What Does This Actually Mean?’ When Excellence in Pain Medicine Is Questioned

On the surface, a center of excellence (COE) recognition can beguile patients, providers and administrators alike. This is because COE should mean comprehensive, patient-centered and multidisciplinary care that offers “excellent healthcare.” In fields other than pain medicine, this is often the case. For instance, bariatric COEs are developed by surgical societies and accrediting bodies. These bariatric COEs are emblematic of transparent, evidence-based standards: minimum procedure volumes, demonstrated outcomes, structural capabilities and adherence to rigorous patient safety protocols, as pointed out in an editorial scheduled to be published in the Journal of Pain Medicine.

In an interview with Pain Medicine News, authors Michael E. Schatman, PhD, of the Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, in New York City; Scott G. Pritzlaff, MD, of the Department of Anesthesiology and Pain Medicine, University of California, Davis; and Samir J. Sheth, MD, of the Sutter Neuroscience Institute, Interventional Pain Medicine, Sutter Health, Roseville, Calif., reflected on the ulterior influence of COE designations in pain medicine—where this accolade is often bequeathed by industry interests in return for utilizing their devices for minimally invasive pain procedures.

“The narrative is you have a sales representative standing next to a proud physician—with either boxes of product or a shiny banner—saying, ‘We’re so excited to proclaim this physician’ or ‘this center as a center of excellence.’ On the surface, in a very superficial way, it makes everyone feel good. But [in reality], we ask the question, ‘What does this actually mean?’” Pritzlaff pondered.

Unmet Need

The American Pain Society and others once awarded reverential and robust COE designations that recognized programs advancing the field through rigorous multidisciplinary practice and innovation. However, this is no longer the case, with no pain societies in coordination with academic and community teams currently offering the designation. According to the authors of the editorial, a lack of COE designations leaves an unmet need of evidence-based, whole-person care.

The authors concede that although industry-sponsored programs can offer some benefits—including post-procedural follow-up, professional development and broader procedural awareness—they risk becoming vehicles for “commercial expansion rather than clinical refinement.”

Industry-driven COEs require case minimums and nominal outcomes tracking, but too often, these are self-reported and unverified.

Utilizing procedural quantity as a proxy for quality—sans patient selection, procedural appropriateness or longitudinal outcomes—is reductive with potentially serious consequences, the authors argued.

Downstream Impact

The authors explained that academic pain centers, multidisciplinary practices, and rural or resource-limited programs could be excluded from COE designation because they do not align with an industry-centric rubric—and not because of poor outcomes.

“Despite delivering excellent care, practices that prioritize non-procedural therapies or remain independent from commercial affiliations risk being marginalized,” the authors wrote.

In an interview with Pain Medicine News, of which he is an editorial advisory board member, Schatman said he is concerned that “if word gets out there that this is how you become a center of excellence, I’m afraid that everyone’s going to get ‘Stimulator X,’ because the [manufacturer] gives out that designation. This may not be the best stimulator for a lot of patients out there—exposing them to risks and unnecessary procedures.”

Academic pain centers also deal with complexity biases that industry-sponsored COE designations rarely acknowledge. These centers serve as catchments for the most challenging cases and offer more sophisticated care. They serve patients with multiple comorbidities, complex pain syndromes, previous treatment failures and psychosocial factors that confound management. Without risk adjustments, such centers could be considered less “excellent.”

“The current industry model, emphasizing procedural volume as well as success rates disconnected from case complexity, creates a perverse incentive structure in which centers might improve their metrics by simply avoiding complex patients. This undermines the mission of academic centers that should be intentionally accepting complex cases as part of their commitment to advancing care for all patients, regardless of complexity,” the authors noted.

Focusing on offering “one-and-done” treatments that are recognized in COE designations in lieu of longitudinal care could also undermine trust in the field of pain medicine.

“This is not good for pain medicine, it’s not good for patients and not going to make primary care happy. Primary care is progressively less trusting of pain medicine as a discipline,” Schatman said.

The authors explained that for patients, navigating a pain care milieu is already challenging without potentially misleading quality designations. Patients interpret COE as a marker of superior care—without appreciation of commercial stakeholders responsible for such designations. This information asymmetry potentially derails informed consent and patient autonomy.

Pritzlaff also worries that promotion of COEs on social media could contribute to disinformation among patients.

“What you’re finding is that companies have kind of drilled into this idea that people consume content that way,” he said.

COE-affiliated practices could also be preferentially assigned for data collection, with future trials biased toward high-volume, rarefied cohorts. This preference could limit generalizability and bias outcomes in favor of institutions that purchase products or services from manufacturers responsible for granting such COE designations. This development could undermine the legitimacy of trial data, the authors admonished.

The overutilization of certain devices and procedures could also saturate the market.

”We all know that if a therapy is dramatically overutilized in a short period of time, that absolutely can affect coverage,” Pritzlaff said.

In an interview with Pain Medicine News, Sheth expressed concerns over how COE status may stoke division in the field of pain medicine.

“COEs create unnecessary competition between physicians in otherwise collaborative markets. The field of pain management is divisive enough with various ‘hit pieces’ against our field that require much of our time to combat. Instead, we should collaborate and come together to be unified in our approach within the field. Ultimately, this helps our patients maintain access to highly effective interventions.”

Path Forward

The authors stressed that standards should stem from transparency, impartiality and patient-centered metrics to enhance pain care. Volume can be used as one parameter to define a COE, they conjectured, but other metrics such as outcomes, infection rates and complication rates should also be considered.

“It needs to be a very patient-centric set of criteria that really focus on outcomes that aren’t largely volume based,” Pritzlaff stated.

Independent bodies could award COE designations with delineated criteria, publicly accessible data and robust, peer-reviewed oversight.

One idea is to qualify COE status in broader terms, such as neuromodulation, Schatman said. But even then, there could be conflicts of interest.

“Neuromodulation societies are hugely backed by industry. I’d be afraid with a number of societies, [it would be] meaningless if they put together a reportedly objective platform for awarding such designation. It would be badly colored,” he said.

A path to COE designation should not be led by prestige, branding, marketing or procedural counts but rather meaningful outcomes, ethical integrity and commitment to patients. To accomplish this goal, professional societies must “reassert leadership in defining and recognizing quality care,” the authors wrote.

Clinicians should critically assess industry designations and prioritize evidence-based practice over promotional affiliations. Patients should readily understand the meaning of these designations. Policymakers and regulators should peruse the association between industry-sponsored recognitions and coverage decisions that may influence access to care.

According to the authors, pain specialists should laud centers that are committed to comprehensive care and reclaim the narrative of excellence. The focus should be appropriate intervention selection, equitable access and meaningful long-term outcomes.

With the cooperation of these various stakeholders, COE designations for pain centers might once again be synonymous with transparency, equity and patient advocacy.

Ultimately, however, there may be no good solution as of yet for the controversy over industry-backed COEs and better alternatives. Instead, the current focus may be on starting a conversation, Pritzlaff said.

“If there’s one thing, that—like the headline or the distillation of what I think we’re trying to do—is we want to just have a conversation that there are some of these issues in pain medicine.”

Sheth summed up the issue as follows:

“While the development of industry-sponsored Centers of Excellence (COEs) presents several concerns, as outlined in our article, it has also inadvertently highlighted critical shortcomings in the current COE landscape. This increased visibility may serve as a catalyst for broader recognition of the need to establish independent, non–industry-sponsored COEs that prioritize objectivity and patient-centered care.”

—Naveed Saleh