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

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

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.

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.

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

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.

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.

• 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.

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.