Reinvigorating the Pulse 

‘ th 5 Vi l Si ’ tal Sign

’

Karl Lorenz, MD MSHS Karl Lorenz, MD MSHS

VA GLAHS

December 10, 2009
Presentation Objectives

 Understand VA’s experience imple

routi i i d th HE

tine pain screenin

g an

d the HE

Project

 Review aims, methods, and results 

anal

y p

sis of alternative 

pain screen

approaches

 Consider implications for research 

Consider implications for research 

quality improvement
Background

 VA mandated the ‘5th vital sign’ in 

ii t mprove pain management

 0-10 u e c at g sca e t o

 numeric rating scale with ro

research properties

 Implemented with national docum

Implemented with national docum

package for CPRS

 Individual and population level pa

management and accountability management and accountability p

p
Background

 Impressed by routine clinician ign

of NRS scores

 Yet pa e a s a uge p ob e 

pain remains a huge problem

with strong evidence base (e.g., 

 How can we understand and use 

How can we understand and use 

for individual and population care

 What information about routine p

screening implementation would screening implementation would 

usefulness? 
Methods - HELP-Vets 

 Hel

pg p 

in

g Veterans Ex

perience Less Pain 

aimed to develop approaches for impromana

gy g ement b

y evaluatin

g: 

 Reproducibility, validity, and clinical mean

of routinely obtained pain, 

 nursing and patient factors associated wit physician and patient factors includin

g 

 pai

associated with the quality of pain manag

 alternative approaches to routine pain scre
Methods - HELP-Vets 

 Cross sectional, random visit-based ou

sample of veterans at all primary careand oncology clinics including CBOCs

 Spanning ~150 miles of VA Los Angele

Lon

g Beach 

– 19 clinics, yg

 3 county re

gi

VISN 22. 

 Sampled clinics proportionally to enco

Sampled clinics proportionally to enco

recorded in the prior year
Methods - HELP-Vets 

 Data collection triangulated on the pai

screeni i ng experience

 Baseline attitudinal knowledge surveys of 

nurses and physicians nurses and physicians

 Surveys of patients and physicians after t

to evaluate the 

p g ain screenin

g encounter

 Chart reviews to characterize objective 

documentation of pain and its manageme

 Response rates from ~70% for patien

~95% for provider surveys
Methods - HELP-Vets 

 Veterans leaving clinics eligible on the 

 Had vital signs taken Had vital signs taken Examined by consenting provider Pass brief co

g (/ nitive screener 

(

c/w no wors

cognitive impairment)

 Stratified by SF-1 / health status 

 All fair / poor health vets; every other good / v

All fair

/ poor health vets; every other good

/ v

excellent (50-50 final ratio)

 Following consent, ~35 minute intervie

t i d h it t traine

d researc

h assis

tan

ts

 Interview immediately replicated NRS, 

other pain measures and questions other pain measures and questions
Methods – Pain Screenin

Strategies

 Reference standard – ‘functionally limit

pai ’ BPI ( f 7 i t f 

in’ = BPI

(average o

f

7 in

terference 

where > 5 = ‘important’

 Alt ti erna ves

 NRS ‘now’ NRS ‘ k’ NRS ‘one week’ Bother ‘ How much did overall pain bother 

the past week the past week ?’

 Importance ‘How important is it for your d

address your pain today?’

 Unacceptable pain, inadequate relief, num

difference scores (exploratory) 
Methods – Pain Screenin

Strategies

 Fit ROC curves for each strateg

compari i ‘ f 

in

g it to ‘re

ference stan

 Determined AUC (0.5 = worthles

= perfect test)

 Calculated sensitivity, p 

 s

pecificit

accuracy (% overall correctly c

 Evaluated various cutoffs for m

Evaluated various cutoffs for m

favoring sensitivity
Methods – Pain Screenin

Strategies

 Determined likelihood ratios (proba

+ in population with / without pain+ in population with

/ without pain

 > 1 increases probability and = 1 mea

not change probability not change probability

 Descriptively compared ‘preferred 

approaches’ in veterans with in veterans with

 poor vs. good health (SF-1)  substance abuse vs. none substance abuse vs. none self reported misuse of substances to 

pain
Results – Patient Recrui

Patients Approached

6138

(862 refused) (862 refused)

Ineligible

4337 Eligible

939

No vitals 2265 Other 384Good health 436 Clinic ineli

g 310 

Refused

289

No MD visit 942

Patients Interviewed Patients Interviewed

650 (528)

Matched Nurse-Research Ratings

627 (509)
Results – Patient Charac
Results - Inferior Single 

 Pain importance 

 AUC 0 66 LR’ 1 0 ll t ff AUC

0.66, LR’s near 

1.0 all cu

toffs

 Inadequate relief from medication

 Sensitivity 68% specificity 45% Sensitivity 68% specificity 45% Numeracy issues, also confounds side effe

treatment preferences 

 Invalid in 20% experiencing ‘excessive rel

 Unacceptable pain

 S i i i 93% ifi i 45% Sensitivity 93% specifi

city 45%

 Numeracy issues  Invalid in 3% with goal pain > current pai

Invalid in 3% with goal pain

> current pai
Results - Pain NRS Now v

Pain NRS Now v
Results - Pain NRS One We

BPI
Results Pain Bother One We

BPI
Results - Single Item Cutoff

BPI
Results - Two-Stage Screeni

BPI
Results - Summary

 Several strategies have favorable tes

properties vs. BPI

 NRS one week and pain bother –single i

sequential 

 Superior to current approach in poor 

(NRS one week, pain bother) and subabuse (NRS one week) subgroups

 Of other approaches – unacceptable 

very p g, romising, but non-numeric s

pe

needed
Discussion

 Optimal strategy may vary with se

 E.g., Are ‘bother’ and ‘overall pain la

more relevant to p y 

rimary care than 

clinics?

 Optimal strategy depends on inten

Optimal strategy depends on inten

 Comparable ratings may be critical t

assessment i b t t il 

t comparisons, but tailore

approaches may be better for clinica
Discussion

 Need to consider patient-rep pp orted appr

nurses didn’t adhere to the formal NRS cases

 Not surprising Not surprising - reflects a normal clinical st

reflects a normal clinical st

How’s the leg today Mr. Jones?)

 Tended to result in pain underestimation – 

more of that pain was mild (so some of it mreflected skilled clinical triage)

 Need to link screening to management Need to link screening to management 

didn’t pay attention to the rating resultquality of care 

 Took action in about 15% of cases
Limitations

 Outpatient – different settings ma

different settings ma

require different approaches (inpa

ED long term care) ED, long term care)

 Our gold standard assumes goal o

management is chronic pain care

 Cross sectional Cross sectional – needs to be eva

needs to be eva

in longitudinal, actual implementa
Next Steps

 Primary and oncology care-based  Implement optimal vs. current str

in longitudinal RCT in longitudinal RCT

 Patient reported component Reminder functionality to foster 

responsibility for responsibility for ‘actionable pain’ actionable pain

 Cancer, depression present
Conclusions

 The ‘5th Vital Sign’ is necessary but no

suffi i t t t i i l ti 

fficient step to improving population 

management

 P bl i l d i l t ti li k 

Problems include implementation, link

action, and test properties of measure 

 Thi t d id i f d b i f 

This study provides informed basis fo

research and quality improvement

 P i i di ti f th h ll 

Pain is paradigmatic of the challenge 

screening failures and addressing a ra

HRQOL-related issues related issues.