Pain Speaking, Plain Speak

Karl Lorenz, Lorenz, MD MSHS

VA Greater Los Angeles, UCLA, Ra

H lh ea t
Overview

• Considerations and research in clinicia

patient‐reported pain screening,

• Current science of evaluating pain qua• Implications for VA pain and symptom

research.

Food for Thought Thought 1

What are ‘missed opportunities’ in 

management? and how should 

characterize them?
Undertreatment...?
Overtreatment

...

?
Wrong Treatment?

QUERI Step 1: Who (Why), W

What?

Patient 

Setting

Tx E
• Should we vary the interval of screeni

• Should we screen for pain ‘and’....(e.g

substance misuse risk)?

• Cancer, long term care, and surgical (

outpatient) settings?
Food for Thought Thought 2

How much variance variance in pain outco

outco

related to its assessment?
Screening and Treatment Gap Meas

by Chart Documentation in Primary Cby Chart Documentation in Primary C

HELP Vet Pain Indicators

Score (%)

100

908070

6050

4030

2010

0

98%

15%

Screening Treatment

Indicator
Screening‐management 
3 item PEG
‐ ‐

Setting and Source Differences in Pain S

Self Report Chart‐Based Chart‐

Score (%)

100

908070

6050

40302010

0

93% 96

53%

CanCORS Outpatient Inpa

Patients
Cancer Pain

100% 

80% 90% 60% 70% 

Rate 

30% 40% 50%

QI R 

10% 20% 30% 

0% 

National Mean National Median VAMCs with 5 or more el

VA outpatient pain screening in advanced c
Food for Thought Thought 3

Implementation Implementation represents represents a large g

screening practice, possibly true rega

approach or platform.
Is pain screening screening faithful faithful to pro

pro

HELP-Vets St du y: 

Informal 

R ti a ng 

Reduces 

S i creen ng 

Sensitivity

F l R ti Formal Rating Informal Rating Informal Rating 

528 Pain ‘5th Vital Sign Ratings by Nu
Lessons Lessons from Screening Screening

• Some settings (cancer care) screening 

happening

• Clinicians need assessment linked to

management

• Providers need a measure of pain imp

they believe!)

• Implementation Implementation of even simplest simplest mea

mea

challenging
Food for Thought Thought 4

Patient Patient‐reported reported outcomes outcomes offer a pro

pro

alternative, but also novel challenges 

to screening
f

Patient Patient Reported Reported Outcom

Outcom

PROMIS definition “health data provi

the patient through a system of repo

• interviews, surveys, and computer ass

– Improve use if b i arr er is st ff a / st ffi a ng (e

cancer clinics)?

– Narrow report variance & reduce the clin

documentation components)?
The Ideal?
The Reality?

Visually impaired, homeless veteran w

difficulty difficulty hearing hearing walks into the clinic 

walker. He takes a seat next to a kiosk 

he’s asked to complete a symptom re

using a computer. While loudly trying the task with a clerk, a bystander offe

help you. Just look here and fill this o
Questions about PRO and Pain

• Could clinician clinician detection detection offer superio

superio

actionability?

• What patients are at risk of unreliable

re

ports? (Mental health, dementia, he

or visual impairment)

• What new forms of report variance variance mi

introduce? (platform specific or enviro

/

bystan

der

effects

)

Future Assessment

Proxy (Knowledgeable and Bystander) Reports

Self Reports

+

Clinician Documented 

Reports

Patient Reports Patient Reports Clinician 

Clinician 

and PatReports
Food for Thought Thought 5

Feedback Feedback is a critical critical aspect of succe

succe

intervention and quality measures p

both process process and outcomes outcomes for gaug

gaug

management.
Screening Screening, also measurem

measurem

,

Pain Measures

• Outcomes (Bereaved Family Survey ite

process (ACOVE, ASSIST)

– Process sets cover geriatrics / primary ca

and its settings

• New measure efforts (e.g., CMS) mov

from process to outcomes

• To actually improve quality, have to ha

Screening and Treatment Gap Meas

Score (%)

S lf R t i S

elf 

Report in 

Cance

r

CanCORS CanCORS Pain Indicators Indicators

100

908070605040302010

0

93% 91%

Screening Indicator Treatment
Screening and Treatment Gap Meas

by Chart Documentation in Primary Cby Chart Documentation in Primary C

HELP Vet Pain Indicators

Score (%)

100

908070

6050

4030

2010

0

98%

15%

Screening Treatment

Indicator
Quality Quality Indicator Indicator 5

ASSIST Pain: Provision of Short‐Acting

Opioid Formulation

Outpatient Inpatient

Patients

60708090

100

(%)

87% 89%

1020304050

Score(

0
Quality Quality Indicator Indicator 6

Score(%)

ASSIST Pain: Offerance of Prescription or

Nonprescription Bowel Regimen

100

908070605040302010

0

Outpatient Inpatient

52%

70%

Patients
Quality Quality Indicator Indicator 9

100

ASSIST Pain: Assessment of

Effectiveness Effectiveness of Changed Changed Regimen Regimen

80

Score (%)

604020

0

69%

Patients
Quality Quality Indicator Indicator 11

Score (%)

ASSIST Pain: Offerance or

Contradindication Contradindication of Single Fraction Fraction

Treatment*

100

80604020

0

Patients

*0% Pass at Event Level
Food for Thought Thought 6

In an era of increasing HRQOL datIn an era of increasing HRQOL dat

availability pain will provide a usef

paradigm for other symptoms challen
Pain and Other Symptoms Symptoms Si

Si

• Reflect subjective states, and patients 

be multi‐sy p m tomatic

• Differing clinician resistance and stand

multiple multiple symptom symptom reports reports (e.g., dyspn

dyspn

example)

• Management algorithms are different
Effective Effective Screening Screening for Pain 

Computer PEG Computer NRS Health M

Nurse assessment and documentation of the NRS
Summary

• Pain screening barriers include clinica

relevance of measure, link to manage

implementation.

• Patient reports offer a solution to sele

facets of screening screening, may pose other ch

ch

• Monitoring of outcome and process a

possible for pain

• Appropriate to screen for multiple sym

but augments management challenge