Longitudinal Course and Impact of Insomnia Symptoms in Adolescents With and Without Chronic Pain

This study aimed to 1) examine trajectories of insomnia symptoms in adolescents with chronic pain compared to their healthy peers; 2) evaluate psychological and behavioral risk factors for longitudinal insomnia symptoms; and 3) evaluate insomnia as a predictor of quality of life, activity limitations, and healthcare utilization over 12 months. Participants included 61 adolescents with chronic pain and 60 youths without chronic pain (12–18 years; 72% female). Questionnaires were completed at enrollment, 6 months, and 12 months and assessed pain intensity, insomnia symptoms, sleep hygiene, presleep arousal, depression, pubertal status, activity limitations, quality of life, and healthcare utilization. Insomnia symptoms persisted for both groups and remained higher at all time points for youths with chronic pain. Generalized estimating equations modeling identified 3 risk factors for longitudinal insomnia symptoms: having chronic pain, poorer sleep hygiene, and higher depressive symptoms. Insomnia symptoms also predicted poorer quality of life over time and were associated with more frequent healthcare utilization. Findings suggest that sleep problems are persistent and associated with negative impact for youths with chronic pain. Treatment of insomnia symptoms in youths with chronic pain may lead to improvements in quality of life and reductions in healthcare costs.     

Equity and need when waiting for total hip replacement surgery

Objectives To explore sociodemographic and health status factors associated with waiting times both for first outpatient appointment and for total hip replacement surgery (THR). Methods A survey of THR in five former English regions was conducted between September 1996 and October 1997. Every patient listed for THR was asked to fill out a questionnaire preoperatively. This questionnaire included the 12‐item Oxford Hip Score (OHS) questionnaire and two questions on the length of time patients waited for an outpatient appointment and subsequently for their operation. Results From multiple logistic regression analyses, region, private vs. public sector, housing tenure and preoperative OHS were all independently associated with a waiting time for an outpatient appointment for > 3 months. Region, housing tenure and gender were also independently associated with a wait of ≥ 6 months on the surgical waiting list. Conclusions A large proportion of patients had long waiting times both for an outpatient appointment and while on a surgical waiting list. There were significant differences in waiting time according to social, geographical and health care system factors. Patients with a worse pain and disability at surgery waited longer for an outpatient appointment. The longer patient waited, the worse was their pain and disability, suggesting that patients were not prioritized by these criteria. Benefits of prioritizing should be tested.     

Using discrete choice experiments to go beyond clinical outcomes when evaluating clinical practice

BACKGROUND: This study builds on the results of a randomized controlled trial concerned with examining the effect of reducing waiting times on the health status of patients referred for non-urgent rheumatology opinion. No difference in clinical outcomes was found between a 'fast-track' and 'ordinary' appointment system. This suggests that rationing by waiting times is not detrimental to health. However, such an approach ignores the value patients attach to reducing waiting time. OBJECTIVES: To estimate the monetary value of reducing waiting time, as well as changes in duration of appointment and the introduction of a pain management service, in the provision of rheumatology services. METHODS: Discrete choice experiment (DCE). SETTING: The main outpatient clinic of the rheumatology service for the Lothian and Borders region. SUBJECTS: 262 patients who had received a specialist rheumatology opinion--73 had received fast-track treatment, 65 standard care and 124 were non-trial patients. RESULTS: A response rate of 71% was achieved. Patients valued a 9-week reduction in waiting time at 131 pounds sterling. However, the introduction of a pain management service was valued at 209 pounds sterling. Thus, the latter is of more value to respondents. Evidence was also found of the internal consistency and theoretical validity of the DCE approach. CONCLUSIONS: The reduction of waiting times is a central plank of NHS policy. Whilst a reduction in waiting time is of value, a pain management service is of more benefit than a 9-week reduction in waiting time. DCE were shown to be a potentially useful technique for valuing different aspects of health care interventions.     

Waiting for coronary artery bypass surgery: a qualitative analysis

Waiting lists for coronary artery bypass surgery (CABS) are common in many developed countries. Yet, there is limited information available regarding patients' health care needs at this time. This paper reports on a prospective study which aimed to investigate the experience of waiting for CABS from a qualitative perspective. An inductive research approach was used to conduct interviews with 70 randomly selected patients at three intervals over the first year on the waiting list - referral for surgery, again after waiting 6 months (n=49), and finally after waiting for 1 year (n=28). Attrition was mainly caused by surgery having been performed (n=36), although death (n=4) and refusal to participate (n=2) also contributed. Domicilliary interviews were taped and transcribed verbatim. Thematic content analysis identified three central themes in this experience - uncertainty, chest pain and anxiety; with six secondary themes - powerless, dissatisfaction with treatment, anger/frustration, physical incapacity, reduced self-esteem, and altered family and social relationships. The nature and meaning inherent in each theme is described using interview quotations, and a model is proposed which summarizes this data and the relationship between themes. From this analysis, uncertainty, chest pain and anxiety emerge as important indicators of a negative outcome for these patients. This report strongly suggests that patients awaiting bypass surgery require more information regarding the waiting time for such a surgery. Nurses should also offer advice regarding pain management to help improve patients' skills and decrease the fear associated with angina. Nursing intervention and support should also be directed at reducing patients' anxiety levels. This is the first known qualitative study which specifically examines patients' perception of the waiting period prior to bypass surgery. It may therefore provide new evidence on which to base practice for nurses in both hospital and community, and may also stimulate further research in this area.     

Preferences for follow-up after treatment for lung cancer: assessing the nurse-led option

Pressure on lung cancer clinics is increasing with the "2-week wait" initiative. This initiative is one of the key targets set out in the National Health Service (NHS) Cancer Plan for the United Kingdom, whereby all patients presenting with symptoms which may be indicative of a cancer diagnosis will be seen by a consultant within 2 weeks of initial presentation at their primary care provider. This has resulted in busy clinics, with the potential for extended clinic waiting times and unmet needs for information and psychosocial support on the part of patients and families. There is increasing interest in the most appropriate mode of follow-up for patients with lung cancer who are under observation, many of whom have completed specific treatments. Such patients may benefit from specialist nurse review for symptom control and psychosocial support. Nurse-led clinics are safe and cost effective in the oncology and research-funded setting. This study aimed to assess the acceptability of nurse-led follow-up in a large general lung cancer clinic seeing approximately 250 new patients annually. Over a 34-week period, there were 487 follow-up attendances and 94 (19.3%) of these were made by 72 patients deemed eligible for nurse-led follow-up. Sixty patients were approached and 54 (90%) agreed to participate in the study. A questionnaire containing vignette scenarios of nurse-led, telephone, GP-led, and standard (hospital, medical) follow-up was completed by 34/54 (63%) of eligible patients, 10/20 (50%) carers, 20/31 (65%) staff, and 11/38 (29%) GPs. Respondents rated acceptability of the scenarios on a range of issues on a scale of 1 to 5. Patients also completed the EORTC QLQ C30 and lung module questionnaire. Subsequent interviews were carried out with samples of these respondent groups.Fatigue, dyspnea, cough, and pain were the most common general symptoms. Both standard and nurse-led follow-up scenarios were highly rated by patients and other respondents and both were highly significantly favored over GP follow-up, which was the least favored in all areas of the questionnaire. Telephone follow-up tended to elicit more polarized reactions, both positive and negative. In interviews, in relation to nurse-led follow-up, the importance of clear protocols, training, and easy access to medical review were highlighted.     

Delivering Virtual Cancer Rehabilitation Programming During the First 90 Days of the COVID-19 Pandemic: A Multimethod Study

ObjectiveTo describe the adaptations made to implement virtual cancer rehabilitation at the onset of the coronavirus disease 2019 pandemic, as well as understand the experiences of patients and providers adapting to virtual care.DesignMultimethod study.SettingCancer center.ParticipantsA total of 1968 virtual patient visits were completed during the study period. Adult survivors of cancer (n=12) and oncology health care providers (n=12) participated in semi-structured interviews.InterventionsNot applicable.Main Outcome MeasuresFramework-driven categorization of program modifications, qualitative interviews with patients and providers, and a comparison of process outcomes with the previous 90 days of in-person care via referrals, completed visits and attendance, method of delivery, weekly capacities, and wait times.ResultsThe majority of program visits could be adapted to virtual delivery, with format, setting, and content modifications. Virtual care demonstrated an increase or maintenance in the number of completed visits by appointment type compared with in-person care, with attendance ranging from 80%-93%. For most appointment types, capacities increased, whereas wait times decreased slightly. Overall, 168 patients (11% of all assessments and follow-ups) assessed virtually were identified by providers as requiring an in-person appointment because of reassessment of musculoskeletal and/or neurologic impairment (n=109, 65%) and lymphedema (n=59, 35%). The interviews (n=24) revealed that virtual care was an acceptable alternative in some circumstances, with the ability to (1) increase access to care; (2) provide a sense of reassurance during a time of isolation; and (3) provide confidence in learning skills to self-manage impairments.ConclusionsMany appointments can be successfully adapted to virtual formats to deliver cancer rehabilitation programming. Based on our findings, we provide practical recommendations that can be implemented by providers and programs to facilitate the adoption and delivery of virtual care.     

Using Lean Healthcare Techniques to Reduce Appointment Times

To reduce extended appointment times at a heart failure clinic, 3 Lean healthcare-based changes were planned and implemented one at a time over 4 months. Findings based on 1,267 appointments showed that appointment times decreased with proper implementation. Although staffing challenges and inadequate sample sizes prevented statistical analysis on consult appointments, follow-up appointment results were statistically significant based on 1-way analysis of variance and Tukey honest significant difference tests. Although the study period prevented the determination of a correlation between monthly clinic end times and average appointment times (patient throughput), in-room minute decreases suggest that lean healthcare techniques can be effective in this context.     

An audit to identify anaemia in patients undergoing lower limb joint arthroplasty

This article investigates the incidence of anaemia in 104 patients over a period of 9 months put on the waiting list for lower limb joint arthroplasty. It examines anaemia and why it is important to try and rectify this prior to surgery. The nurse led audit found that 4.8% of patients put on the waiting list were anaemic, which would have delayed their operation if not discovered until the preoperative assessment clinic appointment. Although the potential impact on the service is minimal the patient would have a further wait whilst treatment was given, with all the additional worry and psychological trauma. Finally it proposes that further study be undertaken with greater numbers to determine if strategies for treatment can be developed and interventions have been successful.     

The Interaction of Waiting Time and Patient Experience during Radiation Therapy: A Survey of Patients from a Tertiary Cancer Center

PurposeThe logistical burdens of appointment scheduling and travel add to the psychological and emotional distress among patients with a new cancer diagnosis. This may be heightened among patients needing radiation therapy (RT), who must travel to and from a treatment facility daily for several weeks. Here, we studied the association between RT appointment waiting time and patient-reported pain and anxiety and explored additional factors that may influence daily waiting time.MethodsNinety-four patients undergoing RT at a single, academic institution were surveyed in the first and final weeks of treatment. On the day of the survey, patients were asked to report: pain (Likert scale: 0–10), anxiety (0–10), commute mode/time, and estimated waiting time for RT. Actual waiting times were calculated per review of the electronic scheduling system.ResultsIncreased objective waiting time was associated with higher pain scores at the start (P = .05) and end (P = 0.004) of RT, although overall pain scores were low at both time points (mean 1.4 and 1.5, respectively). Anxiety scores were also low (mean 1.2 at both time points) and were not associated with objective waiting time (P > .05). Of note, patients reported perceived waiting times that were considerably shorter than actual waiting times (mean 15 vs. 26 minutes, respectively, at first survey early in the RT course). Time of day and tumor site were not associated with waiting time.ConclusionDaily waiting time may play a role in pain and/or anxiety experienced by patients with cancer during RT. Perceived waiting time may differ substantially from actual waiting time and represents a potential area for intervention to improve patients’ quality of life.     

Effectiveness of a community based nurse-pharmacist managed pain clinic: A mixed-methods study

BackgroundChronic pain is predominantly managed in primary care, although often ineffectively. There is growing evidence to support the potential role of nurses and pharmacists in the effective management of chronic pain.ObjectivesTo evaluate the effectiveness of a pain clinic jointly managed by a nurse and pharmacist.DesignA mixed-methods design consisting of qualitative interviews embedded within a quasi-experimental study.SettingsA community-based nurse-pharmacist led pain clinic in the north of England.ParticipantsAdult chronic pain (non-malignant) patients referred to the pain clinic.MethodsPain intensity was the primary outcome. Questionnaires (the Brief Pain Inventory, the Hospital Anxiety and Depression Scale, the SF-36 and the Chronic Pain Grade questionnaire) were administered at the baseline, on discharge and at 3-month post-discharge (Brief Pain Inventory and Hospital Anxiety and Depression Scale only). Patient satisfaction was explored using face-to-face, semi-structured qualitative interviews.ResultsSeventy-nine patients with a mean age of 46.5 years (SD ± 14.4) took part in the quasi-experimental study. Thirty-six and nine patients completed the discharge and 3-month follow-up questionnaires respectively. Compared to baseline, statistically significant reductions were noted for two of the outcome measures: pain intensity (P = 0.02), and interference of pain with physical functioning (P = 0.02) on discharge from the service. Nineteen patients participated in qualitative interviews. The patients were, in general, satisfied with the quality of service. Four contributing factors to patient satisfaction were identified: ample consultation time, in-depth specialised knowledge, listening and understanding to patients’ needs, and a holistic approach.ConclusionsNurse and pharmacist managed community-based pain clinics can effectively deliver quality pain management services as they offer an interdisciplinary holistic approach to pain management. Such services have the potential not only to reduce the burden on secondary care but also decrease long waiting times for referral to secondary care. Further research is required to support the development of evidence based referral guidelines to such services.     

Expanded role for the physical therapist. Screening musculoskeletal disorders.

The primary purpose of this study conducted at two army hospitals was to evaluate the feasibility of using the physical therapist as the primary 'screener' for patients presenting with a complaint of low back pain. The study was organized into two phases. A base line phase consisted of a data collection period under standard operating conditions. Patient waiting times, treatment times, and total care times were measured for patients presenting to various clinics with a complaint of low back pain. The same data were collected during a screeing phase in which all patients presenting with a complaint of low back pain were referred directly to the physical therapist for primary evaluation. An assessment of physical therapist and patient satisfaction and acceptance was made. The quality of care rendered in the screeing clinic was assessed through patient interviews, physician interviews, and record reviews. This concept and the quality of care rendered were found to be acceptable to the patient, the physician, and the physical therapist.     

Waiting time in relation to wait-list size at registration: statistical analysis of a waiting-list registry

OBJECTIVE: To examine the relationship between the length of a waiting list for elective vascular surgery and the delay before undergoing the operation. METHODS: We undertook a prospective cohort study of patients registered on the waiting list for elective vascular surgery at an acute care hospital in Ontario. Regression analysis of wait times to express the admission rate in one group relative to another, with the ratio of rates being a measure of the difference between groups. RESULTS: List length at registration was associated with length of wait (log-rank test 596.4, p < 0.0001). Patients who were registered when the list length exceeded the weekly service capacity had 70% lower conditional probability of undergoing surgery than those on a list with fewer patients (rate ratio 0.30, 95% confidence interval [CI] 0.26-0.36) after adjustment for sex, age, procedure and period. Registering more than 5 patients when the list was short had an independent effect (rate ratio 0.61, CI 0.45-0.82). CONCLUSIONS: The number of registrants on a surgical wait list has an effect on the length of delay in providing necessary treatment. Our results suggest that a regulated list-length policy may contribute to reducing waiting times. Hospital managers may also use the findings to reduce uncertainty in reporting expected waits given the current list size, thereby improving resource planning.     

The Economic Costs of Chronic Pain Among a Cohort of Treatment-Seeking Adolescents in the United States

The aim of this study was to assess the economic cost of chronic pain among adolescents receiving interdisciplinary pain treatment. Information was gathered from 149 adolescents (ages 10–17) presenting for evaluation and treatment at interdisciplinary pain clinics in the United States. Parents completed a validated measure of family economic attributes, the Client Service Receipt Inventory, to report on health service use and productivity losses due to their child's chronic pain retrospectively over 12 months. Health care costs were calculated by multiplying reported utilization estimates by unit visit costs from the 2010 Medical Expenditure Panel Survey. The estimated mean and median costs per participant were $11,787 and $6,770, respectively. Costs were concentrated in a small group of participants; the top 5% of those patients incurring the highest costs accounted for 30% of total costs, whereas the lower 75% of participants accounted for only 34% of costs. Total costs to society for adolescents with moderate to severe chronic pain were extrapolated to $19.5 billion annually in the United States. The cost of adolescent chronic pain presents a substantial economic burden to families and society. Future research should focus on predictors of increased health services use and costs in adolescents with chronic pain.PerspectiveThis cost of illness study comprehensively estimates the economic costs of chronic pain in a cohort of treatment-seeking adolescents. The primary driver of costs was direct medical costs followed by productivity losses. Because of its economic impact, policy makers should invest resources in the prevention, diagnosis, and treatment of chronic pediatric pain.     

Level of Pain and Waiting Time in the Emergency Department

Pain is the leading reason individuals seek emergency care. Studies have concluded that acute pain conditions are underevaluated and undertreated in the emergency department (ED). There is a paucity of information about how the severity of pain influences the time spent in the ED before being seen by a physician. Therefore, this study focuses on what role pain plays regarding time to treatment in the ED, i.e., to examine the effects of patients' perceived level of pain on wait time in the ED. The CDC's National Hospital Ambulatory Medical Survey 2003 data were used in this study. The sample consisted of 12,860 caucasians and African Americans with a mean age of 44.52 years. Analysis of covariance was used to explore differences in length of waiting time in ED based on race, triage nurses rating of the immediacy of the need to be seen by a physician, and the level of pain the patient reported. The findings showed that patients' reports of pain had very little effect on the length of waiting time. Given the sample size, we feel there is adequate power to detect the effect of pain in determining the length of waiting time to see a physician if it were present. In addition, African Americans had a statistically significant longer wait (15.29minutes) than Whites. The effect of race might be interpreted as another example of health disparities or could be a hospital-level effect which was not examined within this model.     

Relating Patient Satisfaction to Waiting Time Perceptions and Expectations: The Disconfirmation Paradigm

Objective: To determine the association of patient satisfaction with waiting time perceptions and expectations.
Methods: A random sample of patients seen at one community hospital ED during a one-year period was surveyed by telephone within two to four weeks of evaluation to determine perceived satisfaction and waiting time perceptions and expectations.
Results: In response to 3, 641 attempted phone surveys, 1, 574 patients had usable interviews. Consistent with a hypothesis derived using the disconfirmation paradigm (i.e., that satisfaction is a function of the magnitude and direction of the difference between perceived service and expected service), the patients were least satisfied when waiting times were longer than expected, were relatively satisfied when waiting times were perceived as equal to expectations, and were highly satisfied when waiting times were shorter than expected (p < 0.0001). Overall. the measure of effect strength (values from 0 to 1) of perceived waiting time vs expectation on the patient satisfaction score was 0.32. indicating moderate association.
Conclusions: The current study supports the validity of the disconfirmation paradigm in relating patient satisfaction to waiting time perceptions and expectations. Furthermore, it emphasizes that achieving satisfaction in a service encounter necessitates that perceived performance meet or exceed patient expectations.     

Waiting times and patient satisfaction in the accident and emergency department.

A survey of the waiting times and patients' opinions of these times was undertaken in a busy district general hospital A&E department. The various components of the overall waiting time are analysed and specific points of the patients' attendance, where waiting times were prolonged, are identified. Standards are derived which is hoped may result in 75% of patients being satisfied with the duration of their wait. The current levels of achievement are compared with these standards. Suggested and actual improvements to the department to improve our performance are described.     

A Cost-Analysis of an Interdisciplinary Pediatric Chronic Pain Clinic

Chronic pain is characterized by high rates of functional impairment, health care utilization, and associated costs. Research supports the use of comprehensive, interdisciplinary treatment approaches. However, many hospitals hesitate to offer this full range of services, especially to Medi-Cal/Medicaid patients whose services are reimbursed at low rates. This cost analysis examines the effect on hospital and insurance costs of patients' enrollment in an interdisciplinary pediatric pain clinic, which includes medication management, psychotherapy, biofeedback, acupuncture, and massage. Retrospective hospital billing data (inpatient/emergency department/outpatient visits, and associated costs/reimbursement) from 191 consecutively enrolled Medi-Cal/Medicaid pediatric patients with chronic pain were used to compare 1-year costs before initiating pain clinic services with costs 1 year after. Pain clinic patients had significantly fewer emergency department visits, fewer inpatient stays, and lower associated billing, compared with the year before without interdisciplinary pain management services. Cost savings to the hospital of $36,228 per patient per year and to insurance of $11,482 per patient per year were found even after pain clinic service billing was included. Analyses of pre-pain clinic costs indicate that these cost reductions were likely because of clinic participation. Findings provide economic support for the use of interdisciplinary care to treat pediatric chronic pain on an outpatient basis from a hospital and insurance perspective.