Institutional Initiatives

Institutional Initiatives

PEP Topic 
Chronic Pain
Description 

Institutional initiatives are interventions done by an organization to facilitate uptake and implementation of new knowledge by healthcare providers, patients, and caregivers to improve care. Interventions include provision of education and distribution of printed materials, and may include development of organizational protocols, procedures, and activities to standardize care. Institutional interventions were evaluated in terms of effect on chronic pain and prevention of infection in patients with cancer.

Effectiveness Not Established

Research Evidence Summaries

Chen, J., Lu, X.Y., Wang, W.J., Shen, B., Ye, Y., Jiang, H., . . . Cheng, B. (2014). Impact of a clinical pharmacist-led guidance team on cancer pain therapy in China: A prospective multicenter cohort study. Journal of Pain and Symptom Management, 48, 500–509. 

doi: 10.1016/j.jpainsymman.2013.10.015
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Study Purpose:

To assess the value of pharmacist-led teams as a model for improving drug delivery and implementing the role of the clinical pharmacist in direct patient care using cancer pain management as a focus area

Intervention Characteristics/Basic Study Process:

Clinical guidance teams included clinical pharmacists, nurses registered in oncology, oncologists, and administrators. Pharmacists had at least two years' residency in the oncology department and underwent training in opioid pharmacotherapeutics, National Comprehensive Cancer Network guidelines, and Chinese practice guidelines, and they had to pass an examination. The pharmacist was responsible for patient and physician education, consulting in complex cases, and monitoring for drug efficacy and side effects. Patients with a history of cancer-related pain were enrolled. Patients were assigned consecutively to the intervention group, in which the guidance team was involved, or the control group, in which no guidance from the cancer pain therapy team was given. Outcomes were evaluated after six months. Patients in the experimental group had follow-up appointments via face to face or telephonic interviews twice a month. Study data were obtained from medical records and follow-ups.

Sample Characteristics:

  • N = 542  
  • AGE = 63.7% aged greater than 60 years
  • MALES: 49.3%, FEMALES: 50.7%
  • KEY DISEASE CHARACTERISTICS: Disease types were not provided.

Setting:

  • SITE: Multi-site  
  • SETTING TYPE: Inpatient    
  • LOCATION: China

Study Design:

Cohort design

Measurement Instruments/Methods:

  • Numeric or visual scale for pain (mean value from follow-up scores used in analysis)
  • Documentation of adverse effects (yes/no evaluation)
  • Quality of life questionnaire (not described)

Results:

Compared to the control group, there were more frequent pain severity evaluations before opioid administration, more standardized dose titrations, more sustained-release formulations (p < 0.001), and fewer errors in dose conversion to other opioids (p = 0.017) in the experimental group. Pain scores were lower in the experimental group (p < 0.05), and the incidence of constipation, nausea, and vomiting was lower in the experimental group (p < 0.05).

Conclusions:

The implementation of the clinical pharmacist role in guidance teams for cancer-related pain was associated with improvements in the process of medication management and pain scores.

Limitations:

  • Key sample group differences that could influence results 
  • Measurement/methods not well described 
  • Risk of bias (no blinding) 
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)  
  • Unintended interventions or applicable interventions not described that would influence results 
  • Other limitations/explanation: No information regarding baseline pain levels was provided, so changes between groups are not known. Patient assignment was consecutive rather than true random assignment. Whether patient assignments to study groups took place within the same institution was not stated, and contamination could have occurred if patients in different groups were in the same location.

 

Nursing Implications:

The findings of this study suggested that the intervention of a multidisciplinary team to guide pain management can improve medication management, monitoring, and chronic pain outcomes.

Herr, K., Titler, M., Fine, P.G., Sanders, S., Cavanaugh, J.E., Swegle, J., . . . Forcucci, C. (2012). The effect of a translating research into practice (TRIP)-cancer intervention on cancer pain management in older adults in hospice. Pain Medicine, 13, 1004–1017.

doi: 10.1111/j.1526-4637.2012.01405.x
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Study Purpose:

To promote the adoption of evidence-based pain practices for older adults with cancer

Intervention Characteristics/Basic Study Process:

  • Five-month engagement phase—receipt of three relevant clinical practice guidelines for experimental (E) and control (C) groups, pain training and activities for E hospices
  • 12-month implementation phase—E group received tools for implementation (e.g., quick reference guides), nurses completed an evidence-based practice (EBP) pain program, sites received a monthly outreach visit from an expert nurse who audited charts for 48 EBP indicators and provided feedback, participation in a monthly teleconference to discuss progress and strategies, sharing on e-sites, weekly pain assessment and management sessions as desired

Sample Characteristics:

  • N = 16 hospices and 738 patients
  • AGE: Hospices see 30 older patients per year; patients were older adults with a mean age of 77.6 years
  • MALES: 55.9%, FEMALES: 44.1%
  • KEY DISEASE CHARACTERISTICS: End-stage cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: 66.3% white

Setting:

  • SITE: Multi-site 
  • SETTING TYPE: Home 
  • LOCATION: Midwest hospices

Phase of Care and Clinical Applications:

  • PHASE OF CARE: End-of-life care
  • APPLICATIONS: Elder care

Study Design:

  • Retrospective, cluster, randomized control trial of 16 hospices
    • Eight in the E group and eight in the C group

Measurement Instruments/Methods:

  • Cancer Pain Practice Index (CPPI), which lists 11 EBP cancer pain practices for older adults
  • Mean pain severity
  • Medical record abstract tool inclusive of 48 indicators of EBP for pain management
  • Numeric Rating Scale 
  • Pain severity scale (0–10)
  • Verbal Descriptor Scale for pain intensity (mild, moderate, severe)

Results:

No significant differences existed between the E and C groups in regards to improvement in the CPPI. A decrease in pain severity was found from baseline to post-intervention in the E group, but this was not statistically significant.

Conclusions:

Numerous factors influence a multicomponent intervention. Culture, competing priorities, intervention complexity, and other factors may have a role. Future studies should focus on more specific factors in need of change. Although the patient sample was large, only eight hospices comprised each group for the study.

Limitations:

  • Small sample (less than 30)
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: The sensitivity of the CPPI to detect change in provider practice was not established a priori.

Nursing Implications:

Translating research into practice is a primary goal of nursing, and pain guideline translation is essential to improving pain outcomes. Translation, however, takes time and may not translate immediately to improved patient outcomes.

Williams, J.E., Peacock, J., Gubbay, A.N., Kuo, P.Y., Ellard, R., Gupta, R., . . . Ross, J. (2015). Routine screening for pain combined with a pain treatment protocol in head and neck cancer: A randomised controlled trial. British Journal of Anaesthesia, 115, 621–628. 

doi: 10.1093/bja/aev263
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Study Purpose:

To compare the effectiveness of a pain management protocol with usual care

Intervention Characteristics/Basic Study Process:

Patients who were referred for pain control were screened for worst pain severity on a 10-point numerical scale, and those who scored four or more were randomized to usual care or the experimental protocol group. The protocol treatment was individualized to the patient based on assessments. Protocols included the formulation of a pain treatment plan, weekly reassessments, the provision of an educational brochure, a discussion with a pain control doctor, and a referral to palliative care or other services as needed. Patients were followed for three months. Usual care patients could be referred to the pain control group but were not proactively scheduled for ongoing weekly assessments. Study assessments were done at baseline and at one and two months.

Sample Characteristics:

  • N = 129
  • MEAN AGE = 59 years (range = 19–80 years)
  • MALES: 58%, FEMALES: 42%
  • KEY DISEASE CHARACTERISTICS: All patients had head and neck cancers, and the majority were cancers of the larynx and pharynx.
  • OTHER KEY SAMPLE CHARACTERISTICS: Overall, 87% of participants were receiving weak opioids at baseline, and the average morphine equivalent dose at baseline was 29 mg per day (range = 5–510 mg).

Setting:

  • SITE: Single site  
  • SETTING TYPE: Not specified  
  • LOCATION: United Kingdom

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Palliative care 

Study Design:

Single-blinded, randomized, controlled trial

Measurement Instruments/Methods:

  • Brief Pain Inventory (BPI), the average of four scales as a pain severity index
  • Pain Management Index (PMI)
  • EuroQol Five Dimensions Questionnaire (EQ-5D)
  • Patient satisfaction
  • Cost effectiveness analysis

Results:

There were no significant differences between the groups in pain measures throughout the study. Patient satisfaction was higher in the study group. The mean cost of pain treatment was significantly higher in the study group. The analysis showed a low probability of the intervention being cost-effective. Pain scores declined significantly over time in both groups.

Conclusions:

The protocol did not demonstrate any significant benefit over usual care.

Limitations:

  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Unintended interventions or applicable interventions not described that would influence results 
  • Key sample group differences that could influence results 
  • Measurement/methods not well described 
  • Other limitations/explanation: The sample was underpowered. At baseline, the range of morphine equivalents was much higher in the usual care group. The timing and method of BPI measures was not described. Changes in medications and the use of additional referrals between groups over time was not discussed, so it was unclear if there were substantial differences in the care between groups. The phase of care was not clearly stated. Both groups were managed in the same pain practice, so it was possible that protocol aspects also were applied to usual care patients.

Nursing Implications:

The findings of this study did not show a benefit of the specific protocol approach with weekly reassessments in the clinic as used here. This study did show that pain screening could be implemented and combined with good usual care to reduce pain severity.

Won, Y., Hwa, Choi, Y., Jung, Ahn, S., Lee, J., Park, J., Yun, Kim, S., . . . Kim, Y.H. (2014). Improving the quality of cancer pain management in an academic medical center emergency department. Clinical Journal of Oncology Nursing, 18, 626–629. 

doi: 10.1188/14.CJON.626-629
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Study Purpose:

To evaluate the impact of a cancer-related pain control project implemented in a specialized cancer emergency department

Intervention Characteristics/Basic Study Process:

A project to improve the management of cancer-related pain was implemented in a cancer emergency department that was established two years prior. The project used standard operating procedures for patient assessments every eight hours and reported any pain within one hour of analgesic administration. The pain management guidelines used included the use of oral analgesics following the World Health Organization analgesic ladder, the use of time-release analgesics for the prevention of pain recurrence, the prophylactic prescription of immediate-release analgesica for breakthrough pain, and the increase of the regular analgesic dose when breakthrough pain occurred more than three times per day. The target pain score on a numeric rating scale was established at three points or less. Medical records were reviewed to obtain study data, and adherence to the guideline and procedures was ranked low, medium, or high based on percent adherence. Findings prior to and after the project's implementation were compared.

Sample Characteristics:

  • N = 455
  • MEAN AGE = 54.9 years
  • MALES: 50%, FEMALES: 50%
  • KEY DISEASE CHARACTERISTICS: The majority of patients had solid tumors of various types.
  • OTHER KEY SAMPLE CHARACTERISTICS: The patients included were those in the emergency department for at least 24 hours.

Setting:

  • SITE: Single site  
  • SETTING TYPE: Outpatient  
  • LOCATION: Korea

Phase of Care and Clinical Applications:

  • APPLICATIONS: Palliative care

Study Design:

Retrospective, descriptive study

Measurement Instruments/Methods:

  • Pain severity Numeric Rating Scale (NRS)
  • Time to reaching target pain NRS score of three or less
  • Guideline adherence high (> 75 %), medium (50%–75%), and low (< 50%)

Results:

The percentage of patients who received pain assessments according to the procedure increased after the intervention (p < 0.001). There was a significant improvement in the appropriate use of short-acting analgesics (p < 0.001), prescriptions for breakthrough pain analgesics (p = 0.013), and the use of time-release analgesics (p < 0.001). The time to reach the target NRS was 27 hours before the intervention and 15 hours after (p = 0.025). There was a significant correlation between guideline adherence and time to reach the target NRS score (p = 0.039).

Conclusions:

The use of standard guidelines and standard operating procedures for the treatment of cancer-related pain was associated with improved frequency of assessment and time to reach a target pain score.

Limitations:

  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Key sample group differences that could influence results
  • Findings not generalizable
  • Other limitations/explanation: The intervention was done in a cancer-specific emergency department. Such a specialized emergency department is not usual. There was no description of how the project and its related changes in practice were actually implemented or what staff education efforts were done to implement the guidelines and procedures.

Nursing Implications:

The findings of this study suggest that organizational initiatives to improve pain control with guidelines and standard operating procedures can improve the management of cancer-related pain.

Yang, Y.P., Ma, Y.X., Huang, Y., Zhao, Y.Y., Xu, F., Tian, Y., . . . Zhang, L. (2014). The good pain management (GPM) ward program in China and its impact on Chinese cancer patients: The SYSUCC experience. Chinese Journal of Cancer, 33, 323–329. 

doi: 10.5732/cjc.014.10031
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Study Purpose:

To evaluate improvementcancer-related pain management after the implementation of a program to improve this aspect of cancer care

Intervention Characteristics/Basic Study Process:

The pain initiative involved the training and education of medical and nursing staff, training in standardized cancer pain management according to National Comprehensive Cancer Network (NCCN) and World Health Organization (WHO) guidelines conducted monthly, patient education in person and via booklets, and the use of a pain assessment scale posted at each bedside. Participating hospitals established cancer pain treatment teams including multiple disciplines. Patients who had multiple bone metastases were included. Patients who were cared for after the program was initiated were compared to historical controls. Pain levels were recorded on admission and after pain management.

Sample Characteristics:

  • N = 475
  • AGE = Not reported
  • MALES: 57.7%, FEMALES: 42.3%
  • KEY DISEASE CHARACTERISTICS: Lung, breast, head and neck, and other cancer types
  • OTHER KEY SAMPLE CHARACTERISTICS: The majority of patients had multiple metastatic bone lesions.

Setting:

  • SITE: Multi-site  
  • SETTING TYPE: Inpatient    
  • LOCATION: China

Phase of Care and Clinical Applications:

  • APPLICATIONS: Palliative care 

Study Design:

Multisite cohort comparison with historical controls

Measurement Instruments/Methods:

  • Pain reporting rate on admission
  • Rate of analgesic administration
  • Numeric Rating Scale (NRS) for pain 
  • Rate of complete pain remission (pain level decreased to none)

Results:

The proportion of patients with pain on admission was higher after the intervention. The complete pain remission rate was higher in the intervention group (54.5% versus 33.7%, p = 0.0002). The uncontrolled pain rate was lower with the intervention group (13.8% versus 31.5%, p = 0.0001). There was greater use of strong opioids after the intervention (p = 0.01). There were no differences between groups in use of bone modifying agents, radiotherapy, or nonsteroidal anti-inflammatory agents.

Conclusions:

The organizational intervention used here, including staff education, patient education, and ongoing visual reminders at the point of care, appeared to have a positive effect on pain management practices and outcomes.

Limitations:

  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Risk of bias (sample characteristics)
  • Measurement/methods not well described
  • Questionable protocol fidelity
  • Other limitations/explanation: The timing of various pain measurements used in the comparison was not stated. The use of historical controls had some inherent potential bias because of the possibility of other confounding variables although the timeframe between groups was only about six months. The duration of management for individual patients was not stated. The medications used and dosages were not provided.

Nursing Implications:

There is some evidence that cancer-related pain continues to be under-reported and undertreated. The program initiated and reported here was associated with some improvements in practices related to pain management and pain outcomes predominantly associated with the increased use of strong opioids. This program provided an approach to encourage clinicians to pay more attention to pain and increase skills for appropriate analgesic use. It appeared to lead them to use strong opioids more. This evaluation could provide ideas for institutional efforts to improve cancer pain management.

Systematic Review/Meta-Analysis

Cummings, G.G., Olivo, S.A., Biondo, P.D., Stiles, C.R., Yurtseven, O., Fainsinger, R.L., & Hagen, N.A. (2011). Effectiveness of knowledge translation interventions to improve cancer pain management. Journal of Pain and Symptom Management, 41, 915–939.

doi: 10.1016/j.jpainsymman.2010.07.017
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Purpose:

To determine the effectiveness of interventions to facilitate uptake of new knowledge by healthcare practitioners, patients, and family caregivers to improve cancer pain management. Primary outcomes of interest were change in behavior or practice of healthcare professionals or patients and caregivers. Secondary outcomes included change in patient quality of life or satisfaction with treatment.

Search Strategy:

Databases searched were CINAHL, MEDLINE, EMBASE, AMED, Web of Science, Cochrane Database of Clinical Trials and Cochrane Database of Systematic Reviews, National Cancer Institute of Canada, Canadian Cancer Society, American Cancer Society, American Society of Clinical Oncology, European Association for Palliative Care, and other websites.

An extensive listing of specific search terms and operators is provided. Main search terms included pain, analgesia, cancer, practice guidelines, evidence based medicine, and organizational innovation.

Studies were included in the review if they

  • Were randomized controlled trials, controlled clinical trials, time series, and pre-post studies that evaluated the effect of knowledge translation interventions on patient outcomes
  • Included patients with cancer.

Case reports, cross-sectional studies, or noncontrolled pre-post studies were excluded.

Literature Evaluated:

  • The initial search yielded 15,625 articles.
  • A total of 308 articles were retrieved and reviewed according to inclusion criteria.
  • Risk of bias assessment was done using methods of the Cochrane Effective Practice and Organization of Care Group.

Sample Characteristics:

A final sample of 26 studies was included: 16 examined interventions for patients only, 4 focused on family caregivers, and 5 investigated effects of interventions targeted to health professionals. One study compared a solo intervention for patients only, and a dyad intervention for patients and their significant others, within the same study.

Results:

  • Of 26 studies, 25 were rated as having high risk of bias due to lack of blinding in the design, incomplete data, lack of allocation concealment, and other issues. Inter-rater reliability of this scoring showed only slight agreement between raters.

Interventions targeting health professionals (5 studies)

  • Findings related to patient outcomes were mixed, with two studies showing decrease in pain intensity and two studies showing no change in patients’ pain.
  • Two studies showed significant increases in healthcare professionals’ knowledge and attitudes.

Interventions targeting patients and caregivers (21 studies)

  • Most interventions were face-to-face coaching sessions and distribution of printed material. In more than half of the studies, in-person or telephone follow-up was used to reinforce education.
  • Eight studies showed significant decrease in patients’ pain intensity with the intervention, and five showed positive change in patient behavior regarding pain control strategies.
  • Five studies targeting patients and family caregivers showed mixed results, with two showing improvement in pain intensity and adherence to therapy, and three showing no effect.

Meta-analysis results

     Interventions targeting patients and caregivers

  • There was no significant effect of interventions on pain interference with activities.
  • In six studies, the effect on usual/average pain showed a tendency favoring the intervention (SMD = 0.43, 95% CI 0.13 – 0.74, effect = 2.76, p = 0.006). These findings are limited by the high heterogeneity among studies.
  • There was no significant overall effect of interventions on worst pain, current pain, or overall pain measures in meta-analysis.
  • There was a significant effect of the intervention on least pain intensity (SMD = 0.93, 95% CI 0.44 – 0.142, p = 0.0002), but this was from only two studies.

Intervention dose and intensity

  • It is noted that the “dose” and intensity of knowledge translation interventions varied greatly. Authors define high- and low-dose parameters and show that those studies with higher dosage of the intervention tended to report significant results on patient outcomes.

Conclusions:

Knowledge translation interventions aimed at healthcare professionals have demonstrated change in practitioner behavior and attitude, but have not demonstrated an effect on patient pain outcomes measured. There is some evidence to suggest that higher intensity and “dose” of these interventions, indicating amount of time spent in education, inclusion of follow-up, patient/family contact, and longer duration of follow- up, tend to be more effective.

Limitations:

Knowledge translation interventions aimed at patients and caregivers have been associated with improvement in patients’ least and average pain scores, but not other pain measures. These findings need to be viewed with caution, since studies included showed high heterogeneity, and the timing, dosage, and intensity of the interventions varied.

Nursing Implications:

Educational and knowledge translation interventions regarding pain management that are aimed at the patient and caregiver have been shown to be effective in improving some measures of pain intensity, and have often, but not always, resulted in improved knowledge, attitudes, and skills related to pain management. Elements of success included more intensive education such as involvement of a multidisciplinary team in face-to-face education, locally constructed education materials, standardized approaches, and patient follow-up to reinforce the education. Pain management educational programs should be constructed to include key elements that are likely to improve outcomes.

Goldberg, G.R., & Morrison, R.S. (2007). Pain management in hospitalized cancer patients: A systematic review. Journal of Clinical Oncology, 25, 1792–1801.

doi: 10.1200/JCO.2006.07.9038
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Purpose:

To provide a systematic review of institutional interventions designed to improve management of pain in hospitalized patients with cancer

Search Strategy:

Databases searched were MEDLINE, Cochrane Library, and authors’ personal libraries.

Search keywords were pain, pain measurement, outcomes assessment, or quality assurance.

Inclusion criteria was not specifically stated, other than that studies involved patients with cancer.

Exclusion criteria was not specifically stated.

Literature Evaluated:

Total number of studies retrieved or initially evaluated is not provided.

Articles were reviewed and independently summarized by the authors, and any disagreements were discussed until consensus was achieved.

Sample Characteristics:

Studies were not exclusively for patients with cancer, but all did involve some cancer care cases.

  • Four studies involving the effect of educational interventions for care providers, encompassing 939 nurses
  • Two studies involving patient education, encompassing 343 patients
  • Ten studies of interventions to improve assessment and documentation of pain, involving more than 2,876 cases
  • Three studies involving the use of auditing and feedback, involving more than 4,662 patients
  • Two studies and one meta-analysis involving use of pain specialty consultation
  • One study involving the use of a computerized decision support system (CDSS) to enhance physician prescribing and treatment of pain

Results:

Nursing educational interventions improve knowledge and correct misconceptions but have not shown improved pain or patient satisfaction.

Studies suggest that patient education and tailored counseling sessions directed at patients can improve pain scores and negative beliefs and misconceptions.

Routine pain assessment has been shown to improve staff and patient satisfaction; however, interventions have not been shown to improve overall pain scores or pain severity.

Provision of audit and feedback of patient pain scores to nursing  staff improved pain assessment rates but had no effect on pain severity.

The study involving CDSS showed some improvement in prescribing practices, predominantly reducing use of meperidine, but did not demonstrate improved pain scores.

Meta-analysis of eight studies in the effect of a hospital-based palliative care team suggests that referral to such programs results in small but positive effects on pain, other symptoms, satisfaction, and reduction in length of stay compared to conventional care.

Conclusions:

The major types of institution-wide interventions aimed at improving pain management include education, inclusion of pain assessment as a vital sign, auditing and staff feedback of pain scores, use of CDSS, and referral to palliative care specialists. Improved knowledge, assessment, and process of care measures have been demonstrated; however, no substantial effects on actual pain scores and severity have been demonstrated as a result of these interventions. From this review, the most promising interventions related to actual pain outcomes appear to be patient education and counseling and referral to palliative care specialists. The authors conclude that no generalizable interventions were identified.

Limitations:

  • Findings are limited by the fact that studies had numerous methodological flaws and, in some cases, very small samples.
  • The search strategy was limited and not well-reported and may have missed reports of some quality improvement efforts that may have not been published or identified in this review.

Nursing Implications:

Findings point to the difficulty of being able to demonstrate the effects of institutional interventions on patients’ measurable pain outcomes other than satisfaction with pain management. Most of these efforts are not necessarily appropriate in a randomized controlled trial type of design, leading to questions of methodological rigor in findings, and suggest that the patient’s experience of pain is complex and not readily determined by standardized processes.

Findings suggest that individual patient interventions including counseling and education are worth further investigation in order to have an effect on pain outcomes.

Involvement of palliative care specialists appears to be somewhat effective to improve pain outcomes; however, it is not clear that universal referrals to such groups for all pain management are practical. This raises the question of how such specialized knowledge, focus, and expertise might be shared and utilized in new ways to impact all patients. It is not clear that educational interventions for staff that have been studied are sufficient to improve knowledge of providers to the extent required to impact pain-related results.

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