Background & Aims

Chronic pain (CP) causes great suffering to the individual and is a major public health problem globally. In Sweden, prevalence of moderate and severe CP in adults is about 20%, with around 7% seeking healthcare (1,2).  Shortcomings have been reported in many areas in a 2016 national rapport with input from clinicians and patients (2). Care for CP was described as unequal and uncoordinated, in both primary and specialized care. Patient organizations considered care to be unequal with shortcomings in treatment, accessibility, and competence of professionals at all levels of care. The report concluded that the pain field needed a national task force to improve pain care, pain education and research. Improved organisation to promote equal pain care was to be prioritised, the aim being to propose a structure for care of the patient group to enable adequate assessment and treatment at different levels of care based on knowledge and existing evidence.

Methods

Since 2018 a joint knowledge-based healthcare management system is being developed by Sweden’s regions, supported by 26 national program areas with experts leading activities in their respective fields. National Action Groups (NAGs) are formed in the program areas as needed. The state and the regions have signed an agreement to develop person-centred and coherent care pathways (PPCPs) for several disease areas (3). A NAG-pain was formed 2019 to improve pain care as stated in 2016 and commissioned to develop a PPCP for adults with CP. Expertise in the NAG-pain included pain medicine, rehabilitation medicine, psychiatry, anaesthesia, neurosurgery, primary care, nursery, psychology, physiotherapy, occupational therapy, and patient representatives (14 members). The expert group developed a PPCP during 2020-2022, including several reviewing processes with different stakeholders in the country. The PPCP for CP the adult population with CP was accepted and published in November 2022 (4).

Results

Challenges from patient perspectives were identified and used as a guide for the PPCP (Fig 1). Criteria for admission and discharge were proposed (Table 1). A flowchart was made including entry and exit points, measures, and decisions reflecting a stepwise strategy within and between primary and specialist care (Fig 2). Main measures were a) clinical assessment including pain analysis, b) biopsychosocial assessment and dialogue with the patient, c) making/reviewing rehabilitation plan, c) type of intervention (unimodal or multimodal), d) focus on drug treatment, patient education, physical exercise, mental health, daily activities, sleep hygiene, lifestyle and work-related interventions, e) follow-up and dialog both between practitioner and patient and between levels of care. To monitor the PPCP, outcome indicators (quality of life, mental wellbeing, and physical exercise), and process indicators (early making of a rehabilitation plan and appointment of a contact person) were proposed.

Conclusions

The PPCP focuses on early pain analysis, biopsychosocial approach, rehabilitation plan (including who does what, how and when, and follow-up), a stable team setting, dialogue and joint plans between levels of care, patient participation, and education on pain and its consequences. By avoiding non-value-adding measures the PPCP optimizes choice and intensity of care level. It has major implications for primary care and to some extent, for specialist care. Changes of work methods and organizational praxis as well as education efforts are required. Studies show poor adherence to existing care pathways. However, compliance increases if implementation efforts are intensive and recurring (5,6). This may increase costs in the short term, but the PPCP reduces indirect costs already in the short term as measures aim to return to normal activity including work. In the longer term, early interventions and better structure lead to less care seeking and costs for patients, healthcare, and society.

References

1 Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment, Eur J Pain. 2006;10(4):287-333.
2 Swedish Association of Local Authorities and Regions. Rivano Fischer M, Stålnacke BM, Gordh T, Brodda Jansen G, Bertilsson BC, Peterson, M, Mannheimer C, Gerdle B. National assignment: Pain. On behalf of the national collaboration group for knowledge management. Stockholm, Sweden; 2016.
3. National system for knowledge-driven management within Swedish healthcare. Published 21 August 2023, https://kunskapsstyrningvard.se/kunskapsstyrningvard/kunskapsstod/publiceradekunskapsstod/nervsystemetssjukdomar/vardforloppsmartalangvarighosvuxna.66690.htm
4. Person-centred and coherent healthcare pathway for chronic pain, in adults. Published 2 January 2024, https://kunskapsstyrningvard.se/kunskapsstyrningvard/kunskapsstod/publiceradekunskapsstod/nervsystemetssjukdomar/vardforloppsmartalangvarighosvuxna.66690.htm
5. Mesner SA, Foster NE, French SD. Implementation interventions to improve the management of non-specific low back pain: a systematic review. BMC Musculoskeletal Disorders (2016) 17:258, DOI 10.1186/s12891-016-1110-z.
6. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder, R. Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain. A Systematic Review and Metasynthesis of Qualitative Studies. Clin J Pain. 2016;32:800–816.

Presenting Author

Marcelo Rivano Fischer

Poster Authors

Marcelo Rivano-Fischer

PhD

Dept of Pain Rehabilitation

Lead Author

Mathilda Björk

Pain and Rehabilitation Centre, and Departement of Health, Medicine and Caring Sciences, Linköping U

Lead Author

Gunilla Brodda Jansen

MD

Dept of Clinical Sciences, Karolinska Institutet, Rehab Med, Danderyd Hospital, Stockholm, Sweden

Lead Author

Gunilla Göran

Patient Representant

Reumatikerförbund, Board member, Stockholm, Sweden

Lead Author

Britt-Marie Stålnacke

MD

Umeå University; Dept of Community Med and Rehabilitation, Umeå University Hospital; Umeå, Sweden

Lead Author

Monika Löfgren

RPT

Dept of Clinical Sciences, Karolinska Institutet, Rehab Med, Danderyd Hospital, Stockholm, Sweden

Lead Author

Topics

  • Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science