Hindawi Pain Research and Management Volume 2022, Article ID 4077139, 12 pages https://doi.org/10.1155/2022/4077139 Research Article Advances and Pitfalls of Specialized Pain Care through Public and Private Health Care Providers in Catalonia and the Balearic Islands: A Physician’s Survey Javier Medel ,1 Ancor Serrano ,2 Carme Batet ,3 Lluis Lorente ,4 Susana Bella ,5 Marta Ferrandiz ,6 Marı́a-del-Mar Monerris ,7 Sergi Boada,8 Jesus Villoria ,9 Maria-Victoria Ribera ,1 Antonio Montes ,10 and Sebastian Videla 11,12 1 Pain Unit, Hospital Universitari Vall d’Hebrón, Passeig de la Vall d’Hebron 119, Barcelona 08035, Spain 2 Pain Unit, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, L’Hospitalet de Llobregat 08907, Spain 3 Pain Unit, Consorci Sanitari Integral, Hospital de Sant Joan Despı́ Moisès Broggi, Carrer Oriol Martorell 12, Sant Joan Despı́ 08907, Spain 4 Pain Unit, Institut de Medicina i Cirurgia de Barcelona, Carrer Bisbe Sivilla 46, Barcelona 08022, Spain 5 Pain Unit, Hospital Universitari Sant Joan de Reus, Avinguda Del Doctor Josep Laporte 2, Reus 43204, Spain 6 Pain Unit, Hospital Universitari de La Santa Creu i Sant Pau, Carrer de Sant Quintı́ 89, Barcelona 08041, Spain 7 Pain Unit, Hospital Universitari Germans Trias i Pujol, Badalona 08916, Spain 8 Pain Unit, Hospital Universitari Joan 23, Carrer Dr. Mallafrè Guasch 4, Tarragona 43005, Spain 9 Department of Design and Biometrics, Medicxact, Plaza Ermita 4, Alpedrete, Spain 10 Pain Unit, Hospital Del Mar, Passeig Marı́tim 25-29, Barcelona 08003, Spain 11 Department of Clinical Pharmacology, Hospital Universitari de Bellvitge, Carrer de La Feixa Llarga, L’Hospitalet de Llobregat 08907, Spain 12 Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, Carrer de La Feixa Llarga, L’Hospitalet de Llobregat 08907, Spain Correspondence should be addressed to Marta Ferrandiz; mferrandizmach@gmail.com and Sebastian Videla; svidelaces@ gmail.com Received 23 October 2021; Revised 8 February 2022; Accepted 18 March 2022; Published 21 May 2022 Academic Editor: Redha Taiar Copyright © 2022 Javier Medel et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Optimal diagnosis and treatment of pain require a multidisciplinary approach that demands considerable coordination and forethought. A cross-sectional physician survey based on an online questionnaire was carried out to assess the adoption of multidisciplinary working patterns, compare the public and private models, and provide an update on the resources and organization of specialized pain care in Catalonia and the Balearic Islands. Active pain practitioners identified through the Catalan Health Service and Pain Society databases were sent an invitation in December 2020. Of the 321 physicians contacted, 91 (28.3%) answered and 71 provided complete responses (commonly anesthesiologists, representing 92 different sites; some worked at public and private sites). Up to 78.7% reported working in pain management teams, but only 53.5% were regularly involved in teaching or research activities. Thus, the proportion of multi- disciplinary sites lies somewhere in-between. Median wait times were significantly shorter and within the recommended standards in private practices (e.g., 15 vs. 90 days in public practices for noncancer patients). In turn, private practices were slightly less staffed and equipped, albeit the differences did not reach statistical significance. Respondents made a median of 530 regular and 30 emergency visits per year, of which 190 involved interventional procedures. They offered a wide range of pharmacological and interventional therapies, although psychotherapy and the most sophisticated procedures were only available in ≤50% of sites. Pain clinicians and facilities are reasonably available in Catalonia, but barely more than half are truly multidisciplinary. Public and private practices differ in some aspects; the latter seems to be more accessible, but it is restricted to patients who can afford it. Compared to previous reports, this update shows both advances and outstanding issues. Multidisciplinary care could be expanded by incorporating more psychologists and some interventional procedures. The public practices should reduce wait times. 2 Pain Research and Management 1. Introduction the related healthcare processes, backed the present study to answer two relevant questions related to these tasks: To what Pain is among the leading causes of disability and disease extent have interdisciplinary or multidisciplinary working burden worldwide, and its prevalence and impact are ex- patterns been adopted by pain services, and what could be pected to grow because of population ageing [1, 2]. Although done to boost them? And, is there any major related dif- most of this burden is attributable to chronic pain, the ference between public and private models of care? The last adequate management of acute pain is vital to prevent question has been scarcely addressed in the past [23]. In chronification [3]. Pain prevalence is considerable. In Spain, turn, this research also offers a regional update of the re- surveys and cross-sectional evaluations found that about one sources, scope of services and activities of pain treatment third of adult individuals have experienced pain in the facilities, and an assessment of their referral patterns, service immediate past and one in five have suffered from chronic utilization, process flows, and caseloads. pain [4–6]. The figures are similar or even higher in other countries [7]. Significantly, up to one third of chronic pain 2. Materials and Methods sufferers may experience a severely disabling condition [8, 9]. Pain can be associated with considerable distress, 2.1. Study Design and Selection of Participants. This was a psychological comorbidities, disability, and impaired quality cross-sectional, prospective, multisite, questionnaire-based of life [10, 11], or even premature mortality [12], and entails survey study. The target population comprised the whole of considerable costs from both direct healthcare expenditures physicians of any medical specialty who dedicate their and productivity losses due to work absences [13]. medical activity (total or partial) to managing patients with Nowadays, it is accepted that a broad, multidimensional pain (active pain practitioners) in Catalonia or the Balearic perspective is required to understand pain and to treat Islands. A search strategy using several databases available to patients adequately. The initial sensory input from disease- the investigators was designed and carried out (see the related neurophysiological changes elicits a range of cog- additional methods in Supplementary Materials). In total, nitive, behavioral, and affective processes. These are further 400 physicians providing care for pain were identified, of modulated by the patient’s socioenvironmental context and whom 321 were invited to participate and 91 (28.3%) pro- eventually render and sustain the integral pain experience vided answers (Figure S1). Sampling methods were not and its consequences [14, 15]. The understanding of pain as a delineated because the initial intention was to obtain data multifaceted phenomenon has led to the development of from every member of the population. However, the low sophisticated, comprehensive, interdisciplinary, and per- response rate led us to compare the reported characteristics sonalized therapies. These treatments are ideally applied at with known external data on pain services (proportions of specialized centers, where a coordinated team can appro- small vs. larger, public vs. private, standalone vs. hospital- priately interact and work in an integrated facility that in- based practices) to calibrate response bias [25], since re- corporates the necessary management services, equipment, sponse representativeness is more important than response and resources [16, 17]. Like in other places, national stan- rate [26]. dards that regulate the operation of these pain treatment facilities have been established. Ideally they should en- 2.2. Survey Instrument. This survey used an ad hoc ques- compass an heterogeneous, interdisciplinary team of tionnaire featuring 45 items (42 closed, 3 open) grouped into healthcare providers and be able to manage both, complex 5 sections that covered the participants’ background, challenging acute, with insufficient response to appropriate workloads and healthcare provision management, the re- biomedical treatments, as well as chronic pain conditions in sources available at their facilities, and the scope of the patients with demanding biopsychosocial needs [18]. services provided. There is a complete description of this tool Meeting such standards, nevertheless is challenging for in Supplementary Materials. It was posted online through a many pain services [19, 20]. Meanwhile, undertreated pain validated remote data capture system and was active from continues to be a public health problem [21], despite its January to March 2021. During this period, up to three adequate management being considered a fundamental reminder emails were sent to all selected physicians to human right [22]. stimulate participation. To compare both models of care, Pain treatment facilities should be periodically evaluated public and private, all items but those related to the par- to address the level of compliance with the demanding ticipants’ background were required in duplicate. The par- standards, expose their organizational performance, identify ticipants had to select the one applicable to their practice or difficulties and areas of intervention, and engage clinicians fill in both if they provided care in the two settings. in reporting the quality of their care as part of quality improvement efforts [23, 24]. Survey research may well be a feasible framework to attain such goals that could otherwise 2.3. Ethics and Transparency. The final study protocol was be unattainable [25]. The Catalan Pain Society (https://www. approved by the Clinical Research Ethics Committee of scdolor.cat), committed to overseeing the quality of pain Bellvitge University Hospital in Barcelona (reference PR340/ care, guiding the pain service provision in Catalonia, or- 20). The need for written informed consent was waived. This ganizing local pain treatment structures and elaborating on study was carried out according to the stipulations of the Pain Research and Management 3 Declaration of Helsinki and the level of protection of confidentiality concerning the protection of personal data as FRANCE required by Spanish law (LOPD 3/2018). No remuneration was provided for participation. The present manuscript was prepared in consideration of the preliminary checklist for reporting of survey studies Girona (CROSS) [27]. Lleida 2.4. Statistical Analysis. The proportion of truly multidis- Barcelona ciplinary sites was estimated via the lower limit of the one- sided 95% exact binomial confidence interval (CI) of the Tarragona sample proportion, which was calculated by combining the data on staff composition and the participation in man- agement teams and teaching/research activities, features that distinguish the most complex and specialized types of pain facilities [18, 28–30]. Separate descriptions were done for the public and private healthcare settings to facilitate compar- isons between them, which were performed using either Mann–Whitney U/Kruskal–Wallis tests or Chi-squared/ generalized Fisher’s exact tests, as appropriate. To adjust for Palma de Mallorca multiplicity, the Type I error was contained by selecting contrasts that globally yielded a nominal false discovery rate (FDR) of 5% [31]. When the estimated number of true null hypotheses was greater than zero, we also calculated the adjusted p values (q-values) as the smallest estimated FDRs at which the test could be declared significant [32], con- strained to be greater than or equal to the raw p values. Only No. of physicians compliant tests were regarded as significant. The sample size 1 was not determined beforehand because the intention was to 2 assess the entire target population. Nevertheless, given that 5 participation was incomplete, we calculated that the preci- 10 sion (half-width) of two-sided 95% CIs for the observed 20 proportions was 8.95% or higher when a sample of 92 (see Supplementary Materials) was drawn from a finite pop- 30 ulation of 400 individuals. Figure 1: Display of the number of surveyed physicians per municipality. 3. Results 3.1. Respondents’ Background and Proportion of Multidisci- sector and private practices. Many respondents received plinary Sites. The participants, commonly anesthesiologists rotating/resident physicians, and about two-thirds imparted with considerable clinical experience (Table 1 and Supple- training activities, mainly hospital general sessions, sessions mentary Materials), represented 92 different sites, 63 public to primary care physicians, and classes in universities. and 29 private sites, and were distributed throughout 18 Compliance with standards was moderate (between 50% and different towns in a dispersed geographical area (Figure 1). 75% of sites, Table 1). The medical practice was mainly based In many instances (77/89, 86.5%), they declared to be on scientific evidence and clinical guidelines or protocols; working in a pain center or clinic, and 70/89 sites (78.7%) personal expertise and experience were less cited. were integrated into pain management teams; these pro- Considering these data, the proportion of sites that can portions were somewhat lower at private sites (data not be regarded as multidisciplinary lies somewhere between 38/ shown). Thirty-eight of the 71 respondents (53.5%) partic- 71 (53.5%) and 70/89 (78.7%), the proportions of sites in ipated in research and teaching activities. Nearly all made which respondents participated in teaching and research contributions to conventions; the number of these contri- activities and being integrated into pain management teams, butions was significantly higher among physicians working respectively. Thus, it can be confidently said that the true in public and private practices (national conferences) or proportion of the target population is at least 43.1% (the among those working only in the private setting (interna- lower limit of the CI of the lowest of these proportions). tional conferences) (Table 1). About one-half contributed publications to biomedical journals and participated in research studies; the number of contributions was signifi- 3.2. Caseloads and Service Provision. Respondents per- cantly higher among physicians working in both the public formed a median of 150 first-time and 380 follow-up visits 4 Pain Research and Management Table 1: Respondents’ general characteristics and participation in teaching or research activities. Pain Research and Management 5 per year, of which 90 and 100, respectively, featured an by the patients themselves or appointments for a second interventional procedure. Second opinion visits were rare, medical opinion. yet significantly more frequent at private than public sites Like in a recent national report [33], just over half the (Table 2). Median wait times were short at private sites (4.5 respondents participated in teaching and research activities, and 15 days for initial visits and 7 and 15 days for follow-up but the estimated proportion of sites that could be regarded visits in cancer and noncancer patients, respectively) and as multidisciplinary (over 53.5%) was slightly higher than long at public sites (7 and 90 days for initial visits, and 15 and nationwide [34]. Although the lower confidence limit of 90 days for follow-up visits in cancer and noncancer pa- 41.3% is not above the national figure, the actual proportion tients, respectively); this difference was statistically signifi- is probably higher because multidisciplinarity does not cant for all types of visits (Table 2). Compliance with wait necessarily entail teaching and researching [28, 29]. Figures time standards was good in private sites and poor in public in other countries were lower or similar, supporting the sites. In both settings, preference was given to cancer pa- external validity of our result, yet the authors also faced tients. Patients were often referred to pain facilities by difficulties in establishing the actual proportion of multi- trauma surgeons, primary care physicians, or neurosur- disciplinary facilities [20, 23, 35–37]. geons. About one-fifth of patients went on their own ini- The lengthy wait times suggest enduring difficulties in tiative, this proportion being significantly higher in the accessing pain services. Except for the first visits of cancer private setting. The main reasons for referral were poor pain patients, wait times at public sites were longer than rec- control (especially in public settings) and the lack of a ommended [38], even though they were shorter than in satisfactory pain diagnosis (more common in private previous surveys [23]. As others have reported [23, 39, 40], practices) (Table 2). The need for interdisciplinary care and a private sites managed to operate with significantly shorter better management of drug toxicities were also common. times and stay within the proposed ranges. Although our Supplementary Materials provide some additional results on delays were in general well below the recommended 6- service provision. month maximum term, this should be improved to ease access for those who do not have access to private healthcare and avoid the deleterious effects associated with delayed pain 3.3. Resources and Staff. Information on facilities and ser- care [41]. The latter is particularly relevant in patients re- vices was available from 82/92 and 79/92 sites (89.1% and ferred to specialized care, who usually present emotional 85.9%), respectively. These results are summarized on distress or psychiatric comorbidities as a result of a lengthy Table 3 and detailed in Supplementary Materials. experience with pain [42] and who appear able to benefit Figure 2 describes the staff composition (other than the from integrated psychological therapies [43]. respondent) of the pain treatment facilities. Professionals A variety of healthcare workers should staff multidis- who commonly worked with the respondents were nurses, ciplinary pain centers or clinics including physicians, nurses, who were present in 49/71 sites (69.0%), other pain clinicians mental health professionals, and physical therapists [18, 28]. in 45/71 (63.4%), psychologists in 40/71 (56.3%), and re- Notably, the availability of psychologists, psychiatrists, re- habilitation specialists in 37/71 (52.1%) sites. Nurses, social habilitation physicians, internal medicine specialists, phys- workers, and rehabilitation physicians were more frequent at ical therapists, and social workers was greater than at the public sites, although statistical significance was just reached national level [33] and compatible with our estimations of for the latter after multiplicity adjustment, whilst dieticians the availability of multidisciplinary services. However, were significantly more frequent at private sites. In 38/72 psychologists, psychiatrists, and physical therapists, who are sites (52.8%; 50.0% public and 59.1% private), the respon- part of the required core staff [28, 29], were still lacking in dents felt that the staff was insufficient. The professionals in about one-half of the sites. Although the national standards demand in 70–90% of sites were physical therapists, psy- also allow for less developed structures regarded as “uni- chologists, rehabilitation physicians, and nurses (detailed disciplinary facilities” [18, 30], they should at least have one results not shown). Also, in private sites (14/16, 87.5%), the psychologist [18]. Indeed, the need for more psychologists need for more pain clinicians was cited. was frequently cited in this survey, and just one-fourth of patients received a psychological assessment during the 4. Discussion initial visits. Paying more attention to psychosocial factors was already recommended one decade ago [44], since failure This research has updated the general picture of to address the psychosocial components of the pain expe- healthcare management and resources for specialized rience can adversely affect the severity of symptoms, pa- treatment of pain in Catalonia and the Balearic Islands. tients’ adaptation, and response to treatment [44, 45], but Pain clinicians and services were reasonably available, there appears to have been little progress since then. Surveys although a substantial proportion did not offer multi- in other countries have also reported a relative lack of disciplinary care and fell under national standards in psychologists [20, 23]. terms of facilities and, at public sites, wait times. Some The initial search for practitioners providing care for resources were scarcer in private settings, but these were patients in pain yielded a total of 400 for a population of more accessible than the public facilities and sometimes 8,889,422 [46], which translates into a ratio of 4.5 per used as a second option, as suggested by the shorter wait 100,000 people, within the range of other medical specialties times and the greater volume of visits scheduled directly in Spain [47]. Therefore, assuming that the prevalence of any 6 Pain Research and Management Table 2: Caseloads and patterns of service utilization. Pain Research and Management 7 Table 2: Continued. 8 Pain Research and Management Table 3: Resources available at surveyed sites. Pain Research and Management 9 Nurses Other pain clinicians Psychologists Rehabilitation physicians p=0.050 Other pain clinicians (in a pain unit) Other medical specialists Physical therapists Internal medicine specialists Psychiatrists Social workers Dieticians p=0.050 Contract staff Acupuncturists Other 0 20 40 60 80 100 Percentage of sites (%) Public (n=50) Private (n=21) Total (public & private, n=71) Figure 2: Availability of peer staff at surveyed sites. Multiplicity-adjusted p values (from Chi-square or Fisher’s exact test) are indicated when there is a statistically significant difference between the groups (public and private). type of pain and chronic pain is 33% and 20%, respectively previous surveys in Spain that revealed a number of issues, (see Introduction), the resulting ratios are 7,334 and 4,445 including the insufficient coordination with primary health patients per physician. These figures clearly improve pre- care, the lack of designated spaces, inappropriate support vious reports, but they still do not match the availability of staff, and the part-time dedication of practitioners specialists for other chronic conditions [44]. Given the [51, 53, 54], there was both improvement and stagnation. significant negative impact of long-term pain, it should be The facilities outperformed previous surveys regarding the considered why chronic pain is not being prioritized as other availability of designated spaces, consultation/examination long-term conditions [48, 49]. Besides the important per- rooms, waiting areas, block rooms, operating theatres, and sonal and societal costs, improper specialized management dedicated day hospitals. Day hospitals were in fact more of pain can also increase the burden of care [50]. widespread than in other regions of Spain [33] and other Also, this improvement should be interpreted with European countries some years ago [23, 55, 56]. On the other caution because our procedure to identify pain clinicians hand, especially at private sites, there was no progress in may have been overinclusive, which cannot be verified aspects such as the absence of nursing stations, adminis- without the information from those who failed to answer the trative and staff areas, rooms for clinic sessions, and dedi- survey. Furthermore, selection bias (which happens when cated hospitalization areas. Although most facilities had respondents disproportionately possess traits that affect the their own space, it was generally deemed insufficient. Op- outcome, such as much interest, longer clinical experience, erating theatres were well equipped but typically shared with or being more frequently employed at large-pain centers or other hospitals or healthcare services. clinics) is probable, since they are not a random selection of A wide offer of therapies, including pharmaceutical and all physicians invited. In fact, the proportion of pain centers interventional techniques, was reported, although the most and clinics identified (77 sites, which would represent 42.1% sophisticated interventions were available in half or less of of the total census of 183 units formerly compiled in Spain the sites (see Supplementary Materials). The respondents [33, 51]) clearly surpasses the 18.8% population share of the suggested that this could be improved. Thus, the incorpo- regions evaluated. Thus, even realizing that Catalonia has ration of either psychologists or interventional techniques more pain facilities than the rest of Spain [52], nonre- could contribute to expanding multidisciplinary care; the sponders would probably work in less structured and cost-effectiveness of these two strategies should be assessed equipped facilities than responders, who in some instances to set development priorities. would also have regarded any organized specialized pain Setting realistic expectations with pain patients is crucial practice as a pain center or clinic. Nonetheless, even if only [16]. Remarkably, patients’ expectations appeared to be 50–66% of the surveyed sites were truly multidisciplinary appropriate as up to 50% only awaited relief instead of cure. (see above), access to such care would be approximately one In consonance with the biopsychosocial model [57, 58], per 174,000–228,000 people, in line with or above other practitioners should acknowledge this fact to avoid merely countries [23] and Spain as a whole [34]. focusing on achieving cures, as this can become a source of Facilities and equipment differed between sites. Some frustration [59]. An opportunity is also provided to mod- lacked certain resources required by national standards [18] ulate the individual patient’s expectations according to the and international recommendations [28]. Compared to potential benefits and disadvantages of a treatment, which 10 Pain Research and Management could greatly impact patients’ satisfaction [60]. Psychosocial 5. Conclusions interventions may also have an important role here: when cure is not possible, which is unfortunately very common, This regional update shows that multidisciplinary working the success of biomedical interventions will greatly rely on patterns have not yet been universally adopted despite some how a patient is able to adapt and self-manage their advances in terms of accessibility, resources, and activities symptoms [42]. compared to previous reports. The private model of care The main limitation of this research stems from the seems to be more accessible than the public system just at the low response rate. Nevertheless, our 28.3% rate falls expense of a slight reduction in resource availability, and of within the expected participation in web-based physician nursing staff in particular, but it is restricted to patients who surveys [61], which has been as low as 11% in other recent can afford it. Shortening wait times in the public system anesthetists’ [62] or pain physicians’ surveys [63]. should be a priority to avoid delaying pain care for the Moreover, low response rates do not usually affect the numerous patients who cannot pay out of pocket for medical internal validity, but representativeness [64]. However, services. While some interventional techniques are still we have already discussed how selection and response lacking in several sites, the shortage of psychologists and biases can affect the external validity of the results and physiotherapists is of relevance. Future research should have given consistent cautious interpretations. In this address the comparative cost-effectiveness between incor- vein, as the responders most likely worked in more porating mental health professionals and the expansion of structured and equipped facilities than the physicians material resources and equipment, especially for the more who did not respond (see above), the availability of sophisticated procedures. services and resources may have been overestimated. However, the correspondence between ours and others’ Data Availability results in several aspects such as the availability of multidisciplinary facilities, the public-private difference No public access to the dataset is planned at this moment. in wait times, the lack of psychologists, or the size of Dr. Cristian Tebé, the Head of the Biostatistics Unit-IDI- population coverages supports the external validity of BELL, will oversee the dataset. Granting access to this in- this survey. Indeed, we think that the participation of formation will be evaluated on a case-by-case basis, upon more than one physician per center is unlikely. There- reasonable request by the interested party, and with per- fore, the proportion of centers represented would be mission from Dr. Antonio Montes, President of the Catalan considerably higher than that of physicians, as their Pain Society. geographical dispersion suggests (Figure 1). Validity apart, this fact boosts the study’s reliability too, because Conflicts of Interest it makes replication of the main results likely regardless AS has received honoraria for the Advisory Board from of the particular clinician reporting from each site. Esteve and consultancy fees from Grünenthal Pharma, Nevertheless, we could not quantify the actual number of Kyowa Kirin, Esteve, and Neuraxpharm, and travel and participants per site because personal data protection congress fees have been financed by Grünenthal Pharma and laws prevented us from knowing their identities. Hence, Neuraxpharm. JV has received honoraria for drafting the magnitude of bias attenuation is uncertain and as is manuscripts for Grünenthal Pharma, Lilly, and Esteve and some degree of data clustering that could not be has received consultancy fees from Amadix, Grünenthal accounted for in statistical inferences. Although we Pharma, Esteve, Novartis, and Vivia Biotech. The remaining sought the views of several specialties, nearly all the authors declare that they have no conflicts of interest re- respondents were anesthesiologists. Still, these are well garding the publication of this paper. placed to report on pain services, which they typically lead and staffed. Another limitation is that survey-based self-reported studies are subjected to reporting biases if, Authors’ Contributions for instance, respondents tend to select more desirable Javier Medel, Ancor Serrano, and Carme Batet contributed outcomes. But as mentioned, the usefulness of physician equally to this work. surveys to evaluate pain treatment facilities is widely accepted [25]. Unobserved variables, such as the time Acknowledgments since founding, the actual number of professionals, or the most prevalent diagnoses at each site, could partially The authors thank all respondents from Catalonia and the explain why some standards were not met. Without this Balearic Islands, without whom this work would not have information, we could have overlooked potential inter- been possible. Also, thanks to Esther Garcia-Lerma MSc and vention targets. Lastly, we have regarded the facilities Cristian Tebé MSc PhD from UBiDi (Unitat Bioestadı́stica staffed by diverse healthcare professionals as just mul- IDIBELL) for their support on REDCap electronic data tidisciplinary since the proportion of truly interdisci- capture tools and statistical analysis, Sarah Cousins for her plinary centers, in which professionals share therapeutic proofreading and editing of the English language during aims and communicate regularly with each other to align manuscript preparation, and Mr. Jaume Solé (Acadèmia on diagnosis, therapeutic plans, and objectives, is Ciències Mèdiques de Catalunya, the authors de Balears) for uncertain. his support in sending the emails to potential participants. Pain Research and Management 11 This research has received funds from the Catalan Pain [15] D. C. Turk and A. Okifuji, “Psychological aspects of chronic Society. pain,” in Principles and Practice of Pain Medicine, C. A. Warfield, Z. H. Bajwa, and R. J. 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