Outcomes of the

STEPS programme at

Fremantle Hospital

The team...

Dr Stephanie Davies: Pain Consultant, Fremantle Hospital, Curtin University

Mr Carl Graham: Clinical Psychologist, Fremantle Hospital, Murdoch University

Mr Luke Parkitny: Physiotherapist, Fremantle Hospital

Ms Tracy Antill: Occupational Therapist, Fremantle Hospital

Dr John Quintner: Rheumatologist, Fremantle Hospital

Mr Paul Knight: Clinical Psychologist (Reg), Fremantle Hospital

Ms Elizabeth Forrester: Psychologist, Fremantle Hospital

Ms Mary Roberts: Research Co-ordinator, Fremantle Hospital

Dr Eric Visser: Pain Consultant, Fremantle Hospital

Professor Stephan Schug: Pain Consultant, Royal Perth Hospital, University of Western Australia

Professor Tanya Packer: Occupational Therapist, Curtin University

Funding assistance provided by:

State Health Research Advisory Council of Western Australia & Fremantle Hospital and Health Service

The nature of the chronic pain problem...

The 1 in 5 prevalence rate of chronic non-malignant pain in Australia occurs at a cost of $10,847 per person

• Patients with chronic pain disorders often have complex presentations; pain overlapping and interacting with other chronic health problems (cardiovascular, musculoskeletal, inflammatory diseases, etc)

• as well as additional psychological and social comorbidities.

The demand for chronic pain treatment services

• There are strong associations between chronic pain and poorer patient self-reported health & quality of life ratings

• Those with chronic pain are 7 times more likely to leave the workforce citing ill health than are those without chronic pain.

• Patients with chronic pain have twice as many contacts with health professionals compared with those without ongoing pain

• And yet 40% remain dissatisfied with the treatment provided

• Average wait-time in public pain clinics in 2010 was 6 mths

• Prior to STEPS the wait at the FHHS PMU was 24 mths

How to sustainably address the demand...

• Long-term outcomes of health professional supplied (passive) treatments for chronic pain are modest and yet they consume most of the health dollars spent treating these conditions

• There has been a growing evidence base demonstrating equal or improved outcomes in chronic pain patients via patient driven (active) pain management strategies addressing broad issues of functional capacity, response to pain and behavioural engagement • So, it was proposed to invite patients to actively participate in their own treatment - in order to lower system costs, reduce demand on health resources and provide equal or improved patient outcomes

Our assumptions in STEPS...

• Chronic pain disorders are generally an interaction of a structural physical problem, a resulting overlay of functional deficits and the interactions between these

Our assumptions in STEPS...

• Chronic pain disorders are generally an interaction of a structural physical problem, a resulting overlay of functional deficits and the interactions between these

• Unlike acute pain, a chronic pain disorder requires a whole-of-person approach focused on active patient engagement

• That an approach which addressed the broad functional components of pain problems would be useful in its own right and might also facilitate improved response to any appropriate medical treatment which might be indicated

Rethinking the model...

Passive Higher cost individual (symptoms)

Active groups Lower cost (function)

Rethinking the model...

Active Lower cost groups (function)

Passive individual Higher cost (symptoms)

So we designed the STEPS approach:

1. To educate patients about the functional components of their problem (which they are often better able to address than us)

2. To create an educated patient who could work as a part of the treatment team as an active participant

3. To give those patients a voice in the treatment type and dose they require

How to sustainably address the demand...

What we did...

Initiated Patient Triage Questionnaires (PTQ)

– to enable the patient to tell us their pain story

– to indicate what they are (and are not) doing to manage pain

If appropriate patients then invited to the 8 hr pre-clinic education and skills group called STEPS (ESL, psych disorders, high opiate)

At programme end patients are encouraged to put active management strategies in place and to seek follow-up on a patient directed basis

What we did...

STEPS consists of:

DAY 1 Orientation to active pain management - clinical psych Pacing skills & goal setting – OT Patients discuss their own pain stories – clinical psych Education on pain physiology & movement – physio

DAY 2 PNI education, distress & load reduction skills - clinical

psych Education on evidence-based medical options - doctor

What we did...

Following STEPS patients determine their own treatment path; manage pain themselves with GP support multidisciplinary team assessment and management

plan medical only review physiotherapy only psychology only• Long multidis CBT pain management group (PUMP) all of the above

So, what happened to the patients?

Pain (VAS) Worst

Least

Average

SF-36: Physical function

Patient satisfaction (7 pt scale)

GPIC (5 pt scale)

Self-management strategies

PRE POST (3mths)

6.32 6.61

4.84 4.68

6.07 6.00

110.26 120.22 p <0.0001

-0.79 (ns) 1.76 (sat) p<0.0003

0.20 -0.41 p <0.0001

2.9 5.5 p <0.0001

And, what happened to the PMU?

Wait list time (weeks)

Referrals to the service

New to follow-up ratio

Unit cost per patient (AUD)

Patients completed STEPS requesting further treatment

PRE POST

105.6 16.1

300 750

1 to 0.98 1 to 0.37

1805 881

47% (53% didn't need us!)

What about the staff experience?

We feel we are working smarter rather than harder

Patients and HP's are interacting meaningfully/broadly

Doctors get to run groups!

• Training GP's in active management principles

• Training Physiotherapists and Clinical Psychologists

• Encouraged them to form ad-hoc community teams

• Feedback from each professional group was positive

Where to from there?

• Its not just about pain

• Most chronic disease can be treated this way

The future...

In conclusion...

Titrating treatment from early broad interventions aimed at functional improvement and moving as the patient indicates a need towards higher cost, more invasive or risky treatments is an effective and resource efficient approach to assisting patients with chronic pain

References:

Blyth F M, March L M, Nicholas M K, &Cousins M J. Self-management of chronic pain: a population-based study Pain, 2005, 285–292

Buchbinder R, Jolley D, Effects of a media campaign on back beliefs is sustained 3 years after its cessation., Spine, 2005, 30/11, 1323-30

Cipher DJ, Fernandez E, & Clifford PA. Cost-Effectiveness and Health Care Utilization in a Multidisciplinary PainCenter: Comparison of Three Treatment Groups Journal of Clinical Psychology in Medical Settings, 2001 Vol. 8(4)

Douglas W, Graham C, Anderson D, & Rogerson K. Managing chronic pain through cognitive change in a multidisciplinary treatment program. Australian Psychologist, 2004; 39(3): 201 – 207

Kerr S, Fairbrother G, Crawford M, Hogg M, Fairbrother D, Khor K E, Patient characteristics and quality of life among a sample of Australian chronic pain clinic attendees., Intern Med J, 2004, 34/7, 403-9

Lorig K R, Ritter P, Stewart A L, Sobel D S, Brown B W, Bandura A, Gonzalez V M, Laurent D D, Holman H R, Chronic disease self-management program: 2-year health status and health care utilization outcomes., Med Care, 2001, 39/11, 1217-23

Turk DC. Treatment of Chronic Pain: Clinical Outcomes, Cost-Effectiveness, and Cost BenefitsDrug Benefit Trends, 2001, 13(9):36-38