Cancer pain management in home hospice settings: A comparison of primary care and oncologic physicians

We compare the effectiveness of terminal cancer pain management delivered b y primary care physicians with that of specialists in home-based hospice se ttings. Each visit record for 223 outpatients in three hospice programs was abstracted for physician type, patient age, medication usage, level of pai n reported, cancer type, and metastatic status. Thirteen percent of patient s reported no pain at any visit and 19% reported pain at all visits; half o f the patients reported pain at two thirds of their visits. No difference w as found in the presence or absence of pain between primary care and oncolo gic patients. When available, the level of pain reported (0-10 scale) was s tatistically (p<0.01) but not clinically different between physician groups ; average pain rating for primary care patients was 3.7 while the mean pain rating for oncologic patients was 3.1. The reported pain level varied sign ificantly among facilities, as did physician mix. Multivariate analysis rev ealed that program and an interaction term between program and physician ty pe, but not physician type independently, explained a significant amount of variation in pain level. Overall, reported pain remained higher than optim al. Research elsewhere has shown that application of the World Health Organ ization (WHO) cancer pain management guidelines can control 70%-90% of canc er pain. Strategies for implementing pain guidelines that emphasize a syste ms approach may be effective.