The Pain Question: Experts Weigh In

Added on Feb 16, 2016

By Diana Mahoney, Editorial Director

Big-Blue-Question-Mark2Does assessment of the patient experience of “pain care” lead to patient harm? That question, which Dr. Michael A. Ashburn and Dr. Lee A. Fleisher ask in an in-press article in Healthcare, is central to outcomes management and care-quality research. So is their answer, which is “no.”

The authors—both with the Department of Anesthesiology and Critical Care at the University of Pennsylvania—looked to the literature to evaluate the validity of the frequently cited concern about a possible link between Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and opioid prescriptions. They determined that the data do not support the association.

“Interestingly, patients can report satisfaction with pain care even when also reporting moderate to severe pain,” the authors explain. “Patient satisfaction does not appear to be associated with the type of anesthesia or pain therapy offered. Rather, satisfaction is more strongly associated with patient impressions of improvement in pain control and their impressions regarding the appropriateness of the care they received.” Additionally, patient satisfaction with pain management reflects the degree to which patients are involved in decision making concerning pain care, and how well that care meets their expectations is a driver of satisfaction, they explain.

The question posed by Dr. Ashburn and Dr. Fleisher gets to the heart of another question that has captured the interest of the health care industry since the introduction of the hospital value-based purchasing program under the Affordable Care Act linking financial incentives to scores on the HCAHPS survey: Should patients’ assessments of pain management be a variable in the value-based care equation?

Proponents argue that patients’ perceptions of how well their pain management needs are being met are an indicator of quality, and as such they should be measured and improved. Opponents counter that linking reimbursement to patients’ perceptions of how well their pain management needs are being met might encourage irresponsible prescription practices among providers seeking improved patient experience ratings. The existing body of evidence favors the proponents’ position.

One study reported in the American Journal of Medical Quality in 2012 assessed the relationship between patients’ perceptions of pain control during hospitalization and their overall experience of care and determined that patient experience scores were more strongly correlated with their perception that caregivers did everything they could to control their pain than with their pain actually being well controlled. The findings indicate that the culture of pain management, rather than pain control, drives patients’ perception of quality.

Similarly, a 2014 study reported in the Annals of Emergency Medicine found no correlation between opioids administered in the emergency department (ED) setting and ED patient experience scores, leading the study authors to conclude that ED clinicians can administer pain medications according to clinical and patient factors without being concerned about negative patient experience scores.

Finally, in an analysis of outcomes from early adopters of the Emergency Department Consumer Assessment of Healthcare Providers and Systems (EDCAHPS) survey, patients’ perceptions that ED caregivers did everything they could to help with pain exerted a greater influence on the patient experience than the receipt of pain medication.

It appears, as Dr. Ashburn and Dr. Fleisher point out, that while good-faith efforts to improve pain care in the inpatient and emergency settings may lead to increased opioid prescription, use and, potentially, abuse, “the problem does not lie in the decision to assess patient satisfaction with pain care.”

In fact, measuring patients’ experiences of pain care and management is part of the solution, they contend. “The challenge—and opportunity—is to properly use the information provided through HCAHPS and other outcome data sources to guide efforts to improve pain care to the people we care for.”