Is Patient Satisfaction a Legitimate Outcome of Pain Management?

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1 264 Journal of Pain and Symptom Management Vol. 25 No. 3 March 2003 Original Article Is Patient Satisfaction a Legitimate Outcome of Pain Management? John Carlson, MS, Richard Youngblood, MA, Jo Ann Dalton, RN, EdD, FAAN, William Blau, MD, PhD, and Celeste Lindley, PharmD School of Nursing (J.C., R.Y., J.A.D.), Department of Anesthesiology (W.B.), and School of Pharmacy (C.L.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Abstract Though many studies have measured patient satisfaction with pain management using the American Pain Society (APS) Satisfaction Survey or its variants, little is known about the relationship among the survey items, or whether items relate to satisfaction at all. In an effort to refine the measurement of patient satisfaction, a modified version of the APS survey, which was given to 787 patients as part of a study of postoperative pain management in six community hospitals, was subjected to principal components analysis to determine the survey s empirical structure. Correlations among the five components found were low; a weak relationship (r 0.24) was discovered between pain intensity and satisfaction. A heuristic model estimated by structural equations analysis yielded additional insights. Though many items thought to influence patient satisfaction were not closely related to patient-reported satisfaction, they indicate important clinical factors relevant to quality of care, and thus, to continuing quality improvement (CQI) efforts. Results suggest that satisfaction was influenced by effectiveness of medication, independent of pain intensity, and by communication. Pain severity ratings near the time satisfaction was measured were more influential than earlier ratings. J Pain Symptom Manage 2003;25: U.S. Cancer Pain Relief Committee. Published by Elsevier. All rights reserved. Key Words Patient satisfaction, pain management, postoperative, measurement, CQI Introduction In an outcomes-based health care environment, demonstration of patient satisfaction with care, along with improvement in health status, has become an important criterion for quality of care assessment. Accordingly, in Address reprint requests to: John Carlson, MS, School of Nursing, CB# 7460, Carrington Hall, University of North Carolina at Chapel Hill, Chapel Hill, NC , USA. Accepted for publication: May 31, , the American Pain Society (APS) established a committee to develop guidelines for quality improvement (QI) approaches to pain management. The APS recommended that patient satisfaction be surveyed as an outcome of clinical practice, and in response, developed the Satisfaction Survey. 1 The survey was an 11- item questionnaire that asked respondents to rate their pain, percent relief obtained from medication or other treatments, general satisfaction with treatment given by physicians or nurses, wait time for medication, and discussion of treatment of pain by physician or nurses. It also inquired about suggestions for 2003 U.S. Cancer Pain Relief Committee /03/$ see front matter Published by Elsevier. All rights reserved. doi: /s (02)

2 Vol. 25 No. 3 March 2003 Patient Satisfaction with Pain Management 265 improvement (Appendix 1). In addition, the survey asks two explicit questions about satisfaction: Select the phrase which indicates how satisfied you are with the way your doctors treated your pain, and Select the phrase which indicates how satisfied you are with the way your nurses treated your pain. The survey was intended to be a guideline for QI assessment of pain management in a variety of settings; thus, revisions to the survey were encouraged. Psychometric analysis was not performed. In 1995, a panel of experts reviewed reports using the 1991 survey, and added six items to the original survey. The first additional question asks for average pain rating in the past 24 hours. To explore why patients report they are satisfied with pain management despite high pain ratings, the second additional question gauges pain tolerance by asking patients to rate the degree to which pain interferes with sleep, walking, work and mood. Since high satisfaction could be related to staff behavior rather than pain intensity ratings, satisfaction with physician and nurse responses to pain is assessed separately from the third additional question, which asks patients to rate overall satisfaction with pain treatment. The fourth and fifth additional questions explore reasons for patients reluctance to ask for stronger medication. The sixth question was added to evaluate instructions for pain management given to outpatients. 2 The first and second questions have been previously validated by Daut and colleagues; 3 the fifth question has been validated by Ward and colleagues. 4 The survey was renamed the Patient Outcome Questionnaire (POQ). Review of the Literature In the past ten years, multiple studies have used variations of the APS survey, including reliance on a single question, to measure satisfaction in a wide range of settings. An evaluation of responses to a 17-item survey developed from the APS standards for pain management suggested the following: Add a 0 10 scale to evaluate overall satisfaction; ask patients why they were satisfied even though their pain treatment was inadequate; evaluate ratings of pain relief, waiting time for medication and requests for treatment change; ask about patients expectations; and ask how treatment could be improved. 5 To develop a pain management report card comparing survey results and institutional goals, Starck and colleagues changed the order of the items of the POQ to form concept clusters and added a question asking patients why they were satisfied or dissatisfied. 6 When satisfaction was measured by asking patients to agree or disagree on a 4-point Likert scale to the statement Overall, I am satisfied with the ways my pain was managed, answers related only slightly with patients perception of overall satisfaction (r 0.19). 7 In another study, questions from the POQ were used to measure the quality of, and satisfaction with, pain management within one week of discharge for day-surgery patients. 8 Though more than 40% of patients experienced moderate to severe pain during their hospital stay and 64% experienced incisional pain seven days post-surgery, 97% of patients at the hospital and 87% at home were either satisfied or very satisfied with their pain management. 8 Elsewhere, Carroll and colleagues used the POQ to develop a tool to measure pain and satisfaction with pain management for critically ill patients. 9 They found that as waiting time for an analgesic and frequency of moderate to severe pain increased, patient satisfaction decreased (r and r -0.36, respectively). Yet patients who expected higher levels of postoperative pain were more satisfied with their pain management (r 0.30). 9 When patients of postoperative anesthesiabased pain services were given the Postoperative Pain Management Quality Assessment Survey (developed from the original 1991 APS survey and the Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Guidelines 10 ), a larger percentage of pain-service patients reported they were very satisfied with postoperative pain relief when compared to non-pain service patients. 11 Myles and colleagues asked 10,811 patients to rate satisfaction with the anesthetic services they received 24 hours after surgery by answering satisfied, somewhat dissatisfied or dissatisfied and to provide reasons for their rating. 12 While only 3% of the patients were dissatisfied with their pain care, 24% experienced moderate or severe postoperative pain, 10% experienced severe nausea and 39% experienced at least one complication. Those who experienced at least moderate pain were four times as likely to be dissatisfied (Odds Ratio (OR) 3.94, P

3 266 Carlson et al. Vol. 25 No. 3 March ). Other postoperative factors contributing to dissatisfaction were severe nausea or vomiting (OR 4.09, P ) and any complication (OR 2.04, P 0.005). 12 In the studies discussed above, many variations of the APS Satisfaction Survey or the Patient Outcome Questionnaire were employed. Though patient satisfaction is widely reported as a measure of the quality of the pain management a patient receives, no evidence has been presented that demonstrates satisfaction is a good outcome measure. 13 Overall, patients report being satisfied with their pain management even though they also report significant levels of pain intensity, long waiting periods for pain medication and, in general, ineffective treatment. 5,6,9,13,14 Efforts have been made recently to determine correlates of satisfaction. Drawing from the POQ and suggestions by Miaskowski, 5 Jamison and colleagues developed a 13-item patient discharge questionnaire which included questions on pain, satisfaction and perceived helpfulness. 15 An examination of the survey s internal structure by exploratory factor analysis identified the following five factors: pain intensity, general satisfaction, helpfulness of treatments, a tendency toward dissatisfaction and amount of expected postoperative pain. Satisfaction with postoperative pain relief was correlated with satisfaction with nurse and physician pain treatment (r 0.50, P 0.01), worse postoperative pain (r 0.34, P 0.01), concern shown by MDs and RNs (r 0.27, p 0.01), helpfulness of medication and other treatments to relieve pain (r 0.26, P 0.01) and pain rating in the past 24 hours (r -0.26, P 0.01). 15 As part of pilot testing of a patient satisfaction questionnaire based on the POQ (n 1,400), construct validity was supported by examination of the relationship between patient satisfaction and wait time for analgesic (r 0.30, P 0.001), pain expectations (r 0.54, P 0.001), frequency of moderate to severe pain (r 0.46, P 0.001) and worst pain intensity (r 0.25, P 0.001). 9 When questions about reasons for pain treatment satisfaction and which pain control methods were used after admission were added to the POQ, and the questionnaire was given to hospital inpatients (n 122, 77% Caucasian), Cronbach s alpha coefficients of 0.68 to 0.82 were reported for four a priori subscales. 16 When the same instrument was given to 104 Hispanic inpatients, Cronbach s alpha coefficients ranged from 0.63 to 0.82, with four a priori subscales pain intensity, pain interference, satisfaction with pain treatment, and beliefs about pain and its treatment. 17 That studies using variations of the APS Survey have reported high levels of satisfaction with pain management despite the occurrence of moderate to severe pain could be due to the lack of explicit models linking the domains measured by the survey. Theoretical and clinical models of the experience and perception of pain have been offered, 18 but they offer little guidance in measuring satisfaction with pain management. Further, the absence of strong relationships among survey items found in some reports might be methodological, i.e., a tendency to collapse items into two levels 17 or to use insensitive measures of association, 19 both of which underestimate the strength of the relationships. To increase the survey s utility for clinicians, it would be useful to examine the APS survey in greater detail using a psychometric perspective. Given that the history of using patient satisfaction as a measure of quality of pain management has produced mixed findings with low explanatory power and seeming contradictions, an examination of the items typically used to measure patient satisfaction with pain management is timely. This paper will empirically examine the domains of the original 1991 APS satisfaction instrument in order to better understand the results obtained from it and to offer alternative approaches. Methods An early step in developing and understanding a tool is to empirically examine the relationships among its items. The reasons for expecting associations between the items reflect models that relate variables to each other. One model relates to measurement. Specifically, it asserts that a significant portion of the variation in a set of observed items is due to variation in an unobserved construct, and that the items should be associated with each other due to their common source of variation. This is the common factor model or effects indicator model in which the observed items are effects

4 Vol. 25 No. 3 March 2003 Patient Satisfaction with Pain Management 267 and an unobserved state, trait or process is the cause. 20 This model is behind many of the tools that clinicians are familiar with. For example, a depression scale includes statements such as I am unhappy and Life is not worth living, and assumes that responses are affected by the mental status of the respondent. A second model, the cause indicators model, is also causally defined, but with a role reversal. Here, the observed items are believed to indicate the level of an unobserved construct because they are causal constituents. For example, socioeconomic status (SES) is often regarded as a single attribute that is indicated by contributory variables such as income, education and occupation. Although the observed items may be correlated with each other in this model, it is not a requirement for the model to be true. A third model asserts that some items are causes of another item. This is a structural model and is often estimated by regression. Causal items may be called independent variables or predictors, and effects may be called dependent variables or responses if causality is not appropriate for the situation. The expectation is that the predictors are associated with the response while the predictors may or may not be associated among themselves. One aspect of the discussions about patient satisfaction with pain management is that no model, either measurement or structural, has been explicitly stated. This may be a source of some of the confusion found in the literature. Sample In a study of six community hospitals of medium size ( beds), a modified version of the APS Satisfaction Survey was used to measure the impact of an educational program on postoperative pain management. 21 From a target sample size of 900 patients (50 patients 6 sites 3 evaluation periods), 787 postoperative patient interviews and charts qualified for analysis. Patients whose charts were audited were approximately two-thirds female (69.3%) and primarily Caucasian (82.7% Caucasian; 14.9% African American; and 2.4% other or not recorded) (Table 1). Mean age for this sample was 51 years. Among the 11 categories of surgical procedures experienced by patients in the study, the most common procedure was major orthopedic. The average length of stay (LOS) for the total sample was 3.6 days (range days); Table 1 Sample Demographics (n 787) n % Gender Female Male Race Caucasian African American Other 6.76 Not Recorded median LOS for the total sample was 3.1 days. The educational program was designed to assist caregivers in community hospitals to use the acute postoperative pain management guidelines developed by AHCPR to promote change in outcomes, including patient satisfaction. 10 Details of the program can be found in Dalton et al. (1999). Instrument Prior to the educational program, upon completion of the program, and six months after the program, approximately 50 patients at each site completed the Discharge Survey at the time of discharge (Appendix 2). To create the survey, the 1991 American Pain Society Satisfaction Survey was modified in the following manner. Ten items from the original 11-item survey were retained. The statement Select the phrase which indicates how satisfied you are with the way your doctors treated your pain was deleted. The question Early in your care, did your doctors or nurses discuss with you that we consider treatment of pain very important, and did they ask you to be sure to tell them when you have pain? was split into two questions. Ten items were added that ask patients about pain immediately after surgery and at first postoperative ambulation on a scale of 0 to 10, hours until postoperative ambulation, frequency of nausea and vomiting, percentage of time pain interfered with sleep, preoperative and postoperative worry about addiction to medication, receipt of written materials about pain management, and helpfulness and intelligibility of these materials (Appendix 3). Procedure The first step of the evaluation examined the associations between the items of the modified

5 268 Carlson et al. Vol. 25 No. 3 March 2003 APS Satisfaction Survey (Appendix 2). Since over 95% of subjects were treated for pain and experienced pain in the 24 hours prior to completion of the survey, Questions 1 and 2 were not informative and thus were not included in the analysis. Since there are 16 items that are included in the analysis, the number of bivariate correlations is 120, clearly too many to perform a correlation-by-correlation examination. To describe the 120 observed correlations efficiently, they were reduced into a small set of components by conducting a principal components analysis. A component, also called a factor or latent construct, is a calculated variable that captures shared variance among the observed items. A component can represent shared variance among any number of items, and thus, the number of components needed to capture the bulk of variance that is shared among a set of observed items often is much smaller than the number of bivariate correlations. A set of items that has relatively high correlations between its members will tend to identify a common component that captures the items shared variance. Initially, the technique extracts as many components as items. The first component extracted captures the largest amount of variance and each successive component captures a smaller amount than the one preceding it. Typically only a few of the components will reflect variance shared by multiple items and thus will be useful for describing correlations between the items. The remaining components are considered to reflect mostly variance that is unique to individual items, and therefore are of little use for describing associations among them. Selection of the number of components to consider for interpretation and further analysis is guided by the eigenvalues of the components, which are functions of the amount of information they contain. Principal components analysis, which aims to account for all of the variance in the items, was chosen over factor analysis, which attempts to describe only the shared variance. 22,23 Components analysis is more consistent with the intent to describe the structure of association among all of the items, not just those that meet customary criteria for retention in the optimal factor analytic solution. Because each item contains information that is important to clinicians, it is appropriate to treat each item as having equal import, at least in this early stage of investigation of the APS Satisfaction Survey. Thus, it is more useful to analyze the total variance of items, not just the shared portion, which is more influenced by the number of similar items. Most of the responses to the items are either ordered categories or simple yes/no responses. Thus the observed correlations, on which the components or factor analysis is based, tend to underestimate the true associations between the variables. In turn, this produces an underestimate of the shared variance among the items. Therefore, components analysis is preferable because its results are not as closely tied to estimates of shared variance, and thus the effects of the underestimated correlations are lessened. Results Initial extraction of components yielded five with eigenvalues greater than 1.0; those five components captured 54% of the total variance in the set of 16 items. While the number of significant eigenvalues in the correlation matrix is determinable, there are an infinite number of ways to organize the items along the axes corresponding to the components. Since it is desirable to define components that produce a simple and interpretable structure, 24 the components are nearly always rotated to achieve that aim. The axes were rotated while maintaining the correlations between them at zero by using a standard rule, varimax, that simplifies the factors by maximizing the variance of the loadings on each factor. 25 Table 2 presents the results of this procedure. Each column of the table corresponds to 1 of the five components, while each row corresponds to an item. Each entry in the table, often called a loading, indicates the contribution of the component to the variance of the item. Since the components were uncorrelated with each other, the loading is an estimate of the correlation between the item and the component. Items that correlated highly with the same component were grouped together to aid in the interpretation of the pattern of loadings. The first 4 items, having to do with pain intensity, had high loadings on Component I, Pain Intensity. All of the signs were positive, so all four indicators of pain intensity increased when the underlying component increased.

6 Vol. 25 No. 3 March 2003 Patient Satisfaction with Pain Management 269 Table 2 Principal Components of Satisfaction Items for Discharge Survey Rotated Factor Pattern a (orthogonal) Component Item I. II. III. IV. V. I. Rate worst pain in last 24 hours Pain rating at first postoperative ambulation Pain rating now (at discharge) Pain rating immediately after surgery II. Satisfaction with nurse s treatment Percent pain relief If treatment did not help, required more pain medication Percent of time pain interfered with sleep Longest time to wait for pain medication III. Prior to surgery, worry about addiction to pain medication After surgery, worry about addiction to pain medication IV. Physician or nurse discuss that they consider pain treatment important Physician or nurse ask patient to notify them when patient experienced pain Prior to surgery, received written materials about pain management V. Hour after surgery able to walk Times experienced postoperative nausea a Loadings are multiplied by 100 for ease of reading. Five items had high correlations with Component II, Satisfaction. Greater satisfaction with nurses treatment and greater percent relief due to medication were associated with increases in the component. The need for additional medication, greater interference with sleep and longer wait time for medication were associated with decreases in the component. The two fear of addiction items were associated with Component III, Fear of Addiction. Component IV, Communication, was positively associated with staff discussion of the importance of pain treatment, with the patient being asked to notify the staff when experiencing pain, and with patients receiving written materials prior to surgery. Increasing time between surgery and ambulation, and greater number of nausea episodes were associated with Component V, Dysfunction. Correlating the components by rotating the components axes according to the promax rule 26 produced a solution that was little different from the solution in which the rotation was performed with the correlations between the components remaining at zero. Although the components were allowed to be correlated in this solution, the correlations between them were low, or essentially zero. The strongest, 0.24, was between Components I and II, indicating a weak to moderate negative relationship between pain intensity and satisfaction with pain management. Discussion The analysis reported here demonstrates that domains thought to be relevant to patient satisfaction were not closely related to each other, nor were they closely related to the domain that most directly measures patient satisfaction. The weak relationship between the pain intensity and satisfaction components is consistent with numerous other studies 5,6,9,13,14 that find that measures of these two aspects of the pain experience are not closely tied empirically. Although a gold standard measure of patient satisfaction has not been established, Component II of the APS Survey, as described and reported here, may represent what patients view as satisfaction with their pain management. In fact, an item that asks about satisfaction per se has the heaviest loading on the component. While it is practically tautological to conclude that responses to an item including the word satisfaction may in fact be caused by a patient s evaluation of the pain treatment he or she received, the role of the other items of Component II degree of relief obtained from medication, whether additional medication was required, the length of waiting for addi-

7 270 Carlson et al. Vol. 25 No. 3 March 2003 tional medication, and the degree of disruption of sleep by pain may not be so clear. Are the responses to these items caused by the patient s evaluation, as is the case with the first item on the component, or are they causal influences and the patient s evaluation is the response? The answer to the question is important in the construction of a valid and reliable measure of patient satisfaction and for suggesting ways to increase satisfaction. None of the standard measurement models mix effects and causes together in a scale. Causes can be used to form indicators, as in the SES example, but the requirements for cause-based indicators are different than for effect-based indicators such as the depression scale example. The most salient requirement is that a set of cause indicators should include all of the important influences on the construct that is being measured. It is probably too early to specify a cause-based indicator of patient satisfaction since there is still much to learn about its causes. Evaluation of quality improvement studies of pain outcomes by an examination of patient self-report surveys, telephone interviews of patients and chart reviews speculated that patient responses often matched patient expectations for satisfying care. 14 Expectations for care could be a valuable addition to the measured causes of satisfaction. An additional item might measure satisfaction by a patient s willingness to refer the treatment setting to others. Even if the set is incomplete, collecting items related causally to patient satisfaction should provide clues to the improvement of care. The development and refinement of these items are important tasks. As a heuristic exercise, the five components described above were modeled as a set of structural equations with latent variables, where the latent variables corresponded to the components and the structural equations stated the relationships among them. The initial model stated that both pain and satisfaction were effects of communication, fear of addiction and function, and that satisfaction was also an effect of pain. Structural equations modeling (SEM) with latent variables can simultaneously test the measurement and the structural aspects of a model and yield insight into what relationships are supported empirically. Rather than relying on assumptions that the variables are measured without error and that the model is correctly specified, the results of SEM indicate the extent that those assumptions are tenable. Comparison of the alternative models is easily incorporated into the general approach. The technique has been described by Bollen, 27 and the particular software used in this analysis was documented by Joreskog and Sorbom. 28 Ideally, a model is explicitly stated prior to testing, or if generated from data, it is formally assessed in a different sample than the one from which it was generated. Since the heuristic model explored in this analysis starts with a set of empirically derived components and the analysis will be based on the same sample, the correctness of the model is not being asserted nor are the results definitive. Rather, the intent is to stimulate discussion and offer suggestions for future research. One result of the modeling suggests that it may be useful to break Component I, Pain Intensity, into early pain measurements (immediately postoperative and at first ambulation) and late pain measurements (24 hours prior to discharge and at discharge). Only the late measurements appeared to impact patient satisfaction: higher late pain intensity decreased satisfaction level. Future research may find that the trajectory of postoperative pain intensity will be the best construct for relating pain intensity to satisfaction measured at the end of hospitalization. Regarding Component II, Satisfaction, consideration of satisfaction with nurses pain treatment as an effect of the other four variables seemed better supported by the data than did considering all five variables as indicators of a latent satisfaction construct. Three of the items, percent relief from pain, requiring more medication and interference with sleep could be used to form a latent construct where, with the latter two reverse scored, higher values might indicate better effect, or greater adequacy of medication. This construct had a positive impact on the lone satisfaction indicator and negative impact on the pain intensity constructs, and had a greater effect on satisfaction than did early or late pain intensity ratings. When the medication construct was introduced and was placed causally prior to early and late pain intensity and satisfaction, the relationships of the intensity constructs to the satisfaction measure changed in ways that suggested that when the effects of medication on intensity and satis-

8 Vol. 25 No. 3 March 2003 Patient Satisfaction with Pain Management 271 faction were introduced, the remaining relationship of intensity to satisfaction was small but positive. These results may shed light on the oftenobserved conundrum of finding high pain intensities accompanied by high satisfaction, and an accompanying low correlation between intensity and satisfaction. While there may be an attenuation of the observed association between intensity and satisfaction due to ceiling effects for one or both variables, it may also be that the relationship of pain intensity with satisfaction is moderated by medication effectiveness or that intensity and satisfaction are moderately associated mutual outcomes of medication effectiveness. Patients expectations regarding their pain experiences might be an important element in an adequate model of these relationships. The remaining item from Component II time waited for medications was modeled as a cause. Results suggested that longer wait times increased early pain intensity and decreased satisfaction, but were not related to late pain intensity. Component IV, Communication, revealed that increased communication improved patient satisfaction, and communication did not strongly impact early or late pain intensity. Results for Components III and V, Fear of Addiction and Dysfunction, respectively, were not clear enough to suggest their roles as predictors of pain intensity or satisfaction. If the suggested model, with Component II including only one effect of patient satisfaction and four causes of satisfaction, is valid, then using patient satisfaction to evaluate the quality of pain treatment implies that multiple items believed to be causally influenced by the patient s evaluation of the pain treatment he or she received should be included in a proposed survey in order to increase both the validity and reliability of measuring satisfaction levels. Indeed, many implementations of the APS Satisfaction Survey 6,11,15 17 contain additional questions that ask directly about satisfaction, usually satisfaction with physicians treatment and overall satisfaction. Those questions, in addition to an item regarding the nurses treatment would be a minimum set. The addition of even a couple of items that address satisfaction levels, perhaps at different time points, or in relation to expectations, would likely yield a substantial increase in the adequacy with which satisfaction is measured. Other implications may follow from the results. One is that the relationships to patient satisfaction of the items associated with Component I, Pain Intensity, are not straightforward, but may need to be placed in contexts such as time point of the pain intensity measure and effect of medication. The roles of the items associated with Components III and V need to be further specified. Items from Components II and IV may not measure patient satisfaction in the way that clinicians are most familiar with, but may measure causes of patient satisfaction. Should items that do not directly indicate a patient s current level of satisfaction be omitted from future surveys? Yes, if patient satisfaction is the only evaluative criterion. No, if the intent is to use broader evaluative criteria. Items on all components were chosen by experts in pain management as relevant to the quality of care. Certainly it would be foolhardy to abandon pain intensity and pain interference with function as critical outcomes of pain treatment, or to drop communication with the patient as an important aspect of quality care. These items are important indicators of quality of care from the viewpoint of the clinician. They measure aspects of quality of care that the patient, who does not have the clinician s expertise in the diagnosis and treatment of pain, may not think of when asked about satisfaction. In the latter case, satisfaction may be thought of as a patient s perception, which should not be confused with what a clinician believes to be important for the treatment of pain. A clear understanding of this distinction will increase the interpretability of surveys of patient satisfaction. Acknowledgments Funding for this research was provided by NIH/NINR NR References 1. Bond MR, Charlton JE, Woolf CF. American pain society quality assurance standards for relief of acute pain and cancer pain. In: Proceedings of the sixth world congress on pain. London: Elsevier Sciences Publishers, 1991: American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 1995; 274:

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10 Vol. 25 No. 3 March 2003 Patient Satisfaction with Pain Management 273 Appendix 1. American Pain Society Satisfaction Survey At any time during your care, have you needed treatment for pain? 2. Have you experienced any pain in the past 24 hours? 3. On this scale, how much discomfort or pain are you having right now? (Category, numerical, or visual analog scales may be used for questions 3 5.) (Record rating) 4. On this scale, please indicate the worst pain you had in the last 24 hours. (Record rating) 5. On this scale, please indicate how much relief you generally obtained from the medication or other treatment you were given for pain. (Record rating) 6. Select the phrase which indicates how satisfied you are with the way your doctors treated your pain. Very satisfied, satisfied, slightly satisfied, slightly dissatisfied, very dissatisfied 7. Select the phrase which indicates how satisfied you are with the way your nurses treated your pain. Very satisfied, satisfied, slightly satisfied, slightly dissatisfied, very dissatisfied 8. When you asked for pain medication, what was the longest time you had to wait to get it? Record answer, or choose from: 15 minutes or less, minutes, minutes, more than one hour, never asked for pain medication. 9. Was there a time that the medication you were given for pain didn t help and you asked for something more or different to relieve the pain? If your answer is yes, how long did it take before your doctor or nurse changed your treatment to a stronger or different medication and gave it to you? Record answer, or choose from: 1 hour or less, 1 2 hours, 2 4 hours, 4 8 hours, 8 24 hours, more than 24 hours. 10. Early in your care, did your doctors or nurses discuss with you that we consider treatment of pain very important, and did they ask you to be sure to tell them when you have pain? 11. Do you have any suggestions for how your pain management could be improved? Appendix 2. Discharge Survey At any time during your care, have you needed treatment for pain? 2. Have you experienced any pain in the past 24 hours? 3. On a scale of 0 10, how much discomfort or pain are you having right now? 4. On a scale of 0 10, how much pain did you experience immediately after surgery? 5. On a scale of 0 10, how much pain were you experiencing at the time of your first postop ambulation? 6. How soon after surgery did you get out of bed to walk? (Answer in hours) Hours 7. On a scale of 0 10, please indicate the worst pain you had in the last 24 hours.

11 274 Carlson et al. Vol. 25 No. 3 March What percent relief did you generally obtain from the medication or other treatments you were given for pain? 9. How satisfied are you with the way your nurses treated your pain? Very satisfied Moderately satisfied Slightly satisfied Dissatisfied Very dissatisfied 10. When you asked for pain medication, what was the longest time you had to wait to get it? 15 minutes or less minutes minutes More than an hour Never asked for pain medication Other (Please specify: ) 11. Was there a time that the medication you were given for pain didn t help and you asked for more or something different to relieve pain? (Go to Question # 13) 12. (If the response to Question # 11 was Yes ) How long did it take before your doctor or nurse gave you a stronger or different medication? 1 hour or less 1 2 hours 2 4 hours 4 8 hours 8 24 hours more than 24 hours Other (Please specify: ) 13. Approximately how many times did you experience nausea and vomiting after surgery? # of events 14. Approximately what percent of the time did unrelieved pain interfere with your sleep? Percent 15. Early in your care, did your physicians or nurses discuss with you the fact that they consider treatment of pain very important? 16. Early in your care, did your physicians or nurses ask you to notify them when you experienced pain? 17. Prior to surgery, were you worried about becoming addicted to the medication that would be given to you to treat your pain? 18. Did you receive written materials about pain management before surgery? (Go to Question # 21) 19. (If the response to Question # 18 was Yes ) How helpful were the written materials given to you before surgery? Very helpful Somewhat helpful Minimally helpful

12 Vol. 25 No. 3 March 2003 Patient Satisfaction with Pain Management 275 t at all helpful impression 20. (If the response to Question # 18 was Yes ) Was the written material given to you before surgery... Too complicated and/or overwhelming A little complicated and/or overwhelming Just right A little simple Much too simple 21. During your treatment for pain, were you concerned about becoming addicted to the medicine you were taking for pain? 22. Do you have suggestions for how your pain management could be improved? Appendix 3. Items Added to the APS Satisfaction Survey (Item numbers are from the Discharge Survey) 4. On a scale of 0 10, how much pain did you experience immediately after surgery? 5. On a scale of 0 10, how much pain were you experiencing at the time of your first post-op ambulation? 6. How soon after surgery did you get out of bed to walk? (Answer in hours) Hours 13. Approximately how many times did you experience nausea and vomiting after surgery? # of events 14. Approximately what percent of the time did unrelieved pain interfere with your sleep? Percent 17. Prior to surgery, were you worried about becoming addicted to the medication that would be given to you to treat your pain? 18. Did you receive written materials about pain management before surgery? (Go to Question # 21) 19. (If the response to Question # 18 was Yes ) How helpful were the written materials given to you before surgery? Very helpful Somewhat helpful Minimally helpful t at all helpful impression 20. (If the response to Question # 18 was Yes ) Was the written material given to you before surgery... Too complicated and/or overwhelming A little complicated and/or overwhelming Just right A little simple Much too simple 21. During your treatment for pain, were you concerned about becoming addicted to the medicine you were taking for pain?