Royal National Orthopaedic Hospital. Chronic Pain Centre

Transcription

1 Royal National Orthopaedic Hospital Chronic Pain Centre Annual Report Financial Year 2016 / 2017 Authors: Dr Rebecca Berman Dr Tacson Fernandez Dr Roxaneh Zarnegar (Audit Lead) (Neuromodulation Lead) (Clinical Lead) 1

2 Contents Introduction 3 Service Development Current Constraints & Limitations 3 Chronic Pain Service Structure 4 Definitions & Abbreviations 5 Service Provision 6 18 Week Waiting times 6 Clinical Load in CPC Clinic 7 General CPC Service 8 Admissions for Residential Pain Management Rehabilitation Programs 9 Case Load in Neuromodulation Clinics 10 First visit PROMs (CPC) data for Adult Pain Clinics 11 Outcomes Data for Neuromodulation Clinics 16 First visit PROMs (Neuromodulation) data for Adult Pain Clinics 17 Friends and Family Test for the Chronic Pain Service 26 Education & Training 27 Research Publications and Conference Abstracts 27 2

3 Introduction This is the third annual report for the RNOH Chronic Pain Centre (RNOH CPC). It should be considered in conjunction with the first report ( ) & second report ( ). Service Development Chronic Pain Centre Website updated including a section on the Neuromodulation Service Commencement of collection of Paediatric Pain Questionnaires, started 2016 UCL Medical School Student Selected Component provision (Pain: the commonest presenting symptom) Appointment of RNOH s first Chronic Pain Specialist Pharmacist Commencement of formal networking with the Royal Free Pain Service A new clinic code (NMOD+) to help track Neuromodulation referrals enabling better data collection on all stages of the clinical pathway Current Constraints & Limitations Over the course of the year, the RNOH Chronic Pain Centre has been confirmed as a service that meets the clinical criteria outlined in the NHS England Standard Specialised Pain specification document (D08/S/a). No financial commitment has been given as yet though discussions are continuing. The figures in this report have been compiled using a combination of RNOH Patient Outcomes Data, Insight and ics databases as well as the paper-based neuromodulation data collection. During data extraction, it became apparent that there were significant discrepancies in these databases. Where possible, data has been reconciled with manual methods but there are still some unresolved minor discrepancies which do not affect this report s overall conclusions. 3

4 Chronic Pain Service Structure Consultants in Pain Medicine Clinical Nurse Specialists Service Manager Assistant Service Manager Secretarial & Administrative RNOH Central Bookings Office Roxaneh Zarnegar (Lead Consultant) Rebecca Berman (Audit Lead) Tacson Fernandez (Neuromodulation Lead) Dan Mihaylov (Education Pain Supervisor) Ramy Mottaleb (Locum Aug 16 June 17) Julia Sach Faustina Aikins-Snyper Michelle Lilley Robert Emmins Ana Ramos Sarah Jason Anna Dayani Sonia Brito Ethal Sangasinha Kristin Rackwitz Data Collection Officer Shrutee Shah Tajinder Manic Pain Medicine Fellows (APT) Anthony Gubbay (Feb 15 Aug 16) David Moore (Aug-16 Feb-17) Martin Marinov (Feb-17 July 17) Pain Specialist Pharmacist Drumita Pindora Meeta Patel The service is supported by: Liaison Psychiatry - George Ikkos, Sarah McNally, Parashar Ramanuj Rehabilitation and Pain Specialist Psychology Service Specialist Physio- and Occupational Therapists in CP and Rehabilitation Gill Thurlow, Nurse Consultant in Rehabilitation 4

5 Definitions & Abbreviations CP: CB: BPI: BAPQ: BAPQ-P: CP: IASP: MDT: NPA: PMP: PROMs: SCS: EPG: IPG: 1st Stage: Chronic Pain Centralised Booking British Pain Inventory Bath adolescent pain questionnaire Bath adolescent pain questionnaire - Parents Chronic Pain International Association for the Study of Pain Multidisciplinary Team National Pain Audit Pain Management Programme Patient Reported Outcome Measures Spinal Cord Stimulation External Pulsed Generator (1 ST Stage Temporary) Internal Pulsed Generator (2 nd Stage Permanent) Temporary implantation of SCS + EPG 2 nd Stage: Permanent Full implantation of SCS + IPG 5

6 Service Provision 18 week RTT Waiting times Fig 1.0 RNOH RTT Target: 92% Target Referral Pathways, Referral Acceptance & Discharge Criteria The report contains detailed information on referral pathways, acceptance and discharge criteria. These have remained unchanged since 2014/

7 Case Load - (Source: Insight) 1st April st April 2017 Demographics of Patients seen for the first time in outpatients (n = 1028) Male Female Total M:F Ratio 1:1.8 1:2.2 1:2 Average Age Referral source RNOH GP (Primary Care) Secondary care Total

8 CPC Service - (1st April st April 2017) - (Source: RNOH Insight, includes neuromodulation) Berman Fernandez Mihaylov Mottaleb Zarnegar Total New Seen By Consultant New Seen By Fellow New Seen By CNS Total Berman Fernandez Mihaylov Mottaleb Zarnegar Total F.U Seen By Consultant F.U Seen By Fellow F.U Seen By CNS In Clinic F.U CNS Telephone F.U Pharmacist Telephone F.U Total Berman Fernandez Mihaylov Mottaleb Zarnegar Total F.U / New Ratio Berman Fernandez Mihaylov Mottaleb Zarnegar Total NEW in Additional clinic F.U in Additional Clinic As % of total new patients seen 2.84% 13.48% 5.17% 5.78% 8

9 Admissions for Residential Pain Self-Management Rehabilitation Programs (PMP Roxaneh Zarnegar) 1st April st April This data does not include admissions under rheumatology and rehabilitation services Number of admissions for pain rehabilitation: 77 Hotel programme: 35 Rehabilitation ward: 42 PMP patient demographics Male Female M:F Ratio 1:2.1 1:2.3 1:2.4 Average Age

10 Neuromodulation Case Load Case Load in Neuromodulation Clinics Neuromodulation Activity April 2016 April 2017 Patient Outcome data collection started at the end of New patients referred to the Neuromodulation Clinic 24 Patients were selected for 2 nd stage full implant New Patients Number of Trials Number of patient who have completed 1 st Stage awaiting 2 nd stage Number of implants 2 nd Stage Number of implants 2nd Stage that completed POD outcomes 17 7 Future 2 nd stage TCI 13 5 New Patients Fully Implanted (n = 24) Male 11 8 Female M:F Ratio 1:3 1:1:4 Average Age

11 Outcomes Data (Excluding neuromodulation clinics & paediatric patients) 1st April st April 2017 (inclusive) General information on PROMs data collection (All clinics) All adult patients are asked to complete European Quality of Life 5 Dimensions, 5 Levels (EQ5D-5L) and Brief Pain Inventory (BPI) in first and subsequent contact with the pain clinic. They complete Global Impression of Change (GIC) in subsequent visits. First visit PROMS Data for Adult Pain Clinics A) European Quality of Life 5 Dimensions -5 Levels Data Table 5: Data on first visit to RNOH Pain Clinic who completed PROMS (n = 813) EQ5D-5L health state Mobility Self-care Usual activities Pain No problems (1) 72 (8%) 256 (32%) 279(34%) 7(1%) 247(31%) Some impact (2) 125(15%) 273(34%) 107(13%) 98(12%) 244(30%) Moderate (3) 300(37%) 207(25%) 431(53%) 401(49%) 189(23%) Severe impact (4) 271(36%) 67(8%) 186(23%) 232(29%) 95(12%) Extreme impact/unable to do activity at all (5) 45(6%) 10(1%) 61(7%) 74(9%) 37(4%) Anxiety/depression Table 4: Data on follow up visit to RNOH Pain Clinic who completed PROMS (n = 307) EQ5D-5L health state Mobility Self-care Usual activities Pain Anxiety/depression No problems (1) 29(9.5%) 80(26%) 14(4.6%) 5(1.6%) 91(30%) Some impact (2) 67(22%) 110(36%) 52(17%) 47(15%) 95(31%) Moderate (3) 104(34%) 89(29%) 135(44%) 129(42%) 77(25%) Severe impact (4) 96(31.3%) 26(8.5%) 85(27.7%) 94(31%) 35(11%) Extreme impact/unable to do activity at all (5) 11(3.6%) 2(0.6%) 21(6.9%) 32(10.4%) 9(3%) Mean Average time between 1 st and F.U appointments = 3 Months 11

12 The overall conclusion from analyzing EQ5D data is that the interventions that are done through RNOH pain clinics (not including neuromodulation and rehabilitation / psychological intervention), reduce pain severity and improve mobility. Pain clinic interventions alone have no impact on anxiety and depression or ability to self-care and difficulty with usual daily activities. The lack of effect on mood, self-care ability and usual activities is unsurprising given that pain clinic interventions are generally tailored towards reduction in pain intensity. The comprehensive assessment that takes place in these clinics paves the way towards other treatment modalities such as neuromodulation and pain management rehabilitation programmes which would have a greater impact on both pain intensity and other PROMs components. 12

13 B) Brief Pain Inventory Data BPI scores show a reduction in pain intensity as well as pain interference after pain clinic interventions at RNOH. Details of this appear in the tables and graphs below. Table 5: BPI Pain severity score at first visit to RNOH Pain Clinic (n = 813) Pain least Pain worst Pain average Pain now Minimum st quartile Median Mean rd quartile Maximum Table 6: BPI Pain Severity score at first visit to RNOH Pain Clinic & follow up Mean least pain Mean average pain severity Mean worst pain Pre Scores Post Scores NRS 11 = Numeric Pain Rating Scale 13

14 Table 7: BPI Pain interference profile at first visit to RNOH Pain Clinic Statistic General activity Mood Walking ability Normal work past 7 days ITEM Relationships with other people Sleep Enjoyment of life BPI interference (mean) Minimum st quartile Median Mean rd quartile Maximum Table 8: BPI Pain interference profile at follow up visit to RNOH Pain Clinic Statistic General activity Mood Walking ability Normal work past 7 days ITEM Relationships with other people Sleep Enjoyment of life BPI interference (mean) Minimum st quartile Median Mean rd quartile Maximum Table 9: Direct comparison of first visit BPI scores for RNOH Pain Clinic & follow up BPI scores. BPI interference (median) BPI interference (mean) RNOH, Pre (n = 813) RNOH, Post (n = 307) 5 5 NRS 11 = Numeric Pain Rating Scale 14

15 GIC - (Generic Impression of Change) Only administered to follow up patients who complete First PROMS. n = 353 total number of patients who completed GIC. 15

16 Outcomes Data (Neuromodulation) 1st April st April 2017 (inclusive) Patients are asked to fill in SCS questionnaires to see if they meet the SCS criteria. These questionnaires are comprised of (EQ5D-5L, BPI, HEALTH VAS, PGIC, SE, PDI, PHQ-2, GIC) the result are represented below. First Visit PROMS Data for Neuromodulation Clinics A) EuroQol 5D-5L Neuromodulation patients with SCS/PNS insertion (24) Key Pre Op Scores Post Op Scores Table 10: Data on Pre-Op visit to RNOH Pain Clinic (n = 17 of the 24 patients who completed proms) EQ5D-5L health state Mobility Self-care Usual activities Pain Anxiety/depression No problems (1) 1(5.5%) 7(41%) 1(5.5%) 0 (0%) 5(29%) Some impact (2) 1(5.5%) 3(17%) 3(17%) 2(12%) 3(17%) Moderate (3) 4(24%) 6(36.5%) 5(29%) 3(17%) 5(29%) Severe impact (4) 11(65%) 1(5.5%) 6(36.5%) 8(47%) 2(12%) Extreme impact/unable to do activity at all (5) 0 (0%) 0 (0%) 2(12%) 4(24%) 2(12%) Table 11: Data on Post Op visit to RNOH Pain Clinic (n = 17 of the 24 patients who completed proms) EQ5D-5L health state Mobility Self-care Usual activities Pain Anxiety/depression No problems (1) 1(5.5%) 5(29%) 1(5.5%) 0 (0%) 6(36%) Some impact (2) 4(24%) 7(41%) 4(24%) 5(29%) 6(36%) Moderate (3) 9(53.5%) 5(29%) 10(58%) 11(65%) 5(29%) Severe impact (4) 3(17%) 0 (0%) 2(12%) 1(5.5%) 0 (0%) Extreme impact/unable to do activity at all (5) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Figure 1: EQ 5D-5L comparative profiles for Pre & Post implantation in neuromodulation patients 16

17 17

18 Table: EuroQol Index Value of Health Status on Pre & Post implantation in neuromodulation patients Average (Mean) Min Max Median 1st quartile 3rd quartile RNOH, Pre (n = 17) RNOH Post (n =17)

19 Health VAS - Neuromodulation patients with SCS/PNS insertion (24) Table 10: EuroQol Index Value of Health Status Pre & Post implantation for neuromodulation. (n = 17 of the 24 patients who completed proms) Average (Mean) Pre Implantation (n = 17) 44.1 Post Implantation (n = 17) 70.2 Table 11: EuroQol Health VAS Scores on Pre & Post implantation for neuromodulation (n = 17 of the 24 patients who completed proms) Median Mean Interquartile range Pre Implantation (n = 17) Post Implantation (n = 17)

20 Brief pain inventory Total patients (24) Table 12: BPI Pain severity score at Pre & Post visit to RNOH Neuromodulation Clinic (n = 17) Pain ratings Pre Pain average Post Pain average Minimum 0 0 1st quartile 7 4 Median 8 6 Mean rd quartile 10 7 Maximum Post Scores - n - 17 NRS 11 = Numeric Pain Rating Scale 20

21 Table 14: BPI Pain interference profile at Pre Implant visit to RNOH Neuro-mod Clinic Statistic General activity Mood Walking ability Normal work past 7 days ITEM Relationships with other people Sleep Enjoyment of life Minimum st quartile Median Mean rd quartile Maximum BPI interference (mean) Table 15: BPI Pain interference profile at Post Implant visit to RNOH Neuro-mod Clinic Statistic General activity Mood Walking ability Normal work past 7 days ITEM Relationships with other people Sleep Enjoyment of life Minimum st quartile Median Mean rd quartile Maximum BPI interference (mean) Table 16: Direct comparison of Pre & Post implantation for neuromodulation (n = 17 of the 24 patients who completed proms) BPI median average pain BPI Interference mean average pain Pre Implantation (n = 17 ) Post Implantation (n = 17 )

22 S-E Questionnaire (Self-Assessment) Table 17: Direct comparison of Pre & Post implantation for neuromodulation (n = 17 of the 24 patients who completed proms) Questions Average Pre Still enjoy things, despite pain I can still do most of household chores despite pain I socialise with friends/family despite pain 3 3 I can cope with pain in most situations I can do some sort of work 3 4 I can still do my many hobbies despite the pain 2 3 I can cope with my pain without medication I can accomplish most of my goals despite the pain I can still live a normal life despite the pain I can gradually become more active despite the pain Average Post (Pain scores are out of a total of 60 Higher number indicates higher health /confidence status.) 22

23 PDI (Pain disability Index) Table 18: Direct comparison of Pre & Post implantation for neuromodulation (n = 17 of the 24 patients who completed proms) Questions Average Pre Family Home Responsibility Recreation 7 6 Social Activity Occupation Sexual Behaviour Self-Care 5 5 Life Support Activity 6 5 Average Post (Pain scores are out of a total of 70 Lower number indicates higher health /confidence status.) 23

24 Patient Health Questionnaire PHQ-2 (24) Table 19: PHQ-2 Patient Health score at Pre & Post implantation for neuromodulation (n = 17 of the 24 patients who completed proms) Questions Average Pre Little interest /pleasure in doing things Feeling down, depressed or hopeless Average Post (Pain scores are out of a total of 6 Higher number indicates lower health /confidence status.) 24

25 Global impression of change Questionnaire Total patients (24) The GIC is broken down into 2 scales: Severity scaling & Improvement scaling. GIC - Severity scales &Global Improvement scaling at Pre & Post implantation for neuromodulation. (n = 17 of the 24 patients who completed proms) Questions Average Pre Average Post How bad is overall pain Compare your health from admission to today, how has it changed (Pain scores are out of a total of 14 Higher number indicates lower health /confidence status.) 25

26 Friends and Family Feedback for the Chronic Pain Service 97% of patients feedback suggested that they where Extremely Likely or Likely with the service provided by the Chronic Pain Centre. 95% of patients feedback suggested that they where Extremely Likely or Likely with the service provided by the Chronic Pain Centre with only 2% saying they where Extremely Unlikely 26

27 Education & Training Local Pain Education Supervisor Dan Mihaylov The RNOH Chronic Pain Centre provides a well-established Advanced Pain Fellowship which is recognised by the Faculty of Pain Medicine of the Royal College of Anaesthetists to count towards the FFPMRCA. 6 months of the 12 month Fellowship are spent here at the RNOH and 6 months at University College London Hospitals. Our Fellows have the opportunity to gain extensive experience particularly in managing patients with pain due to complex spinal pathology, neuropathic pain secondary to traumatic peripheral neuropathy and plexopathy, spinal cord injury related pain, chronic regional pain syndrome and persistent post joint surgery pain syndromes. The RNOH Chronic Pain Centre runs a Neuromodulation service and our Fellows are encouraged and supported in getting involved in its work. We run one of the few residential Pain Management Programmes in the United Kingdom. Our Pain Centre runs a regular chronic paediatric pain clinic, delivered by a Pain Consultant with formal RCoA approved training in paediatric pain management. All clinical activities of the RNOH Chronic Pain Centre are delivered in the context of a multi - disciplinary and multi - specialty environment. Research Publications, & Abstracts Capsaicin 8% patch treatment for amputation stump and phantom limb pain: a clinical and functional MRI study. Privitera R, Birch R, Sinisi M, Mihaylov D, Leech R, Anand P. Journal of Pain Research, Accepted for publication in June Service Users Evaluation Of Patient Reported Outcomes Measures (PROMS) Data Collection In A Pain Clinic. Zarnegar R, Lucas A, Manic T, Goldberg A. British Journal of Pain (2) Supplements 1: pg 20 27