Organisation of Chronic Pain Therapy in Slovenia

1 st Congress of Pain,BLed 9.-10.1 st Congress of Pain,BLed 9.-10.oct.2009oct.2009

Organisation of Chronic Organisation of Chronic Pain Therapy in SloveniaPain Therapy in Slovenia

Prim. mag. Marija Cesar-Komar Prim. mag. Marija Cesar-Komar dr.med.dr.med.

President ofPresident of the the Slovenian Association for Slovenian Association for Therapy of Pain (SZZB)Therapy of Pain (SZZB)

General HospitalGeneral Hospital of of Slovenj Gradec Slovenj Gradec


Historical Historical Re Reviewview 1977 - 1977 - Outpatient clinic for Th of pain in UCC of Outpatient clinic for Th of pain in UCC of

Ljubljana – department for anaesthesiology and Ljubljana – department for anaesthesiology and intensive care medicine (prim Jasna Muller,dr.med.)intensive care medicine (prim Jasna Muller,dr.med.)

1978 1978 - Yugoslav-Chinese Symposium of Traditional - Yugoslav-Chinese Symposium of Traditional Chinese Medicine (Slovenj Gradec, prim Drago Chinese Medicine (Slovenj Gradec, prim Drago Plešivčnik,dr.med.Plešivčnik,dr.med.

1979 -1979 - Yugoslav-Chinese Course for Acupuncture in Yugoslav-Chinese Course for Acupuncture in Zagreb (4 participants from Slovenia)Zagreb (4 participants from Slovenia)

1979 - 1979 - Outpatient clinic for Th of pain in General Outpatient clinic for Th of pain in General Hospital of Slovenj Gradec- Depatment for Hospital of Slovenj Gradec- Depatment for anaesthesiology and intensive care therapy anaesthesiology and intensive care therapy


Units for pain Units for pain therapy in therapy in Slovenia:Slovenia:

1616 13 13 working working

UUCCCC Ljubljana 1977 Ljubljana 1977

OILjubljana 1964- 1980OILjubljana 1964- 1980

UUCCC Maribor 1980C Maribor 1980

GH Jesenice 2003GH Jesenice 2003

GH Novo Mesto NDGH Novo Mesto ND

ZPTA Vrabl 2004ZPTA Vrabl 2004

GHGH Murska Sobota 1988 Murska Sobota 1988

GHGH Slovenj Gradec 1979 Slovenj Gradec 1979

GHGH Izola 2004 Izola 2004

GHGH Ptuj 1991 Ptuj 1991

GHGH Celje ND Celje ND

GHGH Brežice 1991 Brežice 1991

Reh UReh UCC CC Maribor 2001 Maribor 2001

GH Nova Gorica 1988GH Nova Gorica 1988

Nevrol. Nevrol. UMC UMC LjubljanaLjubljana

PPTTA BemA Bem


Medical Association for Pain Medical Association for Pain TherapyTherapy

Slovenian Association for Slovenian Association for Pain Pain Therapy -Therapy - SSlovensko združenje za zdravljenje bolečinelovensko združenje za zdravljenje bolečine ((SZZBSZZB)) 11th Nov. 1996 11th Nov. 1996

3030 founding members founding members 140140 current members current members

IASP-IASP- 1998-1999 Wiena1998-1999 Wiena

EFIC-EFIC- 19971997


Pain Therapy Clinics- PTCPain Therapy Clinics- PTC

Departments of anaesthesiology Departments of anaesthesiology in in general hospitalsgeneral hospitals

Departments oDepartments off anaesthesiology of both anaesthesiology of both Clinical CentresClinical Centres (Ljubljana, Maribor)(Ljubljana, Maribor)

Department of anaesthesiology of Department of anaesthesiology of OncologOncologyycal Institutecal Institute Ljubljana Ljubljana

Two private Two private clinics for out-patients .clinics for out-patients .


In what way is the organisated the In what way is the organisated the pain therapy in pain therapy in SloveniaSlovenia ? ?--

QuestionQuestionnairenaire

Sent to all the heads of PTC in Slovenia (16)Sent to all the heads of PTC in Slovenia (16)

10 questions10 questions

Time - January 2009Time - January 2009

Returned 13 from 16, (81 % )Returned 13 from 16, (81 % )


AimAimss of the questio of the questionnnnaiairree - 1 - 1

1)1) How How many timesmany times and and hours per week-PThours per week-PTC?C?

2)2) How many How many different doctorsdifferent doctors and the and their ir rotationrotation??

3)3) How How many patients per daymany patients per day in the PT in the PTC?C?

4)4) How many How many factors wfactors wereere done done in the year in the year 20082008??

5)5) How many first visits (How many first visits (new patientsnew patients ) ) occured occured in the year 2008in the year 2008??


6)6) Which Which therapeutic methodstherapeutic methods w wereere used, and how used, and how many inmany in % % ? ?

7)7) The cooperation with The cooperation with family family physiciansphysicians, and other , and other specialistsspecialists..

8)8) Is theIs there are a need for need for expansionexpansion of of the clinic?the clinic?

9)9) Where are the Where are the limitationslimitations??

10)10) What are theWhat are the future plans-future plans- wishes wishes ??

Aims of the questionAims of the questionnairenaire - 2 - 2


TableTable 1: Working hours per wee1: Working hours per weekk

UCC UCC LjubljanaLjubljana 40 40

UCC UCC MariborMaribor 40 40

OI LjubljanaOI Ljubljana 40 40

GH JeseniceGH Jesenice 00

PPTC VrablPPTC Vrabl 40 40

GH GH Novo Novo mestomesto 4040

GH GH Murska Murska SobotaSobota 3232

GH Slovenj GH Slovenj GradecGradec 2828

GH IzolaGH Izola 1616

Gh PtujGh Ptuj 1616

GH CeljeGH Celje 16 16

GH BrežiceGH Brežice 1010

Rehab. UCC Rehab. UCC MbMb 10 10

GH Nova GH Nova GoricaGorica 8 8


Table 2: Number of doctorsTable 2: Number of doctorsOI LjubljanaOI Ljubljana > 3> 3

UCC LjubljanaUCC Ljubljana 33

UCC MariborUCC Maribor 33

GH Murska SobotaGH Murska Sobota 33

Rehab. UCC MbRehab. UCC Mb 22

GH Slovenj GradecGH Slovenj Gradec 22

GH IzolaGH Izola 22

GH PtujGH Ptuj 22

GH Nova GoricaGH Nova Gorica 22

GH Novo mestoGH Novo mesto 22

GH BrežiceGH Brežice 11

GH CeljeGH Celje 11


PPTC VrablPPTC Vrabl 11


Table 3: Rotation of doctorsTable 3: Rotation of doctors

UCC MariborUCC Maribor Every dayEvery day

GH Murska SobotaGH Murska Sobota Every second dayEvery second day

GH IzolaGH Izola Every second dayEvery second day

GH PtujGH Ptuj Every second dayEvery second day

GH Novo mestoGH Novo mesto Every second dayEvery second day

Rehab. UCC MbRehab. UCC Mb Every weekEvery week

GH Nova GoricaGH Nova Gorica Every monthEvery month

GH Slovenj GradecGH Slovenj Gradec Every monthEvery month

OI LjubljanaOI Ljubljana Every monthEvery month

UCC LjubljanaUCC Ljubljana when neededwhen needed

GH BrežiceGH Brežice nonenone

GH CeljeGH Celje nonenone

GH JeseniceGH Jesenice nonenone

PPTC VrablPPTC Vrabl nonenone


Table 4: CooperationTable 4: CooperationPTCPTC Family dr. Family dr. Other spec.Other spec.

PsPsychiatrist ychiatrist // psycologistpsycologist

UCC LjubljanaUCC Ljubljana mediummedium goodgood mediummedium

UCC MariborUCC Maribor mediummedium goodgood goodgood

OI LjubljanaOI Ljubljana goodgood goodgood badbad

Rehab. UCC MbRehab. UCC Mb goodgood goodgood goodgood

GH Slovenj GradecGH Slovenj Gradec goodgood goodgood mediummedium

GH Murska SobotaGH Murska Sobota mediummedium goodgood goodgood

GH IzolaGH Izola goodgood goodgood badbad

GH PtujGH Ptuj goodgood goodgood goodgood

GH Nova GoricaGH Nova Gorica goodgood mediummedium goodgood

GH BrežiceGH Brežice goodgood goodgood badbad

GH Novo mestoGH Novo mesto mediummedium mediummedium mediummedium

GH CeljeGH Celje goodgood goodgood mediummedium

GH JeseniceGH Jesenice 00 00 00

PPTCVrablPPTCVrabl mediummedium goodgood mediummedium


Table 5:Needs for extension - PTCTable 5:Needs for extension - PTC

PTPTCC

Needs for exNeeds for extentensionsion

yesyes nononene

UCC LjubljanaUCC Ljubljana XX

UCC MariborUCC Maribor XX

OI LjubljanaOI Ljubljana XX

Rehab. UCC MbRehab. UCC Mb XX

GH Slovenj GradecGH Slovenj Gradec XX

GH Murska SobotaGH Murska Sobota XX

GH IzolaGH Izola XX

GH PtujGH Ptuj XX

GH Nova GoricaGH Nova Gorica XX

GH BrežiceGH Brežice XX

GH Novo mestoGH Novo mesto XX

GH CeljeGH Celje XX


PPTPPTCC Vrabl Vrabl XX


Table 6: Limitations in PTCTable 6: Limitations in PTCLimitationsLimitations

personelpersonel placesplaces ensuranceensurance

UCC LjubljanaUCC Ljubljana XX

UCC MariborUCC Maribor XX XX

OI LjubljanaOI Ljubljana XX

Rehab. UCC MbRehab. UCC Mb XX XX

GH Slovenj GradecGH Slovenj Gradec XX

GH Murska SobotaGH Murska Sobota XX

GH IzolaGH Izola XX

GH PtujGH Ptuj XX XX XX

GH Nova GoricaGH Nova Gorica XX

GH BrežiceGH Brežice XX XX

GH Novo mestoGH Novo mesto XX XX

GH CeljeGH Celje XX XX

GH JeseniceGH Jesenice

PPTPPTCC Vrabl Vrabl XX


PTPTCC Acupuncture Acupuncture ElectrodesElectrodes

GH Novo mestoGH Novo mesto 90%90% 0%0%

GH BreGH Brežžiceice 85%85% 0%0%

GH Slovenj GradeGH Slovenj Grade 70%70% 0%0%

GH JeseniceGH Jesenice 0%0% 0%0%

UCC LjubljanaUCC Ljubljana 50%50% 0%0%

GH Murska SobotaGH Murska Sobota 30%30% 0%0%

PPTPPTCC Vrabl Vrabl 27%27% 0%0%

GH CeljeGH Celje 15%15% 0%0%

OI LjubljanaOI Ljubljana 10%10% 0%0%

Rehab. UCC MbRehab. UCC Mb 10%10% 0%0%

GH IzolaGH Izola 10%10% 0%0%

GH PtujGH Ptuj 10%10% 0%0%

UCC MariborUCC Maribor 0%0% 1%1%

GH Nova GoricaGH Nova Gorica 0%0% 0%0%

TableTable 7-a:7-a: TherapeTherapeuutic methods in tic methods in PTPTCC


PTPTCC PhPharmaarmaccol. block.ol. block. PumpsPumps





GH Nova GoricaGH Nova Gorica 30%30% 5%5%



GH JeseniceGH Jesenice 20%20% 0%0%


GH Slovenj GradecGH Slovenj Gradec 10%10% 5%5%



GH BrežiceGH Brežice 8%8% 0%0%

GH Novo mestoGH Novo mesto 5%5% 1-2 %1-2 %

Tabela 7-b: Therapeutic methods in PTC


PTPTCC MediMediccam.th.am.th. CathetersCatheters



GH Novo mestoGH Novo mesto 100%100% 1-2 %1-2 %


Gh Nova GoricaGh Nova Gorica 65%65% 0%0%







GH JeseniceGH Jesenice NDND NDND

GH Slovenj GradecGH Slovenj Gradec 10%10% 5%5%

GH BrežiceGH Brežice 7%7% 0%0%

Tabela 7-c : Therapeutic methods Tabela 7-c : Therapeutic methods in PTCin PTC


Table 8:Future plans - wishesTable 8:Future plans - wishes PTPTCC place place equipmentequipment invas. treat.invas. treat. bbetter coetter co--opop

UKC LjubljanaUKC Ljubljana XX

UKC MariborUKC Maribor X X XX XX XX

OI LjubljanaOI Ljubljana XX XX

Rehab. UKC MbRehab. UKC Mb X X XX

SB Slovenj GradecSB Slovenj Gradec XX XX

SB Murska SobotaSB Murska Sobota XX XX

SB IzolaSB Izola XX XX

SB PtujSB Ptuj ΧΧ ΧΧ

SB ŠempeterSB Šempeter X X XX XX XX

SB BrežiceSB Brežice X X X X X X

SB Novo mestoSB Novo mesto XX XX XX XX

SB CeljeSB Celje XX XX

ZPBZPBCC Vrabl Vrabl X X XX XX

SB JeseniceSB Jesenice XX XX

9/19/133 10/110/133 9/19/133 8/18/133


Table 9: Number of new patients Table 9: Number of new patients (first visits)(first visits) ,, in the year 2008in the year 2008

UCC LjubljanaUCC Ljubljana 1.5371.537

PPTC VrablPPTC Vrabl 1.2961.296

GH Murska SobotaGH Murska Sobota 1.2841.284

UCC MariborUCC Maribor 1.1841.184

SGH BrežiceSGH Brežice 987987

OI LjubljanaOI Ljubljana 500-550500-550

GH PtujGH Ptuj 521521

GH Novo mestoGH Novo mesto 469469

GHSlovenj GradecGHSlovenj Gradec 458458

GH JeseniceGH Jesenice 0 0

Rehab. UCC MbRehab. UCC Mb 350350

GH IzolaGH Izola 230230

GH CeljeGH Celje 225225

GH Nova GoricaGH Nova Gorica 150150

91919191


Table 10: Number of done factors Table 10: Number of done factors in the year 2008 (324377)in the year 2008 (324377)

UCC LjubljanaUCC Ljubljana 87.564,0087.564,00

GH Murska SobotaGH Murska Sobota 78.702,0078.702,00

UCC MariborUCC Maribor 47.397,3847.397,38


Gh Novo mestoGh Novo mesto 41.681,2841.681,28

GH Slovenj GradecGH Slovenj Gradec 27.840,0027.840,00

GH IzolaGH Izola 26.880,0026.880,00

Rehab. UCC MbRehab. UCC Mb 11.00011.000

GH PtujGH Ptuj 1.0741.074

GH BrežiceGH Brežice 1.0161.016

GH CeljeGH Celje 939939

PPTC VrablPPTC Vrabl 100% konces.100% konces.

OI LjubljanaOI Ljubljana DonDon''t knowt know

GH Nova GoricaGH Nova Gorica DonDon‘‘t knowt know


All work performed in PTCs in All work performed in PTCs in Slovenia in the year 2008Slovenia in the year 2008

332424..09093 3 – factors– factors

9241 9241 new patientsnew patients

1133 PTPTC-workingC-working

3333 different doctorsdifferent doctors

376 376 hours per weekhours per week


Therapeutic methods Therapeutic methods used used in in PTAsPTAs

AcupunctureAcupuncture 10 -90%10 -90% not in UCC Mb and GH NGnot in UCC Mb and GH NG Medicament. Therapy Medicament. Therapy 7-100%7-100% Pharmacological blocks Pharmacological blocks 5-60%5-60% Catheters Catheters 1-30%1-30% Pumps Pumps 1-50%1-50% not in Reh UCC Mb,not in Reh UCC Mb, GH B,GH B, GH J,GH J, PPTPPTCC V V Electrodes (EPI)Electrodes (EPI) for central stimulation for central stimulation only only

in in UKC UKC Mb Mb


Working time in PTCs in Slovenia Working time in PTCs in Slovenia - 1- 1

Full time -40 hours /week in 6 of 14 PTCs.Full time -40 hours /week in 6 of 14 PTCs. UCC LjubljanaUCC Ljubljana UCC MariborUCC Maribor OI Ljubljana OI Ljubljana GH JeseniceGH Jesenice GH Novo MestoGH Novo Mesto PPTC VrablPPTC Vrabl


Working time in PTCs in Slovenia - 2Working time in PTCs in Slovenia - 2

More than halfMore than half - GH Murska Sobota - GH Murska Sobota 3232 GH Slovenj Gradec GH Slovenj Gradec 2828Others Others - - Less than half Less than half

GH Izola,GH Ptuj, GH CeljeGH Izola,GH Ptuj, GH Celje 1616 GH Brežice, Rehab.UCCMariborGH Brežice, Rehab.UCCMaribor 1010 GGHH Nova Gorica Nova Gorica 88 Nevrol. Kl UCC Lj, PTNevrol. Kl UCC Lj, PTCC BEM BEM no datno dataa


Number of doctorsNumber of doctors

More than 3More than 3 -OI Ljubljana -OI Ljubljana 3-3-UCC LJ; UCC MUCC LJ; UCC Mbb;GH Murska Sobota;GH Murska Sobota 2-2-GH Slovenj Gradec,Reh.UCC Mb,GH GH Slovenj Gradec,Reh.UCC Mb,GH

Izola,GH Ptuj, GH Nova Gorica,GH Novo MestoIzola,GH Ptuj, GH Nova Gorica,GH Novo Mesto 1-1-GH Brežice,Celje, Jesenice,PPTGH Brežice,Celje, Jesenice,PPTCC Vrabl Vrabl No datNo dataa-P-PTCTC Bem, Nevr kl UKC Lj Bem, Nevr kl UKC Lj


Rotation of doctors in PTCsRotation of doctors in PTCs

Every dayEvery day - UCC Mb - UCC Mb Every other dayEvery other day-GH MS,GH I,GH P,GH NM,-GH MS,GH I,GH P,GH NM, Every weekEvery week -Reh UCC Mb -Reh UCC Mb Every monthEvery month –GH NG,GH SL G,OI Lj –GH NG,GH SL G,OI Lj NoneNone -GH Br,GH C,GH J,PPTC V, -GH Br,GH C,GH J,PPTC V, Depends on the needsDepends on the needs -UCC LJ -UCC LJ


CooperationCooperation -- multidisciplinary multidisciplinary workwork

FFamily medicineamily medicine doctors doctors goodgood

Other specialistsOther specialists goodgood

Psychiatrists, psychologistPsychiatrists, psychologistss bad bad (3X)(3X)


Needs for extensionNeeds for extension

All - All - yesyes


Limitations in PTCs in SloveniaLimitations in PTCs in Slovenia

PersonelPersonel - (Doctors) - (Doctors) 99

Places - Places - 77

ZZZS - (Insurance) ZZZS - (Insurance) 66


Whishes of doctors in PTCs in Whishes of doctors in PTCs in SloveniaSlovenia

Places Places 9/19/133

EquipmentEquipment 10/110/133

More invasive methods More invasive methods 9/19/133

Better cooperation Better cooperation 7/17/133


Performed factors in PTCs in the Performed factors in PTCs in the year 2008year 2008

324.903 324.903 all in Slovenia all in Slovenia

No data for 3 PTCNo data for 3 PTC

87564-UCC LJ,87564-UCC LJ, GH MS,UCC Mb, GHNM, GH SG, GH I,GH MS,UCC Mb, GHNM, GH SG, GH I,

Others under 25000Others under 25000


SummarySummary QUESTIONQUESTIONNAINAIRREE-- basic status basic status of pain therapy in of pain therapy in

SloveniSloveniaa

In three decades the situation advanced in a great In three decades the situation advanced in a great measure.measure.

Great merits for that lie on the work ofGreat merits for that lie on the work of SZZBSZZB..

In the future we have to continue our activities for In the future we have to continue our activities for the recognition and the proper payment for the the recognition and the proper payment for the already performed and not paid services .already performed and not paid services .

Activities for the recognition as well as the Activities for the recognition as well as the programme of the special knowledge on the field of programme of the special knowledge on the field of pain therapy.pain therapy.


14%

13%

12%

17%

15%

12%

13%

19%

21%

8%

11%

13%

8%

9%

4%

5%

7%

4%

0% 50%

5%

8%

9%

10%

10%

10%

7%

12%

6%

6%

10%

5%

6%

5%

4%

5%

0% 50%

Norveška (n=2,018)

Poljska (n=3,812)

Italija (n=3,849)

Belgija (n=2,451)

Finland (n=2,004)

Avstrija (n=2,004)

Švedska (n=2,563)

Nizozemska (n=3,197)

Nemčija (n=3,832)

Izrael (n=2,244)

Danska (n=2,169)

Švica (n=2,083)

Francija (n=3,846)

VB (n=3,800)

Irska (n=2,722)

Španija (n=3,801)

30%

27%

26%

23%

23%

21%

19%

18%

18%

17%

17%

16%

16%

15%

13%

13%

11%

General Prevalence = 19%

srednje močna 13% močna 6%

General Prevalence = 19%

srednje močna 13% močna 6%

SOURCE: Pain In Europe Survey 2003

Slovenija (n=1,009)


1.987.971

1423882

327.493

180.121

populacija 18-75 let kroničnabolečina

močnakroničnabolečina

About 180.000 of Slovenians suffer strong About 180.000 of Slovenians suffer strong chronical pains (according to VAS 7 or even chronical pains (according to VAS 7 or even

more).more).


onkološka bolečina2%

neonkološka bolečina

98%

Mostly the pains are of nononcological origin Mostly the pains are of nononcological origin (98%)(98%) . .

Izvor bolečine N=386


8%

27%

50%

100%

8%

22%

66%

50%

23%

19%

4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

6 mesecev do < 1 leto 1 leto do <2 leti 2 leti do <5 let 5 let in več

kumulativni odstotki Slovenija Evropa

Povprečje Slovenija = 4,8 let

Trajanje kronične bolečine (lahko tudi z vmesnimi prekinitvami) N=231

The average duration of the chronical pain in The average duration of the chronical pain in Slovenia (4,8 years ) is somewhat shorter than Slovenia (4,8 years ) is somewhat shorter than

in Evrope (7,0 years) .in Evrope (7,0 years) .

Povprečje Evropa = 7,0 let


SUMMARYSUMMARY

We need more place for pain therapyWe need more place for pain therapy We need more doctors for pain therapyWe need more doctors for pain therapy We take activities for better payment of We take activities for better payment of

analgetics preceedures from insurance analgetics preceedures from insurance companycompany

We are preparing clinical guidelines for We are preparing clinical guidelines for the use of opioids for chronic noncancer the use of opioids for chronic noncancer painpain

Documents

Organisation of Chronic Pain Therapy in Slovenia