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Measuring pain as the 5th vital sign does not improve quality of pain management

Abstract

BACKGROUND: To improve pain management, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative in 1999, requiring a pain intensity rating (0 to 10) at all clinical encounters.

OBJECTIVE: To measure the initiative’s impact on the quality of pain management.

DESIGN: We retrospectively reviewed medical records at a single medical center to compare providers’ pain management before and after implementing the initiative and performed a subgroup analysis of patients reporting substantial pain (≥4) during a postimplementation visit.

PARTICIPANTS: Unique patient visits selected from all 15 primary care providers of a general medicine outpatient clinic.

MEASUREMENTS: We used 7 process indicators of quality pain management, based on appropriately evaluating and treating pain, to assess 300 randomly selected visits before and 300 visits after implementing the pain initiative.

RESULTS: The quality of pain care was unchanged between visits before and after the pain initiative (P>.05 for all comparisons): subjective provider assessment (49.3% before, 48.7% after), pain exam (26.3%, 26.0%), orders to assess pain (11.7%, 8.3%), new analgesic (8.7%, 11.0%), change in existing analgesics (6.7%, 4.3%), other pain treatment (11.7%, 13.7%), or follow-up plans (10.0%, 8.7%). Patients (n=79) who reported substantial pain often did not receive recommended care: 22% had no attention to pain documented in the medical record, 27% had no further assessment documented, and 52% received no new therapy for pain at that visit.

CONCLUSIONS: Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.

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References

  1. 1.

    Kirsch B, Berdine H, Zablotsky D, et al. Management strategy: identifying pain as the fifth vital sign. VHSJ. 2000;49–59.

  2. 2.

    Health Care Advisory Board. Pain Management in the VA and the Private Sector. Washington, DC: The Advisory Board Company; 1998.

  3. 3.

    Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No.9. AHCPR Publication No. 94-0592. Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. Public Health Service, March 1994.

  4. 4.

    American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274:1874–80.

  5. 5.

    American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 4th edn. Glenview, IL: American Pain Society; 1999.

  6. 6.

    Veterans Health Administration National Pain Management Strategy. November 12, 1998.

  7. 7.

    Department of Veterans Affairs. VHA Directive 2003-021: Pain Management. May 2, 2003. Available at: http://www1.va.gov/pain_management/docs/VHAPainDirective_03.pdf. Accessed January 2005.

  8. 8.

    Veterans Health Administration Memorandum: Pain as the Fifth Vital Sign. March 1, 1999.

  9. 9.

    Veterans Health Administration. Pain as the 5th vital sign toolkit. October 2000, revised edition. Geriatrics and Extended Care Strategic Healthcare Group, National Pain Management Coordinating Committee. Available at: http://www.va.gov/oaa/pocketcard/pain.asp. Accessed January 2005.

  10. 10.

    American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274:1874–80.

  11. 11.

    JCAHO. Pain Assessment and Management Standards [online]. Available at: www.jcaho.org/standard/pm. Accessed July 16, 2002.

  12. 12.

    Doyle D, Hanks GWG, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd edn. Oxford, U.K.: Oxford University Press; 1998.

  13. 13.

    Hintze J. PASS User’s Guide. Kaysville, UT: NCSS; 2000.

  14. 14.

    Yadgood MC, Miller PH, Mathews PA. Relieving the agony of the new pain management standards. Am J Hospice Pall Care. 2000;17:333–41.

  15. 15.

    Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J. 1995;153:1423–31.

  16. 16.

    Rubenstein LV, Mittman BS, Yano EM, Mulrow CD. From understanding health care provider behavior to improving health care: the QUERI framework for quality improvement. Med Care. 2000;38:I129–41.

  17. 17.

    Weiner DK. Improving pain management for older adults: an urgent agenda for the agenda for the educator, investigator, and practitioner [comment]. Pain. 2002;97:1–4.

  18. 18.

    Du Pen SL, Du Pen AR, Polissar N, et al. Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. J Clin Oncol. 1999;17:361–70.

  19. 19.

    Demakis JG, McQueen L, Kizer KW, Feussner JR. Quality enhancement research initiative (QUERI): a collaboration between research and clinical practice. Med Care. 2000;38:I17–25.

  20. 20.

    Opioid therapy for chronic pain—clinical practice guidelines. Available at: http://www.oqp.med.va.gov/cpg/cot/ot_base.htm. Accessed January 23, 2005.

  21. 21.

    Department of Veterans Affairs. VHA Pain Outcomes Toolkit. February 2003. National VA Pain Outcomes Working Group, National VA Pain Management Coordinating Committee.

  22. 22.

    Craine M, Kerns RD. Pain management improvement strategies in the Veteran’s Health Administration. APS Bull. 2003;13 Available at: http://www.ampainsoc.org/pub/bulletin/sep03/articlel.htm. Accessed February 22, 2005.

  23. 23.

    Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141:938–45.

  24. 24.

    Kerr EA, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med. 2004;17, 141:272–81.

  25. 25.

    Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348:2218–27.

  26. 26.

    Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer SAGE study group. Systematic assessment of geriatric drug use via epidemiology. JAMA. 1998;279:1877–82.

  27. 27.

    Pahor M, Guralnik JM, Wan JY, et al. Lower body osteoarticular pain and dose of analgesic medications in older disabled women: the Women’s Health and Aging Study. Am J Public Health. 1999;89:930–4.

  28. 28.

    Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage. 2000;19:240–8.

  29. 29.

    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;348:2635–45.

  30. 30.

    Clark ME, Gironda RJ, Young RW. Development and validation of the pain outcomes questionnaire—VA. J Rehab Res. 2003;40:381–96.

  31. 31.

    Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA. 2000;283:1715–22.

  32. 32.

    Dresselhaus TR, Luck J, Peabody JW. The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record. J Med Ethics. 2002;28:291–4.

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Author information

Correspondence to Dr. Richard A. Mularski MD, MSHS.

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The authors have no conflicts of interest to report.

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Mularski, R.A., White-Chu, F., Overbay, D. et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med 21, 607 (2006). https://doi.org/10.1111/j.1525-1497.2006.00415.x

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Key words

  • pain
  • quality of health care
  • outcome and process assessment (health care)
  • pain measurement
  • quality indicators