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Tiered Care for Chronic Non-Malignant Pain: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines

Last updated: February 12, 2019
Project Number: RC1074-000
Product Line: Rapid Response
Research Type: Devices and Systems
Report Type: Summary with Critical Appraisal
Result type: Report

Question

  1. What is the clinical effectiveness of tiered or stepped care for patients with chronic, non-malignant pain in outpatient settings?
  2. What is the cost-effectiveness of tiered or stepped care for patients with chronic, non-malignant pain in outpatient settings?
  3. What are the evidence-based guidelines regarding tiered or stepped models of care for patients with chronic, non-malignant pain in outpatient settings?

Key Message

Two systematic reviews (one of which included a meta-analysis), one randomized controlled trial, and six non-randomized studies provide limited evidence for the clinical effectiveness of tiered or stepped care for patients with chronic, non-malignant pain. Although evidence was identified to support that tiered or stepped care is clinically effective based on outcomes such as pain reduction, return to work, mental health parameters, and healthcare or prescription drug utilization, the diversity of outcomes and inconsistent results creates uncertainty in the findings. Therefore, evidence of low quality suggests that tiered or stepped care may be clinically effective for the management of chronic non-malignant pain compared to usual care; however, more research is needed to better inform and guide treatment decisions according to a tiered or stepped care approach. One economic evaluation of moderate quality was identified that addressed cost-effectiveness of tiered or stepped care. The analysis evaluated the incremental cost-effectiveness of three levels of care for sciatica and found that a stepped approach was most cost-effective relative to direct surgical referral, with positive net benefits if certain ceiling limits were applied. The analysis was from the UK so it is unclear if the results would be the same in a Canadian setting and should be considered when interpreting the results. Two evidence-based guidelines were included that describe models of tiered or stepped care for the management of chronic, non-malignant pain. One guideline provides specific recommendations for intensity of care based on a model of risk assessment and risk stratification. In considering these recommendations, it should be noted that the supporting evidence was based on a single randomized controlled trial of fair quality.