Does Screening for Pain Correspond to High Quality Care for Veterans?
Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear.
To assess adherence to measures of pain management quality and identify associated patient and provider factors.
A cross-sectional visit-based study.
One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients.
MEASUREMENT AND MAIN RESULTS
We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that “patients want me to ask about pain” and “pain can have negative consequences on patient’s functioning”. Charts were more likely to document character of pain if providers agreed that “patients are able to rate their pain”. Patients with musculoskeletal pain were less likely to have chart documentation of character of pain.
Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.
- Gureje O, Simon GE, Von Korff M. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92:195–200. CrossRef
- Chodosh J, Solomon DH, Roth CP, Chang JT, MacLean CH, Ferrell BA, Shekelle PG, Wenger NS. The quality of medical care provided to vulnerable older patients with chronic pain. J Am Geriatric Soc. 2004;52:756–61. CrossRef
- Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006;21(6):607–12. CrossRef
- Krebs EE, Carey TS, Weinberger M. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med. 2007;22(10):1453–8. CrossRef
- Pain Assessment: The Fifth Vital Sign. Available at http://www.rn.ca.gov/pdfs/regulations/npr-b-27.pdf Accessed February8, 2010.
- Lorenz KA, Sherbourne CD, Shugarman LR, Rubenstein LR, Wen L, Cohen A, Goebel JR, Hagenmeier EM, Simon B, Lanto A, Asch SM. How reliable is pain as the 5th Vital Sign? J Am Board Fam Practice. 2009;22(3):291–8. CrossRef
- VHA Directive 2003-021: Pain Management. 2003. Available at http://www1.va.gov/geriatricsshg/docs/PainManagement.pdf Accessed February 8, 2010.
- JCAHO Standards for Pain Management. Available at http://www.texmed.org/Template.aspx?id=2392 Accessed February 8, 2010.
- Pain as the 5th Vital Sign Toolkit. Available at http://www1.va.gov/pain_management/docs/TOOLKIT.pdf Accessed on February 8, 2010.
- National Cancer Institute. Theory at a glance: a guide for health promotion practice. U.S. Department of Health and Human Services; 2005.
- Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs: Prentice Hall; 1980.
- Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211. CrossRef
- Henke RM, McGuire TG, Zaslavsky AM, Ford DE, Meredith LS, Arbelaez JJ. Provider and organizational-level factors in the adoption of evidence-based care for depression in primary care. Health Care Manage Rev. 2008;33(4):289–99.
- Wenger NS, Shekelle PG, ACOVE Investigators. Assessing care of vulnerable elders: ACOVE project overview. Ann Intern Med. 2001;135(8 Pt.2):642–6.
- Shekelle PG, MacLean CH, Morton SC, Wenger NS. Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med. 2001;135(8 Pt.2):647–52.
- Chodosh J, Ferrell BA, Shekelle PG, Wenger NS. Quality indicators for pain management in vulnerable elders. Ann Intern Med. 2001;135(8 Pt.2):731–5.
- Wenger NS, Roth CP, Shekelle P, ACOVE Investigators. Introduction to the assessing care of vulnerable elders-3 quality measurement set. JAGS. 2007;55:S247–S252. CrossRef
- Assessing care of vulnerable elders-3 quality indicators. JAGS. 2007;55:S464–S487.
- Asch SM, McGlynn EA, Hogan NM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141(12):938–45.
- McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(266):2635–45. CrossRef
- Du Pen SL, Du Pen AR, Polissar N, Hansberry J, Kraybill BM, Stillman M, Panke J, Everly R, Syrjala K. Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. J Clin Oncol. 1999;17(1):361–70.
- Dobscha SK, Corson K, Flores JA, Tansill EC, Gerrity MS. Veteran’s affairs primary care providers’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008;9(5):564–71. CrossRef
- Jamison RN, Gitner L, Rogers JF, Fairchild DG. Disease management for chronic pain: barriers of program implementation with primary care physicians. Pain Med. 2002;3(2):92–101. CrossRef
- Montauk SL, Martin J. Treating chronic pain. Am Fam Physician. 1997;55(4):1151–60.
- Goebel JR, Doering LV, Evangelista LS, Nyamathi AM, Maliski SL, Asch SM, Sherbourne CD, Shugarman LR, Lanto AB, Cohen A, Lorenz KA. A comparative study of pain in heart failure and non-heart failure veterans. J Card Fail. 2009;15(1):24–30. CrossRef
- Sherbourne C, Asch S, Shugarman L, Goebel J, Lanto A, Rubenstein L, Wen L, Zubkoff L, Lorenz K. Early identification of co-occurring pain, depression and anxiety. J Gen Intern Med. 2009;24(5):620–5. CrossRef
- Meredith LS, Mendel P, Pearson M, Wu SY, Joyce G, Straus JB, Ryan G, Keeler E, Unutzer J. Implementation and maintenance of quality improvement for treating depression in primary care. Psychiatric Serv. 2006;57:48–55. CrossRef
- Hepner K, Rowe M, Rost K, Hickey SC, Sherbourne C, Ford DE, Meredith LS, Rubenstein LV. The effect of adherence to practice guidelines on depression outcomes. Ann Int Med. 2007;147:320–9.
- Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC, Carr DB. American pain society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med. 2005;165:1574–80. CrossRef
- Mularski RA, Heine CE, Osborne ML, Ganzini L, Curtis JR. Quality of dying in the ICU: ratings by family members. Chest. 2005;180:280–7. CrossRef
- Jensen MP, Karoly P. Self-report scales and procedures for assessing pain in adults. In: MR TDC, ed. Handbook of pain assessment. New York: The Guilford Press; 2001:15–34.
- Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40(9):771–81. CrossRef
- Lorenz K, Krebs EE, Bentley T, Sherbourne C, Goebel J, Zubkoff L, Lanto A, Asch S. Exploring alternative approaches to routine outpatient pain screening. Pain Medicine. In press.
- Does Screening for Pain Correspond to High Quality Care for Veterans?
- Open Access
- Available under Open Access This content is freely available online to anyone, anywhere at any time.
Journal of General Internal Medicine
Volume 25, Issue 9 , pp 900-905
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- quality assessment
- Industry Sectors
- Author Affiliations
- 1. Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- 5. New England Health Care Engineering Partnership, 215 North Main Street (11Q), White River Junction, VT, 05009, USA
- 2. RAND Corporation, Santa Monica, CA, USA
- 3. David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- 4. Department of Nursing, California State University School of Nursing, Long Beach, CA, USA