Brief Research Report The Incidence and Severity of Postoperative Pain following Inpatient Surgery

Pain Medicine 2015; 16: 2277 2283 Wiley Periodicals, Inc. Brief Research Report The Incidence and Severity of Postoperative Pain following Inpatient Surgery Asokumar Buvanendran, MD, Jacqueline Fiala, MD, Karishma A. Patel, MD, Alexandra D. Golden, MD, Mario Moric, MS, and Jeffrey S. Kroin, PhD Department of Anesthesiology, Rush Medical College, Chicago, Illinois, USA Reprint requests to: Asokumar Buvanendran, M.D., Department of Anesthesiology, Rush Medical College, 600 South Paulina, Chicago, IL 60612, USA. Tel: 312-942-3685; Fax: 312-942-5773; E-mail: Asokumar@aol.com. Supported by University Anesthesiologists, S.C., Chicago, IL. Disclosure/Conflict of Interest Information: None of the contributing authors have any conflicts of interest. Abstract Objective. In recent years, there has been increased attention to pain management after surgery in the hospital setting along with financial enticement from the US government. The aim of this study is to evaluate the current efficacy of postoperative pain management. Methods. In a prospective study, patients in an academic private nonprofit medical center were asked the same questions about their postoperative pain as in a previously published 2003 survey. Questionnaires on 1) pain intensity on a verbal categorical scale and 2) patient satisfaction with pain medication were completed in the patient s room before hospital discharge, and followed-up by telephone interviews at 1 and 2 weeks later. Numerical Pain Scale (NRS) pain scores were obtained at the same time points. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results for pain management were obtained at bedside interview along with standard mailed HCAHPS survey obtained by Press Ganey. Results. Based on 441 surgical inpatients (Orthopedic, General, Neurosurgery, Gynecological) 12% of patients had Severe-to-Extreme pain and 54% had Moderate-to-Extreme pain at discharge. During the first 2 weeks after discharge, 13% of patients had Severe-to-Extreme pain and 46% had Moderateto-Extreme pain. Pain scores at discharge and after discharge were negatively correlated with patient satisfaction with pain medication (P < 0.0001), indicating that increased pain intensity was associated with decreased patient satisfaction. For the HCAHPS question how often was your pain well controlled?, 66% answered Always in the Press Ganey report versus 51% at bedside (P < 0.0001). Conclusions. The incidence of severe-to-extreme pain in patients before and after discharge following inpatient surgery is 12 13%, and this is a reduction from 10 years ago. Key Words. Postsurgical Pain; Patient Satisfaction; Survey; HCAHPS Introduction In the United States, over 50 million inpatient surgeries are performed annually [1]. Hospital guidelines for postoperative pain management have assumed increasing importance in the past 10 years. The incidence of postoperative pain was surveyed after discharge from surgery in 1995 (surgeries from 1990 to 1995: including inpatient, outpatient, doctor s office, outpatient clinics, free-standing surgery centers) by Warfield and Kahn, which demonstrated that among those with pain, 23% of patients had severe pain and 8% had extreme pain [2]. In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) published new standards for pain assessment and management. It was recommended that these standards be incorporated into patterns of daily practice in healthcare institutions [3]. Later, in 2003, a survey was conducted by Apfelbaum et al. on the incidence of pain in patients at 2277

Buvanendran et al. discharge after inpatient surgery (surgeries from 1998 to 2002); 35% of patients reported severe-to-extreme pain and 64% reported moderate-to-extreme pain [4]. In that paper, postoperative pain after discharge was also recognized as a subject of high priority [4]. The American Society of Anesthesiologists published in 2012 its Practice guidelines for acute pain management in the perioperative setting, its goal being to reduce or eliminate postoperative pain before discharge [5]. In recent years, there has been increased attention to pain management in the hospital and home setting, leading to the expectation that patient outcomes in the last 10 years may have improved. Studies to date of postoperative pain experience were retrospective surveys that relied on data obtained from patient recollections of surgeries performed in the previous few years (without access to medical records) [2,4]. To understand the current incidence and severity of postoperative pain, we performed a prospective study where patients were initially personally interviewed (after due consent) in their hospital room just prior to discharge and then the same patients were interviewed over the next 2 weeks about their postoperative pain experience. Since 2014, physicians and hospitals in the United State have an added incentive to better manage postoperative pain: Medicare and Medicaid reimbursements will be partially based on pain management performance scores [6]. In particular, since 2008, the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey have been used to evaluate performance of US hospitals, including pain management [7 9]. The HCAHPS scores are reported to the public and have provided the ability for patients to compare health care facilities prior to coming in for their elective surgery. As such, understanding the incidence and severity of postsurgical pain, and examining HCAHPS scores, is more important now than ever before. Methods The study had Institutional Review Board approval from Rush University Medical Center, Chicago, IL. It was conducted over a 12-month period, specifically between September 24 2012 and November 9 2012 and then between June 10 2013 and September 20 2013. Each weekday morning, one of the authors (J.F., K.A.P., A.D.G.) was required go to all of the hospital floors where patients were recovering from inpatient surgery (except cesarean section), and obtain a list of patients due to be discharged from the hospital that day. Written informed consent was then obtained in the patient s room before hospital discharge. If a patient was temporarily out of the room, the interviewer would try again later in the morning. Patients were not paid for participating in the study. All patients were asked the same questions (see Appendix) about their postoperative pain experience as in Apfelbaum et al. (2003): 1) Pain intensity on a 5-choice ordinal verbal categorical scale (from no pain to extreme pain ); 2) Patient satisfaction with pain medication on a 6-choice ordinal verbal categorical scale (from very dissatisfied to very satisfied ). 3) Adverse events expressed as yes or no [4]. Additional questions in our study included a more quantitative estimate of pain using the Numerical Pain Scale (NRS) pain score. The NRS score is an 11-point scale with 0 5 no pain and 10 5 worst pain imaginable. In our study, when patients were asked about their pain intensity it was always over last few hours, not just at that instant. In addition, patients were asked the two standard HCAHPS questions on in-hospital pain management: how often did the hospital staff do everything to help with your pain?; how often was your pain well controlled?. These bedside results were compared to the same HCAHPS questions mailed to these patients by Press Ganey Associates (South Bend, IN). At 1 and 2 weeks after discharge, the same patients were contacted by telephone and completed another set of questions (see Appendix) about their postoperative pain. Multiple attempts were made to contact each patient by telephone, but no letters were sent out. Patients who visited their surgeon for a postoperative evaluation in the previous week were not asked any further questions. This postdischarge survey also included questions about pain interfering with normal activity, on a 5-choice ordinal verbal categorical scale (from never to always ). Sample size was chosen to be at least 3 times that of the 1998 2002 data of Apfelbaum et al. [4] (129 inpatients), so we needed >387 patients for the discharge interview. Statistical analyses were performed using SAS version 9.2 (SAS institute, Cary, NC). Differences in frequencies of pain severity or patient satisfaction at discharge among surgical types were performed using chisquare tests of independence. NRS scores at different time points were compared using the repeated measures mixed procedure with post hoc tests adjusted using the Tukey method. Relationship of NRS, verbal pain scores, and pain interfering with normal activity, to patient satisfaction scores were assessed using the Spearman rank correlation coefficient. HCAHPS scores were compared between discharge interview and the Press Ganey mail-in survey with a chi-square test. Results reported as during the first 2 weeks after discharge (matches Apfelbaum et al. [4]) were obtained by including both the week 1 and week 2 scores (even though most patients were included twice). Statistical tests were considered significant at a threshold of 5% type I error (P-value < 0.05). Results Data at discharge was obtained from 441 inpatients in our study. The distribution of the severity of pain at discharge is shown in Figure 1. 12% of patients reported Severe-to-Extreme pain and 54% Moderate-to- Extreme pain. The different types of surgery in our study were: 43% Orthopedic, 34% General, 13% Neurosurgery, 10% Gynecological. When the patients were compared among the 4 surgical groups in our study 2278

Postoperative Pain Survey 3% were dissatisfied. Drowsiness (35%), constipation (22%), and itching (10%) were the 3 most common adverse events. 74% of patients were receiving pain medications at up to 2 weeks after discharge. 61% were receiving some strong opioid (hydrocodone, oxycodone, morphine), with 53% of patients receiving hydrocodone/acetaminophen. The average NRS score at discharge (pain intensity over the last few hours) was 4.18 6 0.11(mean 6 SE) and the scores at 1 and 2 weeks after surgery were 2.56 6 0.12 and 2.05 6 0.16, respectively (Figure 3). The NRS scores 1 and 2 weeks after leaving the hospital were lower than the score at discharge (P < 0.0001). The NRS score at week 2 was less than at week 1 (P 5 0.0102). Figure 1 Patients verbal pain rating at discharge from hospital. there were no differences in the proportions with Severe-to-Extreme pain (P 5 0.3389) or Moderate-to- Extreme pain (P 5 0.1518) among the groups. At discharge, patient satisfaction (%very satisfied 1 %satisfied) with pain medication was 87%, while 3% were dissatisfied (%very dissatisfied 1 %dissatisfied). When the proportion of patients satisfied with pain medication was compared among the 4 surgical groups in our study there were no differences (P 5 0.5019). Most patients in our study were women (60%), and the percentage of patients 55 year or older was 60%. Our mean BMI was 31.0 kg/m 2. The distribution of the severity of pain during the first 2 weeks after discharge showed 13% with Severe-to- Extreme pain and 46% with Moderate-to-Extreme pain (Figure 2). During the first 2 weeks after discharge, patient satisfaction with pain medication was 87%, while When average NRS pain scores at discharge were related to the patient satisfaction with pain medication, the Spearman rank correlation coefficient was r 520.3224, P < 0.0001; indicating that increased pain intensity was associated with decreased patient satisfaction. Similar negative correlations were seen for all other pain measures in the study, including at 1 and 2 weeks after discharge (Table 1). An important consideration is whether pain interfered with daily activities in the weeks after discharge. At 1 week after discharge, 35% reported that pain usually or always interfered with normal activities; this percentage decreased to 22% at 2 weeks (P 5 0.0009). When pain interfered with daily activities scores at one or two weeks after discharge were related to the patient satisfaction with pain medication, the Spearman rank correlation coefficient was negative and significant (Table 1); indicating that when pain interfered with daily activities there was decreased patient satisfaction with pain medication. Figure 2 Patients verbal pain rating during first 2 weeks after discharge. Figure 3 Postoperative pain scores (NRS 0-10 scale) at discharge from hospital and over next 2 weeks. **** different from at discharge, P < 0.0001; # different from week 1 postdischarge, P < 0.05. 2279

Buvanendran et al. Table 1 Negative correlation between pain measures and patent satisfaction with pain medication (Spearman rank-correlation coefficient) Pain measure R-value P-value At discharge NRS average 20.3224 <0.0001 NRS peak 20.2696 <0.0001 NRS lowest 20.3235 <0.0001 Verbal intensity 20.3043 <0.0001 1-week postdischarge NRS movement 20.5230 <0.0001 NRS rest 20.4502 <0.0001 Verbal intensity movement 20.4489 <0.0001 Verbal intensity rest 20.4394 <0.0001 Pain interfered with activity 20.3820 <0.0001 2-week postdischarge NRS movement 20.3752 <0.0001 NRS rest 20.3632 <0.0001 Verbal intensity movement 20.3755 <0.0001 Verbal intensity rest 20.4052 <0.0001 Pain interfered with activity 20.3164 <0.0001 Patient dropout over time was slightly higher than expected. 441 patients consented and answered the questions in-person at discharge, and 356 replied at 1 week after discharge. However, the number declined to 197 at 2 weeks. To match the newer quality control surveys of inhospital pain management, we compared our HCAHPS results obtained in our bedside interview with the standard mailed HCAHPS survey obtained by Press Ganey at up to 6 weeks after being sent to the same patients. In response to how often did the hospital staff do everything to help with your pain?, there was no difference: 82% answered Always in the Press Ganey report versus 84% in our bedside survey (P 5 0.3883). However, in response to how often was your pain well controlled?, the results were different: 66% answered Always in the Press Ganey report versus 51% in our bedside survey (P < 0.0001). Discussion While it is inappropriate to statistically compare our present prospective study with the retrospective 2003 survey study of Apfelbaum et al., [4] the present results suggest a reduction over the last 10 years in severe-to-extreme postoperative pain scores in patients following inpatient surgery: at discharge, 35% in 2003 and 12% in the present study; and during the first 2 weeks after discharge, 22% in 2003 and 13% in the present study. One factor, in addition to improvement in surgical technique, may be the increased use of strong opioids to control postoperative pain, even after discharge. 53% of our patients were receiving hydrocodone/acetaminophen at 2 weeks after discharge, while the earlier study showed that the drugs most frequently prescribed were milder analgesics (acetaminophen alone or codeine/acetaminophen). However, the prescription of potent opioids, initially advocated by JCAHO, may have led to the current increase in prescription drug abuse in the United States. Patient satisfaction with pain medication was high in 2003 (87 90%), [4] and currently remains high (87%). The continued decrease in NRS pain scores when the patient leaves the hospital may be just the expected decrease in postoperative pain with time. But it also suggests that the medication provided to the patient during the first 2 weeks after discharge is adequate to maintain effective pain management. Recall bias may explain why in response to the HCAHPS question: how often was your pain well controlled?, a higher percentage of patients answered Always in the Press Ganey mailed survey than in the bedside interview prior to discharge. While the HCAHPS evaluation of in-hospital pain management obtained weeks after surgery is a still a useful governmental tool for comparing the relative performance of different hospitals (and determining reimbursement), it lacks the immediacy of in-hospital evaluations. Nevertheless, when the HCAHPS evaluation of how often was your pain well controlled? was obtained at a large urban academic medical center from Press Ganey mailed responses, the response Always was associated with decreased PACU NRS pain scores [10]. Earlier postoperative pain surveys included randomly selecting households from a representative United States market research list, [4] or by random-dialing of United States households [2]. A limitation of our study is the possible bias from the fact that our data was obtained solely from one large private nonprofit medical center in a large Midwest city. While a representative population should ideally be from a multicenter prospective study, the logistics of conducting such a prospective survey make the odds insurmountable. The high proportion of dropouts at the 2-week interview in our study may be due to the lack of an incentive to cooperate; and partly due to our protocol of not interviewing patients after they visited their surgeon for a postoperative evaluation. In such a large survey, providing financial incentives to patients to cooperate is impractical, however, interviewees can always be better trained to be more effective/persistent in obtaining interviews at one and 2 weeks after discharge. Also, although originally in our exclusion criteria, interviewing patients at 2 weeks even if they have had interventions (e.g., visit to surgeon s office) over that time period would increase our retention rate and may be compensated in the analysis through the use of covariates or a subset analysis. While a possible reduction in the severity of postoperative pain in the last decade is encouraging, the 12% of patients reporting severe-to-extreme pain at discharge 2280

Postoperative Pain Survey is an unacceptably high number. Physician indifference to pain is not a factor as there is constant pressure at all hospitals to improve HCAHPS ratings, which includes achieving always on the questions: how often was your pain well controlled, and how often did the hospital staff do everything they could to help you with your pain [7,8]. However, one consequence of this may be increased use of prescribed opioids leading to an increase in adverse events associated with it. The correlation between the pain intensity and patient satisfaction in our study, showing decreased patient satisfaction with increased pain intensity, supports the view that one of the rewards of better postoperative pain control will be better patient satisfaction with the pain management team. At present there seems to be an anomaly of high patient satisfaction despite many patients still experiencing significant pain at discharge. However, as patients become more aware of hospital pain management (from websites and other online chats with similar patients) their expectations to be comfortable after surgery will become much higher. If we do not strive for better postoperative pain management, then in the next few years we may see patient satisfaction plummet. References 1 Centers for Disease Control and Prevention. CDC/ National Center for Health Statistics. National Hospital Discharge Survey: 2010 Table. Available at: http:// www.cdc.gov/nchs/fastats/insurg.htm (accessed March 3, 2015). 2 Warfield CA, Kahn CH. Acute pain management. Programs in U.S. hospitals and experiences and attitudes among U.S. adults. Anesthesiology 1995; 83:1090 4. 3 Berry PH, Dahl JL. The new JCAHO pain standards: implications for pain management nurses. Pain Manag Nurs 2000;1:3 12. 4 Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97:534 40. 5 Apfelbaum JL, Ashburn MA, Connis RT, Gan TJ, Nickinovich DG, Caplan RA, Carr DB, Ginsberg B, Green CR, Lema MJ, Rice LJ. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012;116:248 73. 6 Long L. Impressing patients while improving HCAHPS. Nurs Manage 2012;43:32 7. 7 Gupta A, Daigle S, Mojica J, Hurley RW. Patient perception of pain care in hospitals in the United States. J Pain Res 2009;2:157 64. 8 Tighe PJ, Fillingim RB, Hurley RW. Geospatial analysis of hospital consumer assessment of healthcare providers and systems pain management experience scores in U.S. hospitals. Pain 2014;155:1016 26. 9 HCAHPS Hospital Survey. 2015. Centers for Medicare & Medicaid Services, Baltimore, MD. Available at: http://www.hcahpsonline.org (accessed March 3, 2015). 10 Maher DP, Wong W, Woo P, Padilla C, Zhang X, Shamloo B, Rosner H, Wender R, Yumul R, Louy C. Perioperative factors associated with HCAHPS responses of 2,758 surgical patients. Pain Med 2014 Dec 28. doi: 10.1111/pme.12651. [Epub ahead of print] 2281

Buvanendran et al. Appendix : Questionnaires used in the Study 2282

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