ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
25
Agency for Health Care Policy and Research (AHCPR),
which replaced the National Center for Health Services
Research and Health Care Technology Assessment
(NCHSR) in 1989 (28). The Agency for Health Care Policy
and Research developed approximately 15 guidelines, with
a budget of $750 million. The guidelines developed by
AHCPR for managing acute low back pain are of significant
importance for practice of interventional pain medicine
(28). Other guidelines of significance for pain specialists
include those developed by the Quebec Task Force
in the management of spinal disorders and whiplash associated
disorders (29, 30), chronic pain management guidelines
by the American Society of Anesthesiologists (31),
guidelines for performance of facet joint blocks by the International
Spinal Injection Society (32), and interventional
techniques in the management of chronic pain by the Association
of Pain Management Anesthesiologists (33).
Additionally, there are guidelines for migraine headaches
(34), guidelines for managing pain in sickle cell disease
(35), chronic pain management guidelines in the elderly
(36), and guidelines the for management of chronic pain
syndrome (37, 38). Other guidelines include the ones developed
by local Medicare carriers in the form of local
Medicare Review Policies in various states; third-party
payors including Blue Cross and Blue Shield, Aetna and
others; entrepreneurial technological companies such as
Hayes Technologies; and position statements by a multitude
of individuals and organizations. Cochrane collaboration
back review group for spinal disorders was also
started in 1995 (39, 40). McQuay and Moore published a
book of evidence based resource for pain relief (3). Many
of these guidelines were developed at a cost of tremendous
effort and resources to review the assessment and treatment
literature and to develop evidence-based guidelines
to treat various conditions. However, the cost of the guidelines
by various organizations is much less than the ones
developed by the federal government by the AHCPR. A
serious examination of the guidelines shows that about 85%
of the recommendations are not based on any significant
evidence (27). Interventional pain management is no exception
to the general rule.
Purpose
CLINICAL PRACTICE GUIDELINES
Clinical practice guidelines for interventional techniques
in the management of chronic pain are professionally developed
utilizing a combination of evidence, expert opinion
and consensus. The purpose of these clinical guidelines
is to:
1. Improve quality of care,
2. Improve patient access,
3. Improve patient outcomes,
4. Improve appropriateness of care,
5. Improve efficiency and effectiveness, and
6. Achieve cost containment by improving cost-benefit
ratio.
Rationale
The most compelling single reason for the development of
these clinical practice guidelines is to improve the quality
of care and life for patients suffering from painful disorders.
Available evidence documents a wide degree of variance
in the practice of interventional pain management and
pain medicine for even the most commonly performed procedures
and treated condition(s) (6, 23-38, 41-63). These
guidelines also address the issue of systematic evaluation
and ongoing care of chronic or persistent pain, and provide
information about the scientific basis of recommended
procedures, thus potentially increasing compliance, dispelling
misconceptions among providers and patients,
managing patient expectations reasonably, and forming the
basis of a therapeutic partnership among the patient, the
provider, and the payer.
Importance
Interventional techniques are crucial both in the diagnostic,
as well as the therapeutic, arena of managing pain and
providing improvement in the quality of life of the pain
sufferers. Some insurance carriers and other medical specialties
have criticized the practice of interventional pain
medicine and pain management using the wide variations
in treatment protocols and the relative scarcity of conclusive
evidence or consensus for their justification.
Methodology
The two most common methods for the development of
guidelines, often combined, are based on evidence and
consensus. However, reviews, clinical decision analyses,
and economic analyses are also very commonly utilized in
the medical literature. Thus, clinicians are increasingly
being asked to remain current in the aspects of clinical
care and decision making by systematically gathering, analyzing,
and combining evidence that links to outcome (6).
However, many of these publications unfortunately do not
always link information in a direct way to clinical recommendations
(3-5, 24, 25, 64). Implicit in the definition of
Pain Physician Vol. 4, No. 1, 2001