Abstract
BACKGROUND
Researchers and quality improvement advocates sometimes use review of chart-documented pain care processes to assess the quality of pain management. Studies have found that primary care providers frequently fail to document pain assessment and management.
OBJECTIVES
To assess documentation of pain care processes in an academic primary care clinic and evaluate the validity of this documentation as a measure of pain care delivered.
DESIGN
Prospective observational study.
PARTICIPANTS
237 adult patients at a university-affiliated internal medicine clinic who reported any pain in the last week.
MEASURES
Immediately after a visit, we asked patients to report the pain treatment they received. Patients completed the Brief Pain Inventory (BPI) to assess pain severity at baseline and 1 month later. We extracted documentation of pain care processes from the medical record and used kappa statistics to assess agreement between documentation and patient report of pain treatment. Using multivariable linear regression, we modeled whether documented or patient-reported pain care predicted change in pain at 1 month.
RESULTS
Participants’ mean age was 53.7 years, 66% were female, and 74% had chronic pain. Physicians documented pain assessment for 83% of visits. Patients reported receiving pain treatment more often (67%) than was documented by physicians (54%). Agreement between documentation and patient report was moderate for receiving a new pain medication (k = 0.50) and slight for receiving pain management advice (k = 0.13). In multivariable models, documentation of new pain treatment was not associated with change in pain (p = 0.134). In contrast, patient-reported receipt of new pain treatment predicted pain improvement (p = 0.005).
CONCLUSIONS
Chart documentation underestimated pain care delivered, compared with patient report. Documented pain care processes had no relationship with pain outcomes at 1 month, but patient report of receiving care predicted clinically significant improvement. Chart review measures may not accurately reflect the pain management patients receive in primary care.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Chodosh J, Ferrell BA, Shekelle PG, Wenger NS. Quality indicators for pain management in vulnerable elders. Ann Intern Med. 2001;135:731–5.
Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006;21:607–12.
Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization study in primary care. JAMA. 1998;280:147–51.
Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain. 2004;109:514–9.
Burgess FW. Pain scores: are the numbers adding up to quality patient care and improved pain control? Pain Med. 2006;7:371–2.
Krebs EE, Carey TS, Weinberger M. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med. 2007;22:1453–8.
Keller S, Bann CM, Dodd SL, Schein J, Mendoza TR, Cleeland CS. Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clin J Pain. 2004;20:309–18.
Tan G, Jensen MP, Thornby JI, Shanti BF. Validation of the Brief Pain Inventory for chronic nonmalignant pain. J Pain. 2004;5:133–7.
Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005;113:9–19.
Kroenke K, Spitzer R. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann. 2002;32:509–15.
Corson K, Gerrity MS, Dobscha SK. Screening for depression and suicidality in a VA primary care setting: two items are better than one item. Am J Manag Care. 2004;10:839–45.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.
Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med. 2007;22:1596–602.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999;282:1737–44.
Perkins AJ, Kroenke K, Unutzer J, et al. Common comorbidity scales were similar in their ability to predict health care costs and mortality. J Clin Epidemiol. 2004;57:1040–8.
Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9:105–21.
Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42:61–7.
Saigh O, Triola MM, Link RN. Failure of an Electronic medical record tool to improve pain assessment documentation. J Gen Intern Med. 2006;21:185–8.
Jackson JL. Communication about symptoms in primary care: impact on patient outcomes. J Altern Complement Med. 2005;11(Suppl 1):S51–6.
Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49:796–804.
Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357:757–62.
Norenberg DD. The demise of primary care: a diatribe from the trenches. Ann Intern Med. 2009;150:725–6.
Acknowledgements
• This study was funded by the Robert Wood Johnson Foundation Clinical Scholars Program.
• This work was supported in part by the Department of Veterans Affairs, Health Services Research & Development, through Research Career Development Awards to Drs. Krebs and Bair and a Career Scientist Award to Dr. Weinberger.
• An earlier version of this work was presented at the 2009 national meeting of the American Psychosomatic Society.
• The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
Conflict of Interest Summary
Dr. Bair has received research funding and honoraria from Eli Lilly and served on an advisory board for Abbott. The remaining authors report no financial conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Krebs, E.E., Bair, M.J., Carey, T.S. et al. Documentation of Pain Care Processes Does Not Accurately Reflect Pain Management Delivered in Primary Care. J GEN INTERN MED 25, 194–199 (2010). https://doi.org/10.1007/s11606-009-1194-3
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-009-1194-3