P2519: The Impact of Transcatheter Aortic Valve Implantation on Quality of Life: A Mixed Methods Study

Objective: To provide an in-depth understanding of patients' views about the impact of transcatheter aortic valve implantation on self-reported quality of life. Background: Transcatheter aortic valve implantation is considered to be the gold standard of care for inoperable patients diagnosed with severe symptomatic aortic stenosis. Mid- to long-term clinical outcomes are favourable and questionnaire data indicates improvements in quality of life but an in-depth understanding of how quality of life is altered by the intervention is missing. Methods: A mixed methods study design with a total of 89 in-depth qualitative interviews conducted with participants (39% male; mean age 81.7 years), 1 and 3 months post TAVI, recruited from a regional centre in England. Data were triangulated with questionnaire data (SF-36 and EQ5D-VAS) collected, pre, 1 and 3 months post implantation. Results: Participants' accounts were characterised by four key themes; shortened life, extended life, limited life and changed life. Quality of life was changed through two mechanisms. Most participants reported a reduced symptom burden and all explained that their life expectancy was improved. Questionnaire data supported interview data with gradual improvements in mean EQ-5D scores and SF-36 physical and mental domain scores at 1 and 3 months compared to baseline. Conclusion: Findings suggest that TAVI was of variable benefit, producing considerable improvements in either mental or physical health in many participants, while a smaller proportion continued to deteriorate

Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools.

BACKGROUND: There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment. METHODS: We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach. RESULTS: We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations. CONCLUSIONS: There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence

Managing the symptoms of neuropathic pain: An exploration of patients' experiences

The debilitating effects of chronic neuropathic pain on everyday life are considerable but little is known about how individual sufferers manage these effects. Virtually nothing is known about what patients prefer, what measures they take themselves, when, or in what combinations. The aim of this study was to explore patients’ reports of how they managed their neuropathic pain symptoms. Three focus groups including 10 participants were used to generate qualitative data on both individual and shared experiences of managing their symptoms of neuropathic pain. Discussions were recorded and transcribed verbatim. Data were analysed using thematic analysis, identifying categories and broader themes of importance to patients. The most common management strategy was the use of conventional medications, often associated with poor effectiveness and unpleasant side-effects. Complementary and alternative medicine was ineffective but many found resting or retreating helpful. They exhibited a repeated cycle of seeking help to manage the pain, with each unsuccessful attempt followed by new attempts. Some had tried to accept their pain, but there was insufficient psychological, social, emotional and practical support to allow them to do this successfully. This exploratory study provides a basis from which to develop a larger study to validate and extend the findings. Other issues meriting research are the effectiveness of cognitive behavioural therapies for those with neuropathic pain; and an exploration and subsequent evaluation of different types of social, practical and emotional support needed to help live with neuropathic pain

The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective

BACKGROUND:Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group.METHODS:A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory.RESULTS:Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time.CONCLUSIONS:There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital

Effectiveness of a community based nurse-pharmacist managed pain clinic: A mixed-methods study.

BACKGROUND: Chronic pain is predominantly managed in primary care, although often ineffectively. There is growing evidence to support the potential role of nurses and pharmacists in the effective management of chronic pain. OBJECTIVES: To evaluate the effectiveness of a pain clinic jointly managed by a nurse and pharmacist. DESIGN: A mixed-methods design consisting of qualitative interviews embedded within a quasi-experimental study. SETTINGS: A community-based nurse-pharmacist led pain clinic in the north of England. PARTICIPANTS: Adult chronic pain (non-malignant) patients referred to the pain clinic. METHODS: Pain intensity was the primary outcome. Questionnaires (the Brief Pain Inventory, the Hospital Anxiety and Depression Scale, the SF-36 and the Chronic Pain Grade questionnaire) were administered at the baseline, on discharge and at 3-month post-discharge (Brief Pain Inventory and Hospital Anxiety and Depression Scale only). Patient satisfaction was explored using face-to-face, semi-structured qualitative interviews. RESULTS: Seventy-nine patients with a mean age of 46.5 years (SD±14.4) took part in the quasi-experimental study. Thirty-six and nine patients completed the discharge and 3-month follow-up questionnaires respectively. Compared to baseline, statistically significant reductions were noted for two of the outcome measures: pain intensity (P=0.02), and interference of pain with physical functioning (P=0.02) on discharge from the service. Nineteen patients participated in qualitative interviews. The patients were, in general, satisfied with the quality of service. Four contributing factors to patient satisfaction were identified: ample consultation time, in-depth specialised knowledge, listening and understanding to patients' needs, and a holistic approach. CONCLUSIONS: Nurse and pharmacist managed community-based pain clinics can effectively deliver quality pain management services as they offer an interdisciplinary holistic approach to pain management. Such services have the potential not only to reduce the burden on secondary care but also decrease long waiting times for referral to secondary care. Further research is required to support the development of evidence based referral guidelines to such services

The effects of patient-professional partnerships on the self-management and health outcomes for patients with chronic back pain: a quasi-experimental study

Background: Self-management may be a lifelong task for patients with chronic back pain. Research suggests that chronic pain self-management programmes have beneficial effects on patients’ health outcome. Contemporary pain management theories and models also suggest that a good patient-professional partnership enhances patients’ ability to self-manage their condition. Objectives: 1) To investigate whether there is a reciprocal relationship between self-management of chronic back pain and health-related quality of life (HRQoL); 2) to examine the impact of a good patient-professional partnership on HRQoL, either directly, or indirectly via change in the ability to self-manage pain. Design and setting: This quasi-experimental study was designed to take place during routine service appointments and conducted in a community-based pain management service in the United Kingdom. A patient-professional partnership was established in which patients were actively involved in setting up goals and developing individualised care plans. Through this, health professionals undertook patients’ health needs assessment, collaborated with patients to identify specific problems, provided written materials and delivered individualised exercise based on patients’ life situation. Patients were recruited following initial consultation and followed up three months later. Participants: A total of 147 patients (65% female) with a mean age of 48 years (SD: 14 years) were enrolled in the study. Of these, 103 subjects completed the study. Patients were included if they were aged 18 and over, suffered from chronic back pain, had opted in to the clinic and had sufficient ability to read and understand English. Patients were excluded if they opted out this service after the initial assessment, suffered from malignant pain or required acute medical interventions for their pain relief. Methods: Self-reported measures of HRQoL, patient-professional partnerships and self- management ability were collected at baseline and three months later. Pathways proposed were depicted using structural equation modelling. Results: There was no association between patients’ self-management ability and HRQoL at baseline. However, a positive direct effect was detected at three months (-0.38, p<0.01). A patient-professional partnership was not found to be beneficial for patients’ HRQoL through a direct pathway, but via an indirect pathway where self-management was a mediator (- 19.09, p<0.01). Conclusions: This study suggests that the increase in patients’ self-management ability may lead to improvement in HRQoL after pain management support provided in a partnership with health professionals. A good patient-professional partnership appears to be beneficial as an augmentation to self-management practice for patients with chronic back pain