美国《临床肿瘤学杂志》2018年3月15日在线先发

癌症中心住院患者的疼痛管理：一项评价一个系统性综合治疗方法——“爱丁堡疼痛评估和管理工具”——的集群化随机试验

Marie Fallon, Jane Walker, Lesley Colvin, Aryelly Rodriguez, Gordon Murray, and Michael Sharpe ...Show More

Licensed under the Creative Commons Attribution 4.0 License: http://creativecommons.org/licenses/by/4.0/

目的

目前癌症患者的疼痛管理并不满意，为此，我们将医生实施的床旁疼痛评价和管理工具（爱丁堡疼痛评估和管理工具[EPAT]）加入到常规治疗（UC）中，旨在对疼痛转归的影响与单纯常规治疗相对比。

患者和方法

在一项双臂、平行组、集群随机化(1:1)试验中，我们在英国的19家癌症中心，观察了疼痛结果情况，然后随机将这些癌症中心分组，一组实施爱丁堡疼痛评估和管理工具[EPAT]，另一组继续常规治疗。记录从入院到入院后3-5天出现疼痛最严重（采用简明疼痛调查表）时临床上明显（≥2个点）改善情况，主要终点为每一癌症中心研究参与者疼痛最严重时获得明显改善的百分比变化，次要终点包括镇痛药物处方量和阿片类药物相关的不良反应。

结果

10家癌症中心被随机分配到爱丁堡疼痛评估和管理工具[EPAT]实施组,9家分配到常规治疗组。我们入组了1921名患者，从93%（n=1795）的患者中获得了数据结果。参与者(平均年龄60岁，49%的女性）为多种癌症类型的患者。对于随机分配到爱丁堡疼痛评估和管理工具[EPAT]实施组的癌症中心，在疼痛最严重时获得临床明显改善的参与者百分比从47.7%增加到54.1%；对于那些随机分配到继续常规治疗的癌症中心，这种百分比从50.6%下降到46.4%，绝对差值为10.7%(95%CI,0.2%21.1%；P=0.046)，剔除两家应当实施而未实施EPAT的癌症中心，则绝对差值增加到15.4%(95%CI,5.8%-25.0%，P=0.004)。实施EPAT的癌症中心在处方量和简明疼痛调查表疼痛分值上都有更大的改善。其他疼痛和痛苦结果、以及阿片类药物不良反应，EPAT组和UC组之间没有差异。

结论

一种系统的综合治疗方法可以改善癌症中心住院患者的疼痛转归，且不会增加阿片类药物的不良反应。

《壹篇》李晓娜

Pain Management in Cancer Center Inpatients: A Cluster Randomized Trial to Evaluate a Systematic Integrated Approach—The Edinburgh Pain Assessment and Management Tool

Marie Fallon, Jane Walker, Lesley Colvin, Aryelly Rodriguez, Gordon Murray, and Michael Sharpe ...Show More

Licensed under the Creative Commons Attribution 4.0 License: http://creativecommons.org/licenses/by/4.0/

Purpose

Pain is suboptimally managed in patients with cancer. We aimed to compare the effect of a policy of adding a clinician-delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes.

Patients and Methods

In a two-arm, parallel group, cluster randomized (1:1) trial, we observed pain outcomes in 19 cancer centers in the United Kingdom and then randomly assigned the centers to either implement EPAT or to continue UC. The primary outcome was change in the percentage of study participants in each center with a clinically significant (≥ 2 point) improvement in worst pain (using the Brief Pain Inventory Short Form) from admission to 3 to 5 days after admission. Secondary outcomes included quality of analgesic prescribing and opioid-related adverse effects.

Results

Ten centers were randomly assigned to EPAT, and nine were assigned to UC. We enrolled 1,921 patients and obtained outcome data from 93% (n = 1,795). Participants (mean age, 60 years; 49% women) had a variety of cancer types. For centers randomly assigned to EPAT, the percentage of participants with a clinically significant improvement in worst pain increased from 47.7% to 54.1%, and for those randomly assigned to continue UC, this percentage decreased from 50.6% to 46.4%. The absolute difference was 10.7% (95% CI, 0.2% to 21.1%; P = .046) and it increased to 15.4% (95% CI, 5.8% to 25.0%; P = .004) when two centers that failed to implement EPAT were excluded. EPAT centers had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC.

Conclusion

A systematic integrated approach improves pain outcomes for inpatients in cancer centers without increasing opioid adverse effects.

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