A hybrid SWOT analysis of the neuromodulation process for chronic pain

According to recent surveys, one-in-five Europeans (19%) are estimated to suffer from chronic pain (Breivik et al, 2006). In Finland, the prevalence of chronic pain is 19–48%. Chronic pain is associated with significant physical and psychological comorbidity, such as depression and anxiety (Poole et al, 2009a). Neuromodulation therapies are indicated for selected patients with severe refractory neuropathic pain as a part of multidisciplinary care.

In spinal cord stimulation (SCS), therapeutic doses of electrical current are delivered directly to the spinal cord from the epidural space to the dorsal column. Multicontact electrodes are placed under fluoroscopic control over the posterior dura in the spinal canal. Two types of electrodes are used: (i) rigid flat electrodes, which are placed through hemilaminotomy under general anaesthesia, and (ii) wire electrodes, which are placed through a cannula under local anaesthesia. Selection of the electrode type is always patient-specific. Pain relief by a stimulator is tested for about 1week. With sufficient pain relief, a battery-driven stimulator is implanted under the skin, which can be controlled with a handpiece by the patient (Nissen et al, 2019).

The criterion for SCS implantation is intractable chronic neuropathic pain, which is refractory to conventional therapies, including oral analgesics and physical therapy. Before SCS implantation, any surgically treatable pathology, such as nerve root compression, must be ruled out. SCS is an effective treatment and can be used for any neuropathic pain, but the most common indication is failed back surgery syndrome (Mailis-Gagnon et al, 2004).

The precise mechanisms of action of SCS are still unknown. Stimulation of the dorsal column fibres may inhibit wide dynamic range (WDR) neurons, which act as gatekeepers of pain transmission in the dorsal horn (Zhang et al, 2014), or activate gamma aminobutyric acid (GABA)ergic inhibitory interneurons in the dorsal horn (Linderoth and Foreman, 1999). Activation of supraspinal mechanisms may also play a role, which is dependent on the stimulation waveform (Song et al, 2013). Suppression of the neuroimmune response (McCarthy et al, 2013), restoration of disbalance of autonomic nervous system activity (Goudman et al, 2019), and stimulation of peripheral release of vasodilatory proteins (Linderoth et al, 1994) are other postulated mechanisms.

Ineffective and inappropriate pain management generates avoidable costs, leading to repeat visits in primary care and referrals to specialists (Haanpää et al, 2009). Improving the management of neuromodulation treatment is essential because it is a multiprofessional and multidisciplinary process, involving resources from different wards and outpatient clinics. It is important for the success of the treatment that the patient receives timely information about the treatment, its expected benefits and its limitations. The patient also needs support, particularly when the treatment does not meet his/her expectations and inadequate or unsatisfactory treatment response must be accepted. Related hardware costs are high, and therefore there must be special attention to both the effectiveness and cost of the treatment.

Strengths, weaknesses, opportunities and threats (SWOT) analysis is a commonly used tool to analyse operational environments to attain a systematic approach and provide support for strategic decision-making (Hill and Westbrook, 1997). The purpose of applying SWOT is usually to develop and adopt a strategy resulting in a good fit between the internal and external operational environments and a good fit with the objectives of the decision-maker.

A'WOT is a hybrid method combining the SWOT analysis and any multiple-criteria, decision-aid method that yields analytical priorities for the SWOT factors and makes them commensurable (Kurttila et al, 2000; Kajanus et al, 2012). This enables more analytical SWOT procedures (Table 1).

Table 1. Comparison of different methods in hybrid operational environmental analysis

Method	Descriptions
SWOT	Strengths, weaknesses, opportunities and threats (SWOT) analysis is a commonly used tool for analysing operational environments to attain both a systematic approach and support for decision-making. In a SWOT analysis, the internal and external factors most important for the future success of a decision-maker are grouped into four categories: strengths, weaknesses, opportunities and threats (Wheelen and Hunger, 2008; Greco et al, 2016).
MCA	Multiple criteria analysis (MCA) methods are a family of methods that provide transparent and coherent decision support to facilitate communication in complex situations characterised by conflicting objectives, multiple alternatives and actors, and uncertain or insufficient information (Greco et al, 2016).
A'WOT	The idea in using MCA methods within a SWOT framework is to systematically evaluate the SWOT factors and make them commensurable as regards their intensities (Kajanus et al, 2012). SWOT provides the basic frame within which an analysis of the decision situation can be performed, and the applied MCA method enables a more analytical SWOT procedure. A hybrid method called A'WOT enables the use of any MCA method with SWOT.
SMART	The simple multi-attribute rating technique (SMART) provides a family of methods to implement in a simple way the principles of multi-attribute utility theory, where decisions depend on values and probabilities, both subjective quantities (Edwards and Barron, 1994).
Proximity analysis	Proximity analysis is an analytical technique used to determine the relationship between a selected point and its neighbours (units of analysis), for example, to identify the interconnectedness of internal and external factors in SWOT analysis.
PA'WOT	In this study, we developed and applied a new hybrid operational analysis called PA'WOT that combines basic SWOT, A'WOT, and proximity analysis in one solid hybrid analysis.

Table 1. Comparison of different methods in hybrid operational environmental analysis

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PA'WOT combines SWOT, A'WOT and proximity analysis in one solid analysis. This is done by combining the results of proximity analysis with the relative importance of SWOT factors before calculating global priorities. Global priorities are calculated based on the relative importance of SWOT factors, including two components:

• Relative importance based on participants' assessments

• Relative importance weighted with the results of the proximity analysis.

The Finnish Institute for Health and Welfare (2019)recommends ex ante impact assessment for anticipating the effect of a decision on human health and welfare, clarifying the impacts of different options and providing information for decision-making and to help with dealing with conflicts. This is the first attempt to apply this methodology in healthcare. In this study, an approach for holistically managing SWOT together with possible goals and potential actions to be included in the implementation of the strategy are presented.

The aim of this study is to determine what factors professionals perceived to affect patients' wellbeing in the neuromodulation process for chronic neuropathic pain.

Methods

Study population

The study population comprised four nurses (all female, aged 29–57) and four physicians (two male and two female, aged 38–51) on the neuromodulation team at Kuopio University Hospital (KUH). They were interviewed in three consecutive steps: (1) SWOT factors were identified and refined in consensus meetings between the participants; (2) each participant independently assigned mutual weights to the factors by answering a questionnaire; and (3) each participant rated the interconnectedness of internal and external factors by answering a questionnaire. All these interviews were carried out independently and anonymously to avoid bias.

Study environment

This study was conducted as part of the development of the neuromodulation process at KUH, which provides full-time acute and elective neurosurgical services for the 850 000 people in the catchment area in Eastern and Central Finland. Between 1995 and 2014, over 400 patients were treated with SCS at KUH.

During 2015, the KUH neuromodulation process was completely reorganised to meet the increasing patient flow and the complexity and versatility of the novel stimulation hardware from several manufacturers. Full-time dedicated neuromodulation nurses were recruited and trained to educate the patients and adjust the stimulators. At present, each year 40–60 patients are treated with SCS at KUH, and patient selection is carried out by a multidisciplinary treatment group (Figure 1).

Neuromodulation registry and measuring the outcomes of the neuromodulation process at Kuopio University Hospital

Prospective data collection at the KUH neuromodulation registry has been ongoing since 2015, including clinical data and patient reported outcomes, using questionnaires such as Beck's Depression Inventory (Beck et al, 1961), Beck's Anxiety Inventory (Beck et al, 1988), PainDetect (Freynhagen et al, 2006), Oswestry Disability Index (Fairbank and Pynsent, 2000), Sexual Quality of Life (Symonds et al, 2005; Abraham et al, 2008), 15D Quality of Life (Sintonen, 1981), Neuropathic Pain Impact on Quality-of-Life (Poole et al, 2009b) and Global Perceived Effect (GPE) (Dworkin et al, 2005). This allows the measurement of neuromodulation process outcomes using a total of 23 different indicators (Table 2), instead of using only the GPE scale as before. A logic model for the neuromodulation process in which inputs, outputs, and outcomes are logically arranged is shown in Figure2. In addition, retrospective data collection has been completed for all 460 SCS patients treated from 1995 to2014.

Table 2. Indicators of neuromodulation outcomes at Kuopio University Hospital

Measured process outcome	Indicator	Scale/Unit
Treatment outcome
▪ Depression	Beck's Depression Inventory (BDI)	0–63
▪ Anxiety	Beck's Anxiety Inventory (BAI)	0–63
▪ Neuropathic component of pain	PainDetect (Freynhagen et al, 2006)	0–38
▪ Functional capacity	Oswestry	0–100
▪ Sexual quality of life	SQOL-F/SQOL-M	0–100
▪ Quality of life	15D	0–1
▪ Neuropathic pain impact on quality of life	NePIQoL	42–210
▪ Global perceived effect	GPE	1–7
Trial outcome	Percentage of patients receiving permanent stimulator	0–100%
Explantation rate	Percentage of patients with explanted stimulator	0–100%
Complication rate	Percentage of patients with complications	0–100%
Medication use
▪ Neuropathic pain medication		DDD
▪ Opiates		DDD
▪ SSRI medication		DDD
▪ Benzodiazepines		DDD
Working capacity
▪ Sick leaves		Days/month
▪ Disability pension	Percentage of patients retired	0–100%
Process parameters
▪ Queuing time		Days
▪ Throughput time		Days
Patient satisfaction
▪ Query	Visual analogue scale, 15 questions	0–60
▪ Personal communication		n/a
▪ Social media		n/a
Personnel satisfaction
▪ Query	Overall satisfaction	1–3

DDD, daily defined dose (WHO Collaborating Centre for Drug Statistics Methodology, 2018); n/a, not applicable

Table 2. Indicators of neuromodulation outcomes at Kuopio University Hospital

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Neuromodulation nurses: advanced practice registered nurses

Full-time dedicated neuromodulation nurses started at the KUH neurocentre in January 2015. The work is done independently by the nurses in the outpatient clinic, the ward and the operating room. It involves programming the stimulator, which requires training and experience gained through work, as adjustments are always patient-specific. Patient education differs from that in regular nurses' work, as it involves the following: the preparation of patients for surgery, during which they are often awake; examining the stimulator and determining possible problems with the stimulation therapy; guiding the patient programmer; and, crucially, systematically collecting pain and quality of life measures. Shifting these tasks from the neurosurgeon has freed up outpatient clinic time for treatment decisions, for example, and yielded significantly shorter queuing times and better patient satisfaction.

Results

PA'WOT hybrid operational analysis

The mutual weights of SWOT categories and individual SWOT factors calculated using the PA'WOT hybrid operational analysis are shown in Table 3. The five most important factors were excellent or good treatment results, having neuromodulation nurses, having a well-functioning neuromodulation team, vulnerability because of the limited number of specialists, and the establishment of a pain centre.

Table 3. Mutual weights of SWOT categories and individual SWOT factors using the PA'WOT hybrid operational analysis method (the five most important factors are in blue)

SWOT factors	PA'WOT
Strengths	0.328
s1 Excellent / good outcome	0.038
s2 Continuous process development	0.032
s3 Research and data collection	0.032
s4 Long-term clinical follow-up	0.031
s5 Extensive expertise on different hardware	0.028
s6 Neuromodulation nurse	0.038
s7 Continuous professional training and education	0.033
s8 Dedicated operating theatre	0.030
s9 Open-minded introduction of novel modalities	0.029
s10 Well-functioning neuromodulation team	0.037
Weaknesses	0.162
w1 Cost–benefit analysis lacking	0.029
w2 Training of new specialists	0.034
w3 Vulnerability because of the limited number of specialists	0.037
w4 Scalability – difficulty in increasing volume	0.031
w5 Expertise in stimulator programming limited tonurse	0.030
Opportunities	0.292
o1 Additional resources for research and development	0.035
o2 Appropriate marketing and public relations	0.031
o3 Audited and quality-certified process	0.032
o4 Freedom of choice between different manufacturers	0.031
o5 Establishment of pain centre	0.041
o6 Enlightened leadership in hospital	0.033
o7 Public health insurance	0.030
o8 Freedom of choice between healthcare providers	0.031
o9 National database for monitoring quality of care	0.029
Threats	0.219
t1 Insufficient human resources	0.035
t2 Insufficient marketing and communication	0.027
t3 Lack of incentives	0.028
t4 Insufficient resources at outpatient clinic	0.030
t5 Increasing number of patients	0.030
t6 Lack of resources for pain management	0.035
t7 Unawareness of therapy / hostile attitude	0.033
Total	1.000

Table 3. Mutual weights of SWOT categories and individual SWOT factors using the PA'WOT hybrid operational analysis method (the five most important factors are in blue)

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The PA'WOT hybrid operational analysis comprises four steps: carrying out the SWOT analysis; assessment of mutual weights of different SWOT factors; assessment of proximities of internal and external factors; and finally, combining the results in a one solid hybrid analysis.

Identifying SWOT factors in consensus meetings

The SWOT factors were identified in two successive 2-hour meetings. Two nurses and two physicians from the neuromodulation team participated in the first meeting, and an additional physician participated in the second meeting. In the first meeting, the external methodology expert explained the basics of the methods, and then participants suggested possible factors for SWOT during a discussion. If two proposed factors were seen to represent the same entity, they were combined. The first meeting resulted in 16 identified strengths, four weaknesses, 18 opportunities, and eight threats. In the second meeting, these were discussed and reorganised by consensus into ten strengths, five weaknesses, nine opportunities and seven threats (Table3). Two more nurses participated in the subsequent meetings.

Assessing mutual weights of different SWOT factors

The mutual importance of the SWOT factors was determined separately within each SWOT group using the simple multi-attribute rating technique method (Edwards and Barron, 1994). One hundred points were given to the most important SWOT factor in the examined SWOT group, and the importance of other SWOT factors was determined in relation to the most important factor. Next, the most important factors in each SWOT group were evaluated; 100 points were given to the most important of them, and others were determined in relation to the most important one. In this way, all the SWOT factors were scaled. This procedure allowed managing the problem where the number of factors differed considerably in different SWOT groups (for instance, only five weaknesses but ten strengths). Four nurses and four physicians (later participants) evaluated the factors individually and anonymously.

Assessing proximities of internal and external factors

Participants individually rated the interconnectedness of internal and external factors by answering whether, using this strength/weakness, it was possible to exploit this opportunity/threat using the scale from 1 to 3. The answer choices were:

1. Do not agree

2. Agree to some extent

3. Completely agree.

Basic results of A'WOT and proximity analysis

The results were calculated using the following inputs: average of all, average of nurses, average of physicians, and maximum and minimum values (Figure 3). The results were presented in a meeting of the neuromodulation team. The results provided the basis for discussions of the overall averages, the differences among nurses and physicians and the sensitivity of the results.

The overall analysis emphasised strengths (relative weight 0.36) and opportunities (0.28) more than weaknesses (0.15) and threats (0.21). The physicians emphasised the strengths and threats more than the nurses (0.37 and 0.34 and 0.22 and 0.21, respectively), whereas the nurses emphasised the weaknesses and opportunities more than the physicians (0.16 and 0.14 and 0.29 and 0.27, respectively). All respondents evaluated the mutual importance quite similarly (deviation was low).

The proximity analysis of the operational factors revealed that having neuromodulation nurses (s6) was the most important for deploying opportunities. Together with research and data collection (s3), they enable the utilisation of the national neuromodulation database (o9). Extensive expertise in different hardware (s5) enables freedom of choice between different manufacturers (o4). The most important factor for preventing threats was the training of new specialists (w2). Continuous professional training and education (s7) and a well-functioning neuromodulation team (s10) enable an audited and quality-certified process (o3) and the establishment of a pain centre (o5) (Figure 4).

Global priorities were calculated based on the relative importance assessed by the participants, weighted by the results of the proximity analysis. The proximity analysis consists of the matrix of internal and external SWOT factors indicating the interconnectedness of the factors, each cell having a sum of the participants' assessments (1–3). The row sum represents the proximity value of the particular internal factor, and the column sum represents the proximity value of the particular external factor. The proximity values were scaled so the biggest proximity value of 319—Establishment of pain centre (o5)—was given 100 points, and the value of the other factors was calculated in relation to that. In terms of relative importance, the proximity values received a weight of 0.3 (seen as value-adding inputs), and the relative importance of the SWOT factors assessed by the participants received a weight of 0.7 (seen as a baseline for the analysis).

Discussion

Relevant results of the present study

The objective of this study was to find out which factors were perceived by professionals to affect patients' wellbeing in the neuromodulation process for chronic neuropathic pain. The results of the hybrid operational environmental analysis indicated that the most important factors were excellent or good treatment results, continuous process development, having neuromodulation nurses, having a well-functioning neuromodulation team and the establishment of a pain centre. These factors have short-, medium- and long-term impacts, as explained in Figure 2.

As a long-term outcome, patients must be provided with up-to-date evidence-based care. To accomplish this, the neuromodulation team has to cooperate and develop the treatment path continuously. They must also listen to the patients' wishes regarding their care. The team's performance is ensured through continuous training, and when all these things are taken into account, the team can anticipate the threats associated with ignoring the pain path and avoid them.

This study shows how important the fluency of the treatment path and the neuromodulation practitioner nurse who coordinates the treatment with the treating physician and the other members of the multi-professional team are in the treatment of pain patients. We need to consider that professionals can change their jobs. Therefore, there cannot be just one person with such special knowledge and skills; there must be several professionals with the same skills and knowledge. The emphasis must be on transferring knowledge to others, and recruiting has an essential role in this.

Applicability of SWOT

SWOT analysis is a widely applied tool also in the healthcare sector (van Wijngaarden et al, 2012). Too often, it has remained at the level of just pinpointing factors. Furthermore, SWOT itself includes no means for quantifying the importance of factors (Hill and Westbrook, 1997; Ip and Koo, 2004). The A'WOT method was first presented by Kurttila et al (2000) in natural resources management. Later, the hybrid A'WOT method was widely used in different application fields, such as e-government (Kahraman et al, 2007), bioenergy (Okello et al, 2014), the pulp and paper industry (Posch et al, 2015) and tourism management (Heidari et al, 2014). Nikolić et al (2015) applied fuzzy analytic hierarchy process (AHP), and Yüksel and Dagdeviren (2007) used the analytic network process in the A'WOT framework. Other MCA methods have also been applied within the A'WOT framework, such as stochastic multi-criteria acceptability analysis (SMAA) (Kangas et al, 2003), elimination and choice expressing reality (ELECTRE) (Borajee and Yakchali, 2011), the preference ranking organisation method for enrichment evaluations (PROMETHEE) (Dagdeviren, 2008) and the simple multi-attribute rating technique (SMART) (Kajanus et al, 2004; Kuo, 2008). Kangas et al (2016; 2017) developed hybrid SWOT methodologies.

Neuromodulation treatment is a multi-professional and multi-disciplinary endeavour; therefore, it is important to recognise and assess the interconnectedness of the relevant factors. Consequently, we implemented the proximity analysis to analytically determine the interconnectedness of internal and external factors in SWOT analysis. We developed a new hybrid operational analysis called PA'WOT to combine basic SWOT, A'WOT and proximity analysis in one solid hybrid analysis.

PA'WOT was based on two separate individual evaluations (the evaluation of SWOT factors for A'WOT and the evaluation of proximities). Together, these two evaluations took about 1 hour for each participating individual. The PA'WOT analysis indicated more value for the weaknesses and threats in general. The additional resources for research and development, the value of continuous development, the vulnerability because of the limited number of specialists, the lack of cost–benefit effectiveness analysis and the nurses' expertise in the stimulation programming increased in importance in the PA'WOT analysis. The value added by PA'WOT analysis in this study was remarkable.

Further development of neuromodulation management requires the coordination of different perspectives (those of neuromodulators, nurses, other staff, hospital administration, patients, the KUH catchment population and other hospitals) and stakeholder consultation and ideas, as no single individual/party has full knowledge of the subject.

Limitations of the study

We were unable to recruit all physicians and nurses to the study at once. Our neuromodulation team started with two physicians and two nurses, who were recruited to the first meetings. Due to expanding patient volume, a further two physicians and two nurses were employed, and they were recruited to the study immediately after joining our neuromodulation team. They filled all questionnaires independently, without knowing the results from other participants. Hence, we feel that the results were not biased, even though some of the physicians and nurses were added to the study at later dates.

Conclusions

This study highlights the importance of neuromodulation nurses and teamwork in chronic pain neuromodulation. The establishment of a multi-disciplinary pain centre for the treatment of these patients is strongly recommended.

Input–output, SWOT, A'WOT and proximity analysis comprised a logical and understandable methodology chain, and the results were combined in one solid hybrid analysis called PA'WOT. The methodology allowed the participants to jointly analyse the results of this study. The PA'WOT method can be recommended for use in other similar contexts.

KEY POINTS

• Advance practice registered nurses (neuromodulation nurses) have a key role in the treatment of patients who receive spinal cord stimulation, or other neuromodulation, for chronic neuropathic pain

• With better patient education and regular follow-up visits that include stimulator adjustments, patient satisfaction can be increased and costly devices used more efficiently

• Strengths, weaknesses, opportunities and threats (SWOT) analysis of the operational environment is recommended to further improve the neuromodulation treatment process in a hospital

• Factors that are most likely to affect patients' wellbeing are: (1) excellent or good treatment results; (2) having neuromodulation nurses; (3) having a well-functioning neuromodulation team; (4) vulnerability because of the limited number of specialists; wa pain centre.

CPD reflective questions

• What factors affect patients' wellbeing most in theneuromodulation process for chronic neuropathic pain?

• What is the role of advanced practice registered nurses (neuromodulation nurses) in the treatmentprocess?

• What is the role of strengths, weaknesses, opportunities and threats (SWOT) analysis of the operational environment in the development of theneuromodulation process for chronic neuropathic pain?