title: Measuring pain as the 5th vital sign does not improve quality of pain management.
abstract: BACKGROUND
  To improve pain management, the Veterans Health Administration launched the "Pain as the 5th Vital Sign" initiative in 1999, requiring a pain intensity rating (0 to 10) at all clinical encounters.
  
  
  OBJECTIVE
  To measure the initiative's impact on the quality of pain management.
  
  
  METHODS
  We retrospectively reviewed medical records at a single medical center to compare providers' pain management before and after implementing the initiative and performed a subgroup analysis of patients reporting substantial pain (> or =4) during a postimplementation visit.
  
  
  METHODS
  Unique patient visits selected from all 15 primary care providers of a general medicine outpatient clinic.
  
  
  METHODS
  We used 7 process indicators of quality pain management, based on appropriately evaluating and treating pain, to assess 300 randomly selected visits before and 300 visits after implementing the pain initiative.
  
  
  RESULTS
  The quality of pain care was unchanged between visits before and after the pain initiative (P>.05 for all comparisons): subjective provider assessment (49.3% before, 48.7% after), pain exam (26.3%, 26.0%), orders to assess pain (11.7%, 8.3%), new analgesic (8.7%, 11.0%), change in existing analgesics (6.7%, 4.3%), other pain treatment (11.7%, 13.7%), or follow-up plans (10.0%, 8.7%). Patients (n=79) who reported substantial pain often did not receive recommended care: 22% had no attention to pain documented in the medical record, 27% had no further assessment documented, and 52% received no new therapy for pain at that visit.
  
  
  CONCLUSIONS
  Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.
authors.affiliation: Portland Veterans Affairs Medical Center, USA. Richard.Mularski@med.va.gov
authors.forename: Richard A
authors.initials: RA
authors.lastname: Mularski
authors.forename: Foy
authors.initials: F
authors.lastname: White-Chu
authors.forename: Devorah
authors.initials: D
authors.lastname: Overbay
authors.forename: Lois
authors.initials: L
authors.lastname: Miller
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Linda
authors.initials: L
authors.lastname: Ganzini
mesh_terms: D000700:Analgesics / Q000627:therapeutic use; D001794:Blood Pressure; D001831:Body Temperature; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy / Q000503:physiopathology* / Q000517:prevention & control; D059408:Pain Management; D010147:Pain Measurement / Q000592:standards; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies
chemical_list: D000700:Analgesics