Variations in Denominators and Cut-off Points of Pain Intensity in the Pain Management Index: A Methodological Systematic Review
2017; Elsevier BV; Volume: 54; Issue: 5 Linguagem: Inglês
10.1016/j.jpainsymman.2017.08.026
ISSN1873-6513
AutoresRichi Takahashi, Tatsuya Morita, Mitsunori Miyashita,
Tópico(s)Pediatric Pain Management Techniques
ResumoDespite available treatment and the development of effective guidelines for the management of cancer pain, pain is still a persistent problem for patients with cancer. Systematic reviews demonstrated that the prevalence of undertreatment for cancer pain was 32%–43%,1Deandrea S. Montanari M. Moja L. et al.Prevalence of undertreatment in cancer pain. A review of published literature.Ann Oncol. 2008; 19: 1985-1991Crossref PubMed Scopus (662) Google Scholar, 2Greco M.T. Roberto A. Corli O. et al.Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer.J Clin Oncol. 2014; 32: 4149-4154Crossref PubMed Scopus (303) Google Scholar and 66% of patients with advanced cancer had pain.3van den Beuken-van Everdingen M.H. Hochstenbach L.M. Joosten E.A. et al.Update on prevalence of pain in patients with cancer: systematic review and meta-analysis.J Pain Symptom Manage. 2016; 51: 1070-1090Abstract Full Text Full Text PDF PubMed Scopus (782) Google Scholar The Pain Management Index (PMI) developed by Cleeland is the most frequently used tool to assess the adequacy of analgesic therapy.4Cleeland C.S. Gonin R. Hatfield A.K. et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1755) Google Scholar In the original study, patient's worst pain score of the Brief Pain Inventory was classified as: 1–3, mild pain; 4–7, moderate pain; and 8–10, severe pain. In 1995, Serlin et al. proposed the cut-off points for the pain intensity of: 1–4, mild pain; 5–6, moderate pain; and 7–10, severe pain.5Serlin R.C. Mendoza T.R. Nakamura Y. et al.When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function.Pain. 1995; 61: 277-284Abstract Full Text PDF PubMed Scopus (1191) Google Scholar Therefore, cut-off points for defining mild, moderate, and severe pain show some variations. The prevalence of undertreatment is expressed as a negative PMI, calculated by dividing the number of patients with negative scores by the total patients as the denominator. The denominator of Cleeland's original proposal was the number of patients with pain or having taken analgesics daily.4Cleeland C.S. Gonin R. Hatfield A.K. et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1755) Google Scholar Some studies, however, used other denominators, such as patients with pain and the number of all patients who were eligible for inclusion in each study. Variations in the denominators and cut-off points when calculating the PMI may result in some impacts on the prevalence of a negative PMI. The objective of this study was to reveal potential variations in denominators and cut-off points when calculating the PMI in the existing literature. This was a systematic review of the literature covered by two systematic reviews about undertreatment of patients with cancer published in 20081Deandrea S. Montanari M. Moja L. et al.Prevalence of undertreatment in cancer pain. A review of published literature.Ann Oncol. 2008; 19: 1985-1991Crossref PubMed Scopus (662) Google Scholar and its update in 2014.2Greco M.T. Roberto A. Corli O. et al.Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer.J Clin Oncol. 2014; 32: 4149-4154Crossref PubMed Scopus (303) Google Scholar All studies reporting the undertreatment of cancer pain and written in English were included. We obtained data on the percentages of patients with a negative PMI score, denominators, and cut-off points of the pain severity from the included articles. General characteristics such as authors, country, and year of publication were also recorded. After collecting the denominators, we classified them into four groups: A) the number of all patients who were eligible for inclusion, B) the number of patients with pain or having taken analgesics, used in Cleeland's method,4Cleeland C.S. Gonin R. Hatfield A.K. et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1755) Google Scholar C) the number of patients with pain, and D) others. We then recalculated the rate of a negative PMI using different denominators if the study had data available. Finally, we calculated the means of negative PMI values weighted by the sample size in each group of original denominators and each subgroup of denominators capable of being translated. We identified 46 articles from previous systematic reviews.1Deandrea S. Montanari M. Moja L. et al.Prevalence of undertreatment in cancer pain. A review of published literature.Ann Oncol. 2008; 19: 1985-1991Crossref PubMed Scopus (662) Google Scholar, 2Greco M.T. Roberto A. Corli O. et al.Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer.J Clin Oncol. 2014; 32: 4149-4154Crossref PubMed Scopus (303) Google Scholar The first review included 26 articles from 1994 to 2007 and its update included 20 additional articles from 2007 to 2013. Finally, 44 articles4Cleeland C.S. Gonin R. Hatfield A.K. et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1755) Google Scholar, 6Larue F. Colleau S.M. Brasseur L. Cleeland C.S. Multicentrestudy of cancer pain and its treatment in France.BMJ. 1995; 310: 1034-1037Crossref PubMed Scopus (311) Google Scholar, 7Wang X.S. Mendoza T.R. Gao S.Z. et al.The Chinese version of the Brief Pain Inventory (BPI-C): its development and use in a study of cancer pain.Pain. 1996; 67: 407-416Abstract Full Text PDF PubMed Scopus (231) Google Scholar, 8Cleeland C.S. Gonin R. Baez L. et al.Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group minority outpatient pain study.Ann Intern Med. 1997; 127: 813-816Crossref PubMed Scopus (438) Google Scholar, 9Elliott T.E. Murray D.M. Oken M.M. et al.Improving cancer pain management in communities: main results from a randomized controlled trial.J Pain Symptom Manage. 1997; 13: 191-203Abstract Full Text PDF PubMed Scopus (61) Google Scholar, 10Trowbridge R. Dugan W. Jay S.J. et al.Determining the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer.Acad Med. 1997; 72: 798-800Crossref PubMed Scopus (67) Google Scholar, 11Ger L.P. Ho S.T. Wang J.J. et al.The prevalence and severity of cancer pain: a study of newly-diagnosed cancer patients in Taiwan.J Pain Symptom Manage. 1998; 15: 285-293Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 12Uki J. Mendoza T. Cleeland C.S. et al.A brief cancer pain assessment tool in Japanese: the utility of the Japanese Brief Pain Inventory–BPI-J.J Pain Symptom Manage. 1998; 16: 364-373Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 13Saxena A. Mendoza T. Cleeland C.S. The assessment of cancer pain in north India: the validation of the Hindi Brief Pain Inventory–BPI-H.J Pain Symptom Manage. 1999; 17: 27-41Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 14de Wit R. van Dam F. Abu-Saad H.H. et al.Empirical comparison of commonly used measures to evaluate pain treatment in cancer patients with chronic pain.J Clin Oncol. 1999; 17: 1280Crossref PubMed Google Scholar, 15Anderson K.O. Mendoza T.R. Valero V. et al.Minority cancer patients and their providers: pain management attitudes and practice.Cancer. 2000; 88: 1929-1938Crossref PubMed Scopus (278) Google Scholar, 16Wells N. Pain intensity and pain interference in hospitalized patients with cancer.Oncol Nurs Forum. 2000; 27: 985-991PubMed Google Scholar, 17Mystakidou K. Mendoza T. Tsilika E. et al.Greek brief pain inventory: validation and utility in cancer pain.Oncology. 2001; 60: 35-42Crossref PubMed Scopus (101) Google Scholar, 18Beck S.L. Falkson G. Prevalence and management of cancer pain in South Africa.Pain. 2001; 94: 75-84Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 19Cascinu S. Giordani P. Agostinelli R. et al.Pain and its treatment in hospitalized patients with metastatic cancer.Support Care Cancer. 2003; 11: 587-592Crossref PubMed Scopus (39) Google Scholar, 20Shvartzman P. Friger M. Shani A. et al.Pain control in ambulatory cancer patients—can we do better?.J Pain Symptom Manage. 2003; 26: 716-722Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 21Hyun M.S. Lee J.L. Lee K.H. et al.Pain and its treatment in patients with cancer in Korea.Oncology. 2003; 64: 237-244Crossref PubMed Scopus (20) Google Scholar, 22Yun Y.H. Mendoza T.R. Heo D.S. et al.Development of a cancer pain assessment tool in Korea: a validation study of a Korean version of the Brief Pain Inventory.Oncology. 2004; 66: 439-444Crossref PubMed Scopus (106) Google Scholar, 23Di Maio M. Gridelli C. Gallo C. et al.Prevalence and management of pain in Italian patients with advanced non-small-cell lung cancer.Br J Cancer. 2004; 90: 2288-2296Crossref PubMed Scopus (110) Google Scholar, 24Okuyama T. Wang X.S. Akechi T. et al.Adequacy of cancer pain management in a Japanese Cancer Hospital.Jpn J Clin Oncol. 2004; 34: 37-42Crossref PubMed Scopus (51) Google Scholar, 25Cohen M.Z. Musgrave C.F. McGuire D.B. et al.The cancer pain experience of Israeli adults 65 years and older: the influence of pain interference, symptom severity, and knowledge and attitudes on pain and pain control.Support Care Cancer. 2005; 13: 708-714Crossref PubMed Scopus (18) Google Scholar, 26Lin J.T. Mathew P. Cancer pain management in prisons: a survey of primary care practitioners and inmates.J Pain Symptom Manage. 2005; 29: 466-473Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 27Passik S.D. Kirsh K.L. Donaghy K.B. et al.Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse.Clin J Pain. 2006; 22: 173-181Crossref PubMed Scopus (130) Google Scholar, 28Russell P.B. Aveyard S.C. Oxenham D.R. An assessment of methods used to evaluate the adequacy of cancer pain management.J Pain Symptom Manage. 2006; 32: 581-588Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 29Enting R.H. Oldenmenger W.H. Van Gool A.R. et al.The effects of analgesic prescription and patient adherence on pain in a Dutch outpatient cancer population.J Pain Symptom Manage. 2007; 34: 523-531Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 30van den Beuken-van Everdingen M.H. de Rijke J.M. Kessels A.G. et al.High prevalence of pain in patients with cancer in a large population-based study in The Netherlands.Pain. 2007; 32: 312-320Abstract Full Text Full Text PDF Scopus (209) Google Scholar, 31Donovan K.A. Taliaferro L.A. Brock C.W. et al.Sex differences in the adequacy of pain management among patients referred to a multidisciplinary cancer pain clinic.J Pain Symptom Manage. 2008; 36: 167-172Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 32Kalyadina S.A. Ionova T.I. Ivanova M.O. et al.Russian Brief Pain Inventory: validation and application in cancer pain.J Pain Symptom Manage. 2008; 35: 95-102Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 33Torvik K. Hølen J. Kaasa S. et al.Pain in elderly hospitalized cancer patients with bone metastases in Norway.Int J Palliat Nurs. 2008; 14: 238-245Crossref PubMed Google Scholar, 34Apolone G. Corli O. Caraceni A. et al.Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group; Cancer Pain Outcome Research Study Group (CPORSG) Investigators.Br J Cancer. 2009; 100: 1566-1574Crossref PubMed Scopus (141) Google Scholar, 35Gagliese L. Jovellanos M. Zimmermann C. et al.Age-related patterns in adaptation to cancer pain: a mixed-method study.Pain Med. 2009; 10: 1050-1061Crossref PubMed Scopus (43) Google Scholar, 36Fan X.P. Zhou J.Y. Huang H. Analysis of pain status and pain management of home based advanced cancer patients with pain [in Chinese].Zhongguo Xian Dai Shen Jing Ji Bing ZaZhi. 2010; 10: 628-631Google Scholar, 37Lovell M.R. Forder P.M. Stockler M.R. et al.A randomized controlled trial of a standardized educational intervention for patients with cancer pain.J Pain Symptom Manage. 2010; 40: 49-59Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 38Mitera G. Fairchild A. DeAngelis C. et al.A multicenter assessment of the adequacy of cancer pain treatment using the pain management index.J Palliat Med. 2010; 13: 589-593Crossref PubMed Scopus (25) Google Scholar, 39Mitera G. Zeiadin N. Kirou-Mauro A. et al.Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index.J Pain Symptom Manage. 2010; 39: 259-267Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 40Sichetti D. Bandieri E. Romero M. et al.Impact of setting of care on pain management in patients with cancer: a multicentre cross-sectional study.Ann Oncol. 2010; 21: 2088-2093Crossref PubMed Scopus (22) Google Scholar, 41Fisch M.J. Lee J.W. Weiss M. et al.Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer.J Clin Oncol. 2012; 30: 1980-1988Crossref PubMed Scopus (206) Google Scholar, 42Makama J.G. Khalid L. Stephen G.E. et al.The prevalence of under-treatment of cancer pain in Nigerian teaching hospital.Arch Int Surg. 2012; 2: 7-10Crossref Google Scholar, 43Tateno Y. Ishikawa S. Clinical pathways can improve the quality of pain management in home palliative care in remote locations: retrospective study on Kozu Island, Japan.Rural Remote Health. 2012; 12: 1992PubMed Google Scholar, 44Yen J.T. Gubbay A. Kandikattu S. et al.The prevalence and management of pain in gynaecological malignancy within the outpatients setting.Internet J Pain Symptom Control Palliat Care. 2012; 9: 1Google Scholar, 45Gonçalves F. Almeida A. Antunes C. et al.A cross-sectional survey of pain in palliative care in Portugal.Support Care Cancer. 2013; 21: 2033-2039Crossref PubMed Scopus (13) Google Scholar, 46Kwon J.H. Oh S.Y. Chisholm G. et al.Predictors of high score patient-reported barriers to controlling cancer pain: a preliminary report.Support Care Cancer. 2013; 21: 1175-1183Crossref PubMed Scopus (19) Google Scholar, 47Mercadante S. Guccione C. Di Fatta S. et al.Cancer pain management in an oncological ward in a comprehensive cancer center with an established palliative care unit.Support Care Cancer. 2013; 21: 3287-3292Crossref PubMed Scopus (15) Google Scholar, 48TeBoveldt N. Vernooij-Dassen M. Burger N. et al.Pain and its interference with daily activities in medical oncology outpatients.Pain Physician. 2013; 16: 379-389PubMed Google Scholar were selected because one study investigated postoperative pain and the other was written in German. Twenty-four studies6Larue F. Colleau S.M. Brasseur L. Cleeland C.S. Multicentrestudy of cancer pain and its treatment in France.BMJ. 1995; 310: 1034-1037Crossref PubMed Scopus (311) Google Scholar, 9Elliott T.E. Murray D.M. Oken M.M. et al.Improving cancer pain management in communities: main results from a randomized controlled trial.J Pain Symptom Manage. 1997; 13: 191-203Abstract Full Text PDF PubMed Scopus (61) Google Scholar, 10Trowbridge R. Dugan W. Jay S.J. et al.Determining the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer.Acad Med. 1997; 72: 798-800Crossref PubMed Scopus (67) Google Scholar, 11Ger L.P. Ho S.T. Wang J.J. et al.The prevalence and severity of cancer pain: a study of newly-diagnosed cancer patients in Taiwan.J Pain Symptom Manage. 1998; 15: 285-293Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 12Uki J. Mendoza T. Cleeland C.S. et al.A brief cancer pain assessment tool in Japanese: the utility of the Japanese Brief Pain Inventory–BPI-J.J Pain Symptom Manage. 1998; 16: 364-373Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 13Saxena A. Mendoza T. Cleeland C.S. The assessment of cancer pain in north India: the validation of the Hindi Brief Pain Inventory–BPI-H.J Pain Symptom Manage. 1999; 17: 27-41Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 14de Wit R. van Dam F. Abu-Saad H.H. et al.Empirical comparison of commonly used measures to evaluate pain treatment in cancer patients with chronic pain.J Clin Oncol. 1999; 17: 1280Crossref PubMed Google Scholar, 15Anderson K.O. Mendoza T.R. Valero V. et al.Minority cancer patients and their providers: pain management attitudes and practice.Cancer. 2000; 88: 1929-1938Crossref PubMed Scopus (278) Google Scholar, 16Wells N. Pain intensity and pain interference in hospitalized patients with cancer.Oncol Nurs Forum. 2000; 27: 985-991PubMed Google Scholar, 17Mystakidou K. Mendoza T. Tsilika E. et al.Greek brief pain inventory: validation and utility in cancer pain.Oncology. 2001; 60: 35-42Crossref PubMed Scopus (101) Google Scholar, 19Cascinu S. Giordani P. Agostinelli R. et al.Pain and its treatment in hospitalized patients with metastatic cancer.Support Care Cancer. 2003; 11: 587-592Crossref PubMed Scopus (39) Google Scholar, 21Hyun M.S. Lee J.L. Lee K.H. et al.Pain and its treatment in patients with cancer in Korea.Oncology. 2003; 64: 237-244Crossref PubMed Scopus (20) Google Scholar, 22Yun Y.H. Mendoza T.R. Heo D.S. et al.Development of a cancer pain assessment tool in Korea: a validation study of a Korean version of the Brief Pain Inventory.Oncology. 2004; 66: 439-444Crossref PubMed Scopus (106) Google Scholar, 23Di Maio M. Gridelli C. Gallo C. et al.Prevalence and management of pain in Italian patients with advanced non-small-cell lung cancer.Br J Cancer. 2004; 90: 2288-2296Crossref PubMed Scopus (110) Google Scholar, 24Okuyama T. Wang X.S. Akechi T. et al.Adequacy of cancer pain management in a Japanese Cancer Hospital.Jpn J Clin Oncol. 2004; 34: 37-42Crossref PubMed Scopus (51) Google Scholar, 25Cohen M.Z. Musgrave C.F. McGuire D.B. et al.The cancer pain experience of Israeli adults 65 years and older: the influence of pain interference, symptom severity, and knowledge and attitudes on pain and pain control.Support Care Cancer. 2005; 13: 708-714Crossref PubMed Scopus (18) Google Scholar, 27Passik S.D. Kirsh K.L. Donaghy K.B. et al.Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse.Clin J Pain. 2006; 22: 173-181Crossref PubMed Scopus (130) Google Scholar, 33Torvik K. Hølen J. Kaasa S. et al.Pain in elderly hospitalized cancer patients with bone metastases in Norway.Int J Palliat Nurs. 2008; 14: 238-245Crossref PubMed Google Scholar, 35Gagliese L. Jovellanos M. Zimmermann C. et al.Age-related patterns in adaptation to cancer pain: a mixed-method study.Pain Med. 2009; 10: 1050-1061Crossref PubMed Scopus (43) Google Scholar, 36Fan X.P. Zhou J.Y. Huang H. Analysis of pain status and pain management of home based advanced cancer patients with pain [in Chinese].Zhongguo Xian Dai Shen Jing Ji Bing ZaZhi. 2010; 10: 628-631Google Scholar, 37Lovell M.R. Forder P.M. Stockler M.R. et al.A randomized controlled trial of a standardized educational intervention for patients with cancer pain.J Pain Symptom Manage. 2010; 40: 49-59Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 44Yen J.T. Gubbay A. Kandikattu S. et al.The prevalence and management of pain in gynaecological malignancy within the outpatients setting.Internet J Pain Symptom Control Palliat Care. 2012; 9: 1Google Scholar, 46Kwon J.H. Oh S.Y. Chisholm G. et al.Predictors of high score patient-reported barriers to controlling cancer pain: a preliminary report.Support Care Cancer. 2013; 21: 1175-1183Crossref PubMed Scopus (19) Google Scholar, 48TeBoveldt N. Vernooij-Dassen M. Burger N. et al.Pain and its interference with daily activities in medical oncology outpatients.Pain Physician. 2013; 16: 379-389PubMed Google Scholar (55%) used the number of patients with pain as the denominator, Group C; 11 studies4Cleeland C.S. Gonin R. Hatfield A.K. et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1755) Google Scholar, 7Wang X.S. Mendoza T.R. Gao S.Z. et al.The Chinese version of the Brief Pain Inventory (BPI-C): its development and use in a study of cancer pain.Pain. 1996; 67: 407-416Abstract Full Text PDF PubMed Scopus (231) Google Scholar, 8Cleeland C.S. Gonin R. Baez L. et al.Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group minority outpatient pain study.Ann Intern Med. 1997; 127: 813-816Crossref PubMed Scopus (438) Google Scholar, 18Beck S.L. Falkson G. Prevalence and management of cancer pain in South Africa.Pain. 2001; 94: 75-84Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 20Shvartzman P. Friger M. Shani A. et al.Pain control in ambulatory cancer patients—can we do better?.J Pain Symptom Manage. 2003; 26: 716-722Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 26Lin J.T. Mathew P. Cancer pain management in prisons: a survey of primary care practitioners and inmates.J Pain Symptom Manage. 2005; 29: 466-473Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 29Enting R.H. Oldenmenger W.H. Van Gool A.R. et al.The effects of analgesic prescription and patient adherence on pain in a Dutch outpatient cancer population.J Pain Symptom Manage. 2007; 34: 523-531Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 32Kalyadina S.A. Ionova T.I. Ivanova M.O. et al.Russian Brief Pain Inventory: validation and application in cancer pain.J Pain Symptom Manage. 2008; 35: 95-102Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 34Apolone G. Corli O. Caraceni A. et al.Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group; Cancer Pain Outcome Research Study Group (CPORSG) Investigators.Br J Cancer. 2009; 100: 1566-1574Crossref PubMed Scopus (141) Google Scholar, 41Fisch M.J. Lee J.W. Weiss M. et al.Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer.J Clin Oncol. 2012; 30: 1980-1988Crossref PubMed Scopus (206) Google Scholar, 47Mercadante S. Guccione C. Di Fatta S. et al.Cancer pain management in an oncological ward in a comprehensive cancer center with an established palliative care unit.Support Care Cancer. 2013; 21: 3287-3292Crossref PubMed Scopus (15) Google Scholar (25%) used the number of patients with pain or having taken analgesics, Group B; eight studies28Russell P.B. Aveyard S.C. Oxenham D.R. An assessment of methods used to evaluate the adequacy of cancer pain management.J Pain Symptom Manage. 2006; 32: 581-588Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 30van den Beuken-van Everdingen M.H. de Rijke J.M. Kessels A.G. et al.High prevalence of pain in patients with cancer in a large population-based study in The Netherlands.Pain. 2007; 32: 312-320Abstract Full Text Full Text PDF Scopus (209) Google Scholar, 31Donovan K.A. Taliaferro L.A. Brock C.W. et al.Sex differences in the adequacy of pain management among patients referred to a multidisciplinary cancer pain clinic.J Pain Symptom Manage. 2008; 36: 167-172Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 38Mitera G. Fairchild A. DeAngelis C. et al.A multicenter assessment of the adequacy of cancer pain treatment using the pain management index.J Palliat Med. 2010; 13: 589-593Crossref PubMed Scopus (25) Google Scholar, 39Mitera G. Zeiadin N. Kirou-Mauro A. et al.Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index.J Pain Symptom Manage. 2010; 39: 259-267Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 42Makama J.G. Khalid L. Stephen G.E. et al.The prevalence of under-treatment of cancer pain in Nigerian teaching hospital.Arch Int Surg. 2012; 2: 7-10Crossref Google Scholar, 43Tateno Y. Ishikawa S. Clinical pathways can improve the quality of pain management in home palliative care in remote locations: retrospective study on Kozu Island, Japan.Rural Remote Health. 2012; 12: 1992PubMed Google Scholar, 45Gonçalves F. Almeida A. Antunes C. et al.A cross-sectional survey of pain in palliative care in Portugal.Support Care Cancer. 2013; 21: 2033-2039Crossref PubMed Scopus (13) Google Scholar (18%) used the number of all patients who were eligible for inclusion, Group A; and one study40Sichetti D. Bandieri E. Romero M. et al.Impact of setting of care on pain management in patients with cancer: a multicentre cross-sectional study.Ann Oncol. 2010; 21: 2088-2093Crossref PubMed Scopus (22) Google Scholar used the number of patients that had taken analgesics, Group D. The rate of a negative PMI decreased, ranging from 7% to 48% when recalculated after changing the denominator from Group B or C to A, whereas it remained almost unchanged when the denominators were changed between groups B and C, with a difference of less than 2%. The results of weighted means of the negative PMI are reported in Table 1. In the group of original denominators, Group A had the lowest rate of a negative PMI (21%, 95% CI 20–22), whereas Group C had the highest weighted mean of a negative PMI (47%, 95% CI 46–48). In subgroup analysis, as is clear from the definition of denominators, Group A presented the lower percentage of weighted means of the negative PMI regardless of original or recalculated.Table 1Results of Weighted Means of the Negative PMI in Each categorizationCategorization of Denominatorsi) Original Negative PMIii) Original Versus Recalculated Negative PMINo. of StudiesRange of Negative PMI (%)Weighted Mean (95% CI)Categorization of Denominators After TranslatingNo. of StudiesWeighted Mean of the Original Negative PMI in the Subgroup (95% CI)Weighted Mean of the recalculated Negative PMI (95% CI)Group A84–4921 (20–22)—B149 (37–61)57 (44–70)C232 (24–42)39 (29–51)D0Group B1125–7537 (35–38)A640 (38–42)22 (21–23)—C126 (19–34)28 (20–36)D0Group C248–8247 (46–48)A956 (54–58)34 (33–36)B182 (79–85)80 (77–83)—D0Group D1—15 (13–18)A0B0C0—PMI = Pain Management Index.Group A, denominator was the number of all patients who were eligible for inclusion; Group B, denominator was the number of patients with pain or had taken analgesics; Group C, denominator was the number of patients with pain; Group D, denominator was the number of others. Open table in a new tab PMI = Pain Management Index. Group A, denominator was the number of all patients who were eligible for inclusion; Group B, denominator was the number of patients with pain or had taken analgesics; Group C, denominator was the number of patients with pain; Group D, denominator was the number of others. Nineteen studies7Wang X.S. Mendoza T.R. Gao S.Z. et al.The Chinese version of the Brief Pain Inventory (BPI-C): its development and use in a study of cancer pain.Pain. 1996; 67: 407-416Abstract Full Text PDF PubMed Scopus (231) Google Scholar, 8Cleeland C.S. Gonin R. Baez L. et al.Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group minority outpatient pain study.Ann Intern Med. 1997; 127: 813-816Crossref PubMed Scopus (438) Google Scholar, 13Saxena A. Mendoza T. Cleeland C.S. The assessment of cancer pain in north India: the validation of the Hindi Brief Pain Inventory–BPI-H.J Pain Symptom Manage. 1999; 17: 27-41Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 15Anderson K.O. Mendoza T.R. Valero V. et al.Minority cancer patients and their providers: pain management attitudes and practice.Cancer. 2000; 88: 1929-1938Crossref PubMed Scopus (278) Google Scholar, 16Wells N. Pain intensity and pain interference in hospitalized patients with cancer.Oncol Nurs Forum. 2000; 27: 985-991PubMed Google Scholar, 17Mystakidou K. Mendoza T. Tsilika E. et al.Greek brief pain inventory: validation and utility in cancer pain.Oncology. 2001; 60: 35-42Crossref PubMed Scopus (101) Google Scholar, 22Yun Y.H. Mendoza T.R. Heo D.S. et al.Development of a cancer pain assessment tool in Korea: a validation study of a Korean version of the Brief Pain Inventory.Oncology. 2004; 66: 439-444Crossref PubMed Scopus (106) Google Scholar, 24Okuyama T. Wang X.S. Akechi T. et al.Adequacy of cancer pain management in a Japanese Cancer Hospital.Jpn J Clin Oncol. 2004; 34: 37-42Crossref PubMed Scopus (51) Google Scholar, 29Enting R.H. Oldenmenger W.H. Van Gool A.R. et al.The effects of analgesic prescription and patient adherence on pain in a Dutch outpatient cancer population.J Pain Symptom Manage. 2007; 34: 523-531Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 32Kalyadina S.A. Ionova T.I. Ivanova M.O. et al.Russian Brief Pain Inventory: validation and application in cancer pain.J Pain Symptom Manage. 2008; 35: 95-102Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 33Torvik K. Hølen J. Kaasa S. et al.Pain in elderly hospitalized cancer patients with bone metastases in Norway.Int J Palliat Nurs. 2008; 14: 238-245Crossref PubMed Google Scholar, 36Fan X.P. Zhou J.Y. Huang H. 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In groups B and C, the difference in the number of denominators between each group was small, implying that numbers of patients who had no pain owing to their analgesics were limited. Our analyses confirmed that the denominators were important factors for interpreting the results of a negative PMI. In the included studies, the most frequently used cut-off points were 1–4/5–6/7–10. This categorization was proposed by Serlin in 19955Serlin R.C. Mendoza T.R. Nakamura Y. et al.When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function.Pain. 1995; 61: 277-284Abstract Full Text PDF PubMed Scopus (1191) Google Scholar and is different from the original study by Cleeland et al.4Cleeland C.S. Gonin R. Hatfield A.K. et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1755) Google Scholar The PMI score may increase or decrease depending on categorization of the pain intensity because the PMI score is calculated by subtracting the pain level from the analgesic level according to the World Health Organization analgesic ladder. A negative PMI is considered to indicate inadequate analgesic cancer pain management, and previous systematic reviews on the PMI demonstrated that the year of publication, geographic area, economic level, and setting were potential determinants of undertreatment of patients with cancer.1Deandrea S. Montanari M. Moja L. et al.Prevalence of undertreatment in cancer pain. A review of published literature.Ann Oncol. 2008; 19: 1985-1991Crossref PubMed Scopus (662) Google Scholar, 2Greco M.T. Roberto A. Corli O. et al.Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer.J Clin Oncol. 2014; 32: 4149-4154Crossref PubMed Scopus (303) Google Scholar However, our study suggests that in the same study, the percentage of a negative PMI can change methodologically using different denominators and cut-off points. Our study has some limitations. We conducted recalculation using other denominators in the same study only when data were available; we could not assess the original data of all studies. We could not recalculate when detailed data on the pain score were not reported in articles. In conclusion, our study revealed that marked variations in the denominators and cut-off points could affect the percentage of a negative PMI. Uniform denominators and cut-off points are needed to facilitate reliable comparisons of pain undertreatment. This study was supported by the Japan Society for the Promotion of Science KAKENHI grant JP16H05212. The authors declare no conflicts of interest.
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