSP.42,43 There is great hope that optimal acute pain management may be the key to prevention of PPSP.
Table 2.1: Incidence of PPSP After Various Interventions
Total hip arthroplasty
Groin hernia surgery
Source: Perkins F, Kehlet H. Chronic pain as an outcome from surgery: a review of predictive factors. Anesthesiology. 2000;93:1123–1233.
Finally, one of the most intriguing topics in recent years has been the possible role of postoperative pain control in reducing the incidence of cancer recurrence.44 Although studies to date in this regard have been mixed, they have been encouraging enough to warrant further investigation.
5.2. Costs of acute pain medicine
Most analyses of healthcare costs attempt to measure the financial costs associated with medical resource utilization. Such direct costs include materials, labor, and facility expenditures. Examples of commonly tracked direct costs include the following.
5.2.1. Material costs, including drugs, supplies, and equipment
While drug costs for acute pain medicine have usually been shown to be nominal,33 recent developments such as liposomal bupivacaine have challenged this assumption (and prompted cost-benefit analyses of this and other relatively expensive agents). Competition among vendors has turned the acquisition of supplies (like block trays and infusion tubing) into prime opportunities for cost savings. Progress in acute pain medicine has been accompanied by requirements for more advanced equipment such as continuous infusion devices and ultrasound imaging systems.
5.2.2. Labor costs consist of the time and effort expended by the individuals involved in the management of pain
This includes the time required to initiate (e.g., to perform a regional block) and manage pain over time (e.g., pain rounds and telephone care). The savings in labor costs have been a major driver in the development of the familiar physician-led APS team model.
5.2.3. Facility costs range from obvious expenditures such as physical space (e.g., a block room or APS office) to provision of dictation services and electronic medical records
However, as challenging as it may be to determine direct costs, it is certainly even more difficult to measure indirect costs. Indirect costs are those related to the consequences of acute pain management and can include any number of concerns. Adverse drug effects (ADEs), for example, are a type of indirect cost that may be tied to MMA, yet Hoffer and colleagues recently found marked deficiencies in reporting of ADEs in studies of gabapentin and pregabalin for postoperative pain.45 A recent study estimated that the indirect costs from adverse effects associated with intravenous patient-controlled analgesia can be twice the direct costs of this relatively straightforward technique.46 Complications and medicolegal liability associated with peripheral nerve blocks can be considered another form of indirect cost. Uncontrolled pain may generate indirect costs on an inpatient basis (e.g., additional resources, longer hospital stay, need for posthospital institutionalized care) or outpatient basis (e.g., family member taking time off work, prolonged disability). Given the financial constraints in modern healthcare, it is prudent to consider all potential cost “centers” along with strategies to decrease the cost of care when planning to present a proposal to establish a new APS to hospital administrators.
Finally, while healthcare costs are most commonly measured in monetary terms, it is important to appreciate that there are many other types of costs (such as the emotional cost incurred by patients in the form of discomfort or anxiety related to pain or procedures). Given the multiple types of costs involved in healthcare, it is easy to appreciate why healthcare costs are extremely complex and notoriously difficult to accurately measure. Once again, this discussion is not intended be a comprehensive consideration of such costs, but rather a broad overview of the concepts involved.
Predicting the future course of acute pain medicine is extremely challenging. In the rapidly shifting landscape of modern healthcare, economics (to say nothing of economic uncertainty) are playing a growing role. As has been seen in the past, acute pain medicine is particularly susceptible to disruptive innovation such as novel analgesic approaches and minimally invasive surgical techniques.
At present, it appears most likely that acute pain medicine will continue to build on recent successes. Momentum currently exists across several directions.
6.1. Evolution of the acute pain service
Although the APS has achieved widespread adoption—especially in academic settings—it has often proven difficult to link this allocation of resources with economic benefit. This appears to be leading to a transition of APS resources into efforts with more tangible economic metrics.
One example is the merging of anesthesiology resources into accelerated recovery programs. Pain control is an essential component of enhanced recovery programs, which can often readily demonstrate economic benefits (e.g., decreased length of stay). Surveys of Danish anesthesiology departments between 2000 and 2009 indicate that there was a decline in the number of formal APSs during that interval. This was accompanied by a steady increase in anesthesiology resources directed into accelerated multimodal rehabilitation (ERAS) programs (especially for orthopedic and abdominal surgeries). Although there are several possible reasons for these observed changes, the most likely cause of this transition from APS to ERAS services appears to be a more efficient and justifiable use of limited resources.47
Another, more recent, development has been the transitional pain service (TPS). The goal of the TPS is to identify and optimally treat patients at risk for PPSP, with the ultimate objective of preventing the transition of acute to chronic pain.48 Anesthesiologists have taken the lead in the multidisciplinary TPS at Toronto General Hospital, which has already yielded preliminary data for some anticipated outcomes (including substantial cost savings).
6.2. Integration of acute pain medicine into value-based care models
Economic pressures (e.g., bundled payment models) promise to increasingly force value-based practice (i.e., better outcomes at lower cost). To remain competitive, physicians will need to identify opportunities to improve care (the near-universal adoption of the electronic medical record and healthcare informatics should facilitate this process). The continuous analysis of costs and benefits associated with value-driven outcomes can effectively direct efforts to improve care. In this paradigm, acute pain management cannot be separated from the entire process of care and will need to be closely integrated into the team-based care network.
A recent publication by Lee and colleagues nicely illustrates a value-driven program.49 In this study, 2 of the most important baseline processes were to (1) identify the greatest opportunities for cost reduction and outcome optimization, and (2) use value-driven outcomes to improve care. Only one of the 3 selected clinical improvement projects involved acute pain management (total joint replacement). In this instance, although pain management was but a single aspect of multidisciplinary care, it comprised several critical components along the entire clinical pathway (spinal anesthesia, a multimodal pain protocol, and the daily assessment of pain). Over the 1-year study period, a composite quality index for total joint replacement increased from 54% to 80% (a 50% improvement) while direct costs fell by 7%.
6.3. High-quality research
Many unanswered questions remain regarding the optimal management of acute pain. Of 32 recommendations recently published by the American Pain Society regarding the management of postoperative pain, only 4 were supported by high-quality evidence (in contrast, 11 were made on the basis of low-quality evidence).10 Appropriately, urgent calls have been made for improvements in acute pain trial designs and reporting.50 Following publication of its recommendations, the American Pain Society went on to form an interdisciplinary panel to review the available evidence. The panel found much of the evidence regarding acute pain management to be weak and identified key unanswered questions (Box 2.3).51
Areas of intense research currently include the expansion of procedure-specific protocols as well as the optimal anticipation and prevention of pain (particularly PPSP). It is widely anticipated that current research can help provide a stronger evidence base for these pressing clinical issues. Growing economic pressures will likely mean that efforts to control pain will also be accompanied by robust economic analysis, ensuring that pain can be controlled in an efficient and cost-effective manner.
Recent decades have seen vast improvements in the management of acute pain, which have been shown to result in multiple patient benefits. This progress has been accompanied by the simultaneous growth of economic forces in healthcare, which promise to play an increasingly prominent role in patient care.
Despite the ability to control acute perioperative pain, clinical care continues to fall short of its perceived potential. The optimal management of acute postoperative pain is a topic of intense clinical investigation and remains a major challenge for our times.
• The management of acute pain has become an important metric in the analysis of modern patient care.
• The economics of healthcare are being increasingly defined in terms of value, which will demand better outcomes at lower cost.
• The optimal management of acute pain will involve the further development and the adoption of evidence-based patient- and procedure-specific protocols.
• Acute pain management is inseparable from other aspects of perioperative medicine and seems likely to be increasingly integrated into the entire process of care.
• The economic analysis of acute pain medicine has only begun and warrants further study.
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