BACKGROUND: Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low-yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care-associated outcomes for this patient group.
METHODS: We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, and Web of Science from database inception to June 2018 for eligible interventional studies aimed at reducing frequent ED utilization among adult patients with CNCP. Articles were assessed in duplicate in accordance with methodologic recommendations from the Cochrane Handbook for Systematic Reviews of Interventions. Outcomes of interest were the frequency of subsequent ED visits, type and amount of opioids administered in the ED and prescribed at discharge, and costs. Methodologic quality was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias tools for nonrandomized and randomized studies, respectively.
RESULTS: Thirteen studies including 1,679 patients met the inclusion criteria. Identified interventions implemented pain policies (n = 4), individualized care plans (n = 5), ED care coordination (n = 2), chronic pain management pathways (n = 1), and behavioral health interventions (n = 1). All of the studies reported a decrease in ED visit frequency following their respective interventions. These reductions were especially pronounced in studies whose interventions were focused around individualized care plans and primary care involvement. Interventions implementing opioid restriction and pain management policies were largely successful in reducing the amounts of opioid medications administered and prescribed in the ED.
CONCLUSIONS: Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care-associated costs for frequent ED utilizing patients with CNCP.
This is a very helpful review in identifying approaches most likely to succeed in improving care for this difficult ED sub population.
It is difficult to draw conclusions from this study. The authors themselves warn of probable publication bias in the included studies. 12/13 studies were done in the United States. The contexts (size and location of the ED, patient population, primary care provider availability, support programs, withdrawal management programs, etc) are likely to be very different in each place. Like any complex social intervention, it is difficult to tease out what works, for whom, in what setting, and why it works or not. A realist review or realist synthesis methodology would likely be a better choice for approaching the problem of looking at the characteristics and effectiveness of interventions for frequent ED utilization of patients with chronic noncancer pain.
Patients who frequently visit EDs for chronic pain are difficult to help. These studies suggest that certain interventions can decrease their recidivism and the amount of opioids they get, but it's not clear whether or not this equates to any patient-important benefit.