Does adherence to National Comprehensive Cancer Network guidelines improve pain-related outcomes? An evaluation of inpatient cancer pain management at an academic medical center.
BACKGROUND
Evidence-based guidelines are in place for the management of cancer-related pain, yet adherence remains problematic throughout health systems because of efficacy and safety concerns.


OBJECTIVE
To evaluate adherence to the National Comprehensive Cancer Network (NCCN) guidelines on pain management among cancer inpatients and assess whether adherence is associated with pain control.


METHODS
A retrospective chart review of patients admitted to the hematology/oncology service at an academic medical center between April 1, 2011 and September 30, 2011 was conducted, and patients were allocated into groups based on adherence to NCCN guidelines. Pain control and safety outcomes were compared between adherence groups for the first 24 hours of hospital admission. Multivariate analyses were performed to identify predictors of regimens nonadherent to guidelines and predictors of inadequate achievement of analgesia.


RESULTS
Among a random sample of 193 inpatients, 109 met the inclusion criteria of which 70 were guideline adherent and 39 nonadherent. A total of 63% of the patients initiated on NCCN adherent guidelines obtained analgesia at 24 hours compared with 41% in the nonadherent group (P=0.028). Average pain scores across the 24-hour period were lower in the adherent compared with the nonadherent group (3.5 vs. 4.4, respectively, P<0.001). Naloxone use, respiratory depression, and hypoxia did not significantly vary between adherence groups. Chronic home opioid exposure was significantly associated with nonadherent therapy (vs. adherent; odds ratio=3.04, confidence interval=1.28-7.18, P=0.01) and achievement of analgesia at 24 hours (vs. not; odds ratio=0.30, confidence interval=0.12-0.73, P<0.01).


CONCLUSIONS
Adherence to NCCN guidelines remains insufficient, with nonadherence being associated with inadequate analgesia. Opioid-tolerant patients remain at higher risk for guideline nonadherence and inadequate analgesia. Quality improvement initiatives should target opioid-tolerant patients.
Department of Pharmacy, Advocate Condell Medical Center, Libertyville, Illinois, USA. Electronic address: michael.mearis@advocatehealth.com.
Michael
M
Mearis
University of Chicago Medicine, Chicago, Illinois, USA.
Joseph W
JW
Shega
University of Chicago Medicine, Chicago, Illinois, USA.
Randall W
RW
Knoebel
D000368:Aged; D000700:Analgesics / Q000009:adverse effects / Q000627:therapeutic use; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009369:Neoplasms / Q000503:physiopathology*; D010146:Pain / Q000503:physiopathology*; D059408:Pain Management / Q000009:adverse effects / Q000379:methods*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D016896:Treatment Outcome
D000700:Analgesics
Cancer pain; inpatient pain management; opioid analgesic; opioid tolerant; pain management guidelines