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R. Sean Morrison, MD; Diane E. Meier, MD; Daniel Fischberg, MD, PhD; Carlton Moore, MD; Howard Degenholtz, PhD; Ann Litke, MA, MFA; Catherine Maroney-Galin, MA, MPH; Albert L. Siu, MD, MSPH

Arch Intern Med. 2006;166:1033-1039.

Background  Pain is a major quality issue. The objective of this study was to evaluate the effectiveness of a series of interventions on pain management.

Methods  This controlled clinical trial (April 1, 2002, to February 28, 2003) involved the staggered implementation of 3 interventions into 2 blocks of matched hospital units. The setting was an 1171-bed hospital. A total of 3964 adults were studied. Interventions included education, standardized pain assessment using a 1- or 4-item (enhanced) pain scale, audit and feedback of pain scores to nursing staff, and a computerized decision support system. The main outcome measures were pain assessment and severity and analgesic prescribing.

Results  Units using enhanced pain scales had significantly higher pain assessment rates than units using 1-item pain scales (64% vs 32%; P<.001), audit and feedback of pain results was associated with increases in pain assessment rates compared with units in which audit and feedback was not used (85% vs 64%; P<.001), and the addition of the computerized decision support system was associated with significant increases in pain assessment only when compared with units without audit and feedback (79% vs 64%; P<.001). The enhanced pain scale was associated with significant increases in prescribing of World Health Organization step 2 or 3 analgesic for patients with moderate or severe pain compared with the 1-item scale (83% vs 66%; P=.01). The interventions did not improve pain scores.

Conclusions  A clinically meaningful pain assessment instrument combined with either audit and feedback or a computerized decision support system improved pain documentation to more than 80%. The enhanced pain scale was associated with improved analgesic prescribing. Future interventions should be directed toward altering physician behavior related to titration of opioid analgesics.

Author Affiliations: Departments of Geriatrics and Adult Development (Drs Morrison, Meier, and Siu and Mss Litke and Maroney-Galen) and Medicine (Dr Moore), Mount Sinai School of Medicine, New York, NY; Department of Geriatric Medicine, John A. Burns School of Medicine of the University of Hawaii, Honolulu (Dr Fischberg); and Department of Health Policy & Management and the Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pa (Dr Degenholtz).

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