A METHOD FOR EVALUATION OF THE MANAGEMENT OF CHRONIC NON-CANCER PAIN IN GLOBAL CITIES By Shehnaz Fatima Lakha A submitted thesis in conformity with requirements For the degree of Doctor of Philosophy Department of Institute of Medical Sciences University of Toronto 2016 Copyright by Shehnaz Fatima Lakha, 2016
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A METHOD FOR EVALUATION OF THE MANAGEMENT OF
CHRONIC NON-CANCER PAIN
IN GLOBAL CITIES
By
Shehnaz Fatima Lakha
A submitted thesis in conformity with requirements
For the degree of Doctor of Philosophy
Department of Institute of Medical Sciences
University of Toronto
2016
Copyright by Shehnaz Fatima Lakha, 2016
ii
A METHOD FOR EVALUATION OF THE MANAGEMENT OF
CHRONIC NON-CANCER PAIN IN GLOBAL CITIES
Shehnaz Fatima Lakha
Doctor of Philosophy
Department of Institute of Medical Sciences
University of Toronto
2016
ABSTRACT
This dissertation explores the outputs of structures and processes influencing clinical
services for chronic non-cancer pain (CNCP) management globally. It focuses on facilities and
services available in three global cities: Kuwait, Karachi, and Toronto. It develops and
demonstrates qualitative and descriptive survey tools capable of assessing CNCP services and
management, and associated barriers from the perspective of academic pain specialist involved
in delivery of CNCP services in those cities. Those tools are based on an original conceptual
framework for guiding evaluation of CNCP services and management globally.
In addition to a general introduction and discussion sections, the dissertation is made up
of three sections. The first section integrates and reviews the literature on chronic diseases,
CNCP management, and existing health care systems with respect to CNCP services generally
and with a focus on the target global cities in particular. The second section consists of an
analysis of methodological research options and development of a Structure Process Output
evaluation frameworks based on a hybridization of Donabedian and Logistic evaluation
iii
frameworks (DL-Hybrid). Mixed methodology survey and interview instruments were designed
to evaluate perspectives of pain clinic leader using that DL-Hybrid framework and organized to
characterize three output domains: 1) infrastructure utilization, 2) clinical service delivery and 3)
education and research activities. The third section reports on semi-structured interviews with
academic pain specialists using those instruments. Four participants were recruited from each of
the three global cities (8 men and 4 women). Data was analyzed both quantitatively and
qualitatively. Krippendorff’s thematic clustering was used to reveal themes within qualitative
data. The three cities showed important differences in how the health system operated but pain
specialist shared common training and professional goals and barriers.
This qualitative survey provided insights into those goals and barriers. Similarities were
observed across the three cities reflecting perhaps the fact that by definition global cities
resemble each other economically. The biggest shared obstacle was a lack of resources for
coordinating services and evaluating outputs as well as the lack of recognition of the significance
of CNCP. The study highlights similarities and variation in perception of barriers. It
demonstrates how a global cities lens and a systematic evaluation framework can reveal
structural and process issues related to pain clinic outputs aimed at reducing the burden of
chronic diseases such as chronic pain both locally and globally.
iv
“Seek knowledge from the cradle to the grave”
(Prophet Mohammed P.B.U.H)
Special tribute to my late father Haji Haroon Lakha and my mother Mrs. Roshan
Haroon Lakha
v
Certificate of Originality
I hereby declare, I carried out the work described in this dissertation, under the
supervision of Professor Dr. Peter Pennefather, Department of Leslie Dan Faculty of
Pharmacy, and Institute of Medical Sciences, and Collaborative Program of the Global
Health, University of Toronto.
The work is original, unless otherwise stated and has not been presented to any degree
anywhere else.
_________________________________
Shehnaz Fatima Lakha
vi
Acknowledgments
“Knowledge is like a fruit. When a fruit grows on a branch of a tree,
its weight causes that branch to bend and bow.
Similarly, when knowledge increases in a person,
it causes him to become humble and not proud and boastful.”
(Anonymous )
First, I am thankful to Allah for inspiring me and giving me the ability, strength and
desire to conduct this study.
As I reflect on this journey, there are a number of people I wish to acknowledge, who
believed in me and contributed either directly or indirectly to my PhD. This work would not have
been possible without their support and contribution.
First and foremost, my deepest gratitude goes to my supervisor Professor Dr. Peter
Pennefather for giving me a wonderful opportunity to be a part of an exciting project. Without
his willingness to act as my supervisor and guidance in research, this research work would not
have been undertaken. I first met Dr. Pennefather when I took his module “Introduction to
Global Health” to find a co-supervisor, and he encouraged me to speak to several Global Health
Scholars who might be interested in the subject. While looking for supervisor, I kept formulating
my research question with his guidance, though it wasn’t in his primary area of research however
as a true mentor, he never left me alone and demonstrated dedication and belief in my topic—
and me. One day after class, I asked him would he be interested in supervising my candidature,
rest is history! Thank you- Dr. Pennefather for being such a great mentor and incomparable role
model. You have always been positive, patient and encouraging.
I wish to express special thanks to my thesis committee members. I owe a debt of
gratitude to Dr. Peri Ballantyne, whose encouragement and interest for my work have motivated
vii
me to continue my endeavor. I appreciate her edits and detail oriented constructive feedback that
helped improve this thesis. I also thank Professor Dr. Angela Mailis- Gagnon, who encouraged
me to pursue this degree and who has mentored me for almost 12 years, for her insight into what
makes a great teacher, and for challenging my thinking by helping me question assumptions and
view issues from multiple perspectives, which has also inspired this dissertation.
I would like to express my gratitude to my collaborators in Kuwait and Karachi, Dr.
Hanan Badr, and Dr. Mobina Agboatwala because this thesis would not have been possible
without their support and constructive feedback during the whole journey of this thesis.
My special thanks are extended to the Key Informants pain specialist who took time from
their busy schedules to participate in my study and discussions; without them, this research
would not have been possible. Thank you all.
A huge thank you, to all my colleagues at the University Health Network and Leslie Dan
Faculty of Pharmacy, University of Toronto, for their constant support in achieving my goals;
especially Anna Kenyon, Joyce Lee, and Donald Wong for their invaluable assistance, and
encouragement.
A special thanks to Sunita Kak for contributing her expertise and time to help me with
proofreading my early drafts to my final thesis.
A special thanks to my friends: Maria Siddiqui and Ada F. Louffat for their critical mind,
continuous support and friendship; Haris Qasim for his listening ears; and my university group
and Mahjabeen Khan for uplifting prayers.
My Family!!!! How can I ever thank you all? A very special thanks to my mother Mrs.
viii
Roshan Haroon Lakha, whose prayers and supervision assisted me in my education and her
constant encouragement helped build my self-esteem; my brothers (Haris Haroon Lakha,
Mohammed Hussain Lakha, Junaid Alam) my beloved sisters (Farnaz Lakha, Mahnaz Lakha and
Hina Haris); and nieces (Haya Lakha, Hiyam Lakha and Shanze Alam) for their unconditional
love, encouragement and cheerfulness especially at the time of my thesis. I am especially
grateful to my elder brother, who I am so fortunate to have for encouraging me in all of my
pursuits and inspiring me to follow my dreams and who supported me emotionally and
financially. I also would like to thank my nephew, Zaid Lakha, for the laughter gifted to me with
his cute and tender voice on the phone calling me Aunt BA. Also, I want to thank my extended
LAKHA family for encouraging and supporting me.
I would like to thank the Institute of Medical Sciences and Collaborative Program of
Global Health, University of Toronto for providing me with workshops, seminars and resources
to develop the skills related to my study, for funding me (in part) and giving the opportunity to
conduct this thesis. Particularly, I am grateful to Hazel Pollard, Kamila Lear and Dr. Howard
Mount for their continuous support and words of encouragement.
This is special thanks also to my near and dear ones I may not mentioned, due to
limitations of thesis for their patience and encouragement during this journey.
ix
Contribution of Author and Co-Authors in submitted manuscripts from Chapter 4 and 6
Appendix Case studies 1, 2, 3:
Author: Shehnaz Fatima Lakha
Contributions: Conceived, searched and synthesized literature review. Generated first draft of
manuscript, integrated comments by coauthors, submitted final draft
Co-Author: Dr. Peter Pennefather
Contributions: Assisted in conceiving the framework design, provided feedback on all stage of
the manuscript, approved final draft.
Co-Author: Dr. Peri Ballantyne
Contributions: Provided feedback on the early and final drafts of the manuscript.
Co-Author: Dr Hanan Badr
Contributions: Provided feedback on early and final drafts of the manuscript.
Co-Author: Dr Mubina Agboatwala
Contributions: Provided feedback on the manuscript.
Co-Author: Dr. Angela Mailis Gagnon
Contributions: Provided critical input as a CNCP expert. Provided comments on the manuscript
at all stages.
x
List of Abbreviations
ASA: Acetylsalicylic acid
CAM: Complementary and alternative medicine
CNCP: Chronic non-cancer pain
CPS: Canadian Pain Society
CPSO: College of Physicians and Surgeons of Ontario
Chapter 6– A Pain Clinic Director's Perspective on Barriers for Management of
Chronic Non-Cancer Pain in Global Cities- A Qualitative study Abstract ---------------------------------------------------------------------------------------------105
Chapter 7 – Survey of Clinic Outputs Associated with Services Provided for
Management of Chronic Non-Cancer Pain in Global Cities 7.1. Introduction ------------------------------------------------------------------------------------130
Chapter 8- General Discussion and Limitations 8.1. Discussion --------------------------------------------------------------------------------------216
8.2. Limitation of the study------------------------------------------------------------------------219
Chapter 9- Conclusion: Contribution, Implications and Future Direction
neurosurgery) through the host hospital, but only for the in-patients. Patients were admitted to
the in-patient unit for one of two reasons: either a diagnosis or a treatment dilemma that could
not be resolved during the out-patient visit. Some key informants were also involved with
delivery of pain management services at other pain clinics not associated with the academic
hospital. A few of them were primarily interventionists; therefore, they spent from several hours
to several days per week providing diagnostic and treatment procedures for CNCP patients. This
generally involved direct billing for the procedure through OHIP (P4). All key informants from
all sites mentioned that, on occasion, they provided in-patients consultancy through the acute
pain services at their hospital, but we did not determine the extent to which this occurred.
3) Types of Patient Care Delivered
The types of chronic pain problems encountered most frequently across the all pain
clinics were neuropathic pain followed by musculo-skeletal pain, and low back pain. One key
informant mentioned that their pain clinic specialized in assessing spinal pain and that made up
60-70% of their accepted referrals. The clinical focus of each pain clinic was different, ranging
from musculoskeletal, craniofacial and pelvic pain to neuropathic pain, motor vehicle accidents,
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injured workers, and opioid management. All key informants mentioned that they dealt with a
heterogeneous population, but that population was made up predominantly by women and people
in their middle age between 40-60 yrs. One key informant commented on a recent increase in
number of geriatric patients seen at their pain clinic (P1).
4) Treatment Modalities Offered At the Pain Program
All pain clinics offered a variety of pharmacological and non-pharmacological therapies.
The latter included interventional, physical and psychological therapies. All pain clinics provided
different kinds of injections and nerve block interventions. This was done on both an outpatient
and in-patient basis. Only one key informant mentioned that they offered access to spinal
stimulators. In regards to psychological training only cognitive behavioral treatment,
mindfulness and support therapy were offered directly at the clinics. None of these program
offered on-going psychological assessment and treatment. In the present survey, it was found that
there was a wide variation between clinics in the practice of different interventional procedures,
as well as use of pharmacological and opioid prescriptions.
5) Clinical Activities of Pain clinics
Only one key informant reported that the clinic held multidisciplinary rounds twice a
month for their out-patient consultation. None of other clinics held regular multidisciplinary
meetings to discuss clinical cases, but all key informants mentioned that they discussed particular
cases with other physicians and allied professionals, as needed. One key informant mentioned
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that they only had multidisciplinary meeting to discuss the course of action for in-patients. None
of these pain clinics held regular rounds or meetings to review clinical progress or management
issues. Also, in regards to the decisions making process at the clinics, key informants mentioned
that they only consulted with the core team of physicians, and final decision came from the
clinic's executive leadership (P3, P4). All key informants felt that greater collaboration among
pain clinics could help to extend the scope and coverage of services provided to CNCP patients
6) Coordination of Care
Key informants mentioned the challenge of having their pain clinic as part of a large
academic hospital with many priorities. All kinds of other medical teams and individual medical
specialists are available for consultation at the hospital premises, but are also competing for the
same limited resources. One key informant P4 expressed an opinion that all CNCP patients
should have access to these individual consultants as a part of universal health care and
independently of the clinic.
All respondents mentioned that although many laboratory services and allied health
professional resources (physiotherapy, psychologists) are available, they may not be accessible
for all CNCP patients seen at their clinics (P3). One of the key informants provided the example
of physiotherapy services that might be available in the hospital for specific patients but not for
CNCP patients (P3). In the case where lab services are not available within the institution hosting
the clinic, the CNCP patient had to travel to a nearby hospital or clinic or to an institution,
located near where they live, where services are available (P2).
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7) Special Services for Impaired Population
None of these pain clinics had developed special services for physically and mentally
impaired patients, however the academic hospitals in which they are located can provide access
to such services if needed. But, P3 described the process to access those services as cumbersome
and time consuming, in order to facilitate the patients on time.
8) Referral Pathways
All pain clinics provide chronic pain assessment only upon medical referral of the CNCP
patient to the clinic. Each clinic had their own systematic referral form and system developed in-
house to meet their particular needs, however, there was a lot of variation in the patient/problem
description, the format and the process of these referral protocols. These forms ranged from one
page to a multi-page package that the referring or family physician had to fill out. P1 stated that
there is no standard practice for evaluating the relationship between the patient and the referring
physician. The process of accepting a patient is taken care of primarily by administrative staff.
The referrals are received based on pain clinical focus of the clinic and pain management
modalities they offered. The CNCP referrals generally are not prioritized in any way. However,
occasionally the referring physician does communicate in detail with clinic physician about the
severity of the patient’s illness. One key informant mentioned that they have more referrals from
within hospital than from family physicians outside the hospital. In that case, the in-hospital
referrals are from orthopaedic surgeons, neurosurgeons, post-trauma care specialists,
gynecologists, and gastroenterologists, with the majority of referrals for spine problems or
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musculoskeletal problems, the clinic’s specialty. Key informants reported that they recognized a
general pattern of referral from other specialists that reflected their expertise.
All key informants often referred certain types of CNCP patients to other clinics or
practitioners who specialize in specific conditions or pain management. P2 listed a number of
reasons that prompted referral to the other pain clinics. These included: presentation of
fibromyalgia, headaches, and auto-immune disease with chronic pain, CNCP with addiction, and
certain forms of interventional pain management that their clinics was not proficient in. Referrals
to non-pain specialists such as neurologists, urologists, gynecologists, psychiatrists,
gastroenterologists and respirologists were sometime made. All key informants often received
requests for in-patient consultation from their colleagues at the host hospital/institution.
9) Institutional Policies for CNCP Clinic
All key informants commented on the lack of pain assessment institutional policies,
protocol, procedures, and standards for CNCP services. All key informants mentioned there is no
specific written guideline for pain management practices from the hospitals or the institutions
that hosted their pain clinics. One key informant mentioned that they used certain standardized
forms and guidelines produced by the hospital but usually these were for in-patients or for
hospital procedure per se (P2). Two of the key informants mentioned that they used institution
consent forms for their out-patients (P2, P4). All key informants had developed their own semi-
structured protocol for patient evaluation, and the details of this protocol varied from clinic to
clinic. All pain clinics made use of standardized and structured questionnaires that were filled out
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by the patient before the clinic physician saw them. Some parts of these questionnaires included
validated and semi validated instruments, such as: the Opioid Risk Tool, the McGill Pain
Questionnaire and the Opioid Manager.
10) Adaptation and Use of Clinical Guidelines
At present, many physicians from different specialties (e.g. neurosurgery, neurology,
surgery, anesthesiology, psychiatry and physiotherapy) are involved in the care of pain patients in
these pain clinics. Therefore, all key informants mentioned that they use several local and
international guidelines, based on their needs i.e. medical management or procedural. For opioid
management all of them used the nationally developed Canadian Guideline for safe and effective
use of opioids. One key informant expressed an opinion that pain societies guidelines focused on
general pain management and that none offered guidelines for specific interventions. Some of
these pain clinics have adapted international guidelines according to their particular requirement.
One key informant viewed pain society guidelines as of limited use. On the one- hand, they are
targeted to practitioners who do not complete background knowledge of both medical
management and psychological interventions related to pain. On the other hand, pain specialists
practicing in pain clinics are already well aware of different published guidelines (P4).
11) Planning for Discharge and Continuity of care
Key informants expressed that, as very few CNCP patients are cured, complete
“discharge” from health services is unlikely to occur as a result of the care that they provide.
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They mentioned that there are multiple ways through which continuity of care is provided.
However all key informants overwhelmingly agreed that their interaction with the CNCP patient
is only for a limited time and eventually each patient has to be discharged form their clinic back
to the community for on-going management of their chronic condition. Patients who come back
to the clinic after certain time period are all considered new cases referred for a new complaint.
Discharging the CNCP patients back to the community is challenging for these pain
clinics practitioners (P2, P3), because of the view that many community physicians lacks the
skills, experience or resources to CNCP patients (P3). P3 expressed an opinion that in some
cases, by the time an acceptable level of pain management has been obtained, both patients and
their caregivers may have lost sight of who is responsible for on-going pain management,
particularly if a long time has elapsed between first referral, initiation of intervention(s), and
discharge from the clinic. Also, sometimes these patients stopped seeing their pain specialist
during the treatment period for personal reasons. All of the key informants reported that,
regardless of the way that these CNCP patient leave their care, the family physician and referring
doctors receive consultation notes and an evaluation summary along with the recommendation
for on-going pain management. However, key informants mentioned that they never received
any feedback or updates on the progress of the discharged patients (P2, P3, P4).
Summary of Delivery of Clinical Services
All pain clinics offered some unique service that was not available at other clinics in
Toronto
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None of those pain clinics function in an integrated, interdisciplinary manner
Effective services (medical and allied health) not available or accessible for most
patients.
Need to develop collaborative relationships between programs and services caring for
CNCP patients was recognized
Lack of health care resources and support from the affiliated institutions was noted
There are lengthy waitlists at all pain clinics
Discharge concerns and lack of continuity of care.
EDUCATIONAL Activities:
1) Funding Mechanism for Education
The key informants mentioned that there was no expectation or budget from their hospital
for providing pain education activities. Pain clinics had to find outside sponsors for such
activities or had to subsidize those activities through other revenue streams. One of the key
informant mentioned that they organized pain education rounds for family physicians, which was
usually funded through direct fund raising from various sponsors and stakeholders.
2) Education Prospects
All pain clinics provided fellowship training but this was managed under the umbrella of
different clinical departments such as anesthesiology or physical medicine and rehabilitation. All
pain clinics regardless of their department offered one-year pain fellowships but within the
149
discipline of the clinical department in which they were located. Key informants from all pain
clinics offered self-funded fellowships to international medical graduates that provided
additional revenue for the clinic. These fellows go through specific assessment procedure and
interviews before being accepted. These fellowships are affiliated with a specific university and
department and have different protocols dependent on the primary department of origin.
However, none of these pain fellowships are structured or associated with a standardized
pathway, even though they are being carried out in a given clinic. All pain clinics host rotation of
students from different levels of medical education, such as specialty residents and from
divergent areas of medical practices i.e. family practice residents, second and third year medical
students’ electives, etc. For some of these students, this is an elective rotation and these students
stayed at the pain clinics from only two to four weeks.
The pain clinics also accepted less formal visits of international medical students and
physicians. All key informants stated there is no formal orientation in their pain clinic for those
visitors, however, before the students start at the pain clinic, they had usually attended the pain
rounds and had discussion with the pain specialist and their team. P4 mentioned that their clinic
focused on hands-on practical training for all their students and fellows. P1 stated that the
students and fellows are required to meet the clinical director for informal conversation and
direction, and are assigned to a leading pain physician associated with the clinic.
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3) Teaching and Training Practices
All key informant mentioned that there is no structured guideline or protocol for what
these different students and fellows should get out of their time in the clinic. Those trainees all
have quite varied background knowledge and skills. All students are affiliated with a specific
teaching institution and therefore, they follow the guideline of that institution or base hospitals.
Both P1 and P3 mentioned that the facilitating pain specialist generally discusses every patient
with the students and clarifies their queries. None of these pain clinics offered continuing
education programs. However, team members did attend different pain conferences about once a
year and claimed CME credits for the experience. Pain fellows are not certified after their pain
fellowship, because there is no such pain certification offered in Canada. P2 confirmed that
fellows are certified under the distinctive specialties of the departments where the clinic is
located.
4) Student Evaluation
P2 mentioned that all fellows are evaluated at 12 weeks relative to their performance on a
pre-entry assessment program. This assessment is carried out by the pain clinic leadership
assisted by other core members of the pain clinic. However, P2 admitted that these exams are not
rigorously structured or standardized. P1 stated that rotating elective students spend only a short
period at the pain clinics. Therefore, they had to be evaluated at a very limited level and there
was no evaluation on their pain management knowledge. Usually, it is only their participation at
the pain clinic that is verified on the forms supplied by their home institutions/universities.
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5) Pain Education Rounds
Three key informants mentioned that they organized educational rounds once a month in
which a Fellow or a resident speaks on a given topic. Other than this, there is no specific
structured pain educational activity. Pain as a topic is often not a major focus of the clinical
education programs available within the departments that host the clinics. The nature of those
pain lectures depended on which department or pain specialist organized the lecture or round.
One key informant shared his concern with the level of pain training of Canadian students as he
is associated with an international examination board and found that Canadian rate of success in
pain specialist exams is approximately the same as specialists trained in Iran. In addition, P4
expressed dissatisfaction with the pain training among family physicians in general, therefore
and felt that there is need for pain education for family physicians.
Summary of Educational Activities:
Lack of funding for educational activities
Need to develop structural educational programs for all level of students
Establish pain education within the curriculum of undergraduate and postgraduate
training programs
Need of coordinated and structured educational initiative for fellows and team members
Lack of continuing education programs for staff
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RESEARCH Activities:
1) Funding Mechanism for Research
Key informants mentioned that none of their clinics have dedicated budget for research
activities, except the salary of a research coordinator. Budget constraints within the pain clinics
and health system reported by pain specialists seemed to be the major contributing factor to the
shortages of well-designed clinical studies. Key informants were critical about the lack of
resources for research activities. Also, key informants indicating that there are no grants
available in pain clinics for student research activities, and that student conducting researches do
not get any remuneration for their activities. While students can try to apply to grants agencies or
their academic institutions, these are rarely successful.
2) Research Personnel
P1 and P2 reported their involvement in research projects at the time of this survey. Not
all pain specialists or their core team were involved in research activities on a regular basis. P2
and P3 stated that usually students and fellows are the ones involved in research activities, as it is
also part of their fellowship completion requirements. P1 and P3 stated that their clinics had a
fulltime research coordinator to administer the research activities and to assist the pain specialists
and fellows in their research activities. There was no reported formal collaboration and
communication among pain clinics for research activities.
153
3) Research Productivity
Three key informants mentioned that their pain clinic focused on conducting research on
treatment approaches for all types of pain disorders. At the present time, the clinics were
conducting a variety of research studies ranging from retrospective, prospective follow up duties
to literature review on pain disorders. P1 mentioned that their pain clinic usually conducts
retrospective and chart reviews, due to lack of funding for prospective research. The length of
these clinical research studies varies, depending on what is being studied. The numbers of
publications published per year from these pain clinics varied from one to four. None of the pain
specialists interviewed published every year.
Summary of Research Activities:
Need funding for CNCP research
Need to promote and support research in pain
Research agenda should be developed to identify gaps in evidence of CNCP management
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7.3.2. Survey Results – Kuwait:
Background Key information;
Three men and one woman were the key informants selected from Kuwait.
Key informants ranged from 36-45 years of age =3, 45-55 years of age =1.
Practicing pain management from 5-15 years.
All of key informants involved in the care of chronic pain patients were Anesthesiologist.
All pain clinics were located in urban settings.
All graduated from English speaking universities and have training in pain management
from West.
Some form of multidisciplinary services provided (pain physician, a nurse, and a physical
therapist) at minimum.
Among these clinics, all reported that they offered services for the management of
chronic pain but these varied considerably from clinic to clinic.
INFRASTRUCTURE Utilization:
1) Organization and Conceptualization of Pain Care Clinic (use structural/architectural
terms)
As per our inclusion criteria, participants from Kuwait all were responsible for delivery
of chronic pain management services through pain clinics located in large government academic-
affiliated hospitals. An anesthesiologist assisted by a nurse assistant led each clinic. P1 and P2
commented that they have tried in the past to provide interdisciplinary or multi-disciplinary
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services but failed. P2 stated that the Ministry of Health has plans to make their clinics
multidisciplinary. P4 did report providing multidisciplinary services for the assessment and
treatment of chronic pain, but on an ad hoc, case-by-case basis.
All the pain clinics provided the following services: provision of assessment and
diagnosis, interventional and implementation of pathways to pain care. All clinics are under the
jurisdiction of Kuwait Ministry of Health. However, direct support varied in a way dependent on
the clinic's size and the services offered. For all participants, the major mode of delivery of
services for chronic pain was in an outpatient setting. However, the types and condition of CNCP
patients treated varied from clinic to clinic. Kuwaiti pain clinics offered a wide range of expertise
in pain management services for their patients. Key informants reported expertise included
pharmaceutical to interventional management for: low back pain and failed back surgery
management, ultra sound based blocks, acupuncture, spinal stimulators, intrathecal drug pumps
and radio frequency ablation. All pain specialists are paid as anesthesiologist through the
Ministry of Health. P1 mentioned that all provide chronic pain services as a matter of choice
since they do not receive additional income for providing those services.
All the services provided to the Kuwaitis are covered by universal health coverage
system. Non-Kuwaitis, such as migrant workers or their families pay for few services such as
MRI or CT, either through direct payment or indirectly via insurance company payments to the
clinics/hospitals. Indeed, two of the key informants reported running private practices to take
advantage of this additional source of revenue.
156
2) Human Resources:
All clinics had an anesthesiologist and a nurse assistant as part of their core staff. Two of
the key informants mentioned that they had trainee anesthesiologist rotating through as a patient
registrar. One cited having trained a pain technician as an integrated part of their team. This
additional staff assisted the pain specialist in some case assessment or during intervention. All
key informants reiterated there were no other health care professionals that worked directly
within the clinics. However, P4 mentioned that although psychiatrists and psychologists are not
directly integrated into the pain clinic's staffing list, patients are regularly referred to such
specialists.
Pain physicians serve as the principal source of training at the pain clinics. Nurses and
other health care providers such as the registrar and pain technicians work under the supervision
of the principal physician at the pain clinic. Together they provide care at various levels: direct
treatment, prescribing medication and performing pain relief procedures. The numbers of hours
worked by pain specialists in these clinics varied from a day to three days per week. Similarly,
the days they spend doing small procedures and in operating rooms (OR) ranged from one to
three days a week. Nurses were involved in the management of chronic pain patients’ at all four
sites. P1 and P2 both mentioned that they trained their nurse assistants in specific pain
management procedures. The number of hours worked by nurses varied from a few days per
week to one or more full-time equivalent nurses. The nurses in all the pain clinics were involved
in providing assistance during the assessment and interventions. P2 mentioned nurses were also
involved in follow-up and administrative activities, including research. P4 mentioned that
157
support also came from trainee patient registrars and pain technicians who became involved in
patients’ interventions/ procedures, follow-up, report writing and administrative duties.
Key informants reported that physiotherapists were available on all the hospital sites.
Only at one site were psychiatrist and psychologist services directly available to the pain clinic
through the host hospital, usually for cases dealing with spinal stimulators. P1 revealed that the
clinic had recruited a psychologist, however due to the complex nature of the chronic pain
patients seen at the clinic, the psychologist did not stay beyond a month.
With respect to secretarial support, in all clinics offering treatment to chronic pain
patients, nurses of their team undertook the administrative duties. P1 complained about a
shortage of human resource.
3) Pain clinic Space Allocations
All key informants reported that there are no separate rooms for consultation and
assessment. Both P1 and P2 reported that they do their assessment on the examination table,
which is provided in the corner of the consultation room. Two key informants mentioned that
they conduct small procedures in their clinics, whereas two key informants mentioned that they
have access to a separate room for small procedures. All key informants had specific days in OR
for complex procedures. However, P1 explained it takes many efforts to get those OR slots as
surgeons are given priority.
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None of the participants have routine access to in-patient’s beds. P1 mentioned that if a
patient does require one after the surgery or one is needed due to a special scenario, only1-3 beds
were available in the affiliated hospital. None of the pain clinics had a dedicated administrative
area, or a waiting area dedicated for chronic pain patients. Generally, it is one common waiting
area designated for a group of clinics, including the pain clinic.
4) Financial Support for Pain Clinics
All key informants mentioned that the Ministry of Health controls the clinic budget and
funding, and that they have direct involvement in negotiating that funding. There is no special
funding from the hospital for delivering chronic non-cancer pain services. All respondents
mentioned that in the last 5 years, the budget of the pain clinic from their host institution has
stayed either constant or increased only slightly. However, they all agreed that in the near future
the budget would have to increase, as they were to undertake to do more interventions that are
complex and see more CNCP patients.
5) Collaboration and Affiliation within Hospitals
Key informants stated that pain clinics were governed by the Ministry of Health and were
under the umbrella of anesthesia departments of major institutional/ hospitals. Even though these
key informants were academicians at the hospitals, their teaching had no affiliation with the
universities. Key informants expressed their disappointment in receiving no support from the
institution or Ministry for the advancement of these pain clinics. P2 reiterated that the director of
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the institution likely was unaware the institution hosted a pain clinic. Key informants P1 and P2
were both of the opinion that the pain clinics were established and operating only as the result of
their individual efforts and interest.
All key informants mentioned that there is no formal affiliation or collaboration between
pain clinics, except referring complicated cases back and forth. P1 and P2 expressed their
disappointment, as there was no communication between the pain specialists, due to each being
busy providing other services. Key informants mentioned that they have formed a national pain
society called “Pain Kuwait Society”; however, it was not active at the moment. As all the pain
specialist are anesthesiologists and, P1 mentioned that, they meet regularly at anesthesiology
council meetings. P1 shared his frustration that a proposal to establish a chronic pain center for
Kuwait had been rejected repeatedly by the government and believed that this accounted for
reduced enthusiasm of pain specialist for a collaborative center and has caused them to focus on
private pain practice opportunities. One key informant commented that pain specialists were
trained abroad in unique ways and each of them have their own ways of managing CNCP
patients. They each recognized the opportunities that might emerge from combining their
different skill sets for the benefit of the larger communities of pain patients in Kuwait. P4
mentioned that this was the rationale they put forth behind the proposal for national pain center,
which was however, rejected.
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6) Access to Resources for Delivering CNCP services
All key informants were able to access to all laboratories for blood work, x-rays, MRIs, and
equipment for pain management, within premises or nearby hospitals. However, pain clinics on
their own had no such facilities. Two key informants shared their struggle for electromyography/
nerve conduction facility, which is not easily available in all hospitals. All these facilities are
provided free of charge for Kuwaiti patients but non-Kuwaiti patients have to pay a minimum fee
to access some of these services. P2 stated that there was no facility for drug testing in Kuwait.
With regards to equipment used in pain clinics for patients, it was not directly under the control
of the clinic and must be requested through others. P1 and P4 specified that they received access
to needed equipment only after being persistent about it.
Summary of Infrastructure Salient Issues:
Pain specialist belong to a single health care discipline (Anesthesia), with a focused
practice
Budget and funding is controlled by Ministry of Health; there is no direct budget from the
hospital
General resources, staff and space allocation are insufficient
Governance structure and collaboration within hospital and outside are crucial to improve
pain management
Access to resources is needed for better and more coordinated delivery of pain care.
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Delivery of CLINICAL SERVICES:
1) Delivery of CNCP Services at Out-patient Setting
P2 stated the business hours of the all pain clinics in an out-patient setting were between
8:00 am-2:00 pm. One clinic operated every day of the week. P1, P2, P3 stated that they spent
seven hours per week in the assessment of chronic pain patients (while P4 reported spending 14
hours per week).
2) Workload and Waiting Time
As reported by key informants, there are three types of patients, new patients, follow-up
after a procedure; and regular follow-up patients. Key informants mentioned that the total
number of new cases of chronic pain evaluated in the CNCP clinics varied for each pain
specialist. P1 assessed only 2 new CNCP patients per week while others assessed 10 to 20 per
week. All pain clinics asked the new patients to fill out a structured questionnaire on their first
visit. The duration of assessment of a new patient by three key informants was 10-30 minutes on
their first visit. Due to time limitation, they were unable to get into details of the patient’s
personal or social life during that consultation. However, P1 devoted 75 minutes to patient
assessment on the first visit. Based on that assessment P1 then made a decision for further
investigation, consultations or treatment recommendations.
P1, P2, P3 reported that new patients waited approximately one to six months for their
first appointment at the pain service. They mentioned that about 7 to 45 new patients are always
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on their waiting list. P2 on the other hand immediately responded to the patient’s referral and
saw the patient right away. All key informants conducted procedures and spent 2-3 days in OR.
Some of these key informants conducted small procedures in their clinics, others did all types of
their procedures in the OR. P4 suggested that 15 small injections (e.g. trigger points) or only 2
complex procedure (such as stimulator, pump) can be done in a day.
If a patient was booked for a procedure, the pain specialist sees the patients after the
procedure in a follow-up visit. The volume of patients per year in a follow-up visits ranged
approximately from 500 -750 patients’ in these pain clinics. However, the type and volume of
follow-up (procedure or normal patient) were mixed every week, depending upon the activities
of the clinic. P4 reported spending approximately 10-15 minutes on each follow-up evaluation.
All key informants mentioned that they offered follow-up to patients for indefinite period. The
follow up of patients was based on their need and pain specialists’ judgement ranging from 2-6
months. Both P3 and P4 mentioned that if the pain was stable for the patient and they needed
only their medication (prescription) supply, they did not have to come for a follow up but could
get it through an assistant.
P1 mentioned that in order to lessen the burden on pain specialists, the Ministry of Health
had tried to implement a process of directing chronic pain patients to their GPs for a continuous
prescribing regime. However, neither that key informant nor their colleagues had implemented
those services, due to their own fears and hesitations. P1 revealed that there was some loss of
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CNCP patients in follow-up, due either to the patient getting better, being dissatisfied with the
services provided and looking for another doctor, or possibility of death.
Only one clinic offered in-patient services for management of complex patient needs and
they admitted 80 patients per year for complex pain management. Other clinics did not offer any
in-patient services. P1 mentioned that where there is urgent need for admitting a CNCP patient,
they have to request other specialties i.e. medicine or surgery to admit their patient. P1
mentioned that pain specialists provided in-patients consultation through the acute pain services,
as a favor to their colleagues or if the hospital asked them to do so.
P4 emphasized the need of having more pain specialists as presently there were nine
Kuwaiti pain specialists and all of them are from anesthesia and intensive care. All of them have
additional responsibilities such as leading and managing the departments. P2 and P3 were also
involved with delivery of pain management services at other private pain clinics (P2, P3).
All key informants felt that CNCP patients come with unrealistic expectations, which
were difficult to follow. For example, patients may want their pain cured or eliminated. Key
informants try to make them set realistic goals, such as restore functionality or manage pain
better. They treat their CNCP patients with pharmacological options for primary pain complaints,
which were related to biomedical condition. Even though they were very well aware of non-
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pharmacological modalities and their benefits, P1, P2 and P3 were unable to provided
interventional and other alternatives that are feasible.
3) Types of Patient Care Delivered
The most frequent types of chronic pain encountered across the all pain clinics were back
pain followed by musculoskeletal (MSK) pain, and neuropathic pain. Two key informants
mentioned that they have extensive referrals for failed back surgery syndrome from surgeons.
Each pain clinic services focused on different CNCP condition: for e.g., from musculoskeletal
pain, chronic pancreatitis, Crohn’s to neuropathic pain, to post-surgical pain, spine related
problem and its management; to failed back surgery syndrome for spinal simulators. Except for
P2who sees younger CNCP patients between the ages of 20-30 years, all other key informants
see heterogeneous population, middle age, primarily women. Interestingly, P2 estimated that
70% of the musculoskeletal pain cases seen are related to lack of exercise and general inactivity.
4) Treatment Modalities Offered At the Pain Program
All pain clinics offered a variety of pharmacological and interventional therapies. The
pattern of CNCP management of interventional pain specialists has diversified. The varieties of
pain specialist included performance of different kind of injections and blocks. This was done on
an outpatient and same day surgery basis. P3 and P4 mentioned that they offered spinal
stimulators and one (P1) offered acupuncture. None of these pain clinics offered on-going
psychological treatment or any alternative treatment such as massage therapy, or manual
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services. In the present survey, it was found that there was a wide variation in the practice of
different procedures, as well as use of pharmacological and opioid prescriptions. All
pharmaceutical compounds from NSAIDs to anticonvulsants were available for Kuwaiti national
patients. P1 commented that these compounds were available to non –Kuwaitis for a small fee or
entirely covered through third party insurance. P1 and P2 mentioned that new generation
compounds such as Pregabalin and celecoxib and newer opioids, were only available to
Kuwaitis.
P1 mentioned that only some hospitals allowed access to opioids and only some pain
specialists made use of this mode of pain management in their practice. There was a high level of
government regulation over opioid accessibility and there were restrictions from the government
on availability of certain opioids prescription. P1 emphasized their hesitation and fear for
prescribing opioids, due to government’s strict policies. They preferred a combination of pain
relievers for their patients. P4 preferred installing an expensive intrathecal pump instead of
prescribing high doses of oral opioids.
P4 revealed that many patients with failed back surgery were referred and were the best
candidates for spinal simulators. The respondent stated that the cost of the instrument only was
30,000 KD (CND$99,453) and the whole procedure was expensive. Not many patients are able
to pay for this out of pocket, but they have the option of approaching an insurance company or if
the patient is a Kuwaiti then he/she can be referred through a government process.
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4) Clinical Activities of Pain clinics
None of these pain clinics held regular meetings to discuss clinical cases with their team
member i.e. nurses, or held regular meetings to review clinical progress or management issues.
However, P3 did organize regular staff meeting sometimes to audit their clinic routine. All key
informants mentioned that they consulted or had informal meetings with other physicians and
allied professionals, to discuss the course of action for any complex CNCP patient or the
procedure, if needed. P1 mentioned that they hosted general rounds for anesthesia but nothing
specifically dedicated for pain (P1). All key informants indicated that they believed collaboration
among pain clinics would help to extend the scope and coverage of services provided to CNCP
patients in Kuwait.
Coordination of Care
Key informants reported that the pain clinics are part of the hospital, therefore, all kinds
of other medical teams and individual medical specialists are available for consultation at the
hospital premises. All CNCP patients have access to these individual consultants as a part of
universal health care. All respondents mentioned that there are few allied health professional
resources (e.g. physiotherapy, psychologists) available but it may not be accessible for all
patients. CNCP patients have to travel to a particular or a nearby or within their community
hospital to access certain lab services that were not available at their regular hospital
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7) Special Services for Impaired Population
Special services for physically and mentally impaired patients were difficult to find in the
pain clinics but they were accommodated, if possible.
8) Referral Pathways
All pain clinics provided chronic pain assessment or case identification only upon referral
of a CNCP patient to their clinic from other specialists. Each clinic received many referrals from
all different specialist and allied health professionals and departments. A majority of these
referrals were from within the hospitals. P1, P2 and P3 all revealed that they did not receive
many referrals from GPs due to lack of awareness about presence of pain management clinics. In
fact, P2 stated that in 8 years of practice no single GP referral had been received by their pain
clinic.
Each clinic has their own systematic referral form and system developed in-house to meet
their particular needs. However, there is a lot of variation in the patient/problem description, the
format and the process of these referral protocols. These forms ranged from one single to two
pages that were filled out by the referring or family physician. However, P4 mentioned that many
physicians just wrote few lines without explaining the whole pain condition of the patient. P4
also mentioned that some patients came to them based on word of mouth about the pain clinic
from other patients and the pain clinic accepted them. In addition, many referrals came from the
neighboring countries in the Gulf region. Another important finding from this survey was that
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some of these pain clinics were established near the neurosurgery department, so that a
neurosurgeon is available to them immediately for neurosurgical consultation and assessment.
P1 mentioned that the process of accepting a patient is taken care of primarily by nurses.
The referrals were received based on pain specialist expertise and pain management modalities
they offered. These referrals generally were not prioritized in any way and there were no
preferences of Kuwaiti over non-Kuwaiti. However, occasionally in cases of urgency, the
referring physicians did communicate in detail with pain clinic physician about the severity of
the patient’s illness, to prioritize the consultation. All key informants often referred their CNCP
patients to other pain practitioners who specialize in a specific condition or particular pain
management strategy. Key informants often received requests for in-patient consultancy from
their hospitals.
9) Institutional Policies for CNCP Clinics
All key informants highlighted the lack of pain institutional policies, protocols,
procedures and standards for CNCP services. They also mentioned the lack of written guidelines
for pain management practices in the hospitals or the institutions. All the pain clinics had a
standardized and structured questionnaire to be filled out by the patients before seen by the
physician. P1 and P4 mentioned that some part of these questionnaires was developed with
validated and semi validated published instruments used for pain scores, sleep scores and quality
of life.
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10) Adaptation and Use of Clinical Guidelines
All key informants adapted to the international guidelines, based on their needs i.e.
management or procedural. P1 expressed an opinion about the gaps in the guidelines and thus
used them as a reference only. Although all of them adopted the state guidelines where they were
trained, the most commonly used guidelines were from IASP and WHO.
11) Planning for Discharge and Continuity of care
All key informants found that there was continuity of care until these patients were cured
and then discharge. Pain clinic specialists found discharging patients to a community clinic or
GPs was difficult because CNCP patients often had complex cases that required lot of support
and direction. P1 and P2 felt that the GPs would have inadequate ability to deal with these
patients and lacked sufficient chronic pain management knowledge. Although records of all
CNCP patients were kept as per hospital policy, P4 mentioned the clinic nurse also archived
records of patients that had left the clinic in case they returned.
Summary of Delivery of Clinical Services
• Variation in clinical practice of pain specialists (number of patients seen, wait time,
consultation time, follow-up time, type of patient seen, modalities offered, referral
formats.).
• Effective drugs or non-drug modalities not available or accessible to all patients.
• Need of medical professionals and allied health care from diverse fields dedicated to the
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ongoing and integrated care of patient.
• Views about the gaps in the international guidelines.
• Lack of referral connections between general physicians and pain specialists.
• Ongoing longitudinal care provided by a pain specialist.
EDUCATIONAL Activities:
1) Funding Mechanism for Education
Key informants can request funding of the pain educational activities, though there is no
dedicated budget for pain educational activities in the hospital or by the government.
2) Education Prospects
All key informants stated that there is no pain fellowship offered in Kuwait. They explained that
Kuwait Institute of Medical Specialization (KIMS) offers fellowship based on structured
services, and follow systematic guidelines and protocol. P1 mentioned that even if any program
director takes the initiative for this fellowship, pain clinics do not have these kind of regimens.
Two of the key informants stated that their registrars are working anesthesiologists who become
trainees for six months without any prior pain management training. They get a new registrar
every six months. P3 and P4 mentioned that responsibility for recruiting and filling the clinic's
registrar post comes under the umbrella of the Anesthesiology department and its fellowship
program. The Anesthesiology department in every institution offers pain management training as
a clinical rotation for just six month following completion of an anesthesiology fellowship-
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training program. Each anesthesiology department has a structured training guide based on
which they evaluate their students on pain management clinics rotation. Residents from the
hospitals are sent to do a pain management program and the key informants train them. KIMS
provides budget for all these training positions. According to P3, the Anesthesiology fellowship
programs in Kuwait are in their infancy.
3) Teaching and Training Practices
Key informants divulged that there were no structured trainee pain clinic guidelines or
protocols for students and fellows while spending their time in the pain clinic. Thus, trainees
follow the guidelines specified by their teaching institution, which is under the department of
Anesthesiology. Students attend the pain clinics and OR with the pain specialist to observe the
pain management process. P1 generally discusses every patient with the students to clarify any
queries they have. P1 also mentioned that the Kuwaiti Board of Anesthesia is managed by a
program director who appoints a moderator to supervise the overall program for the trainees.
That moderator then establishes the objectives of the rotation.
None of the pain clinics offers a continuing education program to their nurses or other
staff. However, P3 mentioned that pain specialists are allowed and funded to attend pain
conferences, once a year to update their knowledge. They also try to organize national pain
conference once a year and several small workshops for awareness and educational purposes.
Sometimes private companies offer workshops abroad for training of specific equipment used for
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treating pain. P1 suggested that the motives behind these workshops are primarily to sell the
equipment to the physicians.
P4 invited a team of scholars and clinicians from their former training center abroad
once or twice a year to update their knowledge and learn about new procedural techniques that
would assist them for complicated cases. Subsequently P4 would share this knowledge with
anesthesia staff and trainees through lectures. P1 was of the opinion that establishing
standardized protocol and local guidelines would be difficult because the medical fraternity uses
liberally interventional procedures and tries out latest technology coming to the market rather
than participating in an organized and comprehensive approach. Many of these procedures
should not be conducted until other pain management modalities have been tested on the
patients. The respondent shared experience of seeing many patients who have been treated with
procedures they did not need and may have suffered unnecessarily.
P1 was also worried about medical physicians taking short courses and considering
themselves to have sufficient specialized training to start treating the patients with chronic pain.
P3 expressed hope for the future with respect to the quality of pain management provision as
these newcomers had already initiated it at an individual level.
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4) Student Evaluation
Key informants reported that there is no assessment mechanism at the pain clinic and
students were evaluated within their anesthesiology department for their pain management
knowledge.
5) Pain Education Rounds
Key informants noted that fellows or residents on the educational round of anesthesia
were given a topic to present, not necessarily on pain. Other than this, there is no specific
structured educational activity. P3 mentioned that they participated in general rounds for
anesthesia but these were not specifically concerned with pain. P1 mentioned that if pain
specialists felt a need for discussion on any particular case or procedure, they did so informally.
6) Need of Education and Awareness
P1 stated that the lack of knowledge and training for healthcare workers, general
physicians and the population resulted in inadequate provision of pain treatment services in
Kuwait (P1). Many medical professionals treated CNCP patients by themselves as they had as
yet not realized that pain management is a specialty with practitioners available to them in
Kuwait. Both P2 and P3 mentioned that medical professionals only discovered that pain
specialists exist when the need arose because one of their patients presented a complex condition
involving chronic pain. P2 expressed his/her desire to see delivery of pain management practices
in Kuwait similar to those found in the West where they were trained by educating local medical
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professionals and making the public aware about modern understanding of pain and its
management.
Summary of Educational Activities
• Inadequate opportunities for education and training in CNCP within postgraduate
programs
• Insufficient opening in CNCP education for Continuing Health Education for practicing
professionals
• Need of accreditation for healthcare providers to deliver CNCP care.
• Desire to educate medical professionals and help the public to be aware of pain and its
management.
RESEARCH Activities:
1) Funding Mechanism for Research
All key informants stated that there was no dedicated budget available for research of
CNCP management. P1 was critical about the lack of information from government on the
funding resources and noted that a proactive approach was required for discovering opportunities
for research funding from the government.
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2) Research Personnel
Only two key informants reported their involvement in research projects at the time of
this survey. One of those informants had a policy of having the multi-site clinical research or trial
coordinated by a clinic nurse but that their contribution was not mentioned on manuscripts,
submitted for the publication.
3) Research Productivity
P1 related that their pain clinic focused on conducting epidemiological research on
service and patient satisfaction. P4 was more involved in multi-site clinical trials for equipment
and treatment approaches for CNCP. The numbers of publications published from these pain
clinics over the last 5 years were 4 and 5, respectively. P3 found that lengthy and complicated
procedures for getting informed consent from patients, and approval from ethical research boards
discouraged research.
Summary of Research Activities
There is no dedicated funding for research
No organized system to conduct research.
There are several obstacles to conduct the research
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7.3.3. Survey Results -Karachi:
Based on personal information;
Three men and one woman were the key informants selected from Karachi
All key informants ranged from 46 to 55 years of age.
Practicing pain management from 5-15 years.
All pain clinics were located in urban settings.
All key informants involved in the care of chronic pain patients were anesthesiologists.
Graduated from English speaking universities and have training in pain management.
Two of them trained in the UK.
All the clinics were located in large university-affiliated hospitals.
Some form of multidisciplinary services provided (pain physician, a nurse, and a physical
therapist) at minimum.
All reported that they offered services for the management of chronic pain but these
varied considerably.
INFRASTRUCTURE Utilization:
1) Organization and Conceptualization of Pain Care Clinic (use structural/architectural
terms)
As per our inclusion criteria, two of the participants located in government academic-
affiliated hospitals and two participants from charity-run hospitals in Karachi were responsible
for delivery of chronic pain management services through pain clinics. Each of these pain clinics
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treated various kind of patients from acute to cancer to CNCP patients, however due to our
research interest, they provided all the information related to CNCP services. An anesthesiologist
with their clinical fellows led each clinic. P1 stated that they are trying to provide a multi-
disciplinary service for CNCP patients, through better collaboration with other specialists in their
hospital (P1).
All the pain clinics provided the following services: provision of assessment and
diagnosis, interventional services and implementation of pathways to pain care. For all
participants, the major mode of delivery of services for chronic pain was in an outpatient setting.
Government affiliated-hospitals pain clinics were under the jurisdiction of Province of Sindh,
whereas charitable-institutions have Institutional boards and committees for all decisions. The
types of patients treated varied from clinic to clinic. Karachi pain clinics offered a wide range of
expertise in pain management services for their patients. Participants reported a list of their
expertise from pharmaceutical to interventional management that included: Prolapses disc, low
back pain, and failed back surgery syndrome. All pain specialists interviewed were
anesthesiologists with fulltime employment in their institutions. They each emphasized that they
initiated their pain clinics because of their personal interest in the chronic pain. They were not
instructed to do by their institution. In government hospitals, all services provided in the clinics
are free of cost to CNCP patients, covered by the government or by direct donations from friends
or supporters or local community charities (P1). On the other hand charity-hospitals provide
services at a nominal cost and if the patients are unable to pay, depending on the patient’s socio-
economic status the nominal cost can be further reduced from 30% -100% (P3, P4). All the key
informants reported running private practices, in the evenings.
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2) Human Resources:
All clinics had only anesthesiologists as the core staff. However, during patient
assessment or intervention, on-call rotating fellows training in the anesthesiology clinical
fellowship program supported all key informants. The numbers of these fellows ranged from 2-
16. P1 stated that they have female paramedics to assist with female CNCP patients (P1). In
these pain clinics, there were no other specialists or allied health care professionals working
directly with the pain specialists. Pain physicians serve as the principal treating physicians at the
pain clinics and the clinical fellows working in the clinic do so under their supervision. Together
they provide care at various levels: direct treatment, prescribing medication and performing pain
relief procedures. The numbers of hours worked by pain specialists in these clinics vary from 1-5
days per week. Similarly, the days they spend doing the small procedures and in operating rooms
(OR) vary. Female staff were involved as a paramedics or physician’s assistant in two
government pain clinics. In the charity-hospitals, no nurses were dedicated to pain clinics.
However, if needed the pain specialist can request nursing assistance during small procedures or
in the OR. A key informant struggled with the workload due to lack of nursing staff (P4).
Participants reported that physiotherapists were available at all the hospital sites for all CNCP
patients. All sites acknowledged the availability of a psychiatrist for a specific case but no
availability of a psychologist with in the hospital.
Administrative support was available to all pain specialists offering treatment to CNCP
patients. The number of administrative staff in the pain clinic was generally 1 to 2 individuals,
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although one had 4 administrative staff. P3 mentioned that although administrative staff may not
be dedicated to the pain clinics, they could be accessed if there is a need.
3) Pain Clinic Space Allocations
All the key informants reported that the consultation and assessment were conducted in
one room. They do their assessment on the examination table, which is provided in the corner of
the consultation room. All key informants mentioned that they have access to the OR for small or
complex procedures, however, one key informant mentioned that this is not automatic and access
is at the discretion of the surgical department (P1). None of the key informant’s reported routine
access to in-patient’s beds. If patients do require a bed after a procedure that carried out by the
pain specialist, they generally can get access to 1-3 beds in the affiliated hospital (P3). This is not
always sufficient, resulting in increasing wait times for interventions. No clinic had an
administrative area, or waiting area dedicated for CNCP patients visiting the clinics. Generally,
CNCP patients needed to wait in a common area designated for a group of clinics, including the
pain clinic.
4) Financial Support for Pain Clinics
All key informants revealed that the budget and funding of the pain clinic is controlled by
their affiliated institutions/hospitals, and there is no special funding for the pain clinics. These
have stayed constant in the past five years even though costs have increased.
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5) Collaboration and Affiliation within Hospitals
Key informants stated that all pain clinics were under the umbrella of Anesthesia
department of the associated institution or hospital. Three key informants were academicians at
the hospitals and affiliated with some medical college or universities in Pakistan. All key
informants were in agreement that the only reason their pain clinics existed was because of the
pain specialist’s desire to open and run such a clinic.
They also stated that there is no formal collaboration between pain clinics, except
discussing complex patients, if needed. Nevertheless, P1 and P2 felt that their institutions were
trying to be supportive in finding equipment and facilities, despite serious constraints.
6) Access to Resources for Delivering CNCP services
All key informants were in agreement with respect to adequate access to all laboratories
for blood work, x-rays, MRIs, and equipment for pain management, within their hospital or at
least at nearby hospitals. However, pain clinics had no priority in accessing those services. One
key informant mentioned that the location of his hospital outside of the city posed an access
challenge for CNCP patients (P4). All key informants stated that they have access to most of the
equipment needed to carry out their works but not to all the equipment. P3 and P4 specified that
they received the much needed equipment only after making persistent requests. The other two
key informants stated that sometimes they secured their needed equipment and supplies from
alternative resources, for e.g. charitable organizations or pharmaceutical industries (P1, P2).
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A key informant stated that sometimes sophisticated equipment was made accessible to them by
the institution but was not used due to lack of time, human resources or training (P1). All key
informants highlighted the struggle they faced in managing their daily consumption and
replenishment of supplies used for the CNCP patients i.e. medication, needles, injection etc.
Summary of Infrastructure Salient Issues:
• Pain specialist belong to a single health care discipline (Anesthesia), pain specialists were
focused on interventional practice
• Lack of budget and funding for CNCP services. Budget controlled by hospitals
• General resources, staff, space allocation are inadequate
• No specific organizational structure, governance and collaboration among pain clinics
• Access to resources is needed for the better delivery of pain care.
Delivery of CLINICAL SERVICES:
1) Delivery of CNCP Services at Out-Patient Setting
The business hours of the two pain clinics located in government affiliated hospitals in an
out-patient setting were between 9:00 am-2:00 pm, whereas in charity- hospitals, the pain clinics
were scheduled in the morning hours on an ad hoc basis. None of these key informants
performed procedures in the OR every day of the week.
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2) Workload and Waiting Time
There are three types of patients, new patients, a regular follow-up patients and a follow-
up visit after an interventional procedure. The total number of new cases of chronic pain
evaluated in the CNCP clinics varied for each pain specialist. One pain specialist assessed 10
new CNCP patients per day (P2) while others assessed ranging from 2-4 CNCP patient per day.
Only one clinic that was hosted by government hospitals had a standardized assessment form.
The residents working with the pain specialist filled these assessment forms. All key informants
stated that most patients in these pain clinics were of low-socioeconomic status and were not
educated, while one key informant from government-affiliated hospital also attended to 4-6 new
patients every month from a more privileged and educated cohorts drawn from the elite class or
government employees (P1).
For the visit of a new patient, the clinical fellows carried out the initial assessment for 10-
15 minutes followed by an assessment from the pain specialists for 10-30 minutes. One key
informant discussed pressures from the clinic managers in giving less time to CNCP patients and
seeing more patients within the clinic hours (P4).
There is no appointment needed to consult the pain specialist as they are seen on first
come first serve basis and there is no wait time for the assessment in these pain clinics. Patients
can arrange the appointment beforehand but have to wait as the consultant may be busy with
other patients or other tasks (P3). All key informants conducted procedures and spent 1-3 days in
the OR to do small and complex specific procedures for CNCP patients.
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The volume of patients in regular follow-up visits range from 3 -30 CNCP patients/per
day in these pain clinics. However, the type and volume of follow-up (procedure or normal) is
mixed every week, depending upon the activities of the clinic. A pain specialist spends approx.
10 minutes on each follow-up evaluation. If a patient was booked for a procedure, the pain
specialist also would see that patient after the procedure in a follow-up visit. All key informants
acknowledged that many of their CNCP patients never showed up for follow-ups appointments.
They have no way of tracking why this was so but speculated that travel was difficult of simply
that the first visit was sufficient to help them live with their pain (P2). The average timing for the
patients’ follow-up visit ranged between 3-25 days between clinics. After interventional
procedures the pain specialist will emphasize the importance of a follow-up visit (P2). One of the
key informants mentioned that in-patient or admitting the patient for CNCP management is not
common practice in Pakistan (P3). Clinics do not offer any in-patient services, however, one key
informant stated that if a hospital asked them, they provide in-patients consultancy (P2).
3) Types of Patient Care Delivered
The most frequent types of chronic pain encountered across all pain clinics were back
pain followed by musculo-skeletal pain, and neuropathic pain, while two key informants stated
their clinics have 75-80% of patients with chronic back pain. All key informants specified that
surgeons refer patients for low back pain and joint pain to them. Each pain clinic service focused
on different CNCP condition, from knee joint pain and shoulder pain to neuropathic to different
kinds of arthritis to sacroiliac joint involving the back and the legs and buttocks. All key
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informants cater to low-socio economic, middle age, and heterogeneous population,
predominately women.
4) Treatment Modalities Offered At the Pain Program
All pain clinics offered a variety of pharmacological and interventional therapies. The
pattern of CNCP management of the interventional pain specialist was diversified. The
interventions were focused mostly on different kind of injections and blocks. The interventions
were carried out on an outpatient basis and same day surgery. A key informant mentioned that he
had trained in the delivery of acupuncture to release pain. However, that practice had been
discontinued due to lack of supplies (P1). None of the key informants referred any of their
patients for rehabilitative treatments such as psycho-therapy or massage. However, two key
informants cited that psychological modalities were available in the psychiatric department
within their institution and they did refer some of their CNCP patients to that department (P1,
P2). This present survey discovered a wide variation in the practice of different procedures, as
well as use of pharmacological and limited weak opioid prescriptions. All pharmaceutical
compounds such as NSAIDs, anticonvulsant and opioids are available in Karachi, but access to
them is limited. Key informants disagreed on the consequences of the limited availability and
accessibility of opioids in Karachi. Key informants mentioned that only weak opioids were
available in the pharmacies to treat CNCP patients’ i.e. tramadol, buprenorphine. A key
informant emphasized that Karachi being a global city, has only two pharmacies that dispensed
strong opioids and only in the liquid form for the ICU patient and the post- surgical patient.
Sometimes, these special pharmacies do not have strong opioids and if they are available, it is
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only in the form of the morphine tablets (P1, P3). There is a strong regulatory oversight by
government of opioid accessibility. Key informants mentioned the associated long and painful
documentation process as a barrier for physicians and hospitals in prescribing opioids. This led
to a preference for prescribing a combination of non-opioid pain relievers for their patients (P2,
P3, P4). Another key informant described the regulation process of acquiring the prescribing
license for opioids as a lengthy process. A participant revealed that each pain physician had to
register first with the government then at a particular pharmacy, and ensure that there is sample
of their signature at that pharmacy, to prescribe strong opioids (P1).
4) Clinical Activities of Pain clinics
If needed, all key informants consulted or had informal meetings with others physicians
and allied professionals to discuss the course of action for any complex CNCP patient or their
procedures. Two key informants mentioned that they hosted general rounds for Anesthesia in the
hospitals where they invited other consultants however, pain was only sometimes discussed (P1,
P2).
Coordination of Care
Pain clinics are situated in the premises of the affiliated hospitals where all kind of other
medical teams and individual medical specialist are available for consultation therefore the
patients were referred within the hospitals. Pain specialists and CNCP patients have access to
individual consultants. A key informant expressed accessibility of consultation to other specialist
being hindered as most of them only worked part-time in the hospital (P4). Key informants stated
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that despite time limitation, they coordinate the care by contacting each other and providing their
feedback on an ad hoc basis (P4).
7) Special Services for Impaired Population
There is no reported availability of special services for physically or mentally impaired
patients in any of the pain clinics surveyed. However, one key informant expressed hope that
these services would be available in the near future (P3).
8) Referral Pathways
Each clinic received many referrals from all different specialist and allied health
professionals and departments. A majority of these referrals are from within the hospitals.
Interestingly, key informants revealed that they receive few (10%) of referrals from general
practitioners. This likely reflects a lack of awareness about their pain management program since
those general practitioners who do so have generally worked previously in a large tertiary care
setting. The referral notes in pain clinics ranged from one single line to one page filled out by
the referring physicians, except for one pain clinic where one page is mandatory for referral note
related to patient’s history, physical examination and any other investigations that were carried
out. None of the other pain clinics had any systematic referral procedures. One participant was
frustrated about referring physicians’ inadequacy in providing the details of CNCP patient’s
conditions (P1). The referrals received were targeted to the pain specialists’ known expertise and
the pain management modalities they offered (P2). Depending on the needs of the CNCP patient,
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the key informants often referred them to other consultants who specialized in specific condition
or pain management. Key informants often received requests for in-patient consultation from
their hospitals. Before assessing an internal patient for pain, two key informants discussed the
importance of documentation of CNCP patient conditions and stressed the importance of
complete referral notes (P3, P4).
9) Institutional Policies for CNCP Clinics
All key informants emphasized that there were few institutional policies, protocols,
procedures and standards that referred specifically to CNCP services. P4 cited that pain
management is at infancy at their pain clinic.
10) Adaptation and Use of Clinical Guidelines
All the key informants used the guidelines from where they were trained and practiced
internationally. While adapting to the international guidelines, based on their own management
or procedural needs, the most commonly used guidelines were from IASP and WHO (P1, P3,
P4).
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11) Planning for Discharge and Continuity of care
Key informants mentioned that there was no continuity of care protocols at their
institutions. Often, the only indication of continued satisfaction is that some former patients that
they have lost track of refer their relatives to the clinic (P3).
Summary of Delivery of Clinical Services
• Variation in clinical practice of pain specialists (no of patients seen, wait time,
consultation time, follow-up time, type of patient seen , modalities offered, referral
formats.)
• Effective drugs or non-drug modalities not available or accessible to CNCP patients.
• Lack of availability and accessibility of appropriate opioids
• Too many regulations for opioid prescription
• Need for medical professionals and allied health care from diverse fields dedicated to
ongoing and integrated care of patient
• Lack of referral connections between general physicians and pain specialists
• Discontinuity of care, without updating the status of CNCP condition with the attending
pain specialist
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EDUCATIONAL Activities:
1) Funding Mechanism for Education
According to the key informants, there was no dedicated budget for pain educational
activities, in the hospital or from the government. However, some pharmaceutical companies and
affiliated universities supported the pain program for carrying out the educational activities.
2) Education Prospects
Participants reported that there are no pain fellowship programs offered in any of the pain
clinics in Karachi. Two key informants revealed that they were trying to establish such a
fellowship program, to be offered only to anesthesiology fellows as a sub specialty (P1, P2). The
key informants from all pain clinics trained residents and clinical fellows but only within the
context of expectation by the department of Anesthesiology. Two key informants reported having
2-4 students or fellows fulfilling their clinical requirement in the local hospitals under their
supervision while enrolled in a distance education MSc program in Pain Medicine. A University
in another province oversaw this program, but the key informants supervised research projects
that were required of students enrolled in that program (P1, P2). In one-pain clinic, these students
are the employees of the hospital or government and in one they are working without
remuneration. A key informant showed a willingness to recruit trainees and fellows for their pain
clinic, but only if they were provided the institutional support (P3). This respondent discussed
the barriers of recruiting such trainees including lack of funding, pain awareness and support
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from the institution. The institution feared pain clinicians would spend more time with the
student and in research than in providing clinical services.
3) Teaching and Training Practices
P1, P2 with trainees mentioned that they had no dedicated protocol provide guidelines for
how that training was to be delivered within their pain clinics, however they did use the affiliated
university guidelines. All key informants provided informal hands-on training to their clinical
fellows and other rotating students. None of the pain clinics offered a continuing education
program for staff affiliated with the clinic. A key informant emphasized the importance of
continuing education, by updating their training abroad (P3). Pain specialists attend pain
conferences or visit benchmark institutions abroad to update their knowledge, at their own
expense. The Pakistan chapter of IASP, organizes a pain conference every year and all pain
specialist attended that pain conference.
Another key informant emphasized that there is no multidisciplinary pain focused
association in Pakistan and all the pain conferences and meeting activities are under the umbrella
of Anesthesia (P3). Participants shared their desire to have an independent body or organization
for Pain Medicine in Pakistan. Currently, in Pakistan, a majority of the members of IASP
Pakistan chapter are Anesthesiologists.
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4) Student Evaluation
Key informants reported that there was no formal protocol for student performance
assessment at the pain clinics. Students and fellows were evaluated within their anesthesiology
department for their pain management knowledge or the students enrolled in the MSc program
were evaluated every 6 months by the university that managed the program.
5) Pain Education Rounds
Two key informants stated that educational rounds conducted in the pain clinics range
from 1-2 sessions every two months (P1, P2). Those were the general rounds for anesthesia but
not specifically for pain and even then there was no budget dedicated for the general rounds.
Sometimes they invited clinicians from outside the department for the general rounds. If the pain
specialists felt a need for discussion on any particular case or procedure, they discussed it
informally.
6) Need of Education and Awareness
A key informant stated that the lack of knowledge and training for healthcare workers,
general physicians and the population resulted in inadequate provision of pain treatment services
in Karachi. Many medical professionals treat CNCP patients on their own as they have, as yet,
not realized that pain management is a clinical speciality. It was only when the general
practitioner was faced with a complex patient that they look around for assistance from a
specialist and then figured out that such a specialty existed. One key informant emphasized the
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shortage of pain specialists in the city and the country and highlighted the need to organize
workshops and meetings to better coordinate access to this scarce resource (P4). A key informant
shared their experience about a continuing education program that they provided to GPs where
afterwards, the GP complained that neurosurgeons and rheumatologists wanted CNCP cases to
be referred to their respective specialties, and they were confused as to who should see the case
first. Key informants highlighted the need to educate the GPs about how the pain specialist can
assist them in coordinating referrals of these complex CNCP cases to these different specialties
(P2). One key informant was concerned over the pain management material only being available
in English. The Participant felt that English is not a locally used language therefore, pain
awareness and management material and brochures should be available in the local language
(Urdu) along with English. That participant would be willing to make those resources available
in the local language if resources could be found (P3). Another key informant described their
practice for conducting awareness programs within the city by conducting pain camps,
educational activities, and an advertising campaign for awareness of pain management (P1).
Summary of Educational Activities
• Lack of dedicated funding for educational activities
• Inadequate opportunities for education and training in CNCP within postgraduate
programs
• Insufficient opening in CNCP education for Continuing Health Education for practicing
professionals
• Need of accreditation for healthcare providers to deliver CNCP care.
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• Desire to educate the medical professionals and the public aware about pain and its
management.
RESEARCH Activities:
1) Funding Mechanism for Research
There is no dedicated budget available for research of CNCP management at any of the
pain clinics surveyed. Occasionally pharmaceutical company will provide funds or assist these
pain clinics to conduct a clinical study or clinical trial of one of their drugs.
2) Research Personnel
All key informants reported their involvement in research projects at the time of this
survey. However, they were involved at a supervisory level only. The residents and students
coordinated and administered these research projects. A key informant explained that their clinic
was under the umbrella of the Anesthesia department, which had three divisions: general
anesthesia, surgical anesthesia and pain. Clinical fellows in each division were expected to
conduct a relevant research project, some of which were focused on pain. Also, key informants
stated that the students involved in MSc Pain Medicine program had to publish one research
paper on pain management during their master’s program which was supervised by the key
informant (P1).
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3) Research Productivity
Two key informants indicated that their pain clinics focused on conducting clinical
research and trials for equipment and other CNCP treatment modalities either in a self-funded
manner or with industry support. Another key informant’s pain clinic was involved in
development of case reports. One key informant mentioned that currently their clinic is
collecting data concerning patient outcomes (P3). The numbers of publications published in the
last five years varied from one pain clinic to another. In total, the 4 key informants had published
4-5 papers in the last 5 years.
Summary of Research Activities
There is no dedicated funding for research
No organized system to conduct research.
There is no parameter for promoting research.
Mapping of Services Described by Key informant per their Location
Figure 5 illustrates the narrative/ description themes derived from key informants
interviews. Table 4 illustrates that least one key informant from the studied cities commented on
each corresponding theme.
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Table 4: Mapping of Services Described by Key informant per their Location
Domain Kuwait Karachi Toronto
1. INFRASTRUCTURE UTILIZATION 1. Organization and Purpose of Pain Care Clinic P1,P2,P3,P4 P1,P3,---,P4 ---,P2,P3,P4 2. Human Resources P1,P2,P3,P4 P1,P2,P3,P4 P1,P2,P3,P4 3. Pain clinics Space Allocations P1,P2,P3,P4 P1,P2,P3,--- P1,P2,P3,P4 4. Financial Support for Pain Clinics P1,P2,---,P4 P1,P2,P3,--- P1,P2,P3,P4 5. Collaboration and Affiliation within Hospitals P1,P2,---,P4 P1,P2,---,--- P1,P2,P3,P4 6. Access to Resources for Delivering CNCP services P1,P3,---,P4 P1,P2,P3,P4 ---,---P3,P4
2. DELIVERY OF CLINICAL SERVICES 7. Delivery of CNCP services in out-patient settings P1,P2,---,P4 ---,---,---,--- ---,P2,---P4 8. Workload and Wait Time P1,P2,P3,P4 P1,P2,P3,P4 P1,P2,P3,P4 9. Types of Patient Care Delivered P1,P2,P3,P4 P1,P2,P3,P4 P1,P2,P3,P4 10. Treatment Modalities Offered by Pain Program P1,P2,P3,P4 P1,P2,P3,P4 P1,P2,P3,P4 11. Clinical Activities of Pain clinics P1,---,---,P3 P1,P2,---,P4 P1,P2,P3,P4 12. Coordination of Care ---,P2,P3,P4 P1.P2,---,P4 ---,P2,P3,P4 13. Special Services for Impaired Population ---,---,---,--- ---,---,P3,--- --,---,---,--- 14. Referral Pathways P1,P2,P3,P4 P1,P2,P3,P4 P1,P2,P3,P4 15. Institutional Policies for CNCP Clinics ---,P2,---,P4 ---,---,---,P4 P1,P2,P3,P4 16. Adaptation and Use of Clinical Guidelines P1,P2,---,--- P1,P2,P3,P4 --,P2,---,P4 17. Planning for Discharge and Continuity of care P1,---,P3,P4 ---,---,P3,--- P1,P2,P3,P4
3. EDUCATIONAL ACTIVITIES 18. Funding Mechanism for Education ---,---,---,--- P1,P2,---,--- ---,---,P3,--- 19. Education Prospects P1,---,P3,--- P1,P2,P3,--- P1,P2,P3,P4 20. Teaching and Training Practices P1,---,P3,P4 P1,P2,P3,P4 P1,P2,P3,--- 21. Student Evaluation ---,---,---,--- P1,---,---,--- P1,P2,---,--- 22. Pain Education Rounds ---,---,---,--- P1,P2,---,--- ---,P2,P3,P4 23. Need of Education and Awareness P1,P2,P3,--- P1,P2,P3,P4 ---,---,---,---
4. RESEARCH ACTIVITIES 24. Funding Mechanism for Research P1,---,---,--- ---,P2,---,--- ---,---,P3,--- 25. Research Personnel P1,---,---,P4 P1,---,---,--- P1,P2,P3,--- 26. Research Productivity P1,---,P3,P4 P1,P2,--- ,P3 P1,P2,P3,---
Table 4 describes key informant from the city indicated by the column heading reported a
narrative/ description that could be assigned to the theme row.
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Figure 5: Themes of the Survey under the Domain of D-L Hybrid Framework Output
Figure 5 describes the total number of themes identified in the survey interview and can fall
under one domain of D-L hybrid framework
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Figure 6: Themes of the Survey Mapped On D-L Hybrid Framework
Figure 6 illustrates the mapping of survey themes/output on the D-L Hybrid framework domain
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7.3.4. Mapping of Survey Output on the D-L Hybrid Framework:
In this thesis, I have developed the D-L Hybrid evaluation framework for examining
CNCP services that can be applied to a system evaluation. As seen in Chapter 4, this D-L Hybrid
framework was organized according to three main hierarchical constructs: inputs, activities, and
outputs.
The D-L Hybrid Framework proposed connections between inputs, activities, and outputs
from left to right, up to down and the use of boxes and arrows makes the relationships
unidirectional, multidirectional or static in the framework; however, they can be dynamic and
interactive with each other (Fig. 3). At this stage, I set out to examine any relationships or
associations in the studied data of the thesis (Fig 6) as an exploratory rather than confirmatory
research process. The goal was to establish that the framework captured major domains of the
discussion with pain clinic directors concerning how they envisioned outputs of their clinics.
Within the scope of this thesis, the focus was on describing the feasibility of using a systematic
evaluation methodology in a way that was logical and measurable for the case of specialized
clinics capable of delivering CNCP management services. For example, in the output domain of
D-L Hybrid framework related to the delivery of clinical services, the theme of referral for
consultation or referral for intervention (e.g. physiotherapy or nerve block injections) can be
considered from the practice and institutional level. Some discussions related to referral may best
fit as an output while for others it may best be described as a process. Typically, outputs reflect
actions that are under control of those involved in the implementation of services (i.e. clinic
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staff). Another example was the use of specific guidelines that provide one way pain specialists
are delivering CNCP care. Regarding the infrastructure domain, funding, available equipment,
space allocation, access to continuing education regarding CNCP can be considered as indirect
measures of the extent to which hospitals value the pain specialist role in the delivery of CNCP
management services. While I did not specifically address the relationships between constructs,
these relationships arose organically from the pain specialist participant’s description of their
experiences. An important next step in the validation of this framework is to confirm these
posited relationships, their directionality (if any) and the strength of those relationships between
the framework constructs.
Another step in building and validating this framework would be to implement it. I
suggest that such an implementation would require adaptation according to the local, regional or
national level constraints such as those revealed through the case study review procedure. For
example, the framework assumes that a pain specialist is functioning under “normal care
conditions” that are not being disrupted by unexpected or unusual cultural, political, economic,
social or technological events or other unexpected contextual issues (e.g. earthquakes, wars or
other public health emergencies). Standard evaluation will need to await normalization of affairs.
These disruptions may limit the effectiveness of evaluation process of the D-L Hybrid
Framework.
Descriptions of pain clinic director perceptions emerging from application of the D-L
Hybrid evaluation framework can provide a rich representation of the muti-faceted interactions
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that can influence clinic outputs. This source of evaluation material may make it easier to explain
to others like planners, administrators and other health care providers in a position to help
modify structures and processes that impact on outputs what the problem is and what could be
possible consequences of changing the status quo. It can empower advocates of improved CNCP
services by providing a factual description of the specialized pain clinic and identifies areas
where outputs might be improved. Further detailed examples for each construct in the framework
and its utility are elaborated in the discussion section of this chapter where implications of the
described results are discussed in relation to opportunities for improving the four framework
constructs of output related CNCP services provided by specialized pain clinics.
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7.4. Discussion
The work described herein demonstrates the utility of a new approach to evaluating the
globalization of health systems. By interviewing specialists responsible for running specialized
clinics in different global cities, a descriptive landscape vis-a-vis their experience of barriers and
opportunities emerges, colored by the local context. The approach also provides a window into
how the specialist's own particular approaches, normalized by their international level of
training, and is impacted by local and global realities.
The focus was on pain specialists responsible for providing CNCP management services
through specialized pain clinics in three global cities: Kuwait, Karachi, and Toronto, where
global standards of care are available. Four specialist, each responsible for a different specialized
clinic, in each of the three clinics were surveyed for a total of twelve key informants. Through
the application of a semi- structured qualitative method, I was able to identify and elaborate
several distinct themes.
A new form of evaluation framework that was a hybrid of standard Donabedian and
Logic model frameworks was developed for this study. This D-L Hybrid evaluation framework
(which described in the earlier part of this thesis Chapter 5) was used to describe four domains of
output in the delivery of CNCP services: 1) Infrastructure 2) Clinical Services 3) Education
and 4) Research.
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An analysis of systematic review results of CNCP management globally and in the three
target cities led to a focus on those domains and anchored development of a questionnaire that
served to structure interviews about the relationship within and between those domains. The
landscape described by the survey results provides grounding for describing global developments
in CNCP management and enactment of quality improvement efforts through a global cities lens.
This study was designed to document the landscape with respect management of CNCP
patients in four specialized pain clinics in each of the three cities: Kuwait Toronto and Karachi.
In their survey narrative comments, the twelve pain specialists clearly emphasized the challenges
they share while delivering CNCP management services through their clinics. This reflects their
common level of training at internationally recognized healthcare centers. However, that
experience varied among the pain specialists both within and between these global cities,
reflecting differences in healthcare system and governance and how individual practitioners have
adapted to those differences.
Findings from the qualitative analysis of the evaluation survey questionnaire revealed a
breadth of important output barriers. The biggest obstacle revealed related to general lack of
resources for providing the level of CNCP management services that all of these specialists felt
capable of delivering. Across all domains, a broad range of important problems limiting access to
the beneficial clinical services that could be identified. These have global implications. Issues
highlighted in results related to the Infrastructure domain included scarcities of resources and
workforce, especially a scarcity of appropriately trained specialists to provide these effective
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services, and a lack of dedicated space allocated for the delivery of those services. The results
related to the Clinical Services domain were associated with the long hours required by our key
informants’ specialists who had to devote the provision of optimal pain care. There also were a
number of barriers recognized in their efforts to implement the current global standard of cares.
Those barriers included, lack of integration between levels of care, poor communication and
coordination between health-care workers, and unrealistic expectations by the CNCP patients.
Results related to the Education domain highlighted lack of education with respect to CNCP
management among general health-care providers, absence of structured format for specialized
CNCP management training, few opportunities of continuing education for practicing pain
specialist and general lack of awareness of their specialty and their capacity to deal what is often
an unrecognized opportunity for relief in the burden of living with chronic pain. Results related
to the Research domain reflected the inadequate levels of funding, resources and priorities for
research outputs by specialized clinicians running specialized clinics.
Taken together, the results of this study suggested that opportunities for relieving
avoidable distress globally are being missed. This was linked primarily to a scarcity of resources
directed to existing and well-structured pain clinics managed by highly qualified specialists
found in global cities. The qualifications of those specialist was independent of the economic
development of the countries in which those cities are located demonstrating the normative value
of taking a global cities lens to evaluating globalization of health care services for complex
chronic conditions. The results of this survey are concordant with major themes described by the
International Association for the study of Pain (IASP, 2011b) and highlighted missed
opportunities for effectively treating CNCP patients, in three global cities. However, this study
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deepens understanding of those opportunities, by providing additional insight into the logistical
details involved with pain management service procuring in global cities. Therefore, for any
organizational and mobilization efforts to be successful, it will be important to address barriers in
the delivery of CNCP management and services revealed by this survey. Recommendations to
address those barriers are grouped below according to the identified domains.
Suggestions for improving the Infrastructure Barriers
At an institutional level, various factors limit access to CNCP management services
especially scarcity of specialist and limited awareness of their potential as evidenced by lack of
resources dedicated to the supporting the specialty clinics that they run. For example, minimal
space is often allocated to the clinic by the hospital departments that host the clinic. As shown in
this study, nearly half of the pain specialists had access to only one room that was often shared
with other services and did not have designated consultation space for often vulnerable CNCP
patients. Many of these key informants did not have dedicated procedure rooms. This lack of
space strongly limits the possibility of expanding and improving the CNCP services despite
increasing demand as more patients become aware of their services.
Inadequate staffing, lack of drugs and equipment represent additional important factors
hindering the delivery of CNCP services. Chronic pain is commonly viewed as a complex ill-
defined health problem, and several other non-pain specialists were reluctant to be involved in
this treatment unless supported by the institutions. There is need to provide adequate funding for
space, medical staffing and specialized equipment. Implantable devices should be offered on
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subsidized cost and only to individuals who are really in need. Pain specialist with extensive
training in the full spectrum of pain management services always should be involved in assessing
that need. Managerial, secretarial, clerical and information technological support is important to
manage outpatient work. This enables the CNCP services to achieve required targets and
improved quality standards (Rowbotham, 2014).
Besides variability in services related to practice locations, there were also differences in
types of services provided. These services are often limited to simple, instrumental
pharmacological or interventional management designed for acute pain relief. Only a few of the
specialty clinics surveyed were able to implement the recommended multidisciplinary approach
in which they were trained. Although not every CNCP patient requires this multidisciplinary
approach, (Haldorsen, 2002) many complex cases that often provide the greatest burden on the
health care system can benefit substantially in a cost effective manner from coordinated care
from many specialists all of whom have been trained in patient centered pain management (Peng,
2008). This has been recognized for over a decade and all key informants were aware of this
opportunity but organizational barriers prevent its implementation.
Although multidisciplinary treatment requires having more than two health care providers
from different disciplines under the same roof, it may not always mean that the pain condition is
treated in an integrated manner. I would like to argue that the ideal treatment approach should be
‘interdisciplinary’. An interdisciplinary approach is characterized by a variety of disciplines
working together in the same facility in an integrated manner with joint treatment goals and
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coordinated interventions that are facilitated by ongoing communication among members of the
health care team (Clark, 2000; Gardea, 2000). Services, such as physical therapy, psychological
evaluation and mental health clinics, were generally to be found within the institutions hosting
the clinics surveyed. However, the extent of the access and logistics of that access for patients
with chronic pain were limited.
This reflected in part the common practice of treating those patients suffering from
complex chronic conditions as suffering from acute care problems and treating them as
outpatients. Nonetheless, strategies that use coordinated and ongoing access to available
resources (e.g., physical therapy, clinical pharmacists, psychology clinics) overseen by the pain
specialist to deliver clinical services based on a chronic disease model for pain-related care could
prove to be an effective and efficient method of relieving the overall societal burden of chronic
pain. There is experiential evidence that changing models of care are resulting in greater inter-
professional collaboration and involvement of professionals in care in ways that have
traditionally been the domain of a single profession (Murray, 2011b; Valgus, 2010).
Suggestions for improving Clinical Service Barriers
Pain specialists only devoted from 8-20 hours per week treating CNCP patients. This part
time approach coupled with the scarcity of specialty pain clinics and general lack of awareness
of the effectiveness of the services that the clinics can provide means that a there remains poor
access to services that are known to be effective in reducing the burden of this condition. Most
specialists with a clinical responsibility for the treatment of chronic pain are anesthetists in all
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global cities. While it is logical for acute pain services to be closely linked to peri-operative
services or anesthesia, this is less true for CNCP management. Although the anesthetist key
informants were all trained in, and aware of proven chronic pain management strategies, their
exclusive governance through an anesthesia department may be a detriment to necessary
interdisciplinary care for certain CNCP patients.
It is crucial for the pain specialist to have close links with other departments in the
hospital, for the effective delivery of CNCP services. Many of our key informants had developed
such links through informal channels. However, an institution wide chronic pain management
strategy analogous to cross-cutting patient safety of care quality initiatives might be warranted.
Since much of the burden of chronic pain is experienced outside of the hospital or the clinic,
some kind of ongoing community care program coordinated by the pain specialist as the patient
advocate in collaboration with the patient’s general practitioner might be considered.
Services offered to chronic pain patients in all three cities were fragmented and waiting
times were varied. Fragmentation of pain care is perpetuated by the consecutive, and even the
concurrent, evaluation and management of complex pain disorders by multiple physicians with
diverse training skills and competencies. Each specialist views and describes the patient and the
pain disorder from a unique specialty focus. Under the current system, multiple physicians may
contribute to a patient’s “pain management.”
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Based upon the results of this survey, the types of modalities offered to chronic pain
patients by the specialized pain clinics vary considerably from one hospital to the other within
the cities and among the global cities. Treatment may include early, effective use of pain-
relieving medications from the anti-inflammatory and opioid (narcotic) categories, with use of
additional pain-relieving medications or sedatives and local or regional anesthetic blocks as
appropriate. Despite the consensus of pain specialists, and the eminently ethical and medically
justified commentaries to consider opioid therapy in the collection of treatments for moderate to
severe pain (Brennan, 2007), there is concern at the shift from under-treating to over-treating.
In Kuwait and Karachi, there is reluctance by pain specialist to prescribe certain opioids
that are sometimes indicated for patients with chronic pain. Depending on the type of pain and
complexity, treatment of chronic pain should encompass the continuum of self-management and
access to full interdisciplinary pain management teams (Lynch, 2011b). The waiting delays for
the appointment to the specialized pain clinics in Toronto and Kuwait to take a toll on CNCP
patients as well the economy of a nation. A systematic review suggested that wait six months or
longer is, therefore, unacceptable for people with chronic pain (Lynch, 2007).
Referrals between the specialist and levels of care in all global cities have been identified
as an area deficient in coordination and clarity. A common complaint from specialists is that
referral letters fail to include enough information (statement of the problem, current medication
and reason for referral) to adequately address the problem.
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A common cause of communication breakdown is the inadequate transfer of information
from the primary care physician to the specialist and vice versa. Primary care physicians and
specialist perceptions of communication regarding referrals and consultations often differ
(Berendsen, 2009; O’Malley, 2011). Use of a standardized referral form can help to ease the
communication process by highlighting the information sought by the specialist. It is a complex
process that requires the involvement of primary, secondary, and tertiary care provider to come
up with agreements on referral and follow-up modalities. None of these specialized pain clinics
held regular meetings to discuss patient assessment or treatment plans. Ideally, members of pain
management team should communicate with each other and other similar local teams on a
regular basis, both about specific patients and overall improvement of pain clinic outputs.
Suggestions for improving Education Barriers
Continuing education in chronic pain diagnosis, treatment and follow-up was reported as
being generally inadequate and unsatisfying in all cities. Medical schools and allied health
professionals training programs devote less time to the topic of pain, despite, pain being an
important factor driving patients to seek healthcare services. Current accredited training for
physicians in pain is limited to a narrow sub-specialty focus (e.g. a sub-specialty in pain within
an anesthesiology fellowship program). That focus generally is insufficient in length for trainees
to understand the breadth of knowledge and skills necessary for practicing comprehensive pain
medicine. For improvement of pain management programs, pain specialists need to become
familiar with basic principles of pain assessment and treatment and how these can be
incorporated into patterns of practice including documentation systems, policies and procedures,
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standards of practice, orientation, and continuing education programs. These approaches train
pain specialists in advocacy for weaving pain assessment into the very “fabric” of the hospitals
and institutions (Nova Scotia Report, 2006).
The discipline of pain medicine has reached a point in its development at which the
interest in being identified as a specialist is so high that there is now competition for control over
pain medicine training, accreditation, and certification processes. As many organizations exist,
standardization among organizations is highly varied. The qualitative survey analysis of this
thesis show that majority of pain fellowships are administered through the Departments of
Anesthesiology, which is congruent with the existing evidence (Rathmell, 2002; Brotherton,
2004). While this background provides excellent training in interventional approaches to pain
management, training is minimal in clinical, diagnostic, and therapeutic neurosciences, which are
increasingly central to understanding pain (Dubious, 2009). As a result, the discipline of pain
medicine risks becoming increasingly unidimensional and does not meet the needs of the CNCP
patients.
Jurisdictions, such as France and Australia that have made pain management a priority,
and have implemented educational programs for their health professionals. In France, physicians
learn pain management strategies in medical school through a mandatory module on pain
management and palliative care (Dobkin, 2008). An inter-university diploma called “Training in
Pain Management for Health Professionals,” was created to harmonize pain education initiatives
for health care professionals. The University of Toronto Centre for the Study of Pain (UTCSP)
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tackled the education issue by having its Education Advisory Committee provide one integrated
course to all undergraduate students in the Health Science Faculties (Watt-Watson, 2004). These
programs point to an emerging consensus that professional education in pain management at the
grass root level is a basic component for effective and efficient delivery of pain management.
Although, there always will be a need for a pain specialist they need to be more proactive in
educating their generalist and specialists colleagues about how the specialty of chronic pain
management can benefit the lives of patients and the lives of other health professionals treating
the patient for conditions where chronic pain is a co-morbidity.
In the recent survey, pain specialists from Kuwait and Karachi shared their concern of
pain management at the primary care. Primary care providers are often unclear as to when to
refer patients with chronic pain. General practitioners also have insufficient resources to refer the
patient to the appropriate physicians or believe that they can treat chronic pain on their own
(Lakha, 2011). Continuing education programs are necessary to fill the knowledge gap, foster
mutual acquaintance, and develop common discourses among primary physicians and pain
specialist. Commitment from every level of health care and academia needs to support the pain
education, and training of all health professionals in all global cities.
Suggestions for improving Research Barriers
Research into CNCP conditions and responses to care was reported as being severely
underfunded in all global cities. Despite the opportunities that some key informants saw,
evidence showed trends in funding for research on pain has been on a decline (Bradshaw, 2008;
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Lynch, 2009, Sessle 2011). Research into fundamental mechanism underlying CNCP are ongoing
but there are relatively few clinical, practice or implementation research studies looking into
operational ways of improving CNCP management. Thus, despite impressive progress in
understanding pain from a physiologic perspective in recent decades, there is lack of high-quality
operational research to guide management of patients with CNCP and to translate that
understanding into higher quality and more effective care. There was a willingness on the part of
our key informants to engage in research but little encouragement.
Limitation of the Study:
Although small, the sample consisting of twelve pain specialist from Kuwait, Karachi and
Toronto, was able to generate a broadly diversified but representative picture for delivery of
CNCP management services globally. Considering the nature and objectives of the survey, I
believe that this sample allows for some generalizations to the situation globally at least for the
steadily increasing proportion of world living less than a day’s travel from the center of a global
city. This was despite using cross-sectional survey design data, limited further to explore
participant responses.
Despite the survey design, participants with either strong positive or negative opinions
took time to respond to the survey which could be completed in about 1 hours’ time. Each city
has its own culture and tradition, providing a necessary variety in evaluating how global
standards of CNCP management are being applied globally. However, because each participant
was trained in an internationally significant university hospital setting they had a normative level
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of training and skills. This meant that they shared a common language and worldview when it
came to their specialty and talking about the structures processes and outputs that are related to
that specialty. This qualitative research, which focused on unverified reported experiences of
pain specialists, needs to be supported by more direct ethnographic or quantitative observational
studies. In addition, the study only explored the perspective of pain specialists who were in
leadership position regarding the delivery of services for CNCP management. Future studies
should consider the perspectives of other pain consultants and allied health professionals
associated with the CNCP clinics to arrive at perhaps a more comprehensive view of the value of
the clinics outputs. That information will be crucial for helping policy makers and health
administrators to understand and formulate a better and more cost effective way to deliver health
services to CNCP patients.
7.5. Conclusion
The use of “structure-process-output” conceptual D-L Hybrid framework provides a
practical framework for a research agenda that can ultimately assess whether CNCP services at
the specialized pain clinics have adequate outputs and can deliver optimal level of care.
Regardless of whether CNCP is considered a symptom or a distinct clinical entity, the fact
remains that the lives of many CNCP patients are devastated by this problem. Despite significant
efforts to optimize and organize services and to devise generally applicable care protocols for
CNCP patients, many patients fail to receive a level of possible pain relief that should be possible
in these global cities given the access to process and structural resources located in those cities.
The result of a qualitative survey of pain specialist reported here highlights major but solvable
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problems facing CNCP management services globally. The impact of existing specialized CNCP
clinics could be increased with increased support for infrastructure training, education and
research anchored by those clinics. Continuing education, professional development of staff and
regular service evaluation, including audit of outputs and outcomes, will enhance effective, safe
and timely CNCP management services.
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Chapter 8 – General Discussion and Limitations of the Study
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8.1. General Discussion
In this final chapter, I discuss and integrate the significance of my results. Additionally, I
comment how those results met the study aim to develop survey tool for characterizing the
challenges of CNCP management in different locations globally. A global cities lens was taken to
enable the requisite variety of local contexts while ensuring that pain specialists shared similar
training and had access to necessities to practice at a global standard of care.
Numerous studies have shown that the clinical management of various CNCP conditions
remain unsatisfactory globally. Based on my review of the literature, certain challenges with
respect to the management of CNCP were identified. Individual case studies of CNCP
management in the three global cities studied provided a comparative landscape. These case
studies highlighted the availability of pain management services, as well as barriers that impeded
access to CNCP services in each of the global cities. Despite the success of public health reforms
and urban planning in improving the quality of life, these global cities are still confronted by a
significant CNCP burden.
The thesis results emerged from application of a qualitative and pragmatic
methodological approach to capture the experiences of pain specialists involved in the delivery
of CNCP services in specialized pain clinics located in the target cities. Key informants
identified deficits at the provider and system level that must be addressed in order to deliver
appropriate services to CNCP patients. Insight gathered from the key informants related to the
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need for on-going development and increased quality improvement efforts designed to increase
adherence to evidence-based practices for treatment of CNCP.
Themes identified descriptive aspects of working with CNCP patients that could
incentivize commitment to improvement efforts. Study participants identified multiple
experienced and perceived barriers to the provision of effective pain management. Barriers
related to structural factors included lack: of funding, general awareness of pain specialists’
scopes of practice, collaboration and communication with colleagues within institution. Barrier
related to process factors included: poor understanding by general practitioners on how to guide
patients suffering from CNCP to seek specialist advice; challenge in adapting globalized clinical
guidelines to local realities; lack of integration between levels of care; cultural factors;
unrealistic patient expectations that their pain can be cured. Reflecting on the description
provided by the key informants in all three cities, I have concluded that hospital management
could make better use of pain specialists in meeting the needs of CNCP patients that they serve. I
hope that my results stimulate dialogue concerning how that opportunity could be realized with
wider the medical community, as well as health agencies and institutions dealing with the needs
of CNCP patients.
The first task in this comparative inquiry was to define the relevant units of analysis. A
global cities lens ensures that comparable local data on the characteristics of CNCP patients, the
density of medical resources, the extent of health coverage, and health system characteristics can
be obtained. There often is less diversity of training and access to expertise across different
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global cities than across different regions of the countries in which global cities are found. An
urban focus recognizes that a majority of the world’s population now lives in urban settings. This
research sheds light on issues related to existing infrastructure, education, research activities,
delivery and barriers of clinical services for CNCP management in specialized clinics.
This thesis developed an evaluation framework that is a hybrid between Donabedian and
Logic model. It is referred to as the D-L Hybrid framework and links elements of healthcare
system structure and processes to clinic output variables. I used the D-L Hybrid framework for
organizing common themes recognized in the pains specialist discussion with the semi-structured
interview of their clinics operations with regards to CNCP patients. The results of this study
strongly indicate that the relationships within and between structure, process, and output factors
influencing clinic organization are well represented with D-L hybrid framework.
Structure and process characteristics are dynamically interrelated, such as institutional
support for improvements in practice or pain clinic operations, which in turn makes the
institution stronger. Structure also interacts dynamically with output characteristics, such as clear
structural protocols for setting goals for internal evaluation frameworks, periodical re-
evaluations of those goals, documentation of the results of the evaluations and feedback of the
results to the staff. Given the interdependence of structure, process to output, this could indicate
that even though structural aspects, such as resources and administration are important, work to
improve process aspects could further improve outputs. The D-L Hybrid framework provides a
means for thinking about those inter-relationships. If there is enough time to work with features
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(structure), there is more support from colleagues (process), and the way that improvements are
achieved are evaluated (output). Global cities attract health professionals with global training and
provide them with access to infrastructure that meets global standards. Inquiry into how they
perceive their practice varies across global cities and can shed light on how external factors and
local health system policies impact on the quality of their practice outputs. This work has
revealed improvable deficits in those outputs of surveyed pain clinics in each of the global cities
studied. We expect improvable deficits will be found everywhere and that results of applying the
D-L Hybrid evaluation framework more broadly will suggest how globalized standards of care
can be translated and adapted to have broader reach while retaining core features that allow them
to be effective in a culturally appropriate manner. Rogers and Fraser (2003) suggest criteria for
selecting an evaluation approach: plausibility; practicality and evidence that an approach works.
Using the D-L Hybrid framework as a pragmatic process, achieved both aspects of the above
suggested criteria of evaluation approach.
8.2. Limitation of the Study
There are limitations to the approach described in this thesis, to start with getting
approval for this new approach from ethical committees was problematic and lengthy as each of
the global city has their own institutional review board procedures and policies. This was despite
the fact that highly competent medical professionals were the subjects and they faced little
unnecessary risk in talking about efforts that they were obviously proud of. Nevertheless, within
two years we were able to get approval from the academic institution from all three global cities.
Recruitment of a local collaborator was an essential feature of achieving approval.
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Although the questionnaire developed to structure the interviews was generic, it was also
essential to develop a good understanding of the local context in order really hear what key
informants were saying. As a limited, but again necessary, approach to that challenge I prepared
for the visit to each setting by developing a narrative review case study of CNCP practices in that
setting through systematic examination of published literature on the local health system and its
impact of CNCP management.
The scope of the review was wide. Some papers dealt with the change in outcome of a
specific pain management strategy, while others dealt with charges for basic chronic pain
services more generally. The results of this review process were heterogeneous and hard to
summarize quantitatively in a traditional systematic review process. There may be value in
narrowing down the scope of such reviews in the future, although this must be balanced against
the paucity of papers on pain management subject. Perhaps a focus on a specific topic, like
patient referral notes, studied in a wider group of global cities would allow for a more systematic
approach to this review process.
Evaluation of clinical services is neither precise nor conducive to completeness. Whilst a
larger sample may have revealed more themes, the D-L Hybrid evaluation framework proved to
be an effective and efficient audit methodology to investigate the CNCP services. My findings
adequately validated the framework and provided important baseline information for ongoing
assessment of pain specialist service in the global cities. Since, this is a cross-sectional study it is
important to be careful when discussing causal relationships regarding quality measures at
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structure process and output levels. But by focusing on outputs rather than more distant
outcomes, a more direct link may be established between structures and processes exploited by
the pain clinic leadership to achieve desired output goals. The methodology is appropriate for
both external and internal quality assessment.
Other study limitations were related to time, and convincing pain practitioner to spare
sufficient time from their busy practices to participate. As the study was a part of doctoral
program it had to be completed within a given time frame. Securing consent and time from the
participants was tedious and challenging as the respondents had reservations with regard to
answering some questions initially. They worried that providing answers to questions about
barriers faced by their clinics might be perceived as a criticism of the system in which they
practiced a might negatively impact their jobs and positions. It was important to gain their trust
and convince them that their anonymity could be protected. This was additionally challenging
since there was no precedent for this type of study. However, these factors were mitigated by
providing detailed explanations about the study purpose, maintaining an environment conducive
for the interview.
My experience with working in a Toronto pain clinic and in the pain field allowed me to
gain their trust. It will be important to determine in the future if a capacity to develop a common
ground between researcher and subject is a necessary element for the success of this method.
Because only four key informants from each global city contacted for the study participated, we
cannot rule out the possibility of self-selection bias. I did all the coding of themes derived from
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content analysis of the results but these were validated by my supervisor. I did not formally
calculate an index of inter-coder agreement when analyzing our qualitative results.
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Chapter 9 –Conclusion: Contribution, Implications and Future Direction
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9.1. Conclusion
A major contribution of this thesis was to develop a pragmatic method for evaluating the
state of delivery of pain management services globally through specialized pain clinics run by a
pain specialist. It showed how structure process and output domains could usefully organize
themes revealed from structured interviews with pain clinic directors regarding their experiences
in running their clinics. The next obvious step is to begin exploring the dynamic interactions
between those domains, however, this thesis was concerned mainly with demonstrating the
feasibility of acquiring useful information from a single interview. It sets the stage for refining
the questionnaire and interview methodology for probing specific relationships in a qualitative,
quantitative or mixed manner. I have shown how the method can be applied to the evaluation of
CNCP services delivered through specialized pain clinics, but it is apparent that approach is more
broadly applicable to a variety of health challenges currently being dealt with through
specialized clinics attempting to deliver comprehensive care for similarly complex conditions. It
is important to understand the mechanisms and context that link structure and processes to
potential outputs for CNCP patients so that targeted, evidence-based solutions can be
implemented and adapted effectively. Further evaluation of the relationship between the
proposed framework components will be vital to assessing how the care provided to CNCP
patients globally can be improved.
My goal was to gather output baseline data that could be useful immediately for pain
specialists, administrators and educators in appreciating opportunities that could accrue from
better pain management in their jurisdictions. Combining detailed case studies with real life
insights from pain clinic directors is a first step in building the will to improve how pain care is
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delivered through specialized clinics globally. Reflecting upon the descriptions made by key
informants in three representative jurisdictions, one main conclusion was that pain specialists see
themselves as playing an important but under-appreciated role. Although the results reported in
this study should not be interpreted as definitive, they point to opportunities for improvement in:
the operational delivery of CNCP services, the continuing education of general health care
providers and greater involvement of institution and government in evaluating the impact of pain
management services within health systems.
The D-L Hybrid evaluation framework and the global cities lens enabled development of
a survey method that can provide a new approach for evaluating the global dissemination of
emerging trends in healthcare specialization. This framework allows for a standardized and
pragmatic comparison between equivalent clinics located in different global cities. Their location
in global cities ensures that the clinics are operating against a background of similar levels of
economic development and access to practitioners with similar training. Despite those
similarities local contexts can result in the implementation of internationally promoted standards
of care in different ways. The narrative descriptions of the experiences of directors of these
specialized pain management clinics organized in a systematic way through mapping responses
onto the framework provides a pragmatic evaluation of the similarities of barriers encountered
and of opportunities for adapting lessons learned in one location to another. This study points to
the possibility of developing a toolkit for evaluating the deployment of any emerging specialized
care on a global scale, and to understand how general practices could be adapted to local
realities. Many barriers identified as hindering clinic outputs were shown to be independent of
the location while others were specific to the location of the clinic, and still, others were specific
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to the personality and worldview of the clinic directors. Many of the barriers to more satisfactory
outputs of the clinics identified in this thesis can be overcome in ways described in the thesis
discussion and in the case studies in the thesis appendices. However, a first step is understanding
how the landscape in which the clinic is located impacts those barriers. This thesis demonstrates
the feasibility of pragmatically characterizing those barriers on a global scale and distinguishing
global from local from personality perspectives that can affect possible solutions.
9.2. Strength of the study
This study was conducted with key informants who are pain specialist and currently
running specialized pain clinics in Kuwait, Karachi and Toronto. Each clinic provided care for
CNCP patients at the time of data collection. Interviewing these key informants helped in
understanding relevant macro and micro level issues faced by their clinics. In addition, the
process of talking about a clinic that they founded and ran, often with little support from above,
led them to volunteer a rich set of commentary about the subject under study.
The use of a pragmatic combination of descriptive qualitative and quantitative
approaches to collect data is one of this study’s main strengths. Such an approaches integrate the
results revealed by the quantitative and qualitative methods used and aims to develop a more
holistic/humanistic understanding of dynamics of health services (Speziale, 2011). The
employment of a descriptive qualitative and quantitative method helped to explore varied aspects
of the clinical challenges faced by pain specialists within a single interview lasting 1-2 hours.
This qualitative and quantitative approach generates a richer set of data than otherwise would be
possible using either methodology exclusively (Daymon, 2010). In particular, results of the
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descriptive quantitative part of this study revealed a quick overview of perspective barriers in the
delivery of CNCP management in specialized pain clinics globally that was contextualized by the
qualitative results. These results highlighted areas of deficiency where applicable corrective
actions could be implemented or at least studied in greater detail.
Discussions with pain specialist anchored by inquiries about the operational outputs of
their pain clinics helped them express concerns and feelings related to the general challenge of
CNCP burdens globally and in their local context. The fact that they were all practicing in a
global city and had received similar training helped in discrimination between local, global and
personality factors impacting on that challenge. Barriers faced in relation to the delivery of
effective CNCP services and management was apparent in all the interviews with the pain
specialist. Opinions about barriers indicated the significance of this topic for the key informants.
Differences in practice situations resulting from difference in the practitioner outlook and the
locations where they practiced provided a wide range of contexts within which to triangulate data
concerning local and global concerns. Similarities and differences between experiences and
barriers perceived by the pain specialists were consistent across settings and methodologies.
Another strength of the study was our success in recruiting twelve pain specialists from
three global cities who worked in a specialized pain clinic in leadership positions. Our ability to
apply the methodology in three global cities enhanced the representative nature of the study
sample. Additionally, examining current CNCP practices, from the perspective of different
nationalities and cultural backgrounds, allowed insight to be developed concerning problems
faced with dealing with the multicultural mix of patients seen in Toronto pain clinics and many
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other multi-cultural global cities. To conclude, this study has supplemented literature in regards
to CNCP management serving in multicultural health care settings. The qualitative and
quantitative method to collect data for this study enhanced the strength of the results and the
credibility of the analyzed data. The results can serve as baseline data to be used by pain clinic
administrators, educators and researchers to build upon, as presented in the next sections.
9.3. Implications of the Study
The results provided by this preliminary proof of principle study provides a baseline of a
new type of data for guiding pain specialists, and other stakeholders in adapting to global trends
in practice outputs. That, in turn, could lead to continuous improvements to patient care,
regarding pain assessment and management. In addition, it will increase awareness of the
barriers that unnecessarily hinder the efficacy of pain management provided to CNCP patients.
One implication of this study is in identifying a research scenario for gathering more descriptive
and interventional data useful in guiding future practice, administration and education related to
CNCP management.
9.3.1. Clinical Implication
The participants in this study provided insight into infrastructure and process level
deficits that must be addressed if appropriate access to care for CNCP patients is to be instituted.
Although only twelve pain specialists in three global cities were surveyed, the results were
remarkably consistent and were generated in a timely and cost-effective manner. They point to a
new way of allowing healthcare movements engaged in globalized but specialized changes in
practice to engage in reflective self-evaluation.
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The vanguards of these movements will gravitate to global cities and open specialized
clinics. They may be returning home after training at internationally significant clinical training
centers abroad or moving on as immigrants to new settings where they perceive that their
training will provide an opportunity for advancement. In all cases, however, the early successes
that led to the development of the movement will be met with barriers arising from local contexts
differences and the inertia of the way thing were done in the past that will create the need for
adaptation of the success practices that led to the evidence-based movement in the first place.
Nevertheless, their location in global cities will mean that access to the basic
infrastructure they need to practice as they were trained will be available. By understanding the
results from even small D-L Hybrid framework evaluation studies, global leaders of those
movements, as well as local activists can adapt to unexpected realities and maintain the
momentum and growth of the movement. In the case of the global movement to deal with the
global deficit of access to relief from preventable suffering caused by chronic pain, my results
point to a number of necessary moves.
This study employed a combination of descriptive qualitative and quantitative
methodologies. The combination of these approaches allows examiners of the results to get a
realistic and holistic view from which to derive insights into the barriers that may hinder the
delivery of effective pain management globally and in local settings that matter to them. This
perspective can guide decisions on taking suitable corrective actions to eliminate deal with
analogous barriers that they now recognize in the settings that matter to them. Additionally, pain
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specialist facing similar barriers can use their colleagues’ experiences as evidence during
meetings with funding decision makers to discussions about managing future changes that aim at
improving the quality of CNCP management services in global cities everywhere.
Sharing the results with hospital administration will help them re-evaluate policies and
regulations about the specialized pain clinics and delivery of services for CNCP management
services. Given the need documented in my literature review, there is a need to find ways of
identifying and overcoming the deficit of pain specialists and specialized pain clinics globally.
9.3.2. Implications of Model
A systematic and evidence-based approach to services improvement may increase the
chance of effective and efficient use of resources invested in those services (Ovretveit, 2002,
Luxford, 2011). For instance, resources and administration (structure) could be improved by
implementing guidelines for CNCP service improvement and expansion advanced by increasing
the number of allied pain professionals and the availability of dedicated space for pain clinics.
Studies show that clinical guidelines, based on evidence rather than opinion, have the potential to
promote interventions of proven benefit while discouraging ineffective practices (Grimshaw,
1993; Grol, 2003). Guidelines for services improvement might have similar effects. Pain
specialist engaging in professional development programs associated with CNCP management
could increase capacity for cooperation and collaboration, for all stakeholders. Lastly, evaluation
of goal achievement and development of competence measures could benefit from rapid
feedback on which measures are effective or not effective.
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The results described in my thesis can suggest ways of applying more quantitative
methodologies using a sample cohort of a larger set of clinics distributed over a wider set of
global cities. For instance, the results suggest that there is a need to explore the current quality of
referral notes and how the referral process might be improved especially for chronic pain.
Currently, each case of episodic disability, at the heart of all complex chronic condition, is
treated like an acute care incident. The evaluation process itself can be used as a forum for
dialogue and learning. Ideas and generalizations produced through D-L Hybrid framework
evaluations of one class of specialty clinics with a global presence can provide insights into
factors affecting the spread of other analogous specialty clinics globally.
9.4. Future Direction
This study of the organizational aspects of CNCP management in three representative
global city settings revealed some important future directions for research. They form a baseline
for future studies of a wider variety in global cities and of a more diverse set of specialized pain
clinics that are distributed in different regions. It also will be instructive if future quantitative and
qualitative studies were conducted to explore the perspective of patients, other healthcare
providers and administrators concerning the outputs of these specialized pain clinics.
Furthermore, it will be helpful in the future to apply research methodologies aimed at further
validating the current research instrument (the D-L Hybrid evaluation framework) and to identify
how cultural or positional differences that may influence themes identified pain specialists’
responses. Evaluating the achievement of specific services output goals and descriptions of
constraints impacting on those goals could provide other specialists with insight into their own
options for dealing with analogous situations.
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Since cities are widely recognized as engines of economic growth, opportunity and
innovation, it will be important to communicate these results to a city planning audience. As
outlined in the case studies, a link between can be made between economic development and
promotion of CNCP services. Although this was not a primary focus of this thesis it is an area
that I hope to explore in my postgraduate studies. There is an opportunity through generalization
of the methodology to develop a global database and research program around CNCP services in
global cities that promote a systematic examination of comparative experience around CNCP
management service delivery in global cities. These could also assist to identify best practices
and, document informative failures and successes.
The field of pain management continues to grow around the globe, there is an ever-
increasing need for effective metrics to measure the quality of this care. This dissertation was
concerned with the evaluation of pain management services and highlighted a number of metrics
that could be used. However, these do not adequately assess all aspects of pain care in all global
cities. For example, in the study results under the theme of “Type of treatment modalities,” the
issues of prescribing opioids in Toronto is very different from the experience in Karachi and
Kuwait. In the latter two cities, results emphasized issues related to under-prescribing and strict
regulations while Toronto participants discussed the problem of over-prescribing.
I, propose that there is a need for quality assessment programs aimed at supporting
specialists engaged in innovative practices. Such programs would be in keeping with continuous
quality-improvement programs currently being institutionalized in major health centers globally.
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It could be focused on telling the specialist story and helping them to create a compelling
narrative how the structures and processes that they live with can be modified to allow them to
generate outputs they know will have long-term benefits. Their micro activities then could be
better integrated with health system planning at macro levels. These strategies may possibly
include; (a) Updating education on areas of pain management which are observed to be lacking,
(b) incorporation of a protocol for the administration of opioid analgesics which would guide
general physicians and health teams in making safe and effective decisions based on pain
specialist recommendations, (c) facilitation of best practices by updating policies, procedures,
and guidelines relating to pain management, and (d) undertake regular assessments of clinics that
offer pain management services through quality assessment program that implements an analysis
of clinic outputs using the methodology described here.
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Bibliography
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References
Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic
diseases in low-income and middle-income countries. The Lancet. 2007; 370:1929-38.
Abma TA, Nierse CF, Widdershoven GA. Patients as partners in responsive research:
methodological notions for collaborations in mixed research teams. Qual Health Res. 2009;
19:401–15.
Abu-Lughod J. Wacquant: A Reply. Theoretical Criminology. 2000; 4:357-362.
Adams SA. Sourcing the crowd for health services improvement: the reflexive patient and
Write in as many as deemed relevant on back of this sheet
VII Other relevant information
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PART II: PAIN MANAGEMENT LOGISTICS
(A) STRUCTURE: Can you tell me about the description of your pain program
Governance and Infrastructure (include manpower in FTE equivalents MDs, their
specialties space): Interdisciplinary team/ Multi-disciplinary team : Funding Sources: Affiliations / collaborations: Facilities and Equipment
(B) CLINICAL SERVICES: Can you tell me about the delivery of clinical services
Types / yearly volumes of services:
Referral process: comprehensive Follow-up process: Waiting lists: Regular meetings with staff: Yes/No; Frequency: daily/weekly/monthly Fees, if any: What kinds of treatment modalities does your Pain Program offer?
A. – Pharmacology management (Mark all that apply ) ( ) Non-Steroidal Anti-inflammatory Drugs (NSAIDS); ( ) Simple Analgesics; ( ) Muscle