KEY POINTS Effective perioperative pain management is essential to enhance recovery and reduce morbidity after surgery; however, improvements have been less than anticipated despite local quality improvement initiatives and advanced treatment strategies. Comparing the perioperative pain management systems of the four European countries using the Donabedian framework (structure, process and outcome) as a guide might reveal some insights into the differences, similarities and future directions of perioperative pain management. Direct comparison and indication for best practice models are currently not possible because of a variety of different settings, and none seems more promising than the others. It is essential to define assessments beyond pain intensity, to establish acute pain services and make recommendations for acute pain services. Combining efforts to develop optimal quality indicators and international collaborative projects, as well as European guidelines for pain management after surgery (e.g. for patients with preoperative pain, or for opioid use) would pave the way forward for perioperative pain management in Europe. Introduction

Effective perioperative pain management contributes to enhanced recovery,1 reduced morbidity2 and potentially lowers the incidence of chronic postsurgical pain.3,4 Regardless, postoperative pain remains common and under-treated5 despite the availability of guidelines, analgesics, complex pain treatment strategies and acute pain services (APSs). There is wide variation in the availability, function, structure and quality of perioperative pain management between countries because of different healthcare systems, economic situations and types of hospitals, among other reasons.6 This variation potentially influences outcomes; however, based on the current evidence, there is no agreement on the best model of care for perioperative pain management.6,7 As improvements in postoperative pain relief have been less than anticipated, there is a need for understanding which strategies (beyond single drugs or analgesic techniques) enable optimal pain management and improve the quality of care in clinical reality.

Within this narrative review, we, therefore, compare similarities and differences between countries based on the Donabedian conceptual framework. The Donabedian conceptual framework is an established method for evaluating the quality of care by classifying three interrelated indicators: structure, process and outcome (Fig. 1).8,9 Structural indicators describe the environment in which care is delivered, including materials, resources, operational factors, and organisational characteristics and affect processes and outcomes. Process indicators describe how care is provided to patients. The outcome indicators are the result of structure and process and describe the effects of healthcare on the population and the healthcare system.10,11 Such a process might help to reveal similarities and differences between countries, help to better understand what works best and to develop an up-to-date effective model for perioperative pain management in the future.

Fig. 1: Donabedian's conceptual framework of perioperative pain management. Currently identified quality indicators influencing acute pain management according to structure, process and outcomes are shown.11Methodological approach of the narrative review

Using the Donabedian framework, the models of perioperative pain management in four European countries – France, the United Kingdom (UK), Germany and the Netherlands – were compared. These countries were selected because they are not only closely related, suggesting that knowledge or experiences can easily be exchanged but also have different healthcare systems, which can influence structure, process and outcome indicators. For feasibility purposes, we narrowed the number of countries to four. At least one representative familiar in the field of perioperative pain management from each of the four countries was involved in guiding this process (France: FF, VM; Germany: US, EPZ; UK: FC; The Netherlands: SH, RB, KV).

An overview of structure, process and outcome indicators (or so-called ‘quality indicators’) used in previous studies investigating perioperative pain management in adults was provided by Glarcher et al.11 As outlined, structure indicators are the availability and provision of pain protocols, specific techniques and drugs, trained personnel and APS (and APS's characteristics).10,11 Additionally, our group identified legislation and quality management projects as relevant structure quality indicators. Glarcher et al.11 identified several process quality indicators in their review, for example, for pain assessment the frequency, what outcome measure was used and if pain was assessed at rest and during activity. The following process indicators were summarised: the application of protocols, and analgesic techniques, pain assessment, pain documentation, training in pain management and patient information and education in pain management. For outcome assessment, we used a very recent European consensus process involving international stakeholders and patient representatives [part of Innovative Medicine Initiatives (IMI)-PainCare Consortium], which consented on a core outcome set (COS) to be used in clinical studies and clinical practice for assessing the effectiveness and efficacy of any postoperative pain management.12 The following five domains were indicated: physical functioning, pain intensity during activity, pain intensity at rest, adverse events and psychological factors like self-efficacy.12 Self-efficacy is a construct that includes the patient's belief in their own ability to complete tasks while experiencing acute pain.

National structure, process and outcome quality indicators were obtained by a structured analysis of published guidelines, national databases, studies, reports and initiatives by the representative(s) of each country. For each quality indicator, available published information per country was used.

Results

The main results from each country are described here and summarised for comparison in Table 1. For more data, we refer to the Text of Supplemental Digital Content S1, https://links.lww.com/EJA/A880.

France Structure

In 2002, the law on patients’ rights and the quality of the health system recognised pain relief as a fundamental human right.13 Since then, each French healthcare institution is responsible for implementing the Pain Plan, is obligated to have a committee for pain management14 and to include quality indicators on pain management procedures.15 Additionally, some hospitals participate in an international quality-project (improvement of postoperative PAIN OUTcome, PAIN OUT).16 The recommendations on postoperative pain management were updated by the Society of Anaesthesiology and Intensive Care Medicine in 2016.17,18 In 2022, recommended analgesics and nonpharmacological treatment were described in a white paper.19 Anaesthesiologist are mainly responsible for postoperative pain management.20 An APS or any other structure with a similar aim was found in 52% of the surveyed institutions (only in 45% of academic public hospitals),20 which are mostly nurse-based.21 There is a lack of recent data on the availability of APS.

Process

The Postoperative Analgesic Therapy Observational Survey (PATHOS, 2005) demonstrated that 36% of the institutions had pain protocols, which were used in 35% of the patients.20 In major abdominal surgery, intravenous (i.v.) nonmorphine analgesics (78%) and patient-controlled i.v. (PCIA) opioids (82%) were most commonly used, and epidural analgesia in 41% of cases.20 In major orthopaedic surgery, peripheral nerve blocks (PNB) were used in 84% of patient, and after major surgery, balanced analgesia was administered in 87% of patients.20 In 2014, a survey assessing day-case surgery found that a dedicated written protocol for pain management was available in 40% of the institutions,22 there was no standardised take-home analgesic strategy for surgical procedures at risk of moderate-to-severe pain, and practice patterns varied among institutions.22 Tramadol and paracetamol were the most prescribed analgesics after day-case surgery in 78% of the centres,22 and oral morphine in 42%.22 The PATHOS study,20 as well as another evaluation in various surgical centres (n = 1900; 2004–2006),23 provided additional information on pain assessment, staff training and teaching, which is further specified in Table 1.

Outcome

A survey by Fletcher et al.23 showed that 91% of patients experienced pain at rest on day 1 [numeric rating scale (NRS) 3.0 ± 2.2], and 100% of the patients experienced pain on movement (NRS 5.2 ± 2.2). Six and 31% of the patients experienced intense postoperative pain at rest and during movement, respectively. In this setting, 54% of the patients had a maximal pain score of at least 7.23

Germany Structure

In 2020, the German Federal Joint Committee announced that hospitals and practices involved in surgical procedures will be obligated to introduce acute pain management as part of their internal quality management.24 Implementation will be the responsibility of each hospital following particular recommendations (Table Supplemental Digital Content S2, https://links.lww.com/EJA/A881).25 In 2021, the national guideline with at least 150 recommendations related to perioperative pain was updated and released.26 Two benchmarking projects exists with the primary aim of improving postoperative symptom control, one national (quality improvement in postoperative pain therapy, QUIPS)27 and one for Europe (PAIN OUT).16,28,29 Furthermore, certification of hospitals based on their acute postoperative pain management is available on demand.30,31 Pain education has been integrated into the curriculum for medical students since 2016, and certain curricula for physicians, pain nurses and physiotherapists exists.32,33 Two national surveys have evaluated the process and quality of APSs34,35 and five minimal requirements were defined (Table Supplemental Digital Content S3, https://links.lww.com/EJA/A882). In 2021, the German Society for Anaesthesiology and Intensive Care Medicine published their first recommendations on how APSs should be organised to ensure quality.36

Process

Written acute pain management standards on surgical wards were available in 97% of the hospitals.35 In 71% of the hospitals, indications for APS care were defined as: specific analgesic techniques or patient groups, high pain scores and early adverse event related to pain management.35 Daily APS-rounds were performed by physicians and nurses (42%), physicians only (25%) or supervised nurses (31%).35 In 90% of the hospitals, PCIA was provided, epidural anaesthesia in 95% and PCEA in 31%.35 Pain assessment and documentation as well as education in hospitals are outlined in Table 1.

Outcome

With QUIPS data collected until 2010, a large gap in acute pain management was observed, with up to 37.2% of patients (n = 50 199) experiencing severe pain (worst pain NRS ≥6) on day 1 after surgery.37 Especially, relatively small operations were associated with considerable pain, probably because these patients were given less analgesia than needed.37 More recently, for four commonly performed surgical procedures (n = 21 114 from 138 hospitals) were investigated. It was found that pain intensity varied between the 10 ‘worst’ hospitals (NRS 6.3 ± 2.2) compared with 3.6 ± 2.1 at the 10 ‘best’ hospitals. Furthermore, less pain-related functional interference and higher satisfaction were reported in hospitals if pain was documented and patients felt adequately informed.38 Comparable variance in results of pain-related patient-reported outcomes on the first postoperative day were within the project ‘pain free hospital’.39 Finally, recent QUIPS-data support earlier findings of lower pain intensity scores and less functional impairment in patients treated with regional analgesia techniques compared with systemic (opioid-based) analgesia on the first40 and up to several days after surgery.41

United Kingdom Structure

The Royal College of Anaesthetists (RcoA) published ‘Pain after Surgery’ in 1990,42 which raised awareness of perioperative pain management requirements such as dedicated APS, education and training for all staff, the nurse specialist role, the introduction of high dependency units and implementation of advanced techniques. The national guidelines on perioperative pain management were updated in 2020.43 The RcoA44 and the Faculty of Pain Medicine45 provide guidance for APSs, and current standards are summarised in Table Supplemental Digital Content S4, https://links.lww.com/EJA/A883.

The RCoA offers the Quality Improvement Compendium, which is a manual of quality improvement and audit tools for anaesthesiologists,44 and runs the National Audit Projects, which study rare but serious anaesthesia-related complications.46 The multidisciplinary ‘Perioperative Quality Improvement Program (PQIP)’ was established in 2016 and aims to improve outcomes and reduce variability in practice for patients undergoing major noncardiac surgery.47 Additionally, several hospitals in the UK participate in PAIN OUT.16

Education and training for nurses are available.48,49 Anaesthesiologists working in the APS have a higher pain training or a recognised equivalent.44 A survey of 403 APS (2004) revealed that 80% of hospitals had an APS, although 50% stated that they were struggling to manage.50 A decade later, a survey among 209 centres (response rate 141/209) showed that 70% met standards for APS (Table S4, Supplemental Digital Content, https://links.lww.com/EJA/A883).51 Current availability of APS is not evaluated. Nurses provide care during the daytime, and out-of-hours (85%) are covered by critical care physicians or anaesthesiologists.51

Process

All centres providing surgery have local pain management policies based on recommendations from national bodies.51 The nursing team on the ward is responsible for the day-to-day management of inpatient pain and APS nurses focus on patients with complex pain.52 Formal physician led rounds more than weekly are rare.52

A survey among 121 hospitals in 2011 showed that all hospitals use PCIA and PCEA.53 Epidural anaesthesia has diminished in popularity and regional blocks and/or infusions have gained favour.54 The use of continuous wound blocks facilitates early discharge and forms part of ‘Enhanced recovery after surgery’ (ERAS) protocols.55 Some institutions discharge patients with elastomeric infusions.55,56 Pain documentation varies between centres, and there is a mix of technology and paper-based systems.53

Outcome

A multicentre study in predominantly orthopaedic and general surgery (n = 29 080; 2011) showed that 37% of patients reported moderate-to-severe pain.53 Adverse events related to pain management were recorded in 14% of these patients, of whom postoperative nausea and vomiting (PONV) was the most frequently reported adverse event. Major adverse events occurred in 0.23% of all patients, which was mostly respiratory depression.53 In the PQIP report (2019–2021), data from 79 hospital sites across the UK were included.47,57 Approximately 20% of patients reported severe pain at the surgical site within 24 h postoperatively. Drinking, eating, and mobilizing within 24 h postoperatively is a key PQIP target and its incidence depends on the type of surgery.47

The Netherlands Structure

The Dutch Healthcare Inspectorate (HCI) provides guidance for quality improvement of pain management and hospitals have had to deliver data on quality indicators in publicly available annual reports since 2003.58 In 2020, pain assessment, pain documentation and the properties of an APS (Table Supplemental Digital Content S5, https://links.lww.com/EJA/A884) were the requested quality indicators.59 Since 2021, hospitals can deliver institutional quality indicators regarding optimal pain management and minimize the burden for nurses.

In 2008, the government launched the Dutch Hospital Patient Safety Program (DHPSP)60 and recommended: assess movement-evoked-pain (MEP) three times daily, have an acute pain protocol and have a pain education program for ward staff and patients.61 Several hospitals participate in the PAIN OUT registry.16 The multidisciplinary postoperative pain guideline was updated in 2023.

Basic pain education has been integrated into the medical curriculum. Advanced training is available for pain experts62 and for paramedical professionals.59 Almost half of the hospitals did not offer a continuous medical education programme for their ward staff in 2015.63

In 2015, 97% of the APS teams were nurse-based supervised by anaesthesiologists, of which only a few (8%) were specialised in pain.63 Out-of-hours were covered in most cases by the anaesthesiologist on call.63 The program of the HCI has resulted in a 90% availability of APS in hospitals performing surgical procedures,63 scoring between 80 and 100% for the requested properties (Table Supplemental Digital Content S5, https://links.lww.com/EJA/A884).58

Process

Almost all hospitals (97%) had access to a written postoperative pain protocol.63 APS teams follow patients with complex pain techniques, unusual analgesics or a history of chronic pain, and in some cases, all postoperative patients.63

Most hospitals (84%) assessed pain with movement and pain at rest. Only in 46% of the responding hospitals was pain is assessed during all hospital-days.63 In the DHPSP evaluation, the actual number of postoperative pain assessments was lower (53% once daily; 12% three times daily) than the reported number of pain assessments to the HCI (at least once daily 78% in 2012), presumably because of specific samples.64

Outcome

In a cross-sectional university study (2008–2013; n = 9082), it was found that 9% of the patients described their pain as unacceptable; 47% of the patients described their pain as acceptable and 33% of them performed all required physical activities while having high pain scores.65 A more recent single-centre study (n = 1014; 2012–2015) showed that 16.8% of postsurgical patients reported unacceptable pain at least once during the first 3 days, which was related to the occurrence of postoperative complications.66 Finally, patients (n = 2399; 2008–2013) who received epidural anaesthesia and PNB reported lower pain scores than those who received PCIA, after undergoing the same abdominal, thoracic or extremity procedures.67 A similar PONV incidence was found with PCIA and PCEA (approximately 19%), although severe nausea was more common with PCIA (4.2%). Opioid-induced respiratory depression was found in five patients with PCIA (0.1%).67

Discussion

In this narrative review, we aimed to describe and compare the structure, process and outcome indicators used in the healthcare systems of four geographically closely related countries (France, the United Kingdom, Germany and the Netherlands) for the management of perioperative pain management in adult patients. We not only found several differences but also similarities between these four countries, which are summarised in Table 1.

Table 1 - Pain management in four European countries evaluating differences and similarities according to a Donabedian conceptual framework France Germany United Kingdom The Netherlands Structure  Legislation Guidance from law-system, which incorporates the Pain Plan in public health law13 Guidance from German Federal Joint Committee in 2020 (Table S2, http://links.lww.com/EJA/A881)25 Guidance from FPM45 and RCoA44 (Table S4, http://links.lww.com/EJA/A883) HCI requests yearly QIs from hospitals59  Availability of standards in pain management Standards in pain management (2016);17,18 and multidisciplinary recommendations (2022)19 National S3-guideline (2021) describes provision of analgesics and advanced techniques26
Recommendations for organisation of APSs (2021)36 NICE guideline (2020) and describes provision of analgesics and advanced techniques43
Standards for organisation of APSs (Table S4, http://links.lww.com/EJA/A883)45 National guideline (2023) describes provision of analgesics and advanced techniques Recommendations for organisation of APSs (Table S5, http://links.lww.com/EJA/A884)59  Quality improvement projects Three national Pain Plans 1998–201068
PAIN OUT is used in some hospitals16 Certification on qualified pain management; QUIPS since 2003, PAIN OUT since 200716,28,29
CERTKOM by the German Pain Society 201630 Continuous National Audit Projects and audit compendium led by RCoA,44 PQIP since 201647 PAIN OUT is used in some hospitals16 HCI requests a continuous plan-do-act-cycle in hospitals (which is supervised by APS).61
PAIN OUT is used in some hospitals16  Professional training Integrated pain education in the curricula of physicians, anaesthesiologists and paramedical professionals. Nurses: no recent data on availability of specialised pain training21 Integrated pain education in the curriculum of anaesthesiologists and physicians. Medical doctors can specialise in pain management. Special pain education programs for nurses are available and updated based on the EFIC diploma69 Pain education is integrated in the curricula of anaesthesiologists; pain fellowships exist for physicians. APS nurses have postgraduate education48 often at Masters level.49 Ward nurses have basic pain knowledge48 Integrated pain education in the curricula of physicians, anaesthesiologists, paramedical professionals; pain fellowships exist for physicians. APS nurses have in-hospital (51%) and institutional training 38%.63 Ward nurses have basic pain knowledge  Availability of acute pain management specialists and APS Anaesthesiologists cover perioperative pain management20
Each hospital has a pain management committee14
APS or any structure with a similar aim (criteria are not defined) was found in 52% of the institutions in 200520 24/7 coverage for pain consultations: daytime APS or physician; on call, anaesthesiologist in 93%35
APSs are available in 81% of the 403 surveyed hospitals and belong to the anaesthesiology department; only 45% met quality criteria (Table S3, http://links.lww.com/EJA/A882)35 24/7 coverage for pain consultations: day-time APS; on call, critical care physician or anaesthesiologists51
APSs are nurse-led and available in >95% of government hospitals. 70% of surveyed hospitals (141/209, in 2017) met the criteria in Table S4, http://links.lww.com/EJA/A88351 24/7 coverage for pain consultations, day-time APS; on call mostly anaesthesiologist63
APS is available in ≥90% of the hospitals and nurse-led supervised by an anaesthesiologist.63 APSs score 80 to 100% of the requested properties (Table S4, http://links.lww.com/EJA/A883)58 Process  Application of protocols Written protocols available in 36% (2005)20 – 40% (2014) hospitals;22 and are used in 35% of patients20
No to minimal standardised discharge analgesics in day-case surgery (2014)22 Pain protocols are available in 97% of the hospitals on surgical wards and in 51% on nonsurgical wards35 All hospitals have protocols based upon recommendations from national bodies51 97% of the hospitals have written pain protocols63  Application of analgesic techniques PCIA, EA, PNB and balanced analgesia is used20,22 PCIA 90%, EA 95%, PCEA in 31% of the hospitals35 Hospitals use PCIA, PCEA, PNB or wound catheters53,55 Hospitals use PCIA, PCEA and PNB63  Pain assessment At least once daily in 82% of the hospitals; at rest and during movement in 44%20 Pain assessment/documentation in 86% of the hospitals (n = 403); evaluation once/day: 14%; twice/day: 22%, 3 times/day: 22%70; evaluation is not standardized Regular assessment using validated tools45,71,72 Regular assessment using validated tools. Pain at rest and movement (84% of the hospitals); only in 46% pain is assessed during all hospitalised days63  Pain documentation The assessment is documented in 81% of the hospitals20 At least once/shift: 49%; no standardised evaluation: 14%35
Pain at rest >96%, at movement >84%, after rescue analgesics in 38%, analgesic technique 98%, AE 84%, satisfaction 68%35 Documentation of pain at rest, movement and dynamic45 Pain was documented three times per day in 12%; once per day in 53% of the hospitals (2012);64 not in line with reported number (once per day 78%) to the HCI64  Patient information and education In 84% of the hospitals, patients are informed during preanaesthesia evaluation20 Not evaluated in national surveys, however, a variable addressed in the patient questionnaire of QUIPS and PAIN OUT Not evaluated for each hospital but is widely available73,74 In 87% of the hospitals, patients are informed during preanaesthesia evaluation63  Training in pain management Regular on-site training: to 30% of anaesthesiologists, to 6% of surgeons, to 57% of recovery nurses and to 63% of ward nurses.20 No teaching was carried out in 23% of the hospitals20 In 53% of the APS an integrated rotation for training their specialty is available35 The nursing team provides bedside and classroom teaching, offers shadowing. Few universities offer rotations to the APS48 APS teams have an advisory function to ward personnel, provide bedside teaching and are involved in educational tasks and QI programmes63 Outcome  Physical functioning Not evaluated Pain-related functional restriction ranged between 27% and 95% depending on type of surgery38 Incidences vary depending on type of surgery47 ≥70 to 100% of the patients NRS-MEP ≤5 performed all required physical activities and 33% with NRS-MEP ≥7 (n = 9082)65  Pain intensity during activity 100% of n = 1900 experienced pain on POD 1 (NRS 5.2 ± 2.2); of which 31% had severe pain during activity23 Up to 47.2% experienced severe pain on POD 1 (n = 50 523)37 In the 10 ‘worst’ hospitals, NRS 6.3 ± 2.2, versus 3.6 ± 2.1 at the 10 ‘best’ hospitals (n = 21 114)38 Around 20% report severe pain after surgery47,53 Moderate pain on POD 1, 2, 3: 39%, 37%, 32% (n = 1014)66  Pain intensity at rest 91% of n = 1900 experienced pain (NRS 3 ± 2.2); of which 6% had severe pain at rest23 See comment below. Not evaluated Moderate or severe pain 41% day of surgery, 30%, 19%, 16% POD 1, 2, 3 (n = 1490)75  Adverse events Not evaluated PONV: depending on type of surgery and anaesthesia/analgesia 4–70% (n = 23 911)40 Spinal haematoma after EA 1 : 66 2876 In 14% of n = 29 080 AE: 30% were PONV, 0.22% were major AE.53 Permanent injury 4.2 : 100 000; dead or paraplegia of 1.8 : 100 000 after neuraxis blockade46 PONV: PCIA 19.7% > PCEA 19.3%; Severe itching: EA 1.4% >PCIA 0.8%; Respiratory depression: 0.1% (n = 12 399) PCIA67  Self-efficacy, psychological and mental variables Not evaluated Dissatisfaction: university: OR 3.58, 95% CI 1.85 to 6.93, standard care facilities: OR 1.59, 95% CI 1.25 to 2.0238 In 35% of n = 15 040 severe discomfort was experienced (thirst, pain, drowsiness)77
≤5% of patients are ‘dissatisfied’ with their pain management47 Overall, 16.8% experience unacceptable pain in POD 1 to366

AE, adverse events; APS, acute pain service; CI, confidence interval; DrEaMing, Drinking Eating Moving; EFIC, European Pain Federation; FPM, Faculty of Pain Medicine; HCI, Healthcare Inspectorate; i.v., intravenous; NICE, National Institute for Healthcare Excellence; NRS-MEP, Numeric Rating Scale Movement Evoked Pain; OR, odds ratio; PCEA, Patient Controlled Epidural Analgesia; PCM, paracetamol; PCIA, patient-controlled intravenous analgesia; PNB, continuous peripheral nerve block; POD, postoperative day; PONV, postoperative nausea and vomiting; PQIP, Perioperative Quality Improvement Program; PROMS, patient reported outcome measures; PVB, paravertebral block; QI, quality indicator; QUIPS, quality improvement in postoperative pain management; RCN, Royal College of Nurses; RCoA, Royal College of Anaesthetists; s.c., subcutaneous; (T)EA, thoracic epidural analgesia.

Structure

In the Netherlands and France, the government runs national quality improvement programs that encourage hospitals to implement pain assessment and pain protocols, resulting in 90% availability of APS in the Netherlands. In Germany, the government recently established requirements for acute postoperative pain management.25 This seems to be a positive development but whether this has had a positive effect can only be assessed in the future. In the Netherlands, outcome indicators are annually requested from the hospitals to the HCI but as indicated recently, did not entirely reflect clinical practice.64

The UK, the Netherlands and Germany have recently updated multidisciplinary evidence-based guidelines, which are essential for guiding pain management in an evidence-based fashion and increasing acceptance by all professionals. For the future, a joint European perioperative pain management guideline would be beneficial in reducing differences between countries and workload, as guidelines cost a lot of effort and money.

Pain education is integrated into the curriculum for physicians and anaesthesiologists but varied for nurses. Defining the basic and advanced knowledge and competencies for several types of healthcare workers is an important requirement. The International Association for the Study of Pain has provided entry-level pain core curricula to encourage all interprofessional medical programs to utilise the curriculum outline and embed these in basic education.78 Furthermore, the European Pain Federation (EFIC) has developed curricula on pain medicine, physiotherapy, nursing and psychology at a postgraduate level to provide additional depth for each discipline.79 These pave the way for a more aligned education of several professionals related to pain in Europe.

In all four countries, the anaesthesiology department is primarily responsible for perioperative pain management. APSs are implemented in many hospitals, except in France.20 French healthcare institutions are obliged to have a committee for pain management.14 The organisation of APS varies widely, not only between countries but also within countries. For the future development of high-quality APS and evaluation of its efficacy, a basic quality set is needed,6 which can be supplemented with an additional set depending on hospital size and type, and number of patients at high risk of developing severe pain after surgery. Some hospitals around the world are currently initiating new transitional pain services in which interdisciplinary pain management and personalised approaches based on a bio-psycho-social model of chronic pain are implemented to prevent chronification of postsurgical pain.80,81 Evidence of the efficacy of such services is missing but is underway (trial registration: DRKS00025799).

Process

Almost all hospitals in the UK, Germany, and the Netherlands have access to hospital-wide postoperative pain protocols. A more in-depth evaluation of the similarities and differences related to the content of these protocols would be of interest. However, the quality of the recommendations was not assessed except in France where their content varied amongst hospitals.22

In all four countries, patients’ pain education before surgery is emphasised.20,63,59,74 Education might comprise many aspects; an important one might relate to the use of opioids because of a rising concern about postoperative long-term opioid use.82,83 Especially in the UK, opioid intake and prescription problems were recognised.73 Thus, a patient information project was initiated, to promote opioid stewardship and reduce the risk of opioid-related harm in the adult surgical patients.84,85 Whether postoperative opioids are a problem in other European countries is not yet clear.86 Upcoming data from the ‘Pain AND Opioids after Surgery (PANDOS)’ study will elucidate what is the incidence of opioid use before and after surgery, and the association of opioids with persistent pain and adverse event in Europe.27

Outcome

The e