Published online August 1, 2008
PEDIATRICS Vol. 122 No. 2 August 2008, pp. 443-444 (doi:10.1542/peds.2008-1444)

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COMMENTARY

Research to Practice in Pediatric Pain: What Are We Missing?

Jill MacLaren, PhD^a,b and Zeev N. Kain, MD, MA, MBA, FAAP^a,b,c

^a Departments of ^a Anesthesiology and Pediatrics, University of California, Irvine, California
^b Research Department, Children's Hospital of Orange County, Orange, California
^c Child Study Center, Yale University, New Haven, Connecticut

Translation of research findings into standard clinical practice continues to be a significant barrier to improved quality of care and patient outcomes. It is not surprising to most pediatric practitioners that a gap between research and practice exists, but the magnitude of this discrepancy is startling. Recent data have suggested that patients typically receive only a fraction of recommended care. In a recent study of the medical care provided to a random sample of >5000 adults in the United States, participants received, on average, only 54.9% of recommended preventative, acute, or chronic care.¹ Even more startling figures emerge when we consider the extent to which care can be improved simply by implementing current research findings. For example, it has been estimated that up to a 30% improvement in cancer outcomes could result if current knowledge were applied routinely in clinical settings.²

Pain management in children is certainly not spared from this research-to-practice gap. Significant progress has been made since the first reports of children being undermedicated for pain,^3,4 but despite these advances children continue to suffer acute and chronic pain. This is particularly the case in postoperative contexts, in which up to 50% of children experience severe pain in hospital⁵ and up to 25% of children continue to experience clinically significant pain at home.^6,7 The fact that children continue to experience acute pain is not wholly attributable to a lack of effective interventions. Evidence-based practice guidelines for pediatric acute pain have been released from the Agency for Health Care Policy and Research⁸ and the American Academy of Pediatrics.⁹ Although these policies have been in place for up to 15 years, data indicate that they have not yet crossed the chasm from research/policy to standard practice in many settings. In a Swiss survey of practice, only 37% of anesthesiologists and surgeons reported that they regularly assessed therapeutic success of analgesic administration.¹⁰ In a US study of practice in the emergency department, only during 44.5% of children's visits were pain scores documented,¹¹ and in a Canadian study of postoperative pain, only 13% of parents recalled being instructed to use round-the-clock analgesics after their child's surgery.⁶ These are just a few examples of figures documenting that standard pain care for children lags behind established guidelines.

The fact that research has been synthesized into guidelines but these guidelines still have not been fully incorporated into clinical care highlights the need for active steps to address this issue. Simple dissemination of guidelines or information about interventions is not enough; we know that knowledge does not always translate into practice changes.

As a first step, we must ensure that newly developed clinical interventions are applicable under real-world conditions. To do this, there is a need to go beyond efficacy trials. Randomized trials under tightly controlled experimental conditions, although an important first step, need to be continually followed with effectiveness trials in which interventions are tested under real-world conditions. For example, if a new medication requires multiple 15-minute follow-up assessments by the nursing staff, it is unlikely to be widely adopted by an understaffed unit. Similarly, as efficacious as an analgesic may be, parents may not administer the analgesic at home because of a fear of adverse effects or addiction. As researchers, we must accept that the effectiveness of an intervention is affected by the context in which it is used; an intervention may have efficacy, but it is not effective if it cannot be delivered in the way it is intended. To ensure success in effectiveness trials, we must broaden the scope of research with the aim of understanding the context in which our interventions are implemented. Involving the end users (ie, parents, nurses, physicians) at the outset of intervention trials can help to facilitate this understanding. In pediatric pain, some work has been performed to evaluate the attitudes of nurses^12,13 and parents¹⁴ about pain management and knowledge of health care professionals.^15–17 There is a need, however, for more systematic attention to the barriers and general contextual factors that affect pediatric pain management.

Once effective and contextually relevant interventions have been developed, they must be disseminated to end users. Within pediatric pain, there has been a recent burst of reports that evaluated dissemination efforts.^18–20 Most of these studies have been of continuing education efforts or of training programs in pediatric pain management. Although these studies have shown some promising results, it is notable that most have been evaluated for their impact on knowledge and attitudes only, not for their impact on clinical practice.²¹ The majority of those who evaluate clinical practice do so by self-report rather than observational measures, which subjects results to potential reporting bias. Given that clinical practice is a complex phenomenon and that there are more barriers than simple lack of knowledge, there is a need to go beyond training programs to meaningfully affect pediatric pain care. Innovative methods of dissemination including action research,²² social learning through champions,^23,24 and case-study review²⁵ have started to appear in the literature, but there is a need for more systematic evaluations of these techniques. Research designs for evaluating these novel dissemination methods are complex, and replication is required to ensure that these methods are effective across settings. The literature will be further strengthened by theoretical grounding in behavior-change principles such as those outlined by Grol and Wensing.²⁶

There is little question that successfully closing the gap between research and practice in pediatric pain requires a commitment of funding. Some funding agencies have already included knowledge translation in their mandates (eg, Canadian Institutes of Health Research, National Institutes of Health) and have issued requests for proposals to support this type of work. Coordinated efforts such as these will be required for continued development of a science of knowledge translation and, in turn, application of this science to pediatric pain.

	ACKNOWLEDGMENTS

 
This work was supported in part by National Institutes of Health (Bethesda, MD) grants R01-HD037007-04 and R0-1HD048935-01A1.

	FOOTNOTES

 
Accepted May 27, 2008.

Address correspondence to Zeev N. Kain, MD, MA, MBA, FAAP, University of California, Irvine School of Medicine, Department of Anesthesiology, Clinical Research, 333 City Blvd West, Suite 2150, Orange, CA 92868. E-mail: zkain{at}uci.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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