Friday, September 20, 2013

Pain Control & Patient Satisfaction Differ

Pain SurveyTo date, few studies have investigated the direct association between pain-intensity scores and patient satisfaction with the control of their pain. A newly reported study found, surprisingly, that there is no statistical association between pain relief and patient satisfaction with their pain management; however, there were some important limitations and deficiencies of this important investigation to consider.

Shay Phillips — of the University of North Carolina at Chapel Hill, School of Medicine — and colleagues observe that the primary assessment tool used by most healthcare providers to measure the outcomes of pain management programs is the standard 0–10 numerical rating scale (NRS) of pain intensity [Phillips et al. 2013]. However, it is unclear if this clinical tool should be used as the sole indicator of positive outcomes of pain therapy and interventions. Furthermore, while it might be assumed that pain-intensity scores — however, measured — would be correlated with patient satisfaction, few studies have adequately evaluated the association.

Writing in the September online edition of the Journal of Pain Research, the researchers report on a pilot study investigating the relationship between pain intensity and patient satisfaction. During a 7-day period they surveyed patients who received opioid analgesics in general surgery, post-trauma, and oncology departments at a 1018-bed acute care institution. A 14-question survey was adapted from a questionnaire developed by the American Pain Society to assess patient pain control and overall satisfaction with an institution's pain management strategies.

Of 288 surveys distributed, 76 patients provided complete responses to questions on both level of pain and overall level of satisfaction during the prior 24 hours. Respondents were mainly female (63%), Caucasian (67%), and 51±17 years of age on average. Almost all patients (89%) experienced significant pain and about half (51%) reported a mean pain score >5 on a 0-10 NRS (mean 5.5±2.3).

The researchers found no statistical association between pain-intensity score and patient satisfaction with overall pain management (Spearman's rank correlation coefficient = −0.31; 95% Confidence Interval, −0.79 to 0.39). The vast majority of patients surveyed were satisfied (45%) or very satisfied (41%) with their overall pain management, regardless of their pain-intensity scores.

Phillips and colleagues conclude that their findings contribute to a general understanding that healthcare providers and institutions should use pain-intensity scores together with various measures of patient satisfaction with pain treatment when assessing adequacy of patient care and developing quality control programs.

COMMENTARY:

Before going further, it must be noted that there was a fatal failing of this research investigation that questions its validity. Specifically, because there were only 76 fully completed surveys, there were too few subjects to yield statistically significant and reliable outcomes.

The researchers had estimated that, to validly depict significant effects, 150 completed surveys would be needed to achieve 95% statistical power, p=0.05. With only 76 completed surveys in this study, and consequent limited power, the lack of correlation between patient pain-intensity scores and satisfaction may have occurred by random variation or chance alone.

The researchers do not indicate why they did not extend the survey-collection period beyond one week to achieve more responses, nor do they name the specific institution at which the investigation took place — both of which are problematic omissions. It always is of concern when patients’ time and effort are enlisted for research purposes, even for noninvasive studies such as this, when too few subjects are enrolled to achieve worthwhile (reliable and valid) results.

The researchers duly acknowledge the shortcomings in their report, and label their efforts as a “pilot study.” However, one might question why a study like this would even be published when results are so unreliable.

One reason might be that this is a critically important topic, worthy of further consideration by all healthcare providers. As Phillips and colleagues point out, many healthcare practitioners have a misconception that low pain-intensity scores equate to patient satisfaction and, conversely, high pain scores will foster dissatisfaction. However, pain-severity scales alone are inadequate measures because they do not take into account the vitally important biopsychosocial aspects of the pain experience, which should not be overlooked.

PainSatisfactionWithout doubt, the amount of pain relief achieved is an important factor for patients; however, typical pain-rating scales do not consider the complexity of most pain conditions or the multifaceted aspects of pain management. Phillips and colleagues suggest that, within the hospital setting in particular, there are a number of other factors that come into play (see Figure). These would include patient education and provider communication on pain treatment goals and expectations, as well as the empathy of healthcare providers and their responsiveness to patient desires for pain relief.

Of significant importance are patient perceptions that healthcare staff are sensitive to their needs for pain relief, responsive, and sufficiently attempting to relieve their pain. That is, as Phillips et al. suggest, patient satisfaction ultimately may be a reflection of the performance of healthcare providers and not merely an indication of the degree of pain relief.

It appears from this study, and others cited by Phillips et al., that when healthcare staff’s attempts to relieve pain are judged as sufficient by patients, satisfaction with pain control increases even though the pain itself may not be fully relieved. This needs further study in both acute and chronic, inpatient and outpatient pain treatment settings, but it also must be recognized that there are many limitations and potential sources of response bias in studies using patient self-report questionnaires.

REFERENCE: Phillips S, Gift M, Gelot S, Duong M, Tapp H. Assessing the relationship between the level of pain control and patient satisfaction. J Pain Res. 2013(Sep);6:683-689 [article here].

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