The European Journal of Public Health Advance Access originally published online on September 8, 2005
The European Journal of Public Health 2005 15(5):475-479; doi:10.1093/eurpub/cki033
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Health Services Research |
Pain in primary care: an Italian survey
Daniela Koleva1, Iva Krulichova1, Guido Bertolini2, Vittorio Caimi3 and Livio Garattini1
1 CESAV, Centre for Health Economics, Mario Negri Institute for Pharmacological Research, Ranica, Italy
2 Clinical Epidemiology Laboratory, Mario Negri Institute for Pharmacological Research, Ranica, Italy
3 CSeRMEG, Centre for Research in General Practice, Monza, Italy
Correspondence: Dr Livio Garattini, CESAV, Villa Camozzi, Via Camozzi, 3-24020 Ranica (BG), Italy, tel: +39 035 4535360, fax: +39 035 4535372, e-mail: lgarattini{at}marionegri.it
Received March 30, 2004, accepted July 7, 2004
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Abstract |
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Background: Pain is a universal symptom of various pathologies and largely affects human well-being. Pain is therefore commonly observed by general practitioners (GPs) and its management is a useful indicator of quality. In our study we investigated the epidemiology and management of pain in Italian general practice. Methods: Participating GPs were asked to record the first out of every two contacts with pain during two working weeks between November 2000 and February 2001. They entered information on type of pain, pain-related diagnosis, certainty of diagnosis and types of prescription. Results: 89 GPs participated in the study. About one third of all reported contacts were with pain. The number of contacts analysed was 1432. Nearly half the cases were diagnosed as acute. The main complaints were of musculoskeletal and abdominal origin. Pain was 1.5 times more frequent in women than men and the female to male ratios for acute and chronic pain were 1.2:1 and 1.8:1 respectively. The most frequent site of pain was the limbs. ‘Arthropathies and related disorders’, ‘dorsopathies’ and ‘rheumatism excluding the back’ were the commonest groups of diagnoses. Approximately two thirds of contacts with pain led to a drug prescription. Conclusions: The study identified a high proportion of contacts with pain in Italian general practice, with widespread use of drugs. The distribution of chronic and acute pain was rather similar and musculoskeletal pain was the most frequent form. Most types of prescriptions were closely related to certainty of diagnosis.
Keywords: Italy, general practice, pain, pain management, NSAIDs
Pain is a universal symptom of various pathologies, produced and controlled by the interactions of sensory, motivational and cognitive systems of the body, and experienced as a feeling of unpleasantness or other negative emotions.1–4 Accordingly, pain affects human well-being in its physical, mental and social aspects.
Pain is the leading cause of disability in Western countries, particularly chronic pain.5,6 In a recent systematic review on the prevalence of chronic pain the International Association for the Study of Pain (IASP) confirmed chronic pain as among the most disabling and costly afflictions in North America, Europe and Australia.7 Pain is one of the main complaints in the general population,8 so it is often observed by general practitioners (GPs).9 Its management is a useful indicator of quality for primary care.5,10 Prevention and treatment of pain in general practice rely on adequate identification and require a skilful evaluation of patients.
Despite the lack of consensus on the nature and definition of the different types, pain can be pathophysiologically classified as somatic, visceral and neuropathic.3,11–13 Somatic pain results from the activation of pain receptors (nociceptors) in skin, bones, muscles, fascia and joints; it is often readily recognized and responds well to treatment.14,15 Visceral pain arises from noxious stimuli in the vascular smooth musculature or internal organs, is more diffuse and less responsive to treatment than somatic pain and is frequently referred to certain cutaneous sites.3,15 Neuropathic pain is due to pathologic changes of the nervous system, caused by neurologic disorders, which may lead to a perception of pain without an appropriate stimulus of the nerve receptors (non-nociceptive pain); it requires multi-modal and unconventional medications.11,12
Another classification of pain is based on its onset and duration. Acute pain may be defined as pain with sudden onset, an evident cause/effect relationship and a tendency to self-limitation within a short period. It possesses a protective function as it signals the departure of a certain pathology.13,15 According to IASP, chronic pain is merely defined as one with a less apparent biological meaning, persisting beyond the normal tissue healing time (i.e. after resolution of the cause), usually taken to be 3 months.7 Neuropathic pain is typically chronic.11,16,17 The concept of acute and chronic pain, traditionally ambiguous, seems to become somewhat clearer with recent data on two brain proteins that probably amplify and sustain chronic pain.18 The distinction is also clinically relevant since these types of pain need to be managed differently. The treatment of acute pain is mainly aimed at its causes, whereas that of chronic pain to the patient's functional and social rehabilitation.17
Pain is also often classified by site (head, chest, limbs, etc.). Despite the limited information provided by this classification, location is the most frequent starting point in patients' recollections of pain and thus convenient for clinical use.
Pain management is based on conventional therapies (drugs, physical therapy, invasive therapies) and a large amount of psychological and social techniques; successful pain relief generally involves a combination of approaches.12,17,19 Pharmacological treatment is by far the commonest approach and basically consists of non-steroidal anti-inflammatory drugs (NSAIDs) which, however, can cause gastrointestinal side effects. The cost to health care systems and societies of NSAID-related complications is substantial because of the large number of patients using these drugs.9,20
To our knowledge, the epidemiology of pain in general practice in Italy is basically unknown. We surveyed a sample of GPs' contacts with patients afflicted by pain in order to analyse the main epidemiological characteristics. We recorded the proportion of contacts with pain, the distribution of pain by pathogenesis, duration and site, and prescriptions related to pain management.
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Methods |
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This observational, cross-sectional survey was carried out as a preliminary stage of PACO (PAin COst), a project aimed at assessing quality and costs of pain management in Italian general practice.21
All the 99 GPs belonging to CSERMEG (an Italian network of experienced GPs doing clinical research) were contacted and asked on a voluntary basis to directly record their routine activity of two working weeks (freely chosen between November 2000 and February 2001) on a standardised case report form. Since CSERMEG includes only GPs for adults (young patients aged under 13 are looked after by paediatric GPs in Italy), children were excluded from the study. Eighty-nine GPs accepted and were asked to record all consultations and visits, from which we calculated the proportion of contacts related to any kind of pain. During consultations GPs explicitly asked patients if they had pain. To avoid disruption of out-patient practice, GPs were asked to note only the first out of every two contacts with pain. They entered the following information:
- type of pain (origin, duration and site)
- pain-related diagnosis
- confidence in the certainty of the diagnoses (‘certain’ and ‘uncertain’)
- types of prescription (drugs, physical therapy, laboratory tests, diagnostic procedures, specialist referrals, hospital admissions).
GPs were asked to clarify their hypothetical diagnoses according to the International Classification of Diseases, 9th revision (ICD-9). We used the ICD-9 grouping for the purpose of analysis. Although ICD-9 definitions do not always adequately describe the clinical picture from an algological point of view, their use ensured standardised diagnoses for the study purposes. It is also worth noting that the ICD-9 does include a class ‘symptoms, signs and ill-defined conditions’, which actually covers symptoms rather than real diagnoses. GPs were also asked to record the specific drug if they issued a prescription. Drugs were classified according to the Anatomical Therapeutic Chemical (ATC) classification system for the purpose of analysis.
Data were statistically analysed with SAS software. Proportions were used as descriptive statistics for categorical and ordinal variables, mean and standard deviation (SD) for continuous variables. The Mantel–Haenszel chi squared test was used to compare proportions.
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Results |
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Eighty-nine GPs, 50 from the north, 29 from the centre and 10 from southern Italy, participated. The mean number of patients attending their practices was 1322. Of the 89 participating GPs, 82 reported 8012 contacts (57.9% women), 2536 for pain (31.7%). The remaining seven GPs provided details of 164 contacts with pain, but did not specify the number of consultations during the study period and the total number of contacts with pain. Thus, the total number of contacts analysed was 1432 (2536/2 + 164), of which 843 were with women and 569 with men. The mean age was 54.7 years (7.4% <25 years, 65.3% 25–70 years, 27.3% >70 years).
Table 1 shows the main characteristics of the pain. The distribution of acute and chronic disorders was similar (47.2% and 52.8%, respectively). The female to male ratios were 1.2:1 for acute and 1.8:1 for chronic pain. The most frequent origin of pain was somatic (71.9%), the majority being musculoskeletal. Visceral pain was found in 21.7% of contacts (most of them of abdominal origin), particularly among women (1.9:1). Neuropathic pain was identified only in 3.5%, while the remaining contacts (2.8%) were considered of multiple origin. Pain was most frequently in the limbs (28.2%), abdomen (16.4%), back (13.8%) and neck (12.9%); in 11.9% of cases pain was in multiple sites.
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GPs were able to establish a pain-related diagnosis for 89% of contacts, but reported their diagnosis as certain only in 58% of them (table 2). The largest category of diagnoses was ‘arthropathies and related disorders’ (23.2%), followed by ‘dorsopathies’ (16.5%) and ‘rheumatism excluding the back’ (13.1%). Many pathologies were observed similarly in women and men. The major sex differences were found for ‘headache’ (3.3:1), ‘non-infective enteritis & colitis’ (2.3:1), and ‘unspecified myalgia & myositis’ (2.1:1) where the ratio was female-dominated.
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Table 3 illustrates the health care services prescribed by GPs for pain management. Drug therapy was by far the most frequent (70%), followed by diagnostic procedures (28.5%) and specialist referrals (22.3%).
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To further analyse the impact of diagnostic certainty, we investigated its relation with the type of prescriptions (data not shown). The prescription of physical therapy (9.2% for uncertain and 19.6% for certain cases, P < 0.0001) and specialist referrals (17.8% and 24.6%, P = 0.004) increased with the certainty of the diagnosis, while prescriptions for laboratory tests (12.0% and 4.3%, P < 0.0001) and diagnostic procedures (30.1% and 23.9%, P = 0.006) decreased. No significant relationship was found between certainty of diagnosis and hospital admissions.
More than half the prescriptions were for NSAIDs alone or in combination with other drugs (table 4); non-selective NSAIDs like diclofenac or nimesulide were largely prescribed. The second commonest drug group was analgesics/antipyretics (13.5%). Whereas NSAIDs were more prescribed for chronic than acute pain (1.5:1), analgesics/antipyretics were more often used for acute pain (1:1.2).
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Discussion |
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This study surveyed the major characteristics of pain and its management in Italian general practice. Potential limitations should be borne in mind. First, participating doctors cannot be considered representative of all Italian GPs as they were not randomly selected and were distributed differently from the Italian population of GPs (56.2% in the north, 32.6% in the centre and 11.2% in the south versus 37.2%, 30.3%, and 32.6% in Italy). This poses an intrinsic limit on the generalisability of results. Secondly, the study only covered two weeks and information was collected during the winter; this could have overestimated the proportion of contacts with pain since arthropathic pain peaks in the winter. Thirdly, the lack of validated and standardised methods of pain classification may have reflected on the practical assessment of pain22 and obliged GPs to rely mainly on their empirical judgement.11
The major strength of this study is that information on pain assessment and the consequent prescriptions were recorded with the same questionnaire for 1432 contacts in general practice.
The survey showed the high proportion of pain managed in general practice in Italy: three contacts out of 10 were patients with pain. The large proportion of acute pain was striking, since general practice in Italy is commonly believed to serve predominantly patients with chronic pain. About 65% of contacts were patients of working age so considerable social consequences might be expected. Musculoskeletal pain was most frequent, it was usually acute, of traumatic origin, and widespread among the young male population; chronic pain, due to arthropathies, mainly afflicted elderly women.
Diagnostic uncertainty seems to be a critical feature in Italian general practice: 89% of contacts with pain ended with a diagnosis, but GPs reported only 58% of them as ‘certain’. Although this would appear more understandable for acute than chronic pain, diagnostic uncertainty was common for both, suggesting that subsequent pain management was, to some extent, independent of the diagnosis. The relation between resource consumption and degree of certainty in diagnosis was uneven.
The greater recourse to diagnostic procedures and laboratory tests for diagnostic uncertainty is presumably aimed at clarifying the nature of the complaint. It is less obvious why physical therapy, a traditional treatment for specific chronic complaints of the locomotor apparatus, was more often prescribed when diagnoses were certain; one possible interpretation is that physical therapy is sometimes used in place of drugs to avoid adverse effects. The similar pattern for specialist referrals suggests that these respond more to GP's attitudes or occasional patients' requests, than to the need to confirm or clarify a diagnosis. For instance, GPs could refer patients to specialists in order to start specific therapies, or to follow up pathologies considered difficult to manage in general practice.
Non-selective NSAIDs were the drugs most frequently prescribed for pain. This was expected, since the study followed by only a few months the launch of selective NSAIDs in Italy (September 2000). Both non-selective and selective NSAIDs were mostly used for chronic complaints. This could follow from the main indication of NSAIDs for arthropathy-related complaints. Selective agents were used more in elderly patients, perhaps because of their more favourable gastrointestinal profile.23,24 A substantial share of prescriptions involved paracetamol alone or in combination with codeine. This might be because paracetamol is designated as the first-line drug for arthritic pain in several guidelines.25,26 Analgesics were used more frequently for chronic pain and under diagnostic certainty, probably to avoid disguising underlying pathologies by palliating their symptoms (e.g. in abdominal pain).
It is difficult to compare our results with other studies because most articles addressing pain either deal only with chronic pain or the setting is not general practice. Frølund and Frølund (1986) reported on pain in general practice in Denmark.27 They recorded 641 pain contacts, which were 22.2% of all the GPs' consultations during a 5-day period. Although the study mentioned is somewhat dated, was conducted in a different place and included children, the main results were comparable with ours. The Danish authors reported the same female to male ratio for enrolled contacts (1.5:1) and for chronic pain (1.8:1) as we did in our study, and the female to male ratio for acute pain was also similar (1.4:1 versus 1.2:1). The most frequent origin of pain was musculoskeletal (50.4%), followed by visceral (20.4%), as in our study (62.6% and 21.7%, respectively).
In conclusion, this study sheds some light on pain management in Italian general practice, which is basically undocumented at present. The distribution of chronic and acute pain was rather similar and musculoskeletal pain was the most frequent form. Most types of prescriptions were closely related to certainty of diagnosis.
Key points
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Acknowledgments |
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We thank Cecilia Viscarra and Rebecca Facchini for their contribution in the early stage of the study.
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References |
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