Chronic pain is a serious problem in Spain. This multicenter, epidemiological 3-month follow-up study investigates pain management efficacy in Spanish centers using patient satisfaction criteria. 3,414 eligible adult patients (65,6% female) with moderate to severe chronic pain from 146 pain centers were included. Patient satisfaction was assessed based onto question 18 of Spanish healthcare barometer-CSI. Pain evolution (Brief Pain Inventory-Short Form (BPI-SF) and visual analog scale (VAS)), quality of life/EuroQol-5, and pain control expectations fulfillment were also assessed. Mean age was 61.3 years. 64.4% of participating centers employed multidisciplinary pain management approach. After 3 months, mean patient satisfaction was 7.8 (1–10) on the CIS barometer. Medical staff received the highest scores, whereas waiting for tests, appointment request to appointment date time, and waiting times at the center the lowest. Mean pain decreased from 7.4 to 4.0; BPI-SF intensity decreased from 6.5 to 3.8; pain control expectations were met in 78.7% of patients; EuroQoL-5D utility index increased from 0.37 to 0.62,
Chronic pain is a serious public health problem in Spain. It has a prevalence of 23.4% in the Spanish general population and important health and economic repercussions [
Controlling pain becomes increasingly difficult as pain becomes chronic [
Inappropriate pain management is associated not only with increased patient suffering but also with great financial costs, in terms of loss of work time, reduced levels of productivity, and ability to function in society [
However, studies on the efficacy of pain centers or pain units in Spain are scarce.
Information regarding the effectiveness of pain management is based more on experience from routine clinical practices rather than on studies measuring the efficacy of a single drug treatment or therapeutic intervention [
The high prevalence of chronic pain with its associated allocation of resources and corresponding economic impact justifies the need to assess the effectiveness of patient management in the Spanish pain centers. Measurement of patient satisfaction was the selected method to evaluate the centers in terms of effectiveness and to identify existing gaps in management that could be further analyzed and improved.
A 3-month follow-up prospective, longitudinal, multicenter, descriptive, and epidemiological study was conducted among the participating Spanish pain centers. Pain observational studies in general have short follow-up times. A 3-month follow-up time was considered sufficient for valid conclusions. Patients’ degree of satisfaction with such centers was assessed by means of a questionnaire, based onto the question 18 of the Spanish healthcare barometer or CIS barometer, which is related to the healthcare service. As secondary objective, we assessed the evolution of pain, according to the Brief Pain Inventory-Short Form (BPI-SF) and to a visual analog scale (VAS), and the quality of life (QoL) as well, according to EuroQol-5, in patients followed up in the pain units.
The target pain, as estimated by the participating researchers, was 2.2 based on a VAS. The target pain of 2.2 is the median value calculated for each patient by the participating physicians, according to the clinical condition of the patient and the experience of the physician. In addition, the following variables were assessed: patient satisfaction with pain control by means of a VAS, patient global clinical impression of change (PGCI-C), and compliance with patients expectations regarding pain control, based on the Patients Expectations Questionnaire (PEQ) [
The study protocol was carried out in accordance with the declaration of Helsinki (Seoul, 2008). Spanish regulations were taken into account as well, including approvals by the Ethics Committee for Clinical Research of the University Hospital of Getafe (registration number E-08/018), and all other relevant Ethics Committees, as it was deemed necessary for the evaluation of the patients.
One hundred and seventy-three investigators from 146 centers throughout the Spanish national territory participated in the study. To avoid selection bias, inclusion and exclusion criteria were established. The inclusion criteria in the study were as follows: every participating researcher recruited the first 10 to 30 adult patients over the age of 18 that visited the outpatient during the agreed study period. The pain intensity was ≥4 (according to a 1–10 VAS), and the patients were visiting the pain center for the first time. Pain referrals (somatic, visceral, and neuropathic) from all clinical specialties, all social backgrounds, and working status were included (Table
Baseline sociodemographic and clinical characteristics of the patients.
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2,239 (65.6) |
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61.3 ± 14.4 |
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7.4 ± 1.5 |
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Primary care | 768 (22.5) |
Rheumatology | 284 (8.3) |
Traumatology | 1,387 (40.6) |
Internal medicine | 79 (2.3) |
Neurosurgery | 306 (9.0) |
Rehabilitation | 221 (6.5) |
Surgery | 73 (2.1) |
Other | 296 (8.7) |
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Alone | 425 (12.4) |
With family member | 2,878 (84.3) |
Nursery home | 71 (2.1) |
Other | 40 (1.2) |
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748 (22.0) |
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148 (4.3) |
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Able to work | 801 (23.5) |
Retired | 1,672 (49.0) |
Unable to work | 452 (13.2) |
Medical leave of absence | 488 (14.3) |
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Somatic | 2,681 (78.5) |
Visceral | 81 (2.4) |
Neuropathic | 1,996 (58.5) |
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Arthrosis/arthritis | 1,867 (55.6) |
Hernia/disc pathology | 1,435 (42.8) |
Neuropathy | 527 (15.7) |
Osteoporosis | 456 (13.6) |
Myofascial pain syndrome | 418 (12.5) |
Other | 126 (3.8) |
Visceral pain | 61 (1.8) |
Vascular pain | 62 (1.8) |
Failed back surgery syndrome | 47 (1.4) |
Other postsurgical pains | 37 (1.1) |
Vertebral compression fracture | 27 (0.8) |
Other posttrauma pains | 25 (0.7) |
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Better | 126 (3.7) |
Same | 788 (23.1) |
Worse | 2,499 (73.2) |
The following data were collected: medical specialties and analgesic techniques available at the pain unit; sociodemographic and clinical data of the patients, including pain origin, types of pain, and baseline pain, which was classified as moderate-intense (VAS < 7) and very intense (VAS ≥ 7). In addition, the following data were also collected at 3 months: intensity of pain and its impact on activities of everyday living (BPI-SF); current pain intensity (VAS) as assessed by the physician; quality of life (EuroQoL-5). At the 3-month follow-up visit, the following data were collected: patient satisfaction with pain control (VAS), fulfillment of expectations regarding pain control (PEQ), patient’s impression of change in pain (PGCI-C), and patient satisfaction with the pain unit (CIS barometer).
The mean pain intensity (VAS) and total pain interference reductions were divided into two variable categories (mean pain reduction <30% and ≥30% and pain interference reduction <30% and ≥30%), according to the percentage of change, following the definition of “moderately important improvement” by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) group [
The Spanish healthcare barometer or CIS barometer is an annual opinion survey conducted since 1995 by the Spanish Ministry of Health (Ministerio de Sanidad y Política Social) in collaboration with the Sociological Investigation Center (CIS). Its purpose is to understand the general public perception of the public healthcare services (whether they have used them or not) [
The Brief Pain Inventory (BPI) [
The EuroQoL-5D (EQ-5D) is a standardized, non-disease-specific instrument for describing and valuing health-related quality of life [
The patient global clinical impression of change (PGCI-C) [
The Patients Expectations Questionnaire (PEQ) [
Descriptive statistics were performed for every variable, including central and dispersion measurements for continuous variables, and absolute and relative frequencies for categorical variables, with 95% confidence intervals (CIs), at baseline, 1 month, and 3 months. Missing data were not included in the analyses and were considered as lost.
Continuous variables were compared between baseline and 3 months by means of the Student’s
Statistical tests were performed with a bilateral 0.05 significance level. The SPSS software version 17.0 was used for the statistical analyses.
Out of 3,507 patients initially enrolled, 93 patients were excluded: for 74 of them, there was no data available and 19 patients did not comply with the inclusion criteria. Out of the 3,414 eligible patients, 3,127 (91.6%) completed the study, 6 patients died, 7 withdrew their consent, 14 were discharged, 63 were lost to follow-up, and 197 did not complete the study due to other reasons (Figure
Patients flow chart.
Every Spanish region (Autonomous Community) had at least one pain center. Out of the 146 participating pain centers, 64.4% were multidisciplinary (more than one specialty) and 37% had at least three different specialties. In multidisciplinary pain units, medical staff from various specialties (anesthetists, psychologists, and physiotherapists) is involved in the pain management. Regarding available techniques, the most commonly used in almost every center is nerve blocking (96.6%), followed by TENS (83.6%), while spinal stimulation is provided in 50% of pain centers. Almost half of the centers (47.9%) had both spinal stimulation and intrathecal therapy techniques. One-third of the centers had every available pain controlling technique (Figure
Specialties (a) and techniques (b) available in the pain centers.
Patients mean age was 61.3 years and 65.6% were female (Table
After three months of care, mean patient satisfaction with the pain center, as assessed by the CIS barometer, was 7.8, with more than 90% of the patients being satisfied (Table
Patient satisfaction with the pain center at 3 months (PC) and satisfaction with the Spanish healthcare specialists’ service (SH) in 2012.
Items | PC | SH 2012 |
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Time spent by the physician with you |
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6.72 ± 2.00 |
Number of specialists to whom you have access | 7.6 ± 1.8 | 7.64 ± 1.82 |
Waiting time at the center until seeing the doctor | 6.9 ± 2.2 | 5.72 ± 2.11 |
Knowledge of your medical history and follow-up of your health-related problems |
|
6.83 ± 2.04 |
Confidence and trust in your doctor |
|
7.29 ± 2.01 |
Easiness to get an appointment | 7.0 ± 2.3 | 5.72 ± 2.47 |
Equipment and technological means available at the center | 8.0 ± 1.6 | 7.54 ± 1.75 |
Manners of healthcare personnel |
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7.42 ± 1.80 |
Information received about your health problem |
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7.30 ± 1.95 |
Medical advice on diet, exercise, smoking, alcohol, and so forth | 8.0 ± 1.6 | 7.13 ± 2.17 |
Time from medical appointment request to appointment date | 6.9 ± 2.2 | 4.94 ± 2.39 |
Time taken by the diagnostic tests | 6.5 ± 2.2 | 5.04 ± 2.38 |
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Total satisfaction |
7.8 ± 1.2 | |
Not satisfied (<6) | 200 (8.4%) | |
Satisfied (≥6) | 2,168 (91.6%) |
Sanitary barometer 2012 (total, three waves). Executive management of public health, quality, and innovation. Ministry of Health, Social Services and Equality and Sociological Investigation Center (CIS), Madrid, 2013.
Data expressed as mean ± SD (continuous variables) or
Scores ranging from 0 (no satisfaction at all) to 10 (completely satisfied).
In bold: scores above 8.0.
At three months, baseline mean pain (VAS) decreased from 7.4 to 4.0 (Table
Evolution of pain (VAS and BPI-SF) and quality of life (EuroQoL-5D).
Baseline | 3 months |
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7.4 ± 1.5 | 4 ± 1.9 | — |
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BPI-SF intensity summary | 6.5 ± 1.4 | 3.8 ± 1.9 | — |
Pain relief in the last 24 h by received treatment (%) | 29.1% ± 19.9% | 60.9% ± 22.7% | — |
BPI-SF interference summary | 44.8 ± 12.5 | 26.4 ± 15.1 | — |
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Utility index | 0.37 ± 0.21 | 0.62 ± 0.22 | <0.001 |
Today’s health status (VAS) | 40.7 ± 20.1 | 61.9 ± 19.3 | <0.001 |
Patients with problems (2 and 3) in | |||
Mobility | 2,805 (82.2) | 2,127 (65.9) | — |
Self-care | 2,194 (64.2) | 1,224 (37.9) | — |
Usual activities | 3,142 (92.0) | 2,091 (64.8) | — |
Pain/discomfort | 3,389 (99.3) | 2,657 (82.4) | — |
Anxiety/depression | 2,650 (77.6) | 1,415 (43.9) | — |
Data expressed as mean ± SD for continuous variables and as
Data from question 18 of the CIS barometer from 1995 to 2012.
Items | 1995 | 1998 | 2000 |
2002 |
2004 |
2006 |
2008 |
2010 | 2012 |
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Time spent by the physician with you | 6.51 | 6.45 | 6.39 |
5.69 |
6.20 |
6.23 |
6.18 |
6.50 | 6.72 |
Number of specialists to whom you have access | 7.55 | 7.62 | 7.56 | 6.80 |
7.40 |
7.31 |
7.28 |
7.47 | 7.64 |
Waiting time at the center until seeing the doctor | 5.79 | 5.77 | 5.62 |
4.99 |
5.30 |
5.32 |
5.40 |
5.60 | 5.72 |
Knowledge of your medical history and follow-up of your health-related problems | 6.71 | 6.69 | 6.61 |
5.86 |
6.40 |
6.41 |
6.41 |
6.64 | 6.83 |
Confidence and trust in your doctor | 7.17 | 7.09 | 7.08 |
6.35 |
6.90 |
6.90 |
6.97 |
7.13 | 7.29 |
Easiness to get an appointment | 5.49 | 5.39 | 5.26 |
4.89 |
5.20 |
5.27 |
5.32 |
5.60 | 5.72 |
Equipment and technological means available at the center | 7.69 | 7.78 | 7.69 | 6.88 |
7.20 |
7.20 |
7.24 |
7.40 | 7.54 |
Manners of healthcare personnel | 7.56 | 7.44 | 7.37 |
6.63 |
7.06 |
7.11 |
7.09 |
7.20 | 7.42 |
Information received about your health problem | 7.14 | 7.20 | 7.16 | 6.38 |
6.94 |
6.94 |
6.94 |
7.13 | 7.30 |
Medical advice on diet, exercise, smoking, alcohol, and so forth | — | — | — | — | 6.60 | 6.78 | 6.79 | 6.98 | 7.13 |
Time from medical appointment request to appointment date | — | — | — | — | 4.70 | 4.68 | 4.67 | 4.89 | 4.94 |
Time taken by the diagnostic tests | — | — | — | — | — | 4.73 | 4.65 | 4.87 | 5.04 |
Sanitary barometer 1995–2012. Healthcare Information Institute. Ministry of Health, Social Services and Equality Madrid, 2013.
Only the year 1995 and years ending in even number are shown.
In addition, 70.7% of patients at three months felt moderately to much better, according to the PGCI (Figure
Patients global clinical impression (PGCI) of the change at month 3.
Pain control degree according to patients’ expectations.
Regarding quality of life, the EuroQoL-5D utility index increased from 0.37 to 0.62,
Change in EuroQoL VAS (a) and utility index (b) at 3 months and proportion of patients with problems (level 2 or 3) in the EuroQoL dimensions at baseline and 3 months (c).
EuroQoL VAS evolution
EuroQoL utility Index evolution
Patients (%) with problems (level 2 or 3)
Logistic regression analysis showed that patient satisfaction with the pain unit (satisfied VAS ≥ 6 and not satisfied VAS < 6) was affected (
Chronic pain is a complex psychosocial entity, whose management can be very challenging [
A recent European survey on noncancer chronic pain showed poor management of the condition in Spain, with more than half of patients (55%) not being satisfied with their treatment [
In 64% of the centers, a multidisciplinary approach to the pain management was employed. Patients managed at multidisciplinary pain centers have shown to have better outcomes when compared to those managed by nonmultidisciplinary rehabilitation, usual care, or other strategies [
The most recent data of the Spanish CIS Barometer are those of 2012 [
The 146 pain centers participating in the study were distributed across the entire Spanish territory. Every Spanish region (Autonomous Community) had at least one center, which is an improvement from 2002, when only 11 of the 17 Autonomous Communities had at least one [
Patients are satisfied with the management of their painful condition at three months of treatment and studies have shown that the positive effects of the multidisciplinary approach to chronic pain persist long after the cessation of the intervention [
On the other hand, the waiting time for the diagnostic tests results, from the clinic appointment date and to actually seeing the doctor once at the center, was the item with which, patients were satisfied the least. Other studies have shown a negative association between waiting time for pain clinic appointment and healthcare system grade [
As expected, there were more female patients than male, since several chronic pain conditions are more prevalent in women [
As it was discussed already BPI-SF intensity summary decreased from 6.5 to 3.8 and interference summary decreased from 44.8 to 26.4. Sixty-three percent of patients showed a pain interference reduction of at least 30%. The BPI-SF is used to evaluate the severity of a patient’s pain and the impact of this pain on the patient’s daily functioning. The psychometric properties of the tool have been analyzed with acceptable reliability in various populations suffering from cancer and noncancer related pain. Various studies have shown that a two-factor model has better validity for noncancer pain patients [
The quality of life of the patients also improved remarkably as it was tested by the Spanish version of the EQ-5D, which is a simple, valid, and practical measure and can be used as an outcome variable for research purposes and in the allocation of resources. Its ability to discriminate between healthy population and chronic patients is considered to be good [
Various other studies have shown that in general Spanish patients are satisfied with their pain management. Malouf et al. conducted a study with the aim to document the satisfaction with pain management in a Spanish inpatient population. The study showed that patients were satisfied with the received treatment, even when they were in pain, and that patient dissatisfaction was related to the pain intensity and satisfaction with caregivers [
In a survey of chronic pain in Europe across 16 countries (Spain included), interesting differences between countries were observed, possibly because of different cultural backgrounds and local therapeutic preferences. The authors concluded that chronic pain occurs in 19% of adult Europeans with serious effects on the quality of their lives. Only few patients were managed by pain specialists, nearly 50% were treated inadequately and about 60% were satisfied with the effect of treatment [
In conclusion, chronic pain patients are satisfied with the management provided by Spanish pain centers more than the overall population with the hospital specialist services. Ninety percent of patients were satisfied with the management of their pain. Almost 70% of patients experienced a decrease of their pain intensity and a pain interference reduction of at least 30%. They said that at three months they felt better and that their pain control expectations were met.
There is some area for improvement regarding waiting times: time needed for diagnostic tests, time from medical appointment request to appointment date, and waiting time at the center until seeing the doctor. Waiting time shortening will provide better care to patients and higher rates of satisfaction. Many healthcare institutions use methods like revamping of the front-line scheduling process, incorporation of patient preferences, considering alternate ways of care delivery, and making the reduction of waiting times part of the hospital’s culture.
Chronic pain management can have important economic repercussions. Pain management in a multidisciplinary setting may decrease the chronic pain-associated costs, since it can reduce pension expenditures, sick leave days, and usage of healthcare resource. The care provided by the Spanish pain centers seems to be successful, and, thus, although expensive, it might save costs in the long run, which should be the objective of another study.
J. Tesedo Nieto currently works at Hospital Universitario Río Hortega, Valladolid.
The authors have no relevant affiliations or financial involvement with any organization or entity with interest in or conflict with the subject matter discussed in the paper.
The authors would like to thank the participating patients and the study Principal Investigators and Collaborators, listed by states as follows: