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electronic Persistent Pain Outcomes Collaboration

Publications & research

Reports

Information series

This information series investigates how patient demographic characteristics and the patient reported measures of pain and physical, emotional, and cognitive functioning are individually associated with patient perception of change in overall health status following treatment for chronic pain. 

The ePPOC Information Series are brief papers aiming to provide information from the ePPOC data collection, beyond that reported in the standard six-monthly reports to services.

The ePPOC Information Series are brief papers aiming to provide information from the ePPOC data collection, beyond that reported in the standard six-monthly reports to services.

Journal articles

Slater, Helen; Waller, Robert;  Briggs, Andrew M; Lord, Susan M.; Smith, Anne J.  Characterizing phenotypes and clinical and health utilization associations of young people with chronic pain: latent class analysis using the electronic Persistent Pain Outcomes Collaboration database. PAIN:10.1097/j.pain.0000000000003326, July 9, 2024.

Using the Australiasian electronic Persistent Pain Outcomes Collaboration, a binational pain registry collecting standardized clinical data from paediatric ePPOC (PaedsePPOC) and adult pain services (AdultePPOC), we explored and characterized nationally representative chronic pain phenotypes and associations with clinical and sociodemographic factors, health care utilization, and medicine use of young people. Young people ≥15.0 and <25.0 years captured in PaedePPOC and AdultePPOC Australian data registry were included. Data from 68 adult and 12 paediatric pain services for a 5-year period January 2018 to December 2022 (first episode, including treatment information) were analysed. Unsupervised latent class analysis was applied to explore the existence of distinct pain phenotypes, with separate models for both services. A 3-phenotype model was selected from both paediatric and adult ePPOC data, with 693 and 3518 young people included, respectively (at least one valid indicator variable). Indicator variables for paediatric models were as follows: pain severity, functional disability (quasisurrogate “pain interference”), pain count, pain duration, pain-related worry (quasisurrogate “catastrophizing”), and emotional functioning; and, for adult models: pain severity, pain interference, pain catastrophizing, emotional functioning, and pain self-efficacy. From both services, 3 similar phenotypes emerged (“low,” “moderate,” “high”), characterized by an increasing symptom-severity gradient in multidimensional pain-related variables, showing meaningful differences across clinical and sociodemographic factors, health service utilization, and medicines use. Derived phenotypes point to the need for novel care models that differentially respond to the needs of distinct groups of young people, providing timely, targeted, age-appropriate care. To effectively scale such care, digital technologies can be leveraged to augment phenotype-informed clinical care.

Kardash L, Wall CL, Flack M, Searle A (2024) The role of pain self-efficacy and pain catastrophising in the relationship between chronic pain and depression: A moderated mediation model. PLoS ONE 19(5): e0303775. https://doi.org/10.1371/journal.pone.0303775

Chronic pain is a substantial health problem with a high prevalence of comorbid depression. To understand the link between chronic pain and depression, cognitive factors including pain catastrophising and pain self-efficacy have been theorised as significant contributing variables. There is relatively strong evidence that pain catastrophising mediates the relationship between pain severity and depression symptoms. There is also emerging evidence that the mediation role of pain catastrophising may vary as a function of pain self-efficacy. However, it is unknown whether this model will apply in a tertiary pain clinic sample. Thus, this study aimed to examine the respective moderating and mediating roles of pain self-efficacy and pain catastrophising on the association between pain severity and depressive symptoms in a large clinical sample of Australian adults living with chronic pain. Participants (n = 1195) completed all questionnaire measures prior to their first appointments at one tertiary
pain service. As expected, the PROCESS path analysis showed that pain catastrophising mediated the relationship between pain severity and depressive symptoms. Further, there was support for the moderating effect of pain self-efficacy; as pain self-efficacy decreased, the relationship strengthened between both pain severity and pain catastrophising, as well as pain catastrophising and depressive symptoms. These findings may have important clinical implications including how relationships between these factors may be considered in the provision of care for those with chronic pain. Notably, these measures could be used in triaging processes to inform treatment decisions.

Shebeshi Dinberu, Allingham Samuel, White Janelle, Tardif Hilarie, Holloway David (2023) Factors associated with general practitioner visits for pain in people experiencing chronic pain. Journal of Primary Health Care https://doi.org/10.1071/HC23004

People with Chronic Pain (CP)  are high users of general practitioners (GPs)3 and inpatient hospital services, which together are major drivers of health care costs. In Australia, CP affects one in five adults aged 45 and over, and the national estimated cost for CP in 2018 was 139 billion AUD.  Although Australians with CP commonly visit GPs,5 there is a paucity of research that explores the factors associated with GP use. This study will examine the association between rate of pain-related GP visits for patients with CP and relevant factors such as pain severity, pain interference, mood, pain-related cognitions and patient demography.

Holloway D, Allingham S, Bryce M, Cameron K, Cook M and Shebeshi D (2023) A decade of outcomes: The evolution of an australasian outcomes collaboration for chronic pain services. Front. Pain Res. 4:1153001. doi: 10.3389/fpain.2023.1153001

Since the establishment of the electronic Persistent Pain Outcomes Collaboration (ePPOC) in 2013, ongoing improvements in benchmarking and quality improvement activities have provided the opportunity for ePPOC to grow to support more than one hundred adult and pediatric services delivering care to Individuals living with persistent pain throughout Australia and New Zealand. These improvements straddle multiple domains, including benchmarking and indicators reports, internal and external research collaboration and the integration of quality improvement initiatives with pain services. This paper outlines improvements undertaken and lessons learned in relation to the growth and maintenance of a comprehensive outcomes registry and its articulation with pain services and the wider pain sector.

Tardif H, Allingham S F, Rahman M and Daly A (2022) Patterns of patient outcomes following specialist pain management in Australasia: a latent class analysis using the ePPOC database. PAIN. DOI: 10.1097/j.pain.0000000000002799

The increasing demand for pain management and limited resources available highlight the need to measure treatment effectiveness. We analysed data collected at 75 specialist persistent pain services located in Australia and New Zealand to calculate overall treatment outcome for patients receiving care during 2014-2020. Socio-demographic and clinical information was provided for 23,915 patients, along with patient-reported measures assessing pain, pain interference, depression, anxiety, stress, pain catastrophizing and pain self-efficacy.

 Latent Class Analysis identified four distinct outcomes based on patients’ pattern of responses across the assessment tools at treatment end. Group 1 (n=8,369, 35%) reported low/mild severity across all clinical domains at the end of care, while Group 4 (n= 7,081, 30%) were more likely to report moderate/high severity on all domains. Group 2 (n=1,991, 8%) reported low/mild pain with moderate/high psychological distress at treatment end, and Group 3 (n=6,474, 27%) reported moderate/high pain with low/mild psychological distress. Multi-variable logistic regression identified those factors associated with the different groups. In particular, factors most predictive of a poor (Group 4) vs. good outcome (Group 1) were unemployment (due to pain or other reasons), requiring an interpreter, widespread pain, pain of longer duration and attributing the pain to an injury at work. The results may allow identification of those most likely to benefit from the services currently provided, and inform development of alternative or enhanced services for those at risk of a poor outcome.

 

Chen N, Farrell M, Kendall S, Levy L, Mehan R and Katz B (2022) The Pain Clinic for Older People. Pain Medicine http://doi.org/10.1093/pm/pnac111 

Multidisciplinary pain clinics have an established role in the management of persistent pain, but there is little evidence to support this approach in an older population. This study describes the characteristics and pain outcomes of patients attending a pain clinic designed exclusively for older people. A retrospective audit was performed of outcomes of the Pain Clinic for Older People (PCOP) in 2015–2019. Response to treatment was determined by change in Brief Pain Inventory (BPI) scores at initial attendance and after a treatment program.

Patients attending the PCOP had a mean age of 80.5 years and had high rates of frailty (84%), cognitive
impairment (30%), and multimorbidity. Significant reductions in BPI average pain and BPI pain interference
scores were achieved. Clinically meaningful improvement in BPI average pain was achieved in 63% of patients
attending the PCOP who were 65–74 years of age and in 46% of patients who were >75 years of age. Clinically meaningful improvement in BPI pain interference was achieved in 69% of those attending the PCOP who were 65–74 years of age and in 66% of those who were >75 years of age.

This study demonstrates that PCOP clients achieved significant and meaningful improvements in their pain outcomes. Advanced age, cognitive impairment, frailty and multimorbidity should not be regarded as barriers to benefit from a pain clinic specifically designed for older people.

Lewis G, Borotkanics R and Upsdell A (2021) Inequity in outcomes from New Zealand chronic pain services. New Zealand Medical Journal, 134 (1533): 11-20.

The aim of this study was to evaluate outcomes from chronic pain services in New Zealand based on patient ethnicity. Clinical and demographic data were obtained from 4,876 patients from the ePPOC database. All New Zealand patients who had completed referral and discharge questionnaires during the period January 2014 to June 2019 were included. Clinical questionnaires included the Brief Pain Inventory (BPI); Depression, Anxiety and Stress Scale – 21; Pain Catastrophising Scale (PCS); and the Pain Self-Efficacy Questionnaire (PSEQ). Regression analysis (adjusting for age, body mass index, and baseline values) was used to determine whether patient ethnicity was associated with clinical questionnaire data at treatment end and at 3–6-month follow-up.

The results showed that at treatment end, there were significantly poorer scores for Pacific people compared to Europeans for several of the DASS-21 and PCS subscales, while there were no differences between European and Māori and Asian ethnicities. At follow-up, almost all outcome measures were poorer for Māori compared to Europeans, and several of the DASS-21 and PCS subscales were poorer for Asian and Pacific people compared to Europeans.

This study highlights ethnic inequalities in the effectiveness of treatment for chronic pain services in New Zealand. The authors conclude that the cultural safety of the chronic pain clinics should be reviewed regarding both assessment and management procedures, including validity of the assessment tools, addressing communication barriers and understanding cultural beliefs relating to pain.

Tardif H, Hayes C and Allingham S F (2021) Opioid cessation is associated with reduced pain and improved function in people attending specialist chronic pain services. The Medical Journal of Australia, 214 (9): 430-432.

Opioid prescribing varies between pain services, including direct prescribing by the pain specialist and recommendations to patients’ general practitioners. However, a major focus of multidisciplinary care is supporting patients to reduce their opioid use, which typically involves collaboration between the patient, their GP, and the pain service. This paper analysed data from the electronic Persistent Pain Outcomes Collaboration collected at 67 pain services during January 2015 ‒ June 2020, with the aim of exploring the impact of changes in opioid use on outcomes for patients.

Over 10,000 patients provided information at both referral and at the end of their treatment episode: 56% were women, and 34%  had experienced their pain for more than five years. The most frequent site of their main pain was the back (38%). Just over 60% were using opioid medications at referral, with a mean oral morphine daily dose of 56.3mg. People using opioids at referral reported higher mean pain scores and greater interference in daily activities compared to those who were not using opioid medications. They also reported worse depression, anxiety, stress, pain catastrophising, and pain self-efficacy.

At the end of the treatment episode, positive change and clinically significant improvement was greatest for those patients who had ceased opioid use.  Scores for measures specifically related to pain experience (pain severity, interference, catastrophising and self-efficacy) at the end of treatment were similar to or better than those of patients who had not been using opioids at referral, despite greater initial pain severity. Conversely, the smallest mean improvements were for the patients who had not reduced opioid use by at least 50%.

These results are encouraging, showing that significant clinical improvements are possible for people with chronic non-cancer pain attending multidisciplinary pain management services in Australia and New Zealand, even as they discontinue opioid medications. The challenge is to extend these services and supported self-management skills to primary and community care.

Tardif H, Arnold C, Hayes Cand Eagar K (2017) Establishment of the Australasian Electronic Persistent Pain Outcomes Collaboration. Pain Medicine, 18 (6): 1007–1018.

This paper describes establishment of the Australasian integrated outcome centre for persistent pain – ePPOC (the electronic Persistent Pain Outcomes Collaboration). The goals of ePPOC include evaluating treatment of chronic pain in multidisciplinary centres, establishing a benchmarking system to drive quality improvement, and providing answers to important questions regarding types of treatment (“dose,” intensity, and response) and which treatment is appropriate for different patients. The paper details the development and first-phase implementation of ePPOC, including processes for defining the minimum data set, establishing governance structures, protocols for data collection and creation of reports and software.

The benefits the collaboration has delivered to the Australasian pain sector are also described. A standardized data set and protocol has allowed meaningful comparison between services. There is also greater inter-unit communication and a common language to describe treatment pathways and episodes. The analysis of data collected to date has provided a more detailed picture of the characteristics of patients referred to pain management services and fostered enthusiasm for collection of follow-up measures to assess outcomes.

Lord SM, Tardif H, Kepreotes EA, Blanchard M and Eagar K (2019) The Paediatric electronic Persistent Pain Outcomes Collaboration (PaedePPOC): establishment of a binational system for benchmarking children's persistent pain services. PAIN, 160 (7): 1572-1585.

Chronic or persistent pain is a growing global health problem. Internationally, paediatric pain services are a limited resource and must therefore strive to improve equity, outcomes, and value for money. The Paediatric electronic Persistent Pain Outcomes Collaboration (PaedePPOC) is a binational paediatric outcome measurement centre that aims to measure, benchmark, and improve children’s specialist pain services in Australia and New Zealand. This study documents the establishment of PaedePPOC, outlines the methods and resources this required, and presents baseline and initial outcome data.

The PaedePPOC initiative has been successfully integrated into children’s pain services, and nine of the 10 specialist paediatric pain services in Australia and New Zealand are now participating. The collaboration allows collection of timely point-of-care information to support clinicians and families, and valuable binational and service data to inform quality improvement and future sector planning.

Nicholas MK, Costa DSJ, Blanchard M, Tardif H, Asghari A and Blyth FM (2019) Normative data for common pain measures in chronic pain clinic populations: closing a gap for clinicians and researchers. PAIN, 160 (5): 1156-1165.

Normative data provide a baseline against which individual patient or group scores can be compared and interpreted. This study provides normative data for four measures commonly used in the assessment of chronic pain, using information collected under ePPOC for over 13,000 people attending pain clinics across Australia and New Zealand.

The data are presented as summarised normative data, broken down by demographic (age, sex, work status, etc) and pain site/medical variables, collected at referral. The mean BPI severity score was 6.4 (moderate-severe), and mean interference score was 7.0. The mean DASS depression score was 20.2 (moderate-severe), mean DASS anxiety was 14.0 (moderate), and mean DASS stress was 21.0 (moderate). The mean PCS scores were 10.0, 5.9, 14.1, and 29.8 for rumination, magnification, helplessness, and total, respectively. The mean PSEQ score was 20.7. Men had slightly worse scores than women on some scales. Scores tended to worsen with age until 31 to 50 years, after which they improved. Scores were worse for those who had a greater number of pain sites, were unemployed, were injury compensation cases, or whose triggering event was a motor vehicle accident or injury at work or home. These results and comparisons with data on the same measures from other countries, as well as their uses in both clinical practice and clinical trials, are discussed.

Rajappa H, Wilson M, White R, Blanchard M, Tardif H and Hayes C (2019) Prioritizing a sequence of short-duration groups as the standardized pathway for chronic noncancer pain at an Australian tertiary multidisciplinary pain service: preliminary outcomes. Pain Reports, 4 (5): e780.

The implementation of a novel pain management program is described, and patient outcomes following treatment are reported. Referred patients completed a short duration group-based standardized pain management pathway, consisting of group education, assessment and treatment. Measures of pain, mood, self-efficacy, catastrophizing and opioid use were assessed.

The program was found to be resource-efficient and resulted in shorter waiting times. Improvements in average pain intensity, pain interference, depression, anxiety, stress, pain catastrophizing and self-efficacy were equivalent to those reported by other pain management services participating in ePPOC. There was also significantly greater reduction in opioid use, including for those taking more than 40mg of oral morphine equivalent daily dose. This model has implications for other pain services who are resource-limited and have lengthy waitlists.

Giummarra MJ, Tardif H, Blanchard M, Tonkin A and Arnold CA (2020) Hypertension prevalence in patients attending tertiary pain management services, a registry-based Australian cohort study. PLoS ONE, 15 (1): e0228173. 

Persistent pain and hypertension often occur together, and share a number of biological and lifestyle risk factors. This study aimed to examine how common hypertension is in people seeking treatment in specialist pain clinics in Australia, and to describe their demographic, clinical and pain-related characteristics.  

One in four patients seeking pain management were found to have hypertension, which is higher than in the Australian adult population and in primary care patients. They were older, lived in regions with higher socioeconomic disadvantage, had higher body mass index, were more likely to be born outside the Oceania/Australasia region, have comorbid arthritis, diabetes, and severe or extremely severe anxiety symptoms. Hypertension was also associated with moderate to high pain severity.

Understanding the features associated with hypertension in patients with persistent pain may lead to tailored interventions for patients seeking treatment for pain in outpatient pain management settings.

Young J, Mantopoulos S, Blanchard M, Tardif H, Hogg M, Khan F and Galea MP (2020) Interdisciplinary management for chronic pain in central neurological disorders: a retrospective study. International Journal of Therapy and Rehabilitation, 27 (1): doi:10.12968/ijtr.2018.0110.

Chronic pain in central neurological disorders such as multiple sclerosis, stroke, Parkinson’s disease and spinal cord injury is common. The objective of this study was to compare the outcomes for people with a central neurological disorder with those who do not have these conditions, following outpatient interdisciplinary-based treatment.

After engagement with an interdisciplinary pain management service, people who had a central neurological disorder reported reduction in pain severity, pain interference, pain self-efficacy, depression, anxiety and stress. There was a significantly greater improvement in pain catastrophising in those with a central neurological disorder compared to those without. This study shows that people with central neurological disorders can benefit from interdisciplinary pain management and have similar results to those without these conditions. This retrospective study offers an insight into interdisciplinary treatment and the use of the ePPOC outcome centre.

Glare P, Costa D and Nicholas M (2020) Psychosocial characteristics of cancer-related pain in patients attending specialist pain clinics in Australia and New Zealand. Psycho-Oncology, 29 (12): 2097-2100.

Opioids have been the mainstay of cancer pain relief for the past 40 years, but a multidimensional, biopsychosocial approach to assessment and treatment is now recommended. While the intensity of cancer pain and the distress it causes are well known, it is less clear what patients with cancer think about their pain and how they cope with it. The aim of this study was to interrogate the ePPOC dataset to determine (1) pain intensity, pain interference, mood, and pain cognitions in patients with cancer-related pain (CRP), (2) how these data compare to those in patients with chronic non-cancer pain, and (3) whether demographic or clinical variables predict self-efficacy and catastrophizing in patients with CRP.

Of more than 25 000 patients entered into the ePPOC database between 2013 and 2016, some 423 (1.7%) had cancer pain. These people reported slightly less pain intensity, pain interference, distress and disability than those with pain from other causes, but were using higher doses of opioids. In those with cancer-related pain, pain self-efficacy was low, and pain catastrophizing was high, similar to that reported by patients with pain from other causes. Being born in a country other than Australia or New Zealand, a history of depression, and taking higher doses of opioids predicted unhelpful pain thoughts and beliefs.

These results suggest that patients with difficult-to-control cancer pain should be screened for unhelpful pain cognitions which could be reduced with cognitive-behavioural or other psychological treatments.

Research in progress

Chief Investigator: Michael Nicholas

Aim:

The aim of this study is to use analyses based on multidimensional item response theory (IRT) to supplement what is already known about the psychometric properties of the clinical assessment tools currently used within ePPOC. IRT is often used to inform the development of questionnaire short-forms, as it is able to grade items according the amount of information they capture and whether they are best-suited to individuals with a low or high level of the construct of interest. This methodology is commonly used for creating short forms of questionnaires, in that it identifies items that discriminate poorly and items that may be redundant. This would further inform the work conducted thus far on reducing the burden on patients completing the ePPOC questionnaires.   

Chief Investigator: Joel Champion

Aim:

Little is known about the cohort of paediatric patients that transition to adult pain services and whether referral characteristics can predict future need for adult pain services. The objective of this study is to 1) provide the first demographic, clinical and psychosocial data on paediatric patients with chronic pain who require transition to adult pain services across Australia 2) compare this cohort at referral with peers in paediatric services and 3) identify patient factors that predict the need for transition. This research is required to better prepare paediatric and adult care providers to identify and support this group of patients throughout transition.

Chief Investigator: Tiina Jaaniste

Aim:

The study aims to determine the nature and extent of parental burden associated with paediatric chronic pain among children attending paediatric chronic pain clinics in Australia. Specifically, the study will evaluate the impact of paediatric chronic pain on parental work productivity and days off work, the number of healthcare appointments that a parent takes the child to, the number of days that a child is home from school due to the pain, and parental marital relations, psychological (mood, anxiety, worry) and social functioning. A secondary (exploratory) aim will be to establish whether parental burden is related to various child factors (e.g., the child’s age, pain condition, pain duration, pain severity, functioning, comorbid health conditions, amount of health service usage) and/or parent demographic factors (e.g., parental age, sex, marital status, migrant status).

Chief Investigator: A/Prof Suzanne Nielsen, Monash Addiction Research Centre, Monash University

Aim:

To date, studies on pain management for patients on opioid agonist treatment (OAT) are restricted to people on methadone maintenance therapy and buprenorphine treatment. Among people receiving methadone and buprenorphine treatment with chronic pain, there is a high prevalence of comorbid depression and anxiety symptoms, pain-related sleep disorders and other psychiatric disorders. People on OAT have been described as having a “triple diagnosis” of substance use disorders, chronic pain and psychiatric disorders, which require comprehensive interdisciplinary management. Multidisciplinary pain management centres are one setting in which such care could be provided. To date, few studies have compared the characteristics of people on OAT with other people who are prescribed long term opioids. Therefore, little is known about the differences in demographic, clinical and pain-related characteristics. To the best of our knowledge, this is the first study comparing the characteristics of patients on OAT with other opioid users with chronic pain.

Other research using ePPOC data

Chief Investigator: Kristen Kappel

This study found that obese individuals improve, on average, the same amount as non-obese individuals in the areas of pain severity and pain interference as a result of participation in multidisciplinary pain management programs (MPMPs). This result was surprising given the findings of others, however those studies comparing outcomes for participants of pain treatment on the basis of obesity have been limited in numerous ways including small sample size, single therapy approach, a specific type of chronic pain, or small age range.  Conversely, the findings of this study are generalisable across different chronic pain types, for all adults aged 18 and older, and apply to the multidisciplinary approach.

This study also found that BMI was not associated with improvement in pain and interference following pain management. The impact of depression was also explored, with the researchers finding that even after controlling for depression, there was no relationship between BMI and improvement in pain severity or pain interference.

The results of this study formed part of a Masters of Clinical Psychology submitted to Charles Sturt University.