Mularski RA (VA Greater Los Angels Healthcare System)
White-Chu F (Portland Veterans Affairs Medical Center)
Overbay D (Oregon Health & Sciences University)
Miller L (Oregon Health & Sciences University)
Ganzini L (Portland Veterans Affairs Medical Center)
To measure the impact on the quality of pain management after implementation of the Veterans Health Administration’s (VHA) Pain as the 5th Vital Sign initiative (P5thVSi). The P5thVSi requires the measurement and documentation of patients’ self-report of pain on a 0 - 10 scale; ratings of 4 or greater are the criteria set by VHA to "...trigger a comprehensive pain assessment and prompt intervention".
Using a cross-sectional medical record review at a single academic VHA medical center, we examined 7 process indicators developed on the basis of VHA pain guidelines. We compared performance on these indicators for 300 randomly selected unique outpatient visits to internal medicine staff physicians before (pre group) and 300 visits after (post group) the implementation of P5thVSi. Chi-square analysis compared groups.
In the post group, compliance with recording pain level was 82%; 45% of patients had pain as indicated by a measure > 0, mean level 2.2. Over 50% of our sample had existing prescriptions for analgesics and over 60% carried a pain diagnosis. For 32% (n=79) of the post group who reported substantial pain (4 or greater), 21.5% had no acknowledgement of pain documented in the medical record by the provider, 26.6% had no further assessment documented, and 51.9% received no therapy for pain at that visit. The pre-post comparison did not reveal any change between visits before and after P5thVSi (p > 0.05 for all comparisons): subjective provider assessment (49.3% pre group, 48.7% post group), provider exam (26.3%, 26.0%), orders to assess pain (11.7%, 8.3%), new analgesic (8.7%, 11.0%), change in existing medications (6.7%, 4.3%), other treatment (11.7%, 13.7%), or follow-up plans (10.0%, 8.7%).
Routine measurement of pain mandated by the P5thVSi was not associated with increased quality of care. For veterans with pain levels of four or greater, we discovered performance below the initiative’s objectives across all measured indicators.
The P5thVSi approach may be inadequate by itself to improve the quality of pain management. Future research should investigate overlaying other quality improvement techniques like audit/feedback, multidisciplinary Plan-Do-Study-Act improvement cycles, and other provider behavior change strategies.