Search for a command to run...
Perioperative pain management is essential for patients’ well-being and efficient health service delivery.1 Alleviating pain is not merely a matter of goodwill but also part of the duty to prevent harm and protect human rights.2 Biological, psychological, and social dimensions of the pain experience should be considered and understood to provide optimum pain management in the postoperative setting.3 However, in low- and middle-income countries (LMICs), a surgeon-led prescription of postoperative analgesia4 may not address the biopsychosocial dimension of pain and interdisciplinary and multimodal approaches. Despite the declarations that access to pain management is a fundamental human right5 and different initiatives, like the Pain-Free Hospital Initiative (PFHI) and pain as the fifth Vital Sign6 acute postoperative pain remains a challenge across the continent of Africa.4 The global prevalence of moderate-to-severe postoperative pain ranges between 50 and 80%.7 A meta-analysis of 27 studies involving 22,108 patients found that the average prevalence rates of moderate to severe postoperative pain were 31% and 58% 1 day and 1 to 2 weeks after discharge, respectively.8 In Africa, the prevalence of moderate-to-severe postoperative pain has been reported as high as 91.4–95%.4 On the other hand, it is now widely accepted that the severity of untreated postoperative pain is 1 of the most important predictors of prolonged postoperative pain and the development of chronic postsurgical pain.9 The burden of acute pain is compounded by undertreatment and disparity in the availability of analgesic treatments and multimodal analgesia practices.10,11 Significant barriers to effective pain treatment include, among others, the failure of many governments to put in place functioning drug supply systems, the failure to enact policies on pain treatment, poor training of health care workers, and the existence of unnecessarily restrictive drug control regulations.12,13 These barriers are unequally distributed between high-income and LMICs, with the most disadvantaged patients bearing the burden of this disparity.14 Except for a few institutional attempts,4 no comprehensive studies have been conducted to identify research priorities in Africa related to postoperative pain. Establishing key priorities for African postoperative pain research is a logical first step in addressing this issue. Therefore, we used a modified Delphi method to delineate the top 10 research priorities and the 3 principal strategies to address them. STUDY SETTING, EVIDENCE REVIEW, AND CONSENSUS PROCESS Health care providers in Africa who are actively engaged in perioperative pain management and research were invited as study participants inclusive of different educational backgrounds and areas of clinical expertise. We preferred a broad professional mix of experts instead of single-specialty experts. As part of the preparatory phases for the Delphi process, a literature review was conducted at the PubMed and Scopus databases and using the Google Scholar search engine. The search used key terms, and Medical Subject Headings (MeSH) terms (“Postoperative pain, “postsurgical pain,” “pain after surgery,” Africa, African regions). Boolean operators such as “AND” and “OR” were also used to identify the evidence gaps in the literature. The review substituted the open-ended round typically used in classical Delphi studies, thereby reducing participants’ attrition rates and response fatigue.15 After the literature review, the questions were thematized, and a survey template was prepared using Google Forms. A pilot test was subsequently conducted. Semistructured electronic Delphi questionnaires were used as they allowed flexibility and reach.16 Participants were instructed to select 10 statements from a list of 41 potential questions and select 3 strategies from lists of 7 possible options to address the established key priorities (see Supplemental Digital Content I, https://links.lww.com/AA/F419). Each selection was guided by criteria including problem severity, magnitude, feasibility, scientific, practical, and societal relevance, as well as community and government concern. Additionally, participants were invited to propose research questions or strategies beyond those listed in the questionnaire during the first-round survey. The commencement/intention of the research was circulated to different national anesthesia professional societies in Africa, as well as the African Society for Regional Anesthesia (AFSRA); hence, eighteen national leads were attained. The participants were briefed about the Delphi process and deliverables, and the survey template was evaluated and agreed on with minor modifications. The national leads used a multipronged approach of communication to recruit the maximum number of participants for the first-round survey (04/11/2023–21/01/2024); however, it had a limitation in determining the response rates. After the closure of the first-round survey, results were communicated to the participants by email, and a debriefing and consensus virtual meeting was conducted to reframe and decide on the number of questions to be included in the second-round survey. Based on the outcomes of this consensus, statements that achieved more than 25% agreement in the first round (n = 19) and additional statements introduced by participants (n = 7) were deemed eligible for inclusion in the second round. The first-round survey results and the second-round survey form were shared with all participants via email. The round was open from February 2, 2024, through April 20, 2024, and during that time 3 email reminders were sent. The participants reviewed the rating results from the previous round and had the option to modify or retain their initial responses. However, they were restricted to selecting only 10 statements from the list. On the conclusion of the second-round survey, the results were disseminated to the participants. Subsequently, a final virtual consensus meeting was convened to either finalize the top 10 priorities based on their magnitude and stability from the second-round survey results or to determine the necessity of a third-round survey. The participants ultimately agreed to establish the top 10 key priorities and strategies based on the second-round survey results, ordered by magnitude. Modification of the Delphi Technique Common modifications to the classical Delphi method include summarizing existing evidence, conducting in-person or virtual meetings that compromise anonymity, providing group-only vs individualized statistical reports, incorporating focus groups and other qualitative methods, utilizing online survey platforms and discussion forums, and adjusting items and rating criteria across different rounds.15,17 The classical Delphi method starts by identifying unanswered questions through participant input. To mitigate response fatigue, a comprehensive literature search was conducted, generating a long list of statements or questions. Participants prioritized by selecting 10 key priorities or suggesting additional priorities. In the second step, questions from the first-round survey were thematized, though the number of questions remained limited due to the extensive initial list. The third step, involving verification of uncertainties and evidence review, was omitted as the steering committee had already agreed on the long list based on the literature review. The fourth step involved interim prioritization for the second-round online survey. The participants held a virtual consensus meeting to determine the number of questions for this survey. Questions with at least 25% agreement were included, while those with less agreement were excluded (see Figure 1 and Supplemental Digital Content II, https://links.lww.com/AA/F420). Newly added questions from the first-round survey were also included. Based on the results of the second-round survey, a virtual consensus meeting was convened to finalize the top 10 priorities or to determine the necessity of a third round of the online survey. The participants concurred on concluding the survey, as additional rounds could lead to participant attrition and potentially induce forced consensus, wherein participants might alter their responses to align with the majority merely to complete the Delphi process.15 Consequently, the final top 10 priorities for African postoperative pain research and strategies were established after 2 rounds of surveys and 2 virtual consensus meetings.Figure 1.: Flow diagram of the study.Rating the same item on multiple criteria can become too burdensome for participants; hence, stakeholders with different and often opposing preferences need to choose 1 or 2 options from a longer list.18,19 After the recommendation, participants were permitted to select only 10 statements from the extensive lists. A descriptive analysis of participants’ demographic characteristics and statements was conducted to generate interim priorities, ranked by magnitude or percentage of consensus. Comment analyses were performed to integrate participants’ feedback into the second-round survey. The results were summarized in tables, graphs, enumerations, and narrative forms, adhering to published guidelines for reporting Delphi studies.20 A Note on Ethical Approval The Institutional Review Boards (IRBs) of Bahir Dar University determined that no ethical approval or research governance was necessary for this survey. Nevertheless, participants were informed about the study’s purpose, data collection procedures, and the associated risks and benefits of their participation. Informed consent was obtained from the participants through a study information sheet and a consent form programmed using the e-Delphi software. This information was also communicated during a virtual briefing meeting. RESULTS The Delphi technique is a well-established approach to determining clinical research priorities with an iterative process and a predefined criterion, particularly where the opinions and judgments of experts and practitioners are needed but time, distance, and other factors make it unlikely or impossible for the participants to work together in the same physical location.20,21 For this Delphi process, a continental group of experts identified and agreed on the final top 10 research priorities and top 3 strategies to address those (Table 1). Table 1. - Top 10 Postoperative Pain Research Priorities SNo. Top 10 priorities Scope Level of action 1 Practices of Postoperative Pain Management in Africa Evidence on the status quo Research and Policy Direction 2 A cost-effective and efficient way of providing postoperative pain management in Africa Evidence Research and Policy Direction 3 Regional anesthesia training and practice capacities in Africa Education and Pain Management Research and training 4 Patient satisfaction with postoperative pain management in Africa Evidence Research 5 Barriers and enablers to postoperative pain management in Africa Evidence Research and Policy Direction 6 Impact of regional anesthesia and pain management on the surgical outcome Pain management Research and Education 7 The role of regional anesthesia in the prevention and management of pain after surgery Pain management Research and Education 8 Role of preemptive and multimodal analgesia in the prevention of pain after surgery Pain management Research and Education 9 Barriers to postoperative pain management in pediatric surgeries in Africa Evidence Research and Policy Direction 10 Perioperative predictors of acute and chronic postsurgical pain Pain management Research and Education Summary of the top 3 strategies.Development of regional anesthesia training and standards of practice guidelines.Development of a multidisciplinary harmonized continental Curriculum in acute and chronic pain management; tailored training development.Assessing the pain assessment methods in an African context and tool development. In the initial round, 174 participants from 25 of 54 African countries participated, with a predominance of male participants (n = 130, 74.4%). In the subsequent round, 104 participants from 22 African countries participated, resulting in a response rate of 59.8%. This cohort represented all regions of the continent, with a significant proportion from East Africa (12 of 22 countries), as illustrated in Figure 2.Figure 2.: Distribution of experts by country and region.The majority of experts in both the first and second rounds were anesthesia providers (n = 141, 81.1%), with educational backgrounds including anesthesiologists (MD, 44.8%), anesthesia professional specialists (MSc, 22.4%), and nurse anesthetists (BSc, 13.8%). The remaining 33 participants (18.9%) comprised surgeons (general, orthopedic, hepatobiliary, urology, and thoracic), gynecologists and obstetricians, otolaryngologists, emergency and family physicians, radiologists, general practitioners, clinical psychologists, pharmacists, nurses, and midwives (Table 2). Among the 174 participants, 100 (57.5%) were affiliated with academic institutions, holding positions such as Professor (n = 7, 4%), Associate Professor (n = 6, 3.4%), Assistant Professor (n = 43, 24.7%), and Senior Lecturer or Lecturer (n = 44, 25.3%). The remaining 74 participants (42.5%) were nonacademicians used in various health care settings, nongovernmental organizations (NGOs), and research institutions. Table 2. - Educational Background and Area of Specialization of Experts Expert’s professional background and specialization First round Second round Anesthesiologists (MD+) 78 (44.8%) 40 (38.5%) Anesthetist (MSc)a 39 (22.4%) 29 (27.9%) Anesthetist (BSc)b 24 (13.8%) 16 (15.4%) Surgical specialitiesc 17 (9.8%) 15 (14.4%) General practitioners 4 (2.3%) 2 (1.9%) Nursing 4 (2.3%) _ Midwives 3 (1.7%) _ Radiologists, emergency, and family physicians 3 (1.7%) 1 (0.96%) Clinical psychologists, pharmacists 2 (1.2%) 1 (0.96%) Total 174 104 aAn anesthesia provider with a generic or nurse anesthesia background with an MSc.bAn anesthesia provider with a generic or nurse anesthesia background with a BSc.cGeneral surgeon, thoracic surgeon, Hepatobiliary surgeon, orthopedic, urologist, otolaryngologist, obstetrics and gynecology, urogynecologist, and gyneco-oncologist. The top 10 postoperative pain research priorities in Africa underscore the necessity for evidence-based practices, effective pain management strategies, education, and policy direction. Key focus areas include the evaluation of current practices, the identification of cost-effective solutions, and the exploration of barriers and enablers to effective pain management. Additionally, emphasis is placed on leveraging the roles of preemptive analgesia and regional anesthesia in enhancing patient-reported outcomes. To address these priorities, the leading strategies were also established for the African context (Table 1). DISCUSSION Analysis of Priority Agendas The study established the top 10 “highest priority” research questions, which address a wide range of topics pertinent to the unique challenges and needs in Africa. These questions encompass themes such as pain management, training and assessment, clinical practice, and evidence synthesis, with the possible top 3 strategies to address the priority research questions. Priority1. Practices of Postoperative Pain Management in Africa Exploring current practices in Africa reveals challenges in resource-limited settings and highlights opportunities for improvement. This requires evaluating existing practices, identifying trends, and developing strategies to disseminate best practices and address areas for enhancement across the continent.22,23 It will profoundly impact patient care, clinical guidelines, health care policy, and research in Africa. This highlights the need for collaboration with stakeholders across the continent to enhance evidence-based practices and improve patient outcomes.4 Priority 2. A Cost-Effective and Efficient Way of Providing Postoperative Pain Management in Africa Along with other barriers, affordability and technical challenges in different pain management modalities create a greater quality chasm in pain management in Africa.12,13,24 Identifying cost-effective and efficient pain management strategies is crucial for informing policy development and guiding funding agencies in areas such as training, education, innovation, and technology. These strategies aim to enhance patient outcomes and optimize health care resource allocation tailored to the African context. A notable example is Uganda’s implementation of affordable morphine for end-of-life care, which serves as a successful, context-specific pain management model.25 Priority 3. Regional Anesthesia Training and Practice Capacities in Africa Regional anesthesia techniques are extensively advocated due to their numerous advantages, which include a reduction in anesthetic-related complications, decreased opioid consumption, expedited recovery times, cost-effectiveness, enhanced pain management, and overall improved quality of recovery.26–28 Efforts in Africa are concentrated on comprehensively understanding current practices, developing training pathways, guiding targeted interventions, establishing best practice standards, and ensuring resource allocation to areas of greatest need will improve patient outcomes.12,13 Priority 4. Patient Satisfaction With Postoperative Pain Management in Africa Effective postoperative pain relief is essential for patient well-being and satisfaction. Evaluating patient satisfaction serves as a critical metric for assessing the effectiveness of pain management strategies, identifying areas for improvement, and ultimately enhancing the overall quality of care.22,29 Moreover, aligning treatment with patient prospects fosters a patient-centered approach and serves as a benchmark for institutional performance and educational initiatives.11,30 Priority 5. Barriers and Enablers to Postoperative Pain Management in Africa Investigating barriers and enablers of postoperative pain management informs clinical practice improvements, targeted education, multidisciplinary approaches, resource allocation, and policy development.31,32 Identifying knowledge gaps, infrastructure, cultural contexts, training, education, and policy directions in Africa can lead to comprehensive interventions that improve pain management, enhance patient outcomes, and inform tailored policy decisions. Priority 6. Impact of Regional Anesthesia and Pain Management on Surgical Outcome Evidence shows that while regional anesthesia and effective pain management benefit the immediate postoperative period, their long-term impact is still under research and debate.28,33,34 Investigating these areas is crucial for Africa, where the surgical landscape differs due to resource availability, training, disease and cultural Priority Role of Regional Anesthesia in the and Management of Pain After Regional anesthesia is for acute postoperative pain and may the of chronic pain. pain management to the needs and the is essential for Investigating the role of regional anesthesia in the prevention of and chronic surgical pain in Africa is essential for and pain management Priority Role of and in the of Pain After and multimodal analgesia is crucial for acute and prolonged postoperative pain and chronic postsurgical pain, leading to long-term patient However, research is needed on drug long-term outcomes, and regional in availability and Priority Barriers to Postoperative Pain Management in in Africa Investigating barriers to postoperative pain management in pediatric groups is essential due to psychological, and from these in the African context is essential for developing to postoperative pain in ensuring they and Priority Perioperative of and Pain various predictors to identify patients guiding efficient and cost-effective resource allocation and perioperative pain interdisciplinary research is needed to improve perioperative pain assessment and management, with resource and outcomes in the experts on those priority strategies will enhance the work to address the priority as a policy of the research These priorities the consensus of 174 and actively engaged in perioperative pain management and research from 25 African countries that a broad range of topics that are to the challenges and needs in Africa. Despite the extensive of survey, was a as participants were from only 25 African East Africa, with a significant mix of anesthesia and pain Nevertheless, we from health care settings across Africa. a consensus is typically the participants to the top 10 by magnitude than consensus. The other limitation was while is essential in the Delphi process to feedback of or a the was deemed as it a ultimately enhancing the quality of the consensus while ensuring that the survey data remained and AND We conducted a survey and involved in perioperative pain management across Africa to identify the top 10 priority research for postoperative pain through consensus. These priorities are to research collaboration with health care and The established priorities are critical for postoperative pain research in Africa, care resource allocation, enhancing and and patient Research not included in the top 10 priorities and should be considered by the community (see Supplemental Digital Content II, https://links.lww.com/AA/F420). The to their to the experts and who to this study and their informed consent to a crucial role in the Delphi process and the of this of This was