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.


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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Mark S. Barletta said...

So patients where surveyed from a 7day period receiving opioid analgesics for general surgery, post trauma and oncology departments.

A questionnaire of 76 patients was completed on both level of pain and overall level of satisfaction during the past 24 hours.

I don’t see what good this would do when this may be the first time some of the people ever experienced pain, they have nothing to compare their pain to so how can the results worth any value.

SB. Leavitt, MA, PhD said...

Yes, Mr. Barletta, this was a weak study as I noted, but the subject is important and worthy of further investigation. However, considering that all subjects were adults, I doubt it was their first-ever experience of pain.

Mark S. Barletta said...

Mr. Leavitt,
I agree, but most patients that filled out the questionnaire had no tolerance to opioids and should be able to achieve pain relief relatively easy.

Maybe legislative should send a similar questionnaire to those that suffer from ongoing chronic pain. Ask if their receiving adequate pain relief for their ongoing chronic intractable pain. And if these people are not getting the pain relief they deserve then we must see to it they do get the pain relief they need and stop this negative attitude towards pain sufferers and stop hassling doctors that have enough compassion to help those that still have not found relief of their chronic pain.

Lets make a over all generic questionnaire for all that suffer from chronic pain.

At each appointment I go to I wonder and worry what that day may bring me, good news or more bad news.

NANCY From the Shore said...

Agreed, compassion from my Dr means everything because too many doctors that don't care, only worried for the DEA..I am grateful I left such a Dr to find someone w a great medical background and respected.I'm awake at 3am due to lovely pain..its been years.

MakeThisLookAwesome said...

As a pain patient, it's surprising to me that people would even suspect that low pain = high satisfaction and vice versa. That may work for acute pain, but chronic pain is MUCH different.

I can withstand amazing amounts of pain for a goal. And after 10 years of daily pain, I'm not most people. I can work through pain like anyone else. The pain of physical therapy can easily be overlooked and withstood, because the results are desirable: a higher level of functioning. It's only when the pain *stops* me that it's a problem. When that threshold is met, I'm in _severe_ pain that's a lot more difficult to control. Patient satisfaction rises when I know my doctor respects all this and will work with me to keep me working.

If we're *ignored,* patient satisfaction plummets. Chronic pain patients come up with complicated formula for when it falls into the category of requiring medical attention and when it doesn't, because we know that just because there's pain doesn't mean doctors need to be involved. But to that end, we seriously want medical attention when it becomes time to intervene.

If we know our doctor is there for us and will work to find an agreeable solution that is good *enough*, we can hang in there until such time, and will be satisfied in the meantime. If we think we're going to be left alone to suffer in silence, we're as wretched and desperate as a starving man.

Reta Russell Houghton said...

This is an interesting topic but I don't understand what they were trying to prove. I don't feel they really understand the different between acute and chronic pain and the overall effect on an individual. I think this study was directed to acute pain because chronic pain is such a complex issue. Too big to tackle.

Good pain control does not always equate to high satisfaction. A question not mentioned was the cost of pain relief (physical cost on the patient's body)? Many of us put up with some nasty side effects to get some relief. Constipation, GI distress, weight gain, to mention a few.

I also think chronic pain distorts our perception of pain. Chronic pain sufferers learn to tolerate much higher levels of pain over time. It becomes a matter of how much it interferes today. It is like your shadow, always there and it's size depends on the position of the sun. At certain times it is small and other times it is huge--changing and evolving over the day.