gms | German Medical Science

GMS Health Technology Assessment

Deutsche Agentur für Health Technology Assessment (DAHTA)

ISSN 1861-8863

Over-, under- and misuse of pain treatment in Germany

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  • author Markus Dietl - GP Forschungsgruppe, Institut für Grundlagen- und Programmforschung, München, Deutschland
  • corresponding author Dieter Korczak - GP Forschungsgruppe, Institut für Grundlagen- und Programmforschung, München, Deutschland

GMS Health Technol Assess 2011;7:Doc03

doi: 10.3205/hta000094, urn:nbn:de:0183-hta0000944

This is the original version of the article.
The translated version can be found at: http://www.egms.de/de/journals/hta/2011-7/hta000094.shtml

Published: April 19, 2011

© 2011 Dietl et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.

The complete HTA Report in German language can be found online at: http://portal.dimdi.de/de/hta/hta_berichte/hta301_bericht_de.pdf


Outline

Abstract

Background

The HTA-report (Health Technology Assessment) deals with over- and undertreatment of pain therapy. Especially in Germany chronic pain is a common reason for the loss of working hours and early retirement. In addition to a reduction in quality of life for the affected persons, chronic pain is therefore also an enormous economic burden for society.

Objectives
  • Which diseases are in particular relevant regarding pain therapy?
  • What is the social-medical care situation regarding pain facilities in Germany?
  • What is the social-medical care situation in pain therapy when comparing on international level?
  • Which effects, costs or cost-effects can be seen on the micro-, meso- and macro level with regard to pain therapy?
  • Among which social-medical services in pain therapy is there is an over- or undertreatment with regard to the micro-, meso- and macro level?
  • Which medical and organisational aspects that have an effect on the costs and/or cost-effectiveness have to be particularly taken into account with regard to pain treatment/chronic pain?
  • What is the influence of the individual patient's needs (micro level) in different situations of pain (e. g. palliative situation) on the meso- and macro level?
  • Which social-medical and ethical aspects for an adequate treatment of chronic pain on each level have to be specially taken into account?
  • Is the consideration of these aspects appropriate to avoid over- or undertreatment?
  • Are juridical questions included in every day care of chronic pain patients, mainly in palliative care?
  • On which level can appropriate interventions prevent over- or undertreatment?
Methods

A systematic literature research is done in 35 databases. In the HTA, reviews, epidemiological and clinical studies and economic evaluations are included which report about pain therapy and in particular palliative care in the years 2005 till 2010.

Results

47 studies meet the inclusion criteria. An undertreatment of acupuncture, over- and misuse with regard to opiate prescription and an overuse regarding unspecific chest pain and chronic low back pain (LBP) can be observed. The results show the benefit and the cost-effectiveness of interdisciplinary as well as multi-professional approaches, multimodal pain therapy and cross-sectoral integrated medical care. Only rough values can be determined about the care situation regarding the supply of pain therapeutic and palliative medical facilities as the data are completely insufficient.

Discussion

Due to the broad research question the HTA-report contains inevitably different outcomes and study designs which partially differ qualitatively very strong from each other. In the field of palliative care hospices for in-patients and palliative wards as well as hospices for out-patients are becoming more and more important. Palliative care is a basic right of all terminally ill persons.

Conclusion

Despite the relatively high number of studies in Germany the HTA-report shows a massive lack in health care research. Based on the studies a further expansion of out-patient pain and palliative care is recommended. Further training for all involved professional groups must be improved. An independent empirical analysis is necessary to determine over or undertreatment in pain care.

Keywords: accident, analgesia, back pain, biomedical technology assessment, blinded, blinding, care, chronic, chronic pain, clinical study, clinical trial, controlled clinical study, controlled clinical trial, controlled clinical trials as topic, cost analysis, cost control, cost effectiveness, cost reduction, cost-benefit analyses, cost-benefit analysis, cost-cutting, cost-effectiveness, costs, costs and cost analysis, cross over; crossover, cross-over, cross-over studies, cross-over trials, decision making, delivery of health care, diagnosis, doctor's note, double blind, doubleblind, double-blind, double-blind method, early retirement, EBM, economic aspect, economics, economics, medical, effectiveness, efficacy, efficiency, ethics, evaluation studies as topic, evidence based medicine, evidence-based medicine, headache; health, health care, health care costs, health economic studies, health economics, health policy, health technology assessment, healthcare needs, hospice, HTA, HTA report, HTA-report, humans, integrated care, ischialgia, judgment, juricical, lack of work, life qualities, low back pain, lumbar pain, medical assessment, medical care, medical costs, medical evaluation, meta analysis, meta-analysis, methods, migraine, misuse, models, economic, multicenter, multicenter trial, multicentre, multimodal supply, neck pain, overuse, pain, pain care, pain clinic, pain clinics, pain disorder, pain management, pain measurement, pain patient, pain reduction, pain situation, pain therapy, palliative, palliative care, palliative medicine, palliative therapy, palliative treatment, palliative treatments, peer review, pharmaeconomics, placebo, placebo effect, placebos, prevention, program effectiveness, prospective studies, psychotherapy, quality of life, random, random allocation, randomisation, randomised clinical study, randomised clinical trial, randomised controlled study, randomised controlled trial, randomised study, randomised trial, randomization, randomized clinical study, randomized clinical trial, randomized controlled study, randomized controlled trial, randomized study, randomized trial, RCT, rehabilitation, report, research article, research-article, review, review literature, rights, risk assessment, sensitivity, shoulder pain, sick certificate, sick note, sickness costs, single blind, single blind method, singleblind, single-blind, social economic factors, socioeconomic factors, socioeconomics, somatoform disorders, specifity, spinal column, spondylosis, stoppage, supply shortage, systematic review, technical report, technology, technology assessment, technology assessment, biomedical, technology evaluation, technology, medical, therapy, thoracic spine, thoracic vertebral column, treatment, trial, crossover, trial, cross-over, triple blind, tripleblind, triple-blind, underuse, validation studies, vertebral column


Summary

Health political background

By scientific opinion a high sensitivity for pain therapy has been achieved within the relevant stakeholders in Germany. But despite the efforts in recent years pain treatment is neither quantitatively nor qualitatively structurally ensured. For quite some time experts have been pointing out that there is a lack of multidisciplinary and -professional oriented pain centres in the field of out- and in-patient treatment. Furthermore, specialists regarding the medical, psychological, therapeutic and nursing care are missing. The aim of this HTA-report (HTA = Health Technology Assessment) is to determine to what extent over- or undertreatment exists in pain therapy.

Scientific background

Especially in Germany chronic pain is a common reason for the loss of working hours and early retirement. In addition to a reduction in quality of life for the affected persons chronic pain is therefore an enormous economic burden for society. In 2001 the expert advisory board for the evaluation of the development in the healthcare sector introduced the terms over- and undertreatment in Germany. With the methodical use of these terms quality problems in the healthcare system can be described analytically. Over- or undertreatment takes place on various levels. The question of adequate care considers not only the system immanent and contract organisation (meso level) but also the political framework (macro level) and the individual situation (micro level).

Social-medical research questions

  • Which diseases are in particular relevant regarding pain therapy? (Micro level)
  • What is the social-medical care situation regarding pain facilities in Germany? (Meso level)
  • What is the social-medical care situation in pain therapy when comparing on international level? (Macro level)
  • Which effects, costs or cost-effects can be seen on the micro-, meso- and macro level with regard to pain therapy?
  • Among which social-medical services in pain therapy is there over- or undertreatment with regard to the micro-, meso- and macro level?
  • Which medical and organisational aspects that have an effect on the costs and/or cost-effectiveness have to be particularly taken into account with regard to pain treatment/chronic pain?

Social, ethical and juridical research questions

  • What is the influence of the individual needs of the patient (micro level) in different situations of pain (e. g. palliative situation) on the meso- and macro level?
  • Which social-medical and ethical aspects for an adequate treatment of chronic pain on the individual levels have to be specially taken into account?
  • Is the consideration of these aspects appropriate to avoid over- or undertreatment?
  • Are juridical questions included in every day care of chronic pain patients, mainly in palliative care?
  • On which level can appropriate measures prevent an over- or undertreatment?

Methods

A systematic literature research is done by the German Institute for Medical Documentation and Information (DIMDI). Additionally the authors are looking for related studies and literature. The review includes HTA-reports, systematic reviews/meta-analyses, randomised controlled trials (RCT), cost studies, cost minimization studies, cost-benefit-analyses, cost-effectiveness studies and demand analyses which report on pain therapy, palliative care, pain management, pain clinics, out-patient pain departments from 2005 to 2010. With regard to the outcomes the studies have to deliver results about effectiveness, benefit and efficacy. For the evaluation of the studies the classification according to the evidence levels of the Oxford Centre of Evidence-based Medicine of 2006 is used. Furthermore a survey of the European pain societies has been conducted.

Social-medical results

Within the social-medical publications 27 studies analyse curative pain therapy and seven studies palliative care.

Many of the included studies do not deal with interventions. Out-patient palliative care measures are the most often examined healthcare measures. However care services such as cognitive behaviour therapy, acupuncture or chiropractic care, drug treatment as well as guideline-oriented consultations are as well considered.

On the micro level of the doctor-patient-interaction the studies show dissatisfaction with the pain treatment among 22% of the chronic pain patients as well as some provision problems. Maltreatment regarding the drug non-compliance among non-malignant chronic pain is observed as well as deficits regarding acupuncture, over- and misuse regarding opiate prescription and overuse among non-specific chest pain and chronic low back pain (LBP). In Germany there is obviously a clear deficit regarding the use of psychotherapeutic methods in pain treatment although there is strong evidence for the efficacy and cost-effectiveness of cognitive-behavioural interventions and other psychotherapeutic methods.

On the meso level of the supply and the organisation the care is ensured by general practitioners and only rarely by pain specialists. Affected persons report that the access to information about care services of the palliative medicine is difficult.

The results show the benefit and the cost-effectiveness of interdisciplinary as well as multi-professional approaches, multimodal pain therapy and cross-sectoral integrated medical care. Furthermore the benefit of specialised out-patient palliative nursing services is proven but it is also shown that these concepts cannot work cost-effective. Despite an increase of healthcare facilities during the last three years, it can be assumed that there is a further lack of these facilities.

Social, ethical and juridical results

Within the ethical publications eleven studies analyse curative pain therapy and two palliative care. On the micro level it is evident that special attention should be paid to very vulnerable patient groups such as newborn babies, children and teenager as well as old and mentally restricted patients. The impact of empathy as a therapeutic approach in the care of pain patients is entirely insufficient described and investigated. On the meso level it must be taken into consideration that the care of terminally ill patients needs in particular not only clinical but also ethical competence, communication and interdisciplinary cooperation. On the macro level should be noted that patients must be guaranteed the right to an adequate and individually tailored pain therapy. Palliative care is a basic right of all terminally ill persons.

Discussion

In this HTA-report the highest number of studies comprise pain care in the field of low back. In curative treatment level there is a wide range regarding the size of the facilities (meso-level). The facilities are organised as doctor’s surgery, out-patient wards, pain centres and in some cases as new kinds of care facilities. In the field of palliative care hospices for in-patients and palliative wards as well as hospices for out-patients are becoming more and more important. Due to the broad research question the HTA-report contains inevitably different outcomes and study designs which partially differ qualitatively very strong from each other.

Conclusion

Despite the relatively high number of German studies, there is a massive lack in the health services research. Based on the results this HTA-report shows that the analyses are not sufficient to verify a sustainable pain care in Germany or to make a valid comparison with the international situation. Even if the number of pain care facilities has increased over the last few years, there is still a lack in the further development of the programs and regarding the analysis of over- or undertreatment. A further expansion of out-patient pain and palliative care as well as supportive offers for caring relatives can be recommended.

Further training for all involved professional groups must be improved. Especially the subject palliative medicine for future physicians and palliative care for nursing personnel is important. The care of terminally ill patients needs in particular not only clinical but also ethical competence, communication and interdisciplinary cooperation.