title: Clinical pathways can improve the quality of pain management in home palliative care in remote locations: retrospective study on Kozu Island, Japan.
abstract: BACKGROUND
  Recent studies show that a clinical pathway (CP) optimizes pain management in palliative care; however, studies on CPs in home palliative care, especially in remote locations, are scarce. Physicians performing palliative care in remote areas frequently face characteristic difficulties. The CP is an effective tool to overcome these difficulties. This study evaluates the effectiveness of the CP in home palliative care on a remote island.
  
  
  METHODS
  This study reviewed 24 patients (17 in a pre-CP group and seven in a post-CP group) who received home palliative care on Kozu Island in south-eastern Japan from April 2006 to December 2011. To evaluate CP effectiveness, the authors compared patients in whom a rescue opioid was set, and nonsteroidal anti- inflammatory drugs (NSAIDs), antiemetics, and laxatives drug were used with opioids in the post-CP group compared with those in the pre-CP group. To assess pain management quality, authors compared Pain Management Index (PMI) scores on day 1 (baseline); day 8 following CP initiation; and within 3 days before death.
  
  
  RESULTS
  The proportion of patients in whom a rescue dose was set was 100% in the post-CP group versus 46% in the pre-CP group (<em>p</em>=0.04). The proportion of patients in whom NSAIDs were used with opioids was 100% in the post-CP group versus 18% in the pre-CP group (<em>p</em>=0.002). The proportion of patients in whom antiemetics and laxatives were used with opioids was 100% in the post-CP group versus 27% in the pre-CP group (<em>p</em>=0.009). Baseline PMI scores were not significantly different between groups (-1 in post-CP group versus 0 in pre-CP group, <em>p</em>=0.1); however, PMI scores at day 8 and within 3 days before death were significantly higher in the post-CP group (1.9 and 2.9) than in the pre-CP group (0.2 and -0.4) (<em>p</em>=0.007 and <em>p</em>=0.0005, respectively).
  
  
  CONCLUSIONS
  Implementation of a CP for pain management in home palliative care in remote locations could improve compliance with the WHO pain management guidelines and the quality of pain management.
authors.affiliation: Kozu National Health Insurance Clinic, Tokyo, Japan. m02057yt@jichi.ac.jp
authors.forename: Yuki
authors.initials: Y
authors.lastname: Tateno
authors.forename: Shizukiyo
authors.initials: S
authors.lastname: Ishikawa
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D000932:Antiemetics / Q000627:therapeutic use; D057186:Comparative Effectiveness Research; D019091:Critical Pathways / Q000592:standards*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006699:Home Care Services; D006801:Humans; D007564:Japan; D054368:Laxatives / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000503:physiopathology / Q000534:rehabilitation / Q000628:therapy; D009726:Nurses / Q000592:standards; D010146:Pain / Q000188:drug therapy; D059408:Pain Management; D010166:Palliative Care / Q000379:methods* / Q000706:statistics & numerical data; D010821:Physicians, Family / Q000592:standards; D011785:Quality Assurance, Health Care / Q000592:standards*; D012189:Retrospective Studies; D019035:Rural Health Services / Q000592:standards*; D013686:Telemetry
chemical_list: D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D000932:Antiemetics; D054368:Laxatives