학술논문
La cualidad del manejo de dolor postoperatorio en España. Estudio de cohortes con los datos del registro PAIN-OUT
Document Type
Dissertation/Thesis
Author
Source
TDX (Tesis Doctorals en Xarxa)
Subject
Language
Spanish; Castilian
Abstract
Introducción. El dolor postoperatorio entendido como una experiencia emocional y sensorial desagradable ocasionada por un procedimiento quirúrgico, requiere un abordaje multidimensional que incluya adicionalmente a la intensidad del dolor, otras variables igualmente importantes como la interferencia que produce el dolor con las actividades, los efectos adversos secundarios al tratamiento del dolor y la percepción que tiene el paciente del cuidado recibido. La medición de estos resultados de dolor se debe enmarcar dentro de programas de mejora continua que permitan la comparación entre hospitales, la identificación de pacientes con malos resultados de dolor postoperatorio que pueden desencadenar complicaciones y enlentecer la recuperación final, y la identificación de los factores de riesgo asociados. Diseño del estudio. Este estudio utiliza los datos españoles y la metodología del registro PAIN-OUT (Clínicaltrials.gov: NCT02083835), previa aceptación por parte de los investigadores y responsables principales en la Universidad de Jena. Es un estudio observacional multicéntrico prospectivo que recoge datos de tres aspectos de la atención de pacientes en su primer día postoperatorio: 1) datos de estructura, entendida como la organización que permite la atención y tratamiento del dolor en pacientes quirúrgicos y recogida mediante una encuesta a los investigadores de cada centro. 2) datos del proceso de cuidado, entendido como la atención específica perioperatoria y recogida utilizando datos de la historia clínica y 3) Outcomes o resultados de dolor, entendidos como medidas de la salud del paciente relacionadas con el proceso de cuidado y recogida mediante un cuestionario autoadministrado (IPO). Los centros aceptaron participar de forma voluntaria, el comité de ética médica aprobó la realización del estudio y los pacientes fueron incluidos si estaban en el primer día postoperatorio y habían estado en la planta de hospitalización por más de 6 horas. Los criterios de exclusión fueron: declinar participar, estar dormido, sedado, ser incapaz de comunicarse, leer o entender cuestionarios. Resultados. Mediante el análisis de los datos españoles del registro recolectados de 2009 a 2013, que incluía una N= 4650 pacientes reclutados en 13 hospitales distribuidos en 7 comunidades autónomas y que componen la muestra de este estudio se confirma que la adaptación española del IPO tiene una estructura de tres factores que se mantiene invariable en diferentes grupos poblacionales relacionados con el constructo dolor. Se puede utilizar el cuestionario y sus factores para hacer comparaciones entre esos grupos. El análisis de clúster identificó como óptima la solución de tres conglomerados: dos grupos con buenos resultados de dolor diferenciados por el uso o no de bloqueo de nervio periférico y un grupo de pacientes con malos resultados de dolor donde todos los pacientes deseaban más tratamiento para el dolor. Este grupo contenía el 20% de la muestra, la mayoría sometidos a cirugía de miembros inferiores, abdominal y de columna. La comparación de este grupo frente a los dos grupos de buenos resultados identificó los siguientes predictores de pertenecer a este grupo disfuncional: ser joven, ser hombre, uso preoperatorio de opioides, reducción de fractura y cirugías de hueso, institución donde se realizó la cirugía, el número de comorbilidades y los equivalentes de morfina en recuperación. Conclusiones. Esta tesis propone el uso de una nueva medida para evaluar el dolor postoperatorio resumida en el triángulo de resultados postoperatorios y basada en los tres factores del cuestionario IPO: F1: Intensidad de dolor y su interferencia con las actividades; F2: Efectos adversos; F3: Percepción de cuidado, para la identificación de los pacientes con peores resultados, de los factores de riesgo asociados, y de los procedimientos que requieren de forma prioritaria programas de mejora continua.
Introduction. Postoperative pain, understood as an unpleasant emotional and sensory experience caused by a surgical procedure, requires a multidimensional approach that not only assess pain intensity but other equally important variables such as pain interference with activities, adverse effects secondary to pain treatment and the patient’s perception of the quality of pain care. These outcomes along with other process of care and structure measurements should be analyzed to identify patients with poor postoperative pain outcomes that requires different treatment approaches, their risk factors and to promote a quality improvement environment. Study design. This study uses the Spanish patient’s data from the PAIN-OUT registry and its methodology (Clínicaltrials.gov: NCT02083835), after acceptance and authorization by the local researchers and principal investigators at Jena University. It is a prospective multicenter observational study that collects data on three aspects of patient care on their first postoperative day: 1) structure data, understood as the organization that allows care and treatment of pain in surgical patients and collected through a survey to researchers from each center. 2) data on the process of care, understood as specific perioperative care and collected using data from the clinical records and 3) Outcomes, understood as measures of the patient’s health related to the care process and collected using a patient reported outcomes questionnaire (IPO). After approval by the local ethics committee at each center, patients were included if they were on the first postoperative day and had been on the hospital ward for more than 6 hours. Exclusion criteria were declining to participate, being asleep, sedated, unable to communicate, read or understand questionnaires. Results. 4650 Spanish patients were collected in the PAIN-OUT registry from 2009 to 2013, recruited from 13 hospitals distributed in 7 autonomous communities. The study confirmed that the Spanish adaptation of the IPO has a three factors structure that remains unchanged in subgroup of patients related to the pain construct. The questionnaire and its factors can be used to make comparisons between these groups. The cluster analysis identified the solution of three clusters as optimal: two groups with good pain results differentiated by the use or not of peripheral nerve block and a group of patients with poor pain results where all patients desired more pain treatment pain. This group contained 20% of the sample, the majority undergoing lower limb, abdominal and spinal surgery. The comparison of this group against the two groups with good results identified the following predictors of belonging to this dysfunctional cluster: being young, being male, preoperative use of opioids, fracture reduction and bone surgeries, institution where the surgery was performed, the number of comorbidities and morphine equivalents in recovery. Conclusions. This thesis proposes the use of a new measure to assess postoperative pain summarized in the triangle of postoperative outcome and based on the three factors of the IPO questionnaire: F1: Pain intensity and its interference with activities; F2: Adverse effects; F3: Perception of care. This measure could help to identify patients with the worst outcomes, its associated risk factors, and the procedures that require urgent quality improvement programs.
Universitat Autònoma de Barcelona. Programa de Doctorat en Cirurgia i Ciències Morfològiques
Introduction. Postoperative pain, understood as an unpleasant emotional and sensory experience caused by a surgical procedure, requires a multidimensional approach that not only assess pain intensity but other equally important variables such as pain interference with activities, adverse effects secondary to pain treatment and the patient’s perception of the quality of pain care. These outcomes along with other process of care and structure measurements should be analyzed to identify patients with poor postoperative pain outcomes that requires different treatment approaches, their risk factors and to promote a quality improvement environment. Study design. This study uses the Spanish patient’s data from the PAIN-OUT registry and its methodology (Clínicaltrials.gov: NCT02083835), after acceptance and authorization by the local researchers and principal investigators at Jena University. It is a prospective multicenter observational study that collects data on three aspects of patient care on their first postoperative day: 1) structure data, understood as the organization that allows care and treatment of pain in surgical patients and collected through a survey to researchers from each center. 2) data on the process of care, understood as specific perioperative care and collected using data from the clinical records and 3) Outcomes, understood as measures of the patient’s health related to the care process and collected using a patient reported outcomes questionnaire (IPO). After approval by the local ethics committee at each center, patients were included if they were on the first postoperative day and had been on the hospital ward for more than 6 hours. Exclusion criteria were declining to participate, being asleep, sedated, unable to communicate, read or understand questionnaires. Results. 4650 Spanish patients were collected in the PAIN-OUT registry from 2009 to 2013, recruited from 13 hospitals distributed in 7 autonomous communities. The study confirmed that the Spanish adaptation of the IPO has a three factors structure that remains unchanged in subgroup of patients related to the pain construct. The questionnaire and its factors can be used to make comparisons between these groups. The cluster analysis identified the solution of three clusters as optimal: two groups with good pain results differentiated by the use or not of peripheral nerve block and a group of patients with poor pain results where all patients desired more pain treatment pain. This group contained 20% of the sample, the majority undergoing lower limb, abdominal and spinal surgery. The comparison of this group against the two groups with good results identified the following predictors of belonging to this dysfunctional cluster: being young, being male, preoperative use of opioids, fracture reduction and bone surgeries, institution where the surgery was performed, the number of comorbidities and morphine equivalents in recovery. Conclusions. This thesis proposes the use of a new measure to assess postoperative pain summarized in the triangle of postoperative outcome and based on the three factors of the IPO questionnaire: F1: Pain intensity and its interference with activities; F2: Adverse effects; F3: Perception of care. This measure could help to identify patients with the worst outcomes, its associated risk factors, and the procedures that require urgent quality improvement programs.
Universitat Autònoma de Barcelona. Programa de Doctorat en Cirurgia i Ciències Morfològiques