Joy R. Goebel

How Reliable is Pain as the Fifth Vital Sign

Background: Although many health care organizations require routine pain screening (eg, “5th vital sign”) with the 0 to 10 numeric rating scale (NRS), its accuracy has been questioned; here we evaluated its accuracy and potential causes for error. Methods: We randomly surveyed veterans and reviewed their charts after outpatient encounters at 2 hospitals and 6 affiliated community sites. Using correlation and receiver operating characteristic analysis, we compared the routinely measured “5th vital sign” (nurse-recorded NRS) with a research-administered NRS (research-recorded NRS) and the Brief Pain Inventory (BPI). Results: During 528 encounters, nurse-recorded NRS and research-recorded NRS correlated moderately (r = 0.627), as did nurse-recorded NRS and BPI severity scales (r = 0.613 for pain during the last 24 hours and r = 0.588 for pain during the past week). Correlation with BPI interference was lower (r = 0.409). However, the research-recorded NRS correlated substantially with the BPI severity during the past 24 hours (r = 0.870) and BPI severity during the last week (r = 0.840). Receiver operating characteristic analysis showed similar results. Of the 98% of cases where a numeric score was recorded, 51% of patients reported their pain was rated qualitatively, rather than with a 0 to 10 scale, a practice associated with pain underestimation (χ2 = 64.04, P < .001). Conclusion: Though moderately accurate, the outpatient “5th vital sign” is less accurate than under ideal circumstances. Personalizing assessment is a common clinical practice but may affect the performance of research tools such as the NRS adopted for routine use.

Heart Failure: The Hidden Problem of Pain

Although dyspnea and fatigue are hallmark symptoms of heart failure (HF), the burden of pain may be underrecognized. This study assessed pain in HF and identified contributing factors. As part of a multicenter study, 96 veterans with HF (96% male, 67+/-11 years) completed measures of symptoms, pain (Brief Pain Inventory [BPI]), functional status (Functional Morbidity Index), and psychological state (Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Single items from the BPI interference and the quality of life-end of life measured social and spiritual well-being. Demographic and clinical variables were obtained by chart audit. Correlation and linear regression models evaluated physical, emotional, social, and spiritual factors associated with pain. Fifty-three (55.2%) HF patients reported pain, with a majority (36 [37.5%]) rating their pain as moderate to severe (pain>or=4/10). The presence of pain was reported more frequently than dyspnea (67 [71.3%] vs. 58 [61.7%]). Age (P=0.02), psychological (depression: P=0.002; anxiety: P=0.001), social (P<0.001), spiritual (P=0.010), and physical (health status: P=0.001; symptom frequency: P=0.000; functional status: P=0.002) well-being were correlated with pain severity. In the resulting model, 38% of the variance in pain severity was explained (P<0.001); interference with relations (P<0.001) and symptom number (P=0.007) contributed to pain severity. The association of physical, psychological, social, and spiritual domains with pain suggests that multidisciplinary interventions are needed to address the complex nature of pain in HF.

Early Identification of Co-Occurring Pain, Depression and Anxiety

ABSTRACTBACKGROUNDDepression and anxiety frequently co-occur with pain and may affect treatment outcomes. Early identification of these co-occurring psychiatric conditions during routine pain screening may be critical for optimal treatment.OBJECTIVETo determine aspects of pain related to psychological distress, and, among distressed patients, to determine whether pain factors are related to provider identification of distress.DESIGNCross-sectional interview of primary care patients and their providers participating in a Veteran’s Administration HELP-Vets study.SUBJECTSA total of 528 predominately male VeteransMEASUREMENTS AND MAIN RESULTSWe measured self-reported pain, including a 0-10 numeric rating scale and interference items from the Brief Pain Inventory. To evaluate distress, brief indicators of depression, anxiety and PTSD were combined. A substantial number of patients had psychological distress (41%), which was even higher (62%) among patients with moderate-severe current pain. Only 29% of those with distress reported talking to their provider about emotional problems during their visit. In multivariate analyses, other pain factors related to distress included interference with enjoyment of life and relationships with others, pain in multiple locations and joint pains. Prior diagnoses of depression and anxiety were also related to current distress. Only prior diagnosis and patient reported headaches and sleep interference because of pain were related to provider identification of distress.CONCLUSIONSVA patients with moderate-severe pain are at high risk for psychological distress, which often goes unrecognized. Providers need to be more vigilant to mental health problems in patients experiencing high pain levels. Targeted screening for co-occurring conditions is warranted.

Prescription Sharing, Alcohol Use, and Street Drug Use to Manage Pain Among Veterans

CONTEXT Efforts to promote awareness and management of chronic pain have been accompanied by a troubling increase in prescription medication abuse. At the same time, some patients may misuse substances in an effort to manage chronic pain. OBJECTIVES This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors. METHODS We analyzed cross-sectional data from the Help Veterans Experience Less Pain study. RESULTS Of 343 veterans, 35.3% reported an aberrant pain management behavior (24% reported using alcohol, 11.7% reported using street drugs, and 16.3% reported sharing prescriptions to manage pain). Poorer mental health, younger age, substance use disorders (SUDs), number of nonpain symptoms, and greater pain severity and interference were associated with aberrant pain management behaviors. In multivariate analysis, SUDs (odds ratio [OR]: 3.9, 95% confidence interval [CI]: 2.3-6.7, P<0.000) and poorer mental health (OR: 2.3, 95% CI: 1.3-4.3, P=0.006) were associated with using alcohol or street drugs to manage pain; SUDs (OR: 2.4, 95% CI: 1.3-4.4, P=0.006) and pain interference (OR: 1.1, 95% CI: 1.0-1.2, P=0.047) were associated with prescription sharing; and SUDs (OR: 3.6, 95% CI: 2.2-6.1, P<0.000) and number of nonpain symptoms (OR: 6.5, 95% CI: 1.2-35.4, P=0.031) were associated with any aberrant pain management behavior. CONCLUSION Veterans with a history of SUDs, greater pain interference, more nonpain symptoms, and mental health concerns should be carefully managed to deter substance misuse for pain management.

Does Screening for Pain Correspond to High Quality Care for Veterans

BACKGROUNDRoutine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear.OBJECTIVETo assess adherence to measures of pain management quality and identify associated patient and provider factors.DESIGNA cross-sectional visit-based study.PARTICIPANTSOne hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients.MEASUREMENT AND MAIN RESULTSWe used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that “patients want me to ask about pain” and “pain can have negative consequences on patient’s functioning”. Charts were more likely to document character of pain if providers agreed that “patients are able to rate their pain”. Patients with musculoskeletal pain were less likely to have chart documentation of character of pain.CONCLUSIONSDespite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.

A Comparative Study of Pain in Heart Failure and Non-Heart Failure Veterans

BACKGROUND Progress has been made in addressing pain in specific diseases such as cancer, but less attention has focused on understanding pain in nonmalignant states, including heart failure (HF). METHODS AND RESULTS From March 2006 to June 2007, 672 veterans were surveyed and scores for the Brief Pain Inventory, pain distress, clinically significant pain levels (moderate to severe pain), and pain locations were compared using univariate and multivariate models. Fifteen percent of the final sample had HF (95/634). In our study, the HF patients were older (P < .000), reported lower levels of general health (P = .018), had more co-morbidities (P < .000), were more likely to have a history of cancer (P = .035), and suffered more chest pain and fewer headaches (P = .026, P = .03, respectively) than their non-HF cohorts. When controlling for age, co-morbidity and cancer disorders, HF and non-HF patients did not differ in pain severity, interference, distress or locations. Of the patients currently experiencing pain, 67.3% of HF patients and 68.4% of non-HF patients rated their pain as moderate or severe (pain >or=4 on a 0 to 10 scale). CONCLUSIONS Although HF has not been identified as a painful condition, this study suggests the burden of pain is significant for both HF and non-HF ambulatory care patients.

Exploring Alternative Approaches to Routine Outpatient Pain Screening

OBJECTIVE To evaluate potential alternatives to the numeric rating scale (NRS) for routine pain screening. DESIGN Cross-sectional. SETTING Nineteen Veterans Affairs outpatient clinics in Southern California at two hospitals and six community sites. PATIENTS Five hundred twenty-eight veterans from primary care, cardiology, and oncology clinics sampled in proportion to the total number of visits made to each clinic during the previous year. METHODS Veterans were approached following clinic visits to complete researcher-administered surveys about their clinic experience. Using the Brief Pain Inventory (BPI) interference scale of > or =5 as a reference standard for important unrelieved pain, we evaluated potential alternative pain screening items and item combinations by analyzing sensitivity and specificity, area under the receiver operating curve (AUC), and likelihood ratios. RESULTS Of the veterans, 43.6% had unrelieved pain as measured by the reference standard. Approximately half had painful musculoskeletal diagnoses and one-third had comorbid mental health or substance use disorders. The fifth vital sign detected pain less accurately than did an NRS with a 1-week timeframe and an item assessing pain-related bother over the past week. AUCs were 0.79, 0.86, and 0.86, respectively. A sequential approach combining the pain-related bother and NRS with a 1-week timeframe items had good discriminatory ability. CONCLUSIONS Alternative single or combined pain screening strategies assessing pain-related bother may improve routine pain detection.

Caring for special populations: total pain theory in advanced heart failure: applications to research and practice.

TOPIC Total pain theory. PURPOSE Describe total pain theory and apply it to research and practice in advanced heart failure (HF). SOURCE OF INFORMATION Total pain theory provides a holistic perspective for improving care, especially at the end of life. In advanced HF, multiple domains of well-being known to influence pain perception are adversely affected by declining health and increasing frailty. A conceptual framework is suggested which addresses domains of well-being identified by total pain theory. CONCLUSION By applying total pain theory, providers may be more effective in mitigating the suffering of individuals with progressive, life-limiting diseases.

Palliative Care in Neonatal Intensive Care, Effects on Parent Stress and Satisfaction A Feasibility Study

Context: Approximately 1 in 10 infants require neonatal intensive care unit (NICU) hospitalization, which causes parental stress. Palliative care (PC) provides an opportunity to alleviate suffering and stress. Objectives: This study examines the effects of PC on NICU parent stress and satisfaction. Methods: A prospective cohort design compares stress and satisfaction among families receiving or not receiving PC. Results: No significant differences in stress scores were found (P = .27-1.00). Palliative care parents (100%) were more likely to report being “extremely satisfied” with care than usual-care parents (50%). Conclusion: This study supports the feasibility of evaluating NICU PC services. Infants referred for PC typically have higher morbidity/mortality; therefore, higher parental stress scores may be expected. Stress levels were similar in both cohorts, thus PC did not increase stress and may decrease PC parent stress.

Hospice and Palliative Nurses Association 2015-2018 research agenda

Hospice and palliative nursing care occurs in most practice settings, at all stages of chronic illness, and for persons of all ages. Thus, the Hospice and Palliative Nurses Association (HPNA) seeks to provide direction for research by highlighting key gaps in knowledge that serve as barriers to excellent care. The 2015-2018 HPNA Research is designed to (1) provide a focus for graduate students and researchers, (2) guide research funding by the Hospice and Palliative Nurses Foundation, and (3) illustrate to other stakeholders the importance of these research foci. The agenda also begins to outline a procedure for HPNA development and endorsement of clinical practice guidelines. The resulting document has been developed for all HPNA members regardless of role: clinical, academic, or research. Hospice and Palliative Nurses Association members were asked to select from among the 8 domains of the National Consensus Project which domain encompassed the most pressing gaps in knowledge. The 2 most frequently selected domains were (1) structure and processes of care and (2) physical aspects of care. The third component of this agenda, also member driven, will focus on the process of research translation in palliative nursing. While all research in palliative care is important to patients, the 2015-2018 HPNA Research Agenda identifies specific target areas to bring focus to research efforts and highlights the importance of research translation.