The objective of this semi-systematic review identifies the challenges and barriers to patient journey optimization in various chronic pain such as low back pain, neuropathic pain, and osteoarthritis in Mexican patients and explores opportunities in the health system to establish a patientcentric chronic pain management model. Information on a patient journey in chronic pain in Mexico (awareness, screening, diagnosis, treatment, adherence, and control) was obtained from Embase, MEDLINE and BIOSIS, and national and global public portals. Data gaps were bridged by regional insights from experts. Except for the treatment, an alarming situation was observed for all touchpoints for chronic low back pain and osteoarthritis. A worse scenario was found for neuropathic pain with all the touchpoints affected. Evidence-informed healthcare decisions, continuing medical education for pain management, and an increase in patient awareness may bring improvement in Mexico. According to the Global Disease Burden (GBD) Survey in 2016, chronic low-back pain attributed to 56.7 million totals Years Lived in Disability (YLD). Moreover, the 2017 GBD survey observed that low back pain corresponded to a major proportion of YLDs with continuing increasing trend in percentage change from 1990 to 2017, thereby becoming the leading cause of disability for both genders. The prevalence of chronic pain in Low and Middle-Income Countries (LMICs) ranged from 6% (for typical conditions like fibromyalgia) to 48% (for common conditions majorly including musculoskeletal pain) in the general adult population as per a systematic review in 2016. The annual prevalence of low back pain among the adult United States (US) population was 10% to 30% in 2001 and the lifetime prevalence of low back pain in US adults was as high as 65% to 80% in 2010. The prevalence of low back pain in Latin America was found to be within this range (30%) in 2014. Chronic pain is defined as pain that lasts or recurs for more than 3 months. Chronic Low Back Pain With A Neuropathic Component (CLBPNeP) is difficult to diagnose because lack of a gold-standard approach  and also has a significant impact on patient’s adherence to the treatment. Comorbid risk factors like diabetes and mental health conditions may further aggravate the pain perception. Hence, the prevalence of chronic pain is likely to be estimated incorrectly due to overestimation from false diagnoses or underestimation due to lack of awareness. The Population, Concept, and Context (PCC) model will be used to guide study selection and to align the eligibility criteria with the research questions. Here, we will include an article that investigates what has been developed and/or evaluated for patients with chronic pain and OA (population), including data on clinical outcomes through knowledge of epidemiology and deterministic factors in chronic low back pain, OA, and Neuropathic pain management (concept). The context will be limited to a specific geographic location. Full-text quantitative or qualitative studies published from 2010 to 2019 will be included.

We performed a semi-scoping review with a structured and unstructured search. The detailed methodology for undertaking this review has been published recently. The databases considered for the structured search were Embase, MEDLINE, and BIOSIS through the OVID platform, and the sources for the unstructured search included websites of the World Health Organization (WHO), Mexican Ministry of Health, the Incidence and Prevalence Database (IPD), and Google. A comprehensive search strategy was developed to retrieve articles with data on a patient journey for chronic pain in Mexico. Chronic pain was defined as pain lasting >3 months, including osteoarthritis and chronic low back pain. Neuropathic pain was defined as pain due to a lesion or disease of the somatosensory system, including diabetic peripheral neuropathy and low back pain with a neuropathic component. There were additional targeted literature searches in consultation with local subject matter experts performed to get data on the subject matter and for guidance on health system-related issues. Retrieved records were screened by an independent reviewer and verified by another independent reviewer for a bias-free and error-free approach.

tudies were eligible for inclusion if they met the following criteria:

(i) peer-reviewed published systematic review and/or meta-analysis, randomized controlled study, observational study, and narrative reviews in English;

(ii) focused on the adult human population aged ≥ 18 years;

(iii) reporting quantitative data from the patient journey touchpoints for CLBP, OA, and Neuropathic, which includes awareness, screening, diagnosis, treatment, adherence, and control;

(iv) Full-text peer-reviewed articles (English language only);

(v) studies conducted on patient populations with chronic pain conditions, which is characterized as any pain continuing for longer than 3 months, focusing exclusively on LBP, OA, and Neuropathic.

A total of 258 records were retrieved from structured and unstructured searches based on the search strategy. No duplicates were found. On the basis of the relevance to the subject and study objectives, 69 records were excluded. Of 189 screened records, 182 records were excluded based on a mismatch with the country of interest, inclusion criteria, target population characteristics, and patient journey data requirements. This included seven articles excluded for miscellaneous reasons and 9 case reports. To fill the data gaps, eight additional records on both chronic and neuropathic pain were provided by the experts for local insights. Thus, 15 and 11 records were considered for qualitative and quantitative synthesis of extracted data respectively. The majority of patients with non-traumatic musculoskeletal pain used over-the-counter Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) on the basis of self-prescription or even alternative therapies despite questionable efficacy and safety.While OA and other rheumatic diseases were found prevalent in the rural population, the urban population had a comparatively higher prevalence of low back pain.We performed a semi-systematic review of available evidence on pain management scenarios in Mexico for patients with chronic pain conditions including OA, CLBP, CLBP-NeP, and DPN using a scoping review research framework (PCC model). This framework was suitable for this study as there was limited information available on various challenges in chronic pain care pathways. Moreover, the available information was heterogeneous and fragmented. Thus, an exploratory approach with comprehensive nature was deemed fit for our analysis.Major concerns related to chronic pain care pathways in Mexico were observed in form of poor resource allocation, lack of well-defined patient transit algorithms including effective referrals, and sub-optimal knowledge dissemination due to resource constraints. There is a significant d earth o f up-to-date clinical practice guidelines on pain management. Also, the status of validated pain screening/diagnosing tools in Spanish is not known. Clinical practice guidelines are available for public hospitals; however, their review has been pending for almost a decade. Thus, up-todate knowledge is not available to care practitioners on pain management. Also, there is the likelihood of ineffective clinical outcomes from alternative therapies with unclear regulations, fragmented availability, and limited knowledge of practitioners.

It can be concluded that for both chronic pain and neuropathic pain, patient journey touch points showed an alarming situation. The existence of a known-do gap, a high degree of heterogeneity in the target population, and subjective concerns impede the translation of pain management from evidence to practice in Mexico. Given the treatment challenges due to resource constraints, subjective preferences of GPs, and issues related to patient perceptions in Mexico. Thorough observation and analysis of health-seeking behavior and associated clinical needs may help to better understand pain from the patient’s perspective. Also, unlike the current case of provider-driven decision-making, patients should be educated, encouraged, and empowered for shared clinical decisionmaking. Last but not the least, outcome-oriented research like our study would be given paramount importance given the fact of booming use of patient-reported outcomes and health care quality. This would include components like periodic reviews of patient satisfaction, treatment feedback, patient engagement, and a high degree of research inclination towards the quality-oflife studies and economic evaluation of healthcare interventions, to name a few.

Regards,
Alisha
Journal Coordinator,
Journal of Medical & Clinical Reviews