The Veterans Administration (VA) faces a substantial challenge in trying to improve end of life care. Foremost among the gaps in research on end-of-life care is inadequate knowledge about how to ensure pain relief. Studies show that pain is a major symptom for patients with a variety of serious chronic conditions. Drawing upon different clinical paradigms for the evaluation and treatment of pain, this study focuses on improving measurement and interpretation of routine pain screening in ambulatory VA patients as well as veterans with CHF as an important step to improving end-of-life care.
Two small single site studies suggested that the 0-10 numeric rating scale (NRS), also known as the Fifth Vital Sign, was only moderately sensitive and specific and did not change clinical practice. We undertook a study in VISN 22, one of the earliest adopters of the NRS for routine pain screening, aiming to compare the NRS to a reference standard, to evaluate nurse and patient factors associated with variation in the NRS, and to determine how the NRS is used in clinical pain management.
From March 2006-April 2007 we interviewed 528 veterans at hospital and community-based clinics (CBOC)s at the VA Greater Los Angeles (VA GLA) and Long Beach (VA LB) healthcare systems in VISN 22. From April 2007-June 2007 we supplemented that with an additional 124 veterans in VA GLA cardiology clinics. The overall response rate was 652/938 (69.2%). We approached all clinic staff physicians and nurses and nursing support staff prior with a baseline survey about attitudes, knowledge, and experience with pain screening and management. Respondents included 145/155 (94%) nursing staff and 208/280 (74%) physicians. We also surveyed providers after all study encounters they were involved in, and reviewed the charts of those encounters, in order to triangulate on the patient interviews and better understand the patient's pain and decisions about how to manage it. Patient interviews addressed extensive aspects of pain, a wide range of symptoms including mental health, and the medical encounter. Provider surveys used behavioral frameworks to address a range of attitudes, beliefs, knowledge, and training related to pain management. Chart reviews used validated quality indicators and addressed comorbidity and other aspects of the patient encounter.
The main findings of the study included that the NRS within the research interview was strongly correlated to the BPI, but that the NRS as conducted during routine pain screening was only moderately correlated, and that the lower correlation was associated with use of an informal screening procedure (e.g., 'Mrs. Jones, do you hurt?) rather than the formal 0-10 scale. Co-occurring mental health conditions were common, especially among veterans in moderate to severe pain (62%), but only 29% of veterans with distress discussed it with their providers. Among veterans with moderate to severe pain detected on routine screening, 73% of providers noted the pain, but only around 20% documented further evaluation, and only 15% had their treatment augmented or documentation of a reason it was not augmented. Two Brief pain inventory (BPI) items accounted for most NRS variation - interference with enjoyment of life, and relationships. Of a number of other single items, compared to the NRS using a 'pain now' timeframe, the NRS using a one week timeframe and pain bother were also with receiver operating characteristics area under the curve for these approaches of 0.79, 0.86, and 0.86 respectively. A pain bother combined with the NRS, both using a one week recall offered the best alternative to the fifth vital sign, with a post test probability among those with bother negative, bother positive but NRS < 4, and bother positive and NRS > 4 of 0.05, 0.26 and 0.69.
Training is needed now to improve use of the current fifth vital sign, as are efforts to tie screening to management. Evaluation of novel screening approaches including those that integrate mental health conditions with pain, and combinations of simple strategies incorporating interference and / or bother in addition to severity may improve the detection of chronic pain which is common among veterans in poorer health.
External Links for this Project
- 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. Journal of cardiac failure. 2009 Feb 1; 15(1):24-30. [view]
- Seow H, Snyder CF, Mularski RA, Shugarman LR, Kutner JS, Lorenz KA, Wu AW, Dy SM. A framework for assessing quality indicators for cancer care at the end of life. Journal of pain and symptom management. 2009 Dec 1; 38(6):903-12. [view]
- Goebel JR, Sherbourne CD, Asch SM, Meredith L, Cohen AB, Hagenmaier E, Lanto AB, Simon B, Rubenstein LV, Shugarman LR, Lorenz KA. Addressing patients' concerns about pain management and addiction risks. Pain Management Nursing : Official Journal of The American Society of Pain Management Nurses. 2010 Jun 1; 11(2):92-8. [view]
- Zubkoff L, Lorenz KA, Lanto AB, Sherbourne CD, Goebel JR, Glassman PA, Shugarman LR, Meredith LS, Asch SM. Does screening for pain correspond to high quality care for veterans? Journal of general internal medicine. 2010 Sep 1; 25(9):900-5. [view]
- Sherbourne CD, Asch SM, Shugarman LR, Goebel JR, Lanto AB, Rubenstein LV, Wen L, Zubkoff L, Lorenz KA. Early identification of co-occurring pain, depression and anxiety. Journal of general internal medicine. 2009 May 1; 24(5):620-5. [view]
- Stone SC, Mohanty SA, Gruzden C, Lorenz KA, Asch SM. Emergency department research in palliative care: challenges in recruitment. Journal of palliative medicine. 2009 Oct 1; 12(10):867-8. [view]
- Riopelle D, Wagner GJ, Steckart J, Lorenz KA, Rosenfeld KE. Evaluating a palliative care intervention for veterans: challenges and lessons learned in a longitudinal study of patients with serious illness. Journal of pain and symptom management. 2011 Jun 1; 41(6):1003-14. [view]
- Lorenz KA, Krebs EE, Bentley TG, Sherbourne CD, Goebel JR, Zubkoff L, Lanto AB, Asch SM. Exploring alternative approaches to routine outpatient pain screening. Pain medicine (Malden, Mass.). 2009 Oct 1; 10(7):1291-9. [view]
- Shugarman LR, Asch SM, Meredith LS, Sherbourne CD, Hagenmeier E, Wen L, Cohen A, Rubenstein LV, Goebel J, Lanto A, Lorenz KA. Factors associated with clinician intention to address diverse aspects of pain in seriously ill outpatients. Pain medicine (Malden, Mass.). 2010 Sep 1; 11(9):1365-72. [view]
- Lorenz KA, Shugarman LR, Lynn J. Health care policy issues in end-of-life care. Journal of palliative medicine. 2006 Jun 1; 9(3):731-48. [view]
- Goebel JR, Doering LV, Shugarman LR, Asch SM, Sherbourne CD, Lanto AB, Evangelista LS, Nyamathi AM, Maliski SL, Lorenz KA. Heart failure: the hidden problem of pain. Journal of pain and symptom management. 2009 Nov 1; 38(5):698-707. [view]
- Lorenz KA, Sherbourne CD, Shugarman LR, Rubenstein LV, Wen L, Cohen A, Goebel JR, Hagenmeier E, Simon B, Lanto A, Asch SM. How reliable is pain as the fifth vital sign? Journal of the American Board of Family Medicine. 2009 May 1; 22(3):291-8. [view]
- Shugarman LR, Goebel JR, Lanto A, Asch SM, Sherbourne CD, Lee ML, Rubenstein LV, Wen L, Meredith L, Lorenz KA. Nursing staff, patient, and environmental factors associated with accurate pain assessment. Journal of pain and symptom management. 2010 Nov 1; 40(5):723-33. [view]
- Grudzen CR, Timmermans S, Koenig WJ, Torres JM, Hoffman JR, Lorenz KA, Asch SM. Paramedic and emergency medical technicians views on opportunities and challenges when forgoing and halting resuscitation in the field. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2009 Jun 1; 16(6):532-8. [view]
- Grudzen CR, Koenig WJ, Hoffman JR, Boscardin WJ, Lorenz KA, Asch SM. Potential impact of a verbal prehospital DNR policy. Prehospital Emergency Care : Official Journal of The National Association of Ems Physicians and The National Association of State Ems Directors. 2009 Apr 1; 13(2):169-72. [view]
- Dy SM, Asch SM, Lorenz KA, Weeks K, Sharma RK, Wolff AC, Malin JL. Quality of end-of-life care for patients with advanced cancer in an academic medical center. Journal of palliative medicine. 2011 Apr 1; 14(4):451-7. [view]
- Malin JL, O'Neill SM, Asch SM, Dy SM, Walling AM, Tisnado D, Antonio AL, Lorenz KA. Quality of supportive care for patients with advanced cancer in a VA medical center. Journal of palliative medicine. 2011 May 1; 14(5):573-7. [view]
- Walling AM, Asch SM, Lorenz KA, Roth CP, Barry T, Kahn KL, Wenger NS. The quality of care provided to hospitalized patients at the end of life. Archives of internal medicine. 2010 Jun 28; 170(12):1057-63. [view]
- Cadogan MP, Edelen MO, Lorenz KA, Jones M, Yosef J, Hascall T, Simon B, Harker JO, Ferrell B, Saliba D. The relationship of reported pain severity to perceived effect on function of nursing home residents. The journals of gerontology. Series A, Biological sciences and medical sciences. 2008 Sep 1; 63(9):969-73. [view]
- Shugarman L, Sherbourne C, Rubenstein LV, Wen L, Asch SM, Lorenz KA. How can we improve the accuracy of routine pain screening? Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC. [view]
- Lorenz K, Sherbourne C, Cohen AB, Hagenmaier E, Kroenke K, Rubenstein LV, Simon B, Lanto A, Asch S. How does recall timeframe affect pain screening in routine outpatient care? Poster session presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 25; Toronto, Canada. [view]
- Zubkoff L, Lorenz KA, Lanto AB, Sherbourne CD, Goebel JR, Glassman PA, Shugarman L, Meredith LS, Asch SM. The Association of Provider Factors with Quality Routine Pain Management. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 29; Chicago, IL. [view]
- Goebel JR, Sherbourne C, Asch S, Meredith L, Cohen AB, Hagenmaier E, Lanto A, Simon B, Rubenstein L, Lorenz K. The Influence of Social Cognitive Domains on Pain Vignette Performance. Poster session presented at: Western Institute of Nursing Annual Meeting; 2007 Apr 12; Portland, OR. [view]
Aging, Older Veterans' Health and Care, Health Systems
Treatment - Observational
End-of-life, Pain, Screening