Xuan Wang，Xian-Cui Wu

Department of Oncology，Nanjing First Hospital（The Affiliated Hospital of Nanjing Medical University），Nanjing，Jiangsu 210029，China

Original article

Application of transitional care model in cancer pain management after discharge：a randomized controlled trial

Xuan Wang，Xian-Cui Wu*

Department of Oncology，Nanjing First Hospital（The Affiliated Hospital of Nanjing Medical University），Nanjing，Jiangsu 210029，China

A R T I C L E I N F O

Article history：

Received 14 November 2015

Received in revised form

2 December 2015

Accepted 15 December 2015

Available online 16 June 2016

Transitional care model

Cancer

Pain management

Continuum of care

Randomized control trial

Objective：We sought to determine any benefits of applying a transitional care model in the continuum of cancer pain management，especially after patients'discharge from the hospital.

Methods：A total of 156 eligible participants were recruited and randomly assigned into intervention or control groups.The control group received standard care，while the intervention group received extra，specialized transitional care of pain management.Outcomes were measured at weeks 0 and 2-4 and included demographic data，the Brief Pain Inventory，Global Quality of Life Scale，and Satisfaction Degree of Nursing Service.Adequacy of analgesia and severity of pain were assessed with the Pain Management Index and interview findings.

Results：After 2-4 weeks of intervention，there was a significant difference in the change in average pain score between intervention and control groups（P＜0.05）.Reductions in pain scores were significantly greater in the intervention group than in the control group（difference：0.98，P＜0.05）.Regarding pain management outcomes，there was a significantly better condition in the intervention group compared with the control group；in the intervention group，79%of patients had adequate opioids，whereas in the control group，only 63%of patients reported having adequate opioids.Furthermore，there was a significant difference between the two groups in quality of life（QOL）scores（P＜0.05）；the intervention group had significantly higher quality of life than the control group（difference：1.06）.Finally，there was a significant difference in the degree of satisfaction with the home nursing service；the intervention group had a significantly higher degree of satisfaction with the home nursing service in three aspects：quality，content，and attitude of service.

Conclusions：The application of a transitional care model in cancer pain management after discharge could help patients to improve their cancer pain management knowledge and analgesics compliance.In addition，the continuum of care service will contribute to effective communication between health care providers and patients，which could further improve their relationship.

©2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：//creativecommons.org/licenses/by-nc-nd/4.0/）.

1.Introduction

Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations，for instance，from hospital to the patient's home.1It includes logistical arrangement，education of the patient and family，as well as coordination among health professionals involved in the transition.1The transitional care model can be described as a bridge between two places of care.Patients suffering from cancer often require a shift from different stages of treatment approach and a change of different locations. Therefore，due tothe illness progression and complexcare needs of cancer patients，high quality of transitional care becomes a more and more essential part of providing care to such a group of people.

Numerous doctors and nurses engaged in cancer care recognize that a proportion of the patients either at presentation or during the course of therapy will show advanced and progressive disease or symptoms，2-5for instance，cancer pain.According to the previous review，pain is experienced by 53%of patients with cancer at any stage of disease，and one-third of these patients grade it as moderate or severe.6，7Furthermore，unrelieved severe pain will affect people's quality of life and increase levels of anxiety and depression.8-10Pain also has a significant impact on care givers.11

http：//dx.doi.org/10.1016/j.cnre.2016.06.003

2095-7718/©2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：//creativecommons. org/licenses/by-nc-nd/4.0/）.

In China，pain management in grade-three hospitals has been attracting more and more attention.Many hospitals have established a series of strategies of pain management，but how to help patients to manage their pain when they are discharged from the hospital is still under exploration.Many patients revealed that cancer pain is well managed in the hospital setting，whereas at home，cancer pain brings them and their family anxiety and frustration.One of the most frequent problems faced bycancer patients at home is pain，patients with which accounted for 54%.12

Some of barriers result from concerns，such as fear of addiction，which have led to suboptimal use of opioids.13-15Others are because patients and their caregivers lack sufficient pain managementknowledge.Whenpatientshave such troublesome symptoms，they do not know from whom and where they could seek help.

It is clear that the care of patients suffering from cancer is not limited in the hospital setting；home care is also an important part. With the primary goal of improving cancer patients'quality of life（QOL），we conducted a randomized controlled trail to investigate any benefits of applying a transitional care model in the continuum of cancer pain management.

2.Methods

2.1.Settings and participants

We recruited a total of 156 hospitalized patients from two districts（Jianye and Xuanwu District）in Nanjing urban areas who were receiving regular chemotherapy and radiation therapy in the participating hospital during the period from August 2014 to November 2014.The selection criteria were that patients had cancer pain scores≥2 of 10 in the past week，a life expectancy of more than 3 months for measurement of outcomes，older than 18 years，and signed informed consent.Exclusion criteria were cognitive，visual，or hearing impairment.The interval between two times of hospitalization therapy was on average 2-4 weeks，which means that during the course of therapy，every patient had to stay at home at least for 2-4 weeks.

2.2.Study design

2.2.1.Establishment of multidiscipline teams（MDTs）for providing transitional care of pain management

The MDTs are composed of the pain management group of Oncology in Nanjing First Hospital，36 general physicians and nurses from 18 community hospitals from the Jianye District and Xuanwu District.All members of MDTs had received a series of training sessions on knowledge and practical skills on pain management and passed a final test before the start of the study.

2.2.2.Intervention

Participants were randomly assigned into two groups1：control group and2intervention group.

2.2.2.1.Control group.After admission，patients received standard care during chemotherapy and radiation therapy according to the standard of nursing care developed by the Department of Nursing Management.When patients were discharged from the hospital，nurses and doctors conducted regular health guidance to patients and their families，including health lifestyle，drug use，and referral information.

2.2.2.2.Intervention group.In addition to the same care services as the control group，participants in this group also received extra transitional care services.

（1）Two days before discharge from the hospital，patients and their caregivers received a specialized session on how to manage pain at home.They also received the booklet of pain management developed by the authors.The content of the booklet included use of analgesics，the observation method of adverse reaction of analgesics，the knowledge of home self-care，how to seek help at the community level，and the contact information of community MDTs members.

（2）Oneweek afterdischarge from thehospital，a team organized by local community doctors and nurses who are members of MDTs conducted a home visit for every eligible patient，and provided individual pain management services according to patients'and their caregivers'needs.

（3）At home，the patients and their families could consult community members of MDTs on pain management problems during working hours.If necessary，community doctors and nurses could further consult the specialized pain management group of oncology in Nanjing First Hospital.

2.3.Data collection

The demographic data collected included age，sex，type of tumor，education level，and marital status.

Outcomes of management are as follows：

（1）Wisconsin Brief Pain Inventory（BPI）.The BPI questionnaire includes items regarding the presence of pain，site of pain，severity on average，at present and at its worst in the past month on a 0-10 scale，current medication and percentage response， characteristics of pain， and degree of interference.16

（2）Pain Management Index（PMI）.This is a measure of adequacy of analgesia by comparing the most potent analgesic used by a participant relative to the level of their reported pain. Analgesic strength is categorized as 0（no analgesic），1（paracetamol or other nonsteroidal anti-inflammatory drug），2（“weak”opioid），or 3（“strong”opioid）.We categorized pain into four levels according to the worst pain item from the BPI（scored from 0 to 10）：0（no pain=0），1（mild pain=1-4），2（moderate pain=5-6），and 3（severe pain=7-10）.The PMI is calculated by subtracting the pain score from the analgesic score.A negative result indicates inadequate analgesia，and zero or positive value indicated adequate analgesia.17

（3）Uniscale for Global Quality of Life，18which is a wellestablished measure of QOL.

（4）The Satisfaction Degree of Nursing Service，which includes the degree of satisfaction with both hospitalization and home nursing services.The evaluation score is composed of three aspects：the quality of service（30%），content of service（40%），and attitude of service provider（30%）.

Data were collected 2 days before discharge and at patients' admission for next hospitalization.The interval between the first and second therapy was normally 2-4 weeks.

2.4.Statistical method

All analyses were performed with SPSS 13.0.The comparisons of data were applied with t-test and P＜0.05 was considered as statistically significant.

Table 1 Demographic data of intervention and control groups.

Table 2 Characteristics of outcome measurements on BPI，MPI，and QOL.

3.Results

There was no significant difference between intervention and control groups in gender，type of cancer，education level，and marital status（Tables 1 and 2）.

3.1.Effect on BPI average pain and the worst pain

At the beginning of the study，on a scale of 0-10，patients rated their worst pain at 5.88（SD：2.69）（overall mean）and average pain rated at 4.16（SD：2.39）（overall mean）.After 2-4 weeks of intervention，there was a significant difference in the change in average pain scores between intervention and control groups（P＜0.05）. Reductions in worst pain scores were significantly greater in the intervention group than in the control group（difference：0.98，P＜0.05）（Table 1）.

3.2.Effect on pain management

Many patients were using some type of medication to control their pain，with 66%of patients using opioids（both strong and weak opioids）at the beginning.Overall，17%reported using inadequate analgesia，as assessed by the PMI and patients'interviews. After 2-4 weeks of intervention，there was a significant difference in the use of analgesics between the intervention and control groups and the overall amount at the beginning（P＜0.05），which reported that the intervention group used more opioids.Meanwhile，there was evidence that use of opioids decreased significantly in the control group compared with overall data at the beginning（P＜0.05）.There was a significant difference between intervention and control groups in PMI outcomes（P＜0.05）.

3.3.Effect on BPI pain interference and QOL

The BPI interference scale score was 1.98（0.89），indicating that pain interfered moderately with activity.There was no significant difference in the change in interference scores between intervention and control groups（P=0.96）.Regarding QOL scores，there was a significant difference between the two groups in QOL scores（P＜0.05）；the intervention grouphad significantly higher QOL than the control group（difference：1.06）（Table 3）.

There is no significant difference between the two groups in the degree of satisfaction with hospitalization of nursing service，but there is a significant difference in the degree of satisfaction with home nursing service；the intervention group had a significantly higher degree of satisfaction with home nursing service in three aspects.

4.Discussions

According to the study，during the therapy interval（2-4 weeks），the intervention group managed cancer pain significantly better than the control group，as well as in their QOL.From the author's perspective，a great contribution could be owed to the MDTs，who shared basic information of patients and knowledge and skills of pain management，and they worked together to tackle the problems for patients.This system would provide many benefits.On the one hand，a study19reported that community health providers should pay more attention to cancer patients'home caring.They should be responsible for health education，motivation of family caregivers，and participation in social organizations for family caring of cancer patients.On the other hand，community doctors and nurses are the most convenient resources for cancer patients when they are at home.Establishment of the MDTs could ensure that basic information of patients and doctors'and nurses'pain management knowledge and skills are consistent，which means that general hospitals and community hospitals have the same treatment plan and goal for pain management.This could further contribute to the quality of the continuum of pain management.

Table 3 Results of degree of satisfaction with hospitalization/x（SD）.

The study revealed that the team and education-based intervention showed that it had effect to reduce the average and worst pain.Furthermore，the most important finding of the study was that with the pain management education and support from MDTs，the fear of addiction to analgesics was also reduced；the intervention group increased their opioid use in the 2-4 weeks of intervention，increasing by 3%compared with overall data at the beginning，whereas in the control group，that decreased by 16%. During the discussion session after the intervention，many participants and their family caregivers reported that they felt they were moreinvolved with theirownpain management，and this helped to reduce the fear of addiction to analgesics，which is similar to the previous study conducted in Australia 2010.20

Furthermore，the results of the study showed that the intervention group had a significant increase in the degree of satisfaction with home nursing service in three aspects（quality of service，content of service，and attitude of service）.A previous research21showed that after discharge the continuum of care contributed to the effective communication between health care providers and patients，which helped patients to have the right attitude towards their symptoms and to make proper decisions.This finding proved that the continuum of care could further contribute to the relationship between patients and health care providers.

However，this study also has some limitations.Barriers to effective cancer pain management exist in the knowledge，beliefs，and attitudes of cancer patients and their family caregivers；in the skills and behaviors of health care professionals；on the level of institutional practice and policies；and in government policies and regulations.22Our study was limited only to an urban area，where community health care services are quite mature and good and the educational level of patients was normally higher than that in rural areas.Further studies will be needed for cancer pain management in rural areas.Moreover，establishment of information management systems for the continuum of cancer pain management is also an essential part，which could further contribute to the quality of such care.

5.Conclusions

Currently，the continuum of care for cancer patients includes four types of models：Discharge Planning Model，Transitional Care Model，Case Management Model，and Family Physician Model.23In China，most interventions on the continuum of care for cancer patients were restricted only to Discharge Planning Model，which means that the participating hospital is the center for providing subsequent follow-up and care.24After discharge，tele-follow-up is the most commonway to provide continuing care and establish the communication between health care provider and patients or their family.25

However，there was a study26describing the high rate of loss and rejection rate of tele-follow-up；this made the effect of telefollow-up a controversial issue.Therefore，in the authors'opinion，with the faster and faster development of a combination health service between general health care facilities and community health facilities in China，the application of a transitional care model in cancer pain management after discharge could help patients to improve their cancer pain management knowledge and analgesic compliance.In addition，the continuum of care service will also contribute to the effective communication between health care providers and patients，which could further improve their relationship.

Conflicts of interest

All contributing authors declare no conflicts of interest.

1.American Geriatrics Society（AGS）Position Statement.Improving the Quality of Transition Care for Person with Complex Care Need.Assisted Living Consult；2007：30-32.

2.L¨ofmark R，Nilstun T，Bolmsj¨o IA.From cure to palliation：concept，decision and acceptance.J Med Ethics.2007；33：685-688.

3.Finlay E，Casarett D.Making difficult discussions easier：using prognosis to facilitate transitions to hospice.CA Cancer J Clin.2009；59：250-263.

4.Agren Bolmsj¨o I，Nilstun T，L¨ofmark R.From cure to palliation：agreement，timing and decision making within the staff.Am J Hosp Palliat Med.2007；24：366-370.

5.Schickedanz A.Of value：a discussion of cost，communication，and evidence to improve cancer care.Oncologist.2010；15：73-79.

6.Daut RL，Cleeland CS.The prevalence and severity of pain in cancer.Cancer. 1982；50：1913-1918.

7.van den Beuken-van Everdingen MH，de Rijke JM，Kessels AG，Schouten HC，van Kleef M，Patijn J.Prevalence of pain in patients with cancer：a systematic review of the past 40 years.Ann Oncol.2007；18：1437-1449.

8.Ferrell BR，Grant MM，Rhiner M，Padilla GV.Home care：maintaining quality of life for patient and family.Oncology.1992；6：136-140.

9.McMillan SC，Tofthagen C，Morgan MA.Relationships among pain，sleep disturbances，and depressive symptoms in outpatients from a comprehensive cancer center.Oncol Nurs Forum.2008；35：603-611.

10.Tavoli A，Montazeri A，Roshan R，Tavoli Z，Melyani M.Depression and quality of life in cancer patients with and without pain：the role of pain beliefs.BMC Cancer.2008；8：177.

11.Ferrell BR，Borneman T，Juarez G.Integration of pain education in home care. J Palliat Care.1998；14：62-68.

12.Tsigaroppoulos T，Mazaris E，Chatzidarellis E，Skolarikos A，Varkarakis I，Deliveliotis C.Problems faced by relatives caring for cancer patients at home. Int J Nurs Pract.2009；15：1-6.

13.Potter VT，Wiseman CE，Dunn SM，Boyle FM.Patient barriers to optimal cancer pain control.Psychooncology.2003；12：153-160.

14.Deandrea S，Montanari M，Moja L，Apolone G.Prevalence of undertreatment in cancer pain.A review of published literature.Ann Oncol.2008；19：1985-1991.

15.Ward SE，Goldberg N，Miller-McCauley V，et al.Patient-related barriers to management of cancer pain.Pain.1993；52：319-324.

16.Daut RL，Cleeland CS，Flanery RC.Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases.Pain.1983；17：197-210.

17.Zelman DC，Cleeland CS，Howland EW.Factors in appropriate pharmacological management of cancer pain：a cross-institutional investigation.Pain.1987；30：S136.

18.Sloan JA，Loprinzi CL，Kuross SA，et al.Randomized comparison of four tools measuring overall quality of life in patients with advanced cancer.J Clin Oncol. 1998；16：3662-3673.

19.Wu LD.Analysis of health problems and nursing needs for patients with tumor after operation.Chin J Mod Nurs.2009；15：328-330（in Chinese）.

20.Lovell MR，Forder PM，Stockler MR，et al.A randomized controlled trial of a standardized educational intervention for patients with cancer pain.J Pain Symptom Manage.2010；40：49-59.

21.Gagliardi AR，Dobrow MJ，Wright FC.How can we improve cancer care？A review of interprofessional collaboration models and their use in clinical management.Surg Oncol.2011；20：146-154.

22.Ingham JM，Foley KM.Pain and the barriers to its relief at the end of life：a lesson for improving end of life health care.Hosp J.1998；13：89-100.

23.Zhang FL，Ye B，Liu MJ.Research progress of the continuum of care in cancer patients after discharge.Chin Nurs Manag.2012；12：91-94（in Chinese）.

24.Chen Q，Jiang XY.Research process of discharge planning model.Chin Nurs Res. 2011；25：1137-1140（in Chinese）.

25.Yu TY.Nursing review of patients'telephone follow-up after discharge.Chin J Nurs.2006；41：246-247（in Chinese）.

26.Wang SY，Wang JH，Chen CH.Application of the continuum of care for patients with specialized needs.Hosp Adm J Chin People's Liberation Army.2008；15：191-192（in Chinese）.

How to cite this article：Wang X，Wu X-C.Application of transitionalcaremodelin cancer pain managementafterdischarge：a randomized controlled trial.Chin Nurs Res.2016；3：86-89.http：// dx.doi.org/10.1016/j.cnre.2016.06.003

*Corresponding author.

E-mail address：810150136@qq.com（X.-C.Wu）.

Peer review under responsibility of Shanxi Medical Periodical Press.