A Study in Goals, Outcomes and Costs

Prolonged and excessive pain after surgical procedures can lead to longer healing times, higher healthcare costs and other post-surgical complications, as well as the potential for chronic pain. The goal of multimodal pain management is to lessen these risks and reduce the use of narcotics after surgery.

Multimodal pain management is the use of two or more medications that have different mechanisms of action before, during and after surgery, says Kara Fortune, PharmD, BCOP, director of Clinical Integration and Implementation at HealthTrust. For example, it could involve using both a local anesthetic and NSAIDs to treat post-operative pain, or a combination of peripheral nerve blocks, anticonvulsants and COX-2 inhibitors before surgery. A multimodal pain management plan could also include physical therapy, particularly in the case of orthopedic surgery.

This type of multipronged pain management began to be considered because of the growing incidence of post-surgical pain. “There are about 35 million ambulatory surgeries in the United States annually, and about 45 million inpatient surgeries with more than 80 percent of those patients experiencing pain from the time of the procedure up to two weeks post-op,” Fortune says. “The sheer volume makes hospitals and physicians want to do a better job in managing pain for their patients.”

Volume is not the only factor. Since facilities now have to report patient satisfaction with pain management as part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in order to get reimbursed, they want to make sure patients’ pain is satisfactorily managed. Value-based incentive payments and purchasing programs are calculated from these HCAHPS scores, making it essential for hospitals to have good pain management outcomes.

One of the goals of the multimodal pain management approach is to reduce narcotic consumption because of the associated side effects, such as nausea, vomiting, respiratory distress and gastrointestinal delays.

Nurse helping patient walk down hospital corridor“Older people in particular can have neurological side effects, such as hallucinations,” says Lynn Tarkington, assistant vice president, SourceTrust. Addiction can also be a problem. “The most common narcotics used are the most commonly abused. Physicians want to keep people from having pain, but not with so much narcotic pain medication that when they get out of the hospital, they’re addicted to it,” she adds.

Combining narcotics with other medications helps reduce the need for narcotics, as well as decreases the associated side effects, according to a review by Jan G. Jakobsson from the Karolinska Institutet in Stockholm, Sweden, published in Pharmaceuticals (July 24, 2014).

Poor pain management can lead to increased healthcare costs due to longer length of stay, readmission or post-surgical complications, such as infection, poor wound healing, deep vein thrombosis or pulmonary embolism, Fortune says. Excessive pain can also cause greater fear, which is the biggest factor in controlling pain, says Penney Cowan, founder of the American Chronic Pain Association. “The more we think about our pain, the more we suffer,” she says. “Fear is going to slow down everything, and it can control you.”

As far as the costs associated with multimodal pain management, those are still being researched, Tarkington says. “You’re adding some kind of additional therapy to have multimodal pain management, but if you decrease the narcotics, you decrease costs there. If you control patients’ pain better, the sooner they can get up and move around. The sooner they can move around, the sooner they can go home. There are a multitude of benefits from multimodal pain management.”

Fortune says ongoing pain management studies are taking several factors into consideration, including length of stay. “Pharmacy directors have to answer to their CFO about direct drug costs. Some of the medications used in this approach are extremely expensive, so economic trials are currently being conducted to see if the expensive drugs decrease hospital costs in the long run,” she says. Even with an expensive medication, if it takes a day off of a hospital stay, it could potentially be worth the cost, Fortune continues.

Patient satisfaction with a hospital’s ability to manage pain is also still being studied, but the future looks promising. The pain management section of the HCAHPS survey has gone up from an average of 67 percent of U.S. patients saying their pain was always handled in 2008 to 71 percent in 2013, according to the HCAHPS website.

“The goal around the multimodal approach is to improve those scores and improve reimbursement for facilities,” Fortune says.

Patient education prior to surgery is key to helping pain management, Cowan says. “Post-op begins in pre-op, in helping patients to prepare for surgery,” she says. “Healthcare providers play a vital role in communicating with patients about what their post-op responsibilities are so they have a smoother recovery and don’t prolong pain or experience additional pain.”

Post-op, patients also need to be very careful not to push themselves too hard, too fast. People tend to want to do everything they couldn’t do right away after surgery once they start to feel better.

“We often don’t listen to the warnings our bodies give us and wait until we can’t move,” Cowan says. “In that time, there could be some kind of nerve damage or muscular damage. Patients have to pace themselves.”

The future of multimodal pain management in reducing costs and risks appears positive as more research is being conducted and patient satisfaction has continued to climb slowly but steadily. As Tarkington puts it, “A patient without pain or in less pain is likely to recover faster and be happier.”

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