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Jason Robert Guertin,1,2,* M Gabrielle Pagé,3,4,* Jean-Éric Tarride,5 Denis Talbot,1,2 Judy Watt-Watson,6 Manon Choinière3,4 1Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada; 2Centre de recherche du Centre hospitalier universitaire de Québec, Université Laval, Quebec City, QC, Canada; 3Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada; 4Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; 5Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; 6Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada *These authors contributed equally to this work Objective: The study objective was to determine use of pain-related health care resources and associated direct and indirect costs over a two-year period in cardiac surgery patients who developed chronic post-surgical pain (CPSP). Methods: This multicentric observational prospective study recruited patients prior to cardiac surgery; these patients completed research assistant-administered questionnaires on pain and psychological characteristics at 6, 12 and 24 months post-operatively. Patients reporting CPSP also completed a one-month pain care record (PCR) (self-report diary) at each follow-up. Data were analyzed using descriptive statistics, multivariable logistic regression models, and generalized linear models with log link and gamma family adjusting for sociodemographic and pain intensity. Results: Out of 1,247 patients, 18%, 13%, and 9% reported experiencing CPSP at 6, 12, and 24 months, respectively. Between 16% and 28% of CPSP patients reported utilizing health care resources for their pain over the follow-up period. Among all CPSP patients, mean monthly pain-related costs were CAN$207 at 6 months and significantly decreased thereafter. More severe pain and greater levels of pain catastrophizing were the most consistent predictors of health care utilization and costs. Discussion: Health care costs associated with early management of CPSP after cardiac surgery seem attributable to a minority of patients and decrease over time for most of them. Results are novel in that they document for the first time the economic burden of CPSP in this population of patients. Longer follow-up time that would capture severe cases of CPSP as well as examination of costs associated with other surgical populations are warranted. Summary: Economic burden of chronic post-surgical pain may be substantial but few patients utilize resources. Health utilization and costs are associated with pain and psychological characteristics. Keywords: CARD-PAIN, chronic post-surgical pain, health care utilization, costs, cardiac surgery

Background: Over the past two decades, the prevalence of chronic pain has significantly increased globally, with approximately 20% of the world's population living with pain. Although quantitative measures are useful in identifying pain prevalence and severity, qualitative methods, and especially arts-based ones, are now receiving attention as a valuable means to understand lived experiences of pain. Photovoice is one such method that utilizes individuals' own photography to document their lived experiences., Aims: The current study utilized an arts-based method to explore immigrant Indian women's chronic pain experiences in Canada and aimed to enhance the understanding of those experiences by creating a visual opportunity for them to share their stories., Methods: Twelve immigrant Indian women captured photographs and participated in one-on-one interviews exploring daily experiences of chronic pain., Results: Women's photographs, and description of these photographs, provided a visual entry into their lives and pain experiences. Three themes emerged from our analysis: (1) bodies in pain, (2) traversing spaces including immigration, and (3) pain management methods. Findings revealed that women's representations of pain were shaped by a clash between culturally shaped gender role expectations and changing gender norms due to immigration processes. The use of photovoice visually contextualized and represented pain experiences, proving to be a valuable tool for self-reflection., Conclusions: This research uncovers the multifaceted nature of chronic pain and identifies the influence of immigration, gender, and social relations on the exacerbation of pain in immigrant Indian women., (© 2024 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Objective: To determine timing and risk factors associated with readmission within 30 days of discharge following noncardiac surgery., Background: Hospital readmission after noncardiac surgery is costly. Data on the drivers of readmission have largely been derived from single-center studies focused on a single surgical procedure with uncertainty regarding generalizability., Methods: We undertook an international (28 centers, 14 countries) prospective cohort study of a representative sample of adults ≥45 years of age who underwent noncardiac surgery. Risk factors for readmission were assessed using Cox regression (ClinicalTrials.gov, NCT00512109)., Results: Of 36,657 eligible participants, 2744 (7.5%; 95% confidence interval [CI], 7.2-7.8) were readmitted within 30 days of discharge. Rates of readmission were highest in the first 7 days after discharge and declined over the follow-up period. Multivariable analyses demonstrated that 9 baseline characteristics (eg, cancer treatment in past 6 months; adjusted hazard ratio [HR], 1.44; 95% CI, 1.30-1.59), 5 baseline laboratory and physical measures (eg, estimated glomerular filtration rate or on dialysis; HR, 1.47; 95% CI, 1.24-1.75), 7 surgery types (eg, general surgery; HR, 1.86; 95% CI, 1.61-2.16), 5 index hospitalization events (eg, stroke; HR, 2.21; 95% CI, 1.24-3.94), and 3 other factors (eg, discharge to nursing home; HR, 1.61; 95% CI, 1.33-1.95) were associated with readmission., Conclusions: Readmission following noncardiac surgery is common (1 in 13 patients). We identified perioperative risk factors associated with 30-day readmission that can help frontline clinicians identify which patients are at the highest risk of readmission and target them for preventive measures., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Continuing professional development is an important means of improving access to effective patient care. Although pain content has increased significantly in prelicensure programs, little is known about how postlicensure health professionals advance or maintain competence in pain management., Aims: The aim of this study was to investigate Canadian health professionals' continuing professional development needs, activities, and preferred modalities for pain management., Methods: This study employed a cross-sectional self-report web survey., Results: The survey response rate was 57% (230/400). Respondents were primarily nurses (48%), university educated (95%), employed in academic hospital settings (62%), and had ≥11 years postlicensure experience (70%). Most patients (>50%) cared for in an average week presented with pain. Compared to those working in nonacademic settings, clinicians in academic settings reported significantly higher acute pain assessment competence (mean 7.8/10 versus 6.9/10; P < 0.002) and greater access to pain specialist consultants (73% versus 29%; P < 0.0001). Chronic pain assessment competence was not different between groups. Top learning needs included neuropathic pain, musculoskeletal pain, and chronic pain. Recently completed and preferred learning modalities respectively were informal and work-based: reading journal articles (56%, 54%), online independent learning (44%, 53%), and attending hospital rounds (43%, 42%); 17% had not completed any pain learning activities in the past 12 months. Respondents employed in nonacademic settings and nonphysicians were more likely to use pocket cards, mobile apps, and e-mail summaries to improve pain management., Conclusions: Canadian postlicensure health professionals require greater access to and participation in interactive and multimodal methods of continuing professional development to facilitate competency in evidence-based pain management., Competing Interests: The authors have no conflicts of interest to report., (© 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Competency-based education is now considered the best approach for pain educational programs provided for pre and postgraduate healthcare providers (HCPs). To demonstrate learners' progression, an assessment tool that aligns with this educational approach and targets different HCPs is needed. A Pain Competence Assessment Tool (PCAT) was developed based on the pain management core competencies that align with the International Association for the Study of Pain interprofessional pain curriculum. The PCAT is an online competency-based assessment tool for HCPs that consists of 5 case scenarios followed by 17 key-feature questions. HCPs and trainees completed the PCAT through a series of studies to assess its psychometric properties. The preliminary evaluation suggested that the PCAT had adequate content validity. Apart from 6 questions, the PCAT questions demonstrated homogeneity and acceptable reliability, and substantial stability. No ceiling or floor effect was found. A significant difference was detected between the HCPs' and trainees' scores. The PCAT scores strongly correlated with other variables reflecting different competence levels. The PCAT scores showed significant changes in the baseline scores compared to scores after attending an educational intervention. The PCAT offers a first-of-its-kind tool for assessing HCPs' competence (ie, knowledge and its application) in managing chronic pain. Future research is needed for further validation and adaptation of the PCAT. PERSPECTIVE: The Pain Competence Assessment Tool (PCAT) offers a first-of-its-kind tool for assessing clinicians' core competencies that overlap between different professions and support the clinicians' capacity to successfully manage chronic pain in the real world focusing on the patient-centered perspective rather than the profession-specific perspective., (Copyright © 2021 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Background: National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada., Aims: This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context., Methods: A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators., Results: Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being "very satisfied" with the process., Conclusions: This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions., Competing Interests: The nature of participatory research is that stakeholders are participants and are expected to have investments in the area researched; this investment is part of the research process. Consistent with this approach to research, the majority of the authors are university lecturers or professors focusing on pain education and receive a salary for this work. In addition, the following authors report financial compensation and/or royalties related to their work in pain education outside of their academic positions: DW, YTL, LS, MHB, RF, NP, and TW., (© 2022 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Background: Women with physical disabilities are faced with challenges in many aspects of life-education, work, income, relationships, as well as their general health. These women are at a greater risk of developing heart disease. This study aimed to explore the cardiac pain experiences of women with physical disabilities and heart disease within a Canadian healthcare context., Methods: In this qualitative study, 8 women with physical disabilities and heart disease from across Canada were interviewed. They were asked about their pre-, peri-, and post-diagnostic experiences in the Canadian healthcare system. Transcripts of the interviews were analyzed using a hermeneutic phenomenological approach inspired by Ricoeur., Results: Two main themes were uncovered in the analysis of the transcripts, as follows: (i) the diagnostic journey; and (ii) life with cardiac symptoms and a disability. The women indicated that they had experienced difficulties in utilizing the Canadian healthcare system prior to receiving a cardiac diagnosis, including long waitlists, expensive and unreliable transport, issues with accessibility, and dealing with providers' attitudinal barriers regarding disability. Receiving a diagnosis was challenging due to poor relationships with healthcare providers; however, having a same-sex provider seemed essential to receiving adequate care. Self-managing a disability and heart disease had significant physical and psychological impact, which was lightened by financial and social supports, modified lifestyle choices, and self-advocacy., Conclusions: Women with physical disabilities are often forgotten in discussions encompassing equity and inclusion. The participants' experiences offer insight into what changes are needed within the Canadian healthcare system in order to improve outcomes for these women., (© 2021 The Authors.)

Background : Chronic pain is a growing public health concern affecting 1.5 million people in Canada. In particular, it is a concern among the expanding immigrant population, because immigrant groups report higher pain intensity than non-immigrants. In 2011, the Indian population became the largest visible minority group and continues to be the fastest growing. Though the prevalence of chronic pain among Canadian Indians is unknown, research has found a higher prevalence among Indian women than men in India, Malaysia, Singapore, and the United Kingdom, with women reporting more severe pain. An understanding of how pain is experienced by this particular group is therefore important for providing culturally sensitive care., Aims: This study explores the lived experiences of chronic pain among immigrant Indian women in Canada., Methods: Thirteen immigrant Indian women participated in one-on-one interviews exploring daily experiences of chronic pain., Results: Using thematic analysis informed by van Manen's phenomenology of practice, four themes emerged: (1) the body in pain, (2) pain in the context of lived and felt space, (3) pain and relationships, and (4) pain and time. Women revealed that their experiences were shaped by gender roles and expectations enforced through culture. Specifically, a dual gender role was identified after immigration, in which women had to balance traditional household responsibilities of family labor and care alongside employment outside the home, exacerbating pain., Conclusions: This research uncovers the multifaceted nature of chronic pain and identifies factors within the sociocultural context that may place particular groups of women at greater risk of living with pain., Competing Interests: The authors have no conflicts of interest to report., (© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Introduction: More women experience cardiac pain related to coronary artery disease and cardiac procedures compared with men. The overall goal of this programme of research is to develop an integrated smartphone and web-based intervention (HEARTPA♀N) to help women recognise and self-manage cardiac pain., Methods and Analysis: This protocol outlines the mixed methods strategy used for the development of the HEARTPA♀N content/core feature set (phase 2A), usability testing (phase 2B) and evaluation with a pilot randomised controlled trial (RCT) (phase 3). We are using the individual and family self-management theory, mobile device functionality and pervasive information architecture of mHealth interventions, and following a sequential phased approach recommended by the Medical Research Council to develop HEARTPA♀N. The phase 3 pilot RCT will enable us to refine the prototype, inform the methodology and calculate the sample size for a larger multisite RCT (phase 4, future work). Patient partners have been actively involved in setting the HEARTPA♀N research agenda, including defining patient-reported outcome measures for the pilot RCT: pain and health-related quality of life (HRQoL). As such, the guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols (SPIRIT-PRO) are used to report the protocol for the pilot RCT (phase 3). Quantitative data (eg, demographic and clinical information) will be summarised using descriptive statistics (phases 2AB and 3) and a content analysis will be used to identify themes (phase 2AB). A process evaluation will be used to assess the feasibility of the implementation of the intervention and a preliminary efficacy evaluation will be undertaken focusing on the outcomes of pain and HRQoL (phase 3)., Ethics and Dissemination: Ethics approval was obtained from the University of Toronto (36415; 26 November 2018). We will disseminate knowledge of HEARTPA♀N through publication, conference presentation and national public forums (Café Scientifique), and through fact sheets, tweets and webinars., Trial Registration Number: NCT03800082., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background : With coronary heart disease affecting over 2.4 million Canadians, annual cardiac and major vascular surgery rates are on the rise. Unrelieved postoperative pain is among the top five causes of hospital readmission following surgery; little is done to address this postoperative complication. Barriers to effective pain assessment and management following cardiac and major vascular surgery have been conceptualized on patient, health care provider, and system levels. Purpose : In this commentary, we review common patient, health care provider, and system-level barriers to effective postoperative pain assessment and management following cardiac and major vascular surgery. We then outline the SMArTVIEW intervention, with particular attention to components designed to optimize postoperative pain assessment and management. Methods : In conceptualizing the SMArTVIEW intervention design, we sought to address a number of these barriers by meeting the following design objectives: (1) orchestrating a structured process for regular postoperative pain assessment and management; (2) ensuring adequate clinician preparation for postoperative pain assessment and management in the context of virtual care; and (3) enfranchising patients to become active self-managers and to work with their health care providers to manage their pain postoperatively. Conclusions : Innovative approaches to address these barriers are a current challenge to health care providers and researchers alike. SMArTVIEW is spearheading this paradigm shift within clinical research to address barriers that impair effective postoperative pain management by actively engaging health care providers and patients in an accessible format (i.e., digital health solution) to give primacy to the need of postoperative pain assessment and management following cardiac and major vascular surgery., Competing Interests: No potential conflict of interest was reported by the authors., (© 2019 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Background : Despite the same surgical approach, up to 40% of patients develop chronic postsurgical pain (CPSP) following cardiac surgery, whereas the rest are chronic pain free. This variability suggests that CPSP is controlled partially through genetics, but the genes for CPSP are largely unknown. Aims : The aim of this study was to identify potential CPSP phenotypes by comparing patients who developed CPSP following cardiac surgery vs. those who did not. Methods : A research ethics board-approved, cross-sectional study of post-cardiac surgery pain was conducted at Toronto General Hospital from 2011 to 2015. Patients were recruited to complete a short survey of chronic pain scores and the Short-Form McGill Pain Questionnaire-2. A subset of patients completed a longer survey of eight validated pain phenotyping questionnaires and/or four psychophysical assessments. All surveys and psychophysical testing were conducted after surgery. Patients were stratified by presence of chronic pain and groups were compared using descriptive statistics. Results : Six hundred forty-three patients completed the short form survey. The mean postsurgery assessment time was 41.5 (SD = ±25.1) months. Over a quarter (27.8%) reported CPSP at the chest as a consequence of their surgery. Of patients reporting CPSP, 46.6% reported mild pain (0-3), 35.8% reported moderate pain (4-7), and 17.6% reported severe pain (7-10) in accordance with the numerical rating scale. Patients with moderate and/or severe CPSP were younger, had a greater body mass index, and had higher anxiety sensitivity, pain catastrophizing, and somatization scores. Conclusions : Chronic pain levels after cardiac surgery are associated with anxiety, catastrophizing, and sensory abnormalities in body parts outside the field innervated by injured nerves, indicating the presence of widespread central sensitization to incoming sensory inputs from intact nerves., Competing Interests: No potential conflict of interest was reported by the authors., (© 2019 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Introduction: Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not., Methods and Analyses: In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score., Ethics and Dissemination: This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals., Trial Registration Number: NCT01842568., Competing Interests: Competing interests: M­­­­HM and PJD are members of a research group with a policy of not accepting honorariums or other payments from industry for their own personal financial gain. They do accept honorariums/payments from industry to support research endeavours and costs to participate in meetings. Based on study questions, PJD has originated and grants he has written, he has received grants from Abbott Diagnostics, Boehringer Ingelheim, Covidien, Octapharma, Philips Healthcare, Roche Diagnostics and Stryker. PJD has participated in an consultancy advisory board meeting for Boehringer Ingelheim., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The challenges of moving the pain education agenda forward are significant worldwide, and resources, including online, are needed to help educators in curriculum development. Online resources are available but with insufficient evaluation in the context of prelicensure pain education. Therefore, this pre-post study examined the impact of an innovative eLearning model: the Pain Education Interprofessional Resource (PEIR) on usability, pain knowledge, beliefs, and understanding of pain assessment skills including empathy., Methods: Participants were students (N = 96) recruited from seven prelicensure health sciences programs at the University of Toronto. They worked through three multifaceted modules, developed by an interprofessional team, that followed a patient with acute to persistent postsurgical pain up to one year. Module objectives, content, and assessment were based on International Association for the Study of Pain Pain Curricula domains and related pain core competencies. Multimedia interactive components focused on pain mechanisms and key pain care issues. Outcome measures included previously validated tools; data were analyzed in SPSS. Online exercises provided concurrent individual feedback throughout all modules., Results: The completion rate for modules and online assessments was 100%. Overall usability scores (SD) were strong 4.27/5 (0.56). On average, pain knowledge scores increased 20% (P < 0.001). The Pain Assessment Skills Tool was sensitive to differences in student and expert pain assessment evaluation ratings and was useful as a tool to deliver formative feedback while engaged in interactive eLearning about pain assessment., Conclusions: PEIR is an effective eLearning program with high student ratings for educational design and usability that significantly improved pain knowledge and understanding of collaborative care.

Background: There is a growing societal need for health professional competency in pain care. The University of Toronto Centre for the Study of Pain-Interfaculty Pain Curriculum (UTCSP-IPC) has been offered since 2002. Content and process have been updated annually. In addition, participating health professions programs have advanced their pain teaching. A curricular scan was needed to creatively and constructively advance the UTCSP-IPC., Aim: The aim of this study was to map curricular pain content in participating health professions programs onto the UTCSP-IPC content as a first step to further curriculum design., Methods: UTCSP-IPC committee members and faculty representatives from six health profession programs completed a 27-item online survey in this collaborative action study. Descriptive statistics were completed in Microsoft Excel., Results: The UTCSP-IPC provided an average of 43.3% (range 32%-62%) of total pain content teaching hours to participating health professions students and a range of 8% to 100% of total opioid-related teaching hours. Curricular overlaps and gaps in pain content were identified and will be used to update and inform the iterative design of the UTCSP-IPC. Ninety-three percent of participating health professions faculty indicated that the interprofessional focus on pain care in the UTCSP-IPC was important., Conclusion: This study highlighted the value of the UTCSP and areas of curricular refinement to ensure continued relevance in relationship to pain content within the six participating health professions programs. Mapping a coordinated approach between uniprofessional and interprofessional teaching will both meet the demands of professional competence and create greater applicability to future practice settings., (Published with license by Taylor & Francis Group, LLC.)

Competing Interests: Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Objective: To describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping., Design and Setting: Literature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age., Interventions: Self-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain., Primary and Secondary Outcomes Measures: Outcomes included those related to knowledge, self-efficacy, function and health-related quality of life., Results: The literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%-100% women and the mean age was 63 years., Conclusions: Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain., Prospero Registration Number: CRD42016042806., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Although the University of Toronto Centre for the Study of Pain has successfully implemented an Interfaculty Pain Curriculum since 2002, we have never formalized the process in a design model. Therefore, our primary aim was to develop a model that provided an overview of dynamic, interrelated elements that have been important in our experience. A secondary purpose was to use the model to frame an interactive workshop for attendees interested in developing their own pain curricula., Methods: The faculties from Dentistry, Medicine, Nursing, Occupational Therapy, Pharmacy, and Physical Therapy met to develop the model components. Discussion focused on patient-centered pain assessment and management in an interprofessional context, with pain content being based on the International Association for the Study of Pain-Interprofessional Pain Curriculum domains and related core pain competencies. Profession-specific requirements were also considered, including regulatory/course requirements, level of students involved, type of course delivery, and pedagogic strategies., Results: The resulting Pain Interprofessional Curriculum Design Model includes components that are dynamic, competency-based, collaborative, and interrelated. Key questions important to developing curricular components guide the process. The Model framed two design workshops with very positive responses from international and national attendees., Conclusions: The Pain Interprofessional Curriculum Design Model is based on established pain curricula and related competencies that are relevant to all health science students at the prelicensure (entry-to-practice) level. The model has been developed from our experience, and the components resonated with workshop attendees from other regions. This Model provides a basis for future interventions in curriculum design and evaluation., (© 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom., Objective: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT)., Methods: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups., Results: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016., Conclusions: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS., Competing Interests: In-kind industry support is provided by the following industry partners: Philips, QoC Health, XAHIVE, and mPath. The following authors are employed by Philips: Karsten Russell Wood, Michael Weber, Jolene McNeil, and Robyn Alpert. Sarah Sharpe is Co-Founder and shareholder, QoC Health; Sue Bhella is employed by QoC Health. David Mohajer is Co-Founder, Chief Executive Officer, and Vice President, XAHIVE; Sem Ponnambalem is Co-Founder, Chief Operating Officer, and President, XAHIVE. Naeem Lakhani and Rabia Khan are Co-Founders, mPath.

Background: Persistent postoperative pain continues to be an underrecognized complication. We examined the prevalence of and risk factors for this type of pain after cardiac surgery., Methods: We enrolled patients scheduled for coronary artery bypass grafting or valve replacement, or both, from Feb. 8, 2005, to Sept. 1, 2009. Validated measures were used to assess (a) preoperative anxiety and depression, tendency to catastrophize in the face of pain, health-related quality of life and presence of persistent pain; (b) pain intensity and interference in the first postoperative week; and (c) presence and intensity of persistent postoperative pain at 3, 6, 12 and 24 months after surgery. The primary outcome was the presence of persistent postoperative pain during 24 months of follow-up., Results: A total of 1247 patients completed the preoperative assessment. Follow-up retention rates at 3 and 24 months were 84% and 78%, respectively. The prevalence of persistent postoperative pain decreased significantly over time, from 40.1% at 3 months to 22.1% at 6 months, 16.5% at 12 months and 9.5% at 24 months; the pain was rated as moderate to severe in 3.6% at 24 months. Acute postoperative pain predicted both the presence and severity of persistent postoperative pain. The more intense the pain during the first week after surgery and the more it interfered with functioning, the more likely the patients were to report persistent postoperative pain. Pre-existing persistent pain and increased preoperative anxiety also predicted the presence of persistent postoperative pain., Interpretation: Persistent postoperative pain of nonanginal origin after cardiac surgery affected a substantial proportion of the study population. Future research is needed to determine whether interventions to modify certain risk factors, such as preoperative anxiety and the severity of pain before and immediately after surgery, may help to minimize or prevent persistent postoperative pain.

Background: Ontario has introduced strategies over the past decade to reduce wait times and length of stay and improve access to physiotherapy for orthopaedic and other patients. The aim of this study is to explore patients' experiences of joint replacement care during a significant system change in their care setting., Methods: A secondary analysis was done on semi-structured qualitative interviews that were conducted in 2009 with 12 individuals who had undergone at least two hip or knee replacements five years apart at a specialized orthopaedic centre in Ontario, Canada. Interview transcripts were coded and then organized into themes., Results: Although the original study aimed to capture participants' experiences with changes in anaesthetic technique between their first and second joint replacements, the participants described several unrelated differences in the care they received during this period. For example, participants had difficulty obtaining a referral to an orthopaedic surgeon from their family physician. They also noted that the hospital stay and in-hospital physiotherapy they received were shorter after the second joint replacement surgery. They identified guidance from physiotherapists as an important component of their recovery, but sometimes had difficulty arranging physiotherapy after hospital discharge following their most recent surgery., Conclusions: The changes described between the first and second joint replacements provide the participants' perspective on the impact of policy changes on wait times, reduced lengths of hospital stay and physiotherapy access. The impact of these policy changes, often made in an attempt to improve access to care, had an unintended and detrimental effect on participants' perceptions and experiences of the quality of care provided., (Copyright © 2014 Longwoods Publishing.)

Objective: The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported., Methods: An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached., Results: The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain., Conclusions: These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain., (Wiley Periodicals, Inc.)

Background: Although unrelieved pain continues to represent a significant problem, prelicensure educational programs tend to include little content related to pain. Standards for professional competence strongly influence curricula and have the potential to ensure that health science students have the knowledge and skill to manage pain in a way that also allows them to meet professional ethical standards., Objectives: To perform a systematic, comprehensive examination to determine the entry-to-practice competencies related to pain required for Canadian health science and veterinary students, and to examine how the presence and absence of pain competencies relate to key competencies of an ethical nature., Methods: Entry-to-practice competency requirements related to pain knowledge, skill and judgment were surveyed from national, provincial and territorial documents for dentistry, medicine, nursing, pharmacy, occupational therapy, physiotherapy, psychology and veterinary medicine., Results: Dentistry included two and nursing included nine specific pain competencies. No references to competencies related to pain were found in the remaining health science documents. In contrast, the national competency requirements for veterinary medicine, surveyed as a comparison, included nine pain competencies. All documents included competencies pertaining to ethics., Conclusions: The lack of competencies related to pain has implications for advancing skillful and ethical practice. The lack of attention to pain competencies limits the capacity of health care professionals to alleviate suffering, foster autonomy and use resources justly. Influencing professional bodies to increase the number of required entry-to-practice pain competencies may ultimately have the greatest impact on education and practice.

1. The management of pain frequently requires healthcare professionals (HCPs) to work together; thus, educational preparation should afford them opportunities to learn about the management of pain together. 2. Survey data suggest that most HCPs' curricula do not provide opportunities for learners to come together to learn about pain and understand their professional roles. 3. Despite the growth of published evaluations of interprofessional education (IPE) and pain, the ability to draw firm conclusions has been hampered by the lack of methodological heterogeneity across studies. 4. New directions in IPE and pain include innovative pedagogical approaches, web-based learning, standardised patients and simulated learning. 5. Harnessing the political agenda can offer a valuable opportunity to raise the profile and prominence of pain education for HCPs.

Introduction: The present article describes educational innovation processes and design of a web-based pain interprofessional resource for prelicensure health science students in universities across Canada. Operationalization of educational theory in design coupled with formative evaluation of design are discussed, along with strategies that support collaborative innovation., Methods: Educational design was driven by content, theory and evaluation. Pain misbeliefs and teaching points along the continuum from acute to persistent pain were identified. Knowledge-building theory, situated learning, reflection and novel designs for cognitive scaffolding were then employed. Design research principles were incorporated to inform iterative and ongoing design., Results: An authentic patient case was constructed, situated in interprofessional complex care to highlight learning objectives related to pre-operative, postoperative and treatment up to one year, for a surgical cancer patient. Pain mechanisms, assessment and management framed content creation. Knowledge building scaffolds were used, which included video simulations, embedded resources, concurrent feedback, practice-based reflective exercises and commentaries. Scaffolds were refined to specifically support knowledge translation. Illustrative commentaries were designed to explicate pain misbeliefs and best practices. Architecture of the resource was mapped; a multimedia, interactive prototype was created. This pain education resource was developed primarily for individual use, with extensions for interprofessional collective discourse., Discussion: Translation of curricular content scripts into representation maps supported the collaborative design process by establishing a common visual language. The web-based prototype will be formatively and summatively evaluated to assess pedagogic design, knowledge-translation scaffolds, pain knowledge gains, relevance, feasibility and fidelity of this educational innovation.

Unlabelled: BACKGROUND⁄, Objectives: Pain-related misbeliefs among health care professionals (HCPs) are common and contribute to ineffective postoperative pain assessment. While standardized patients (SPs) have been effectively used to improve HCPs' assessment skills, not all centres have SP programs. The present equivalence randomized controlled pilot trial examined the efficacy of an alternative simulation method - deteriorating patient-based simulation (DPS) - versus SPs for improving HCPs' pain knowledge and assessment skills., Methods: Seventy-two HCPs were randomly assigned to a 3 h SP or DPS simulation intervention. Measures were recorded at baseline, immediate postintervention and two months postintervention. The primary outcome was HCPs' pain assessment performance as measured by the postoperative Pain Assessment Skills Tool (PAST). Secondary outcomes included HCPs knowledge of pain-related misbeliefs, and perceived satisfaction and quality of the simulation. These outcomes were measured by the Pain Beliefs Scale (PBS), the Satisfaction with Simulated Learning Scale (SSLS) and the Simulation Design Scale (SDS), respectively. Student's t tests were used to test for overall group differences in postintervention PAST, SSLS and SDS scores. One-way analysis of covariance tested for overall group differences in PBS scores., Results: DPS and SP groups did not differ on post-test PAST, SSLS or SDS scores. Knowledge of pain-related misbeliefs was also similar between groups., Conclusions: These pilot data suggest that DPS is an effective simulation alternative for HCPs' education on postoperative pain assessment, with improvements in performance and knowledge comparable with SP-based simulation. An equivalence trial to examine the effectiveness of deteriorating patient-based simulation versus standardized patients is warranted.

Background: Appreciative inquiry (AI) is an innovative knowledge translation (KT) intervention that is compatible with the Promoting Action on Research in Health Services (PARiHS) framework. This study explored the innovative use of AI as a theoretically based KT intervention applied to a clinical issue in an inpatient pediatric care setting. The implementation of AI was explored in terms of its acceptability, fidelity, and feasibility as a KT intervention in pain management., Methods: A mixed-methods case study design was used. The case was a surgical unit in a pediatric academic-affiliated hospital. The sample consisted of nurses in leadership positions and staff nurses interested in the study. Data on the AI intervention implementation were collected by digitally recording the AI sessions, maintaining logs, and conducting individual semistructured interviews. Data were analysed using qualitative and quantitative content analyses and descriptive statistics. Findings were triangulated in the discussion., Results: Three nurse leaders and nine staff members participated in the study. Participants were generally satisfied with the intervention, which consisted of four 3-hour, interactive AI sessions delivered over two weeks to promote change based on positive examples of pain management in the unit and staff implementation of an action plan. The AI sessions were delivered with high fidelity and 11 of 12 participants attended all four sessions, where they developed an action plan to enhance evidence-based pain assessment documentation. Participants labeled AI a 'refreshing approach to change' because it was positive, democratic, and built on existing practices. Several barriers affected their implementation of the action plan, including a context of change overload, logistics, busyness, and a lack of organised follow-up., Conclusions: Results of this case study supported the acceptability, fidelity, and feasibility of AI as a KT intervention in pain management. The AI intervention requires minor refinements (e.g., incorporating continued follow-up meetings) to enhance its clinical utility and sustainability. The implementation process and effectiveness of the modified AI intervention require evaluation in a larger multisite study.

Background: The use of opioids for chronic noncancer pain (CNCP) remains controversial. Despite a number of randomized controlled trials showing efficacy and safety in the short term, long-term data are limited., Objective: To survey a selected cohort of patients with intractable CNCP with regard to long-term efficacy and safety of opioids., Methods: The present study reports long-term results from a survey of 84 patients with CNCP. The majority of patients had neuropathic pain, were treated with opioids and were followed every three months for a median of 8.4 years. Outcomes examined were pain severity, adverse effects, pain relief, satisfaction, mood, problematic opioid use, tolerance, physical dependency, functional status, health-related quality of life, immune status, sexual function, morbidity and mortality. Measures included a numerical rating scale, the Hospital Anxiety and Depression Scale, Brief Pain Inventory interference scale, Pain Disability Index and Short-Form Health Survey 12, version 2., Results and Conclusions: Both long- and short-acting opioids were reported to be effective, with few significant long-term adverse effects in many subjects in the present selected cohort. The majority of patients reported at least 50% or greater pain relief and a moderate improvement in disability. Functional status and health-related quality of life scores were not severely affected. Problematic opioid use, tolerance and serious adverse effects, including constipation, were not major issues. The authors emphasize that the results obtained in the present selected group may not be generalizable to all CNCP patients in whom opioids are being initiated.

Background: Coronary artery bypass graft (CABG) surgery is performed more frequently in individuals who are older and sicker than in previous years. Increased patient acuity and reduced hospital length of stays leave individuals ill prepared for their recovery., Objectives: To test the feasibility of a peer support program and determine indicators of the effects of peer support on recovery outcomes of individuals following CABG surgery., Methods and Results: A pre-post test pilot randomized clinical trial design enrolled men and women undergoing first-time nonemergency CABG surgery at a single site in Ontario. Patients were randomly assigned to either usual care or peer support. Patients allocated to usual care (n=50) received standard preoperative and postoperative education. Patients in the peer support group (n=45) received individualized education and support via telephone from trained cardiac surgery peer volunteers for eight weeks following hospital discharge. Most (93%) peer volunteers believed they were prepared for their role, with 98% of peer volunteers initiating calls within 72 h of the patient's discharge. Peer volunteers made an average of 12 calls, less than 30 min in duration over the eight-week recovery period. Patients were satisfied with their peer support (n=45, 98%). The intervention group reported statistical trends toward improved physical function (physical component score) (t [89]=-1.6; P=0.12) role function (t [93]=-1.9; P=0.06), less pain (t [93]=1.30; P=0.20) and improved cardiac rehabilitation enrollment (chi2=2.50, P=0.11)., Conclusions: These preliminary results suggest that peer support may improve recovery outcomes following CABG. Data from the present pilot trial also indicate that a home-based peer support intervention is feasible and an adequately powered trial should be conducted.