title: A comparison of the clinical utility of pain assessment tools for children with cognitive impairment.
abstract: BACKGROUND
  Difficulty assessing pain has been cited as one of the primary reasons for infrequent and inadequate assessment and analgesia for children with cognitive impairment (CI). Several behavioral observational pain tools have been shown to have good psychometric properties for pain assessment in this population; however, routine clinical use may depend largely on their pragmatic qualities. We designed this study to evaluate pragmatic attributes or clinical utility properties of three recently developed pain assessment tools for children with CI.
  
  
  METHODS
  A sample of clinicians from three medical centers were asked to review 15 videotaped observations of children with CI, recorded during their first three postoperative days during participation in a previous study. Participants scored pain using the revised-Face, Legs, Activity, Cry, Consolability (r-FLACC) tool (individualized for the child during the previous study) for five observations, the noncommunicative Non-Communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV) for five, and the Nursing Assessment of Pain Intensity (NAPI) for five observations. After their review of all segments, participants completed the Clinical Utility Attributes Questionnaire (CUAQ) ranking three attributes of clinical utility; complexity, compatibility, and relative advantage.
  
  
  RESULTS
  Five physicians and 15 nurses comprised the sample. There was excellent agreement between the coded pain scores (i.e., mild, moderate, severe pain) assigned using all tools and r-FLACC scores assigned by original observers (88%-98% exact agreement; kappa 0.71-0.96). The internal consistency or reliability of the CUAQ was supported by high alpha values for each of the subscales (alpha = 0.84-0.93). Subscale and total CUAQ scores were higher for the r-FLACC and NAPI compared with the NCCPC-PV. The r-FLACC had similar scores for complexity, but slightly higher scores for compatibility, relative advantage, and total utility compared with the NAPI.
  
  
  CONCLUSIONS
  We found that clinicians rated the complexity, compatibility, relative advantage, and overall clinical utility higher for the r-FLACC and NAPI compared with the NCCPC-PV, suggesting that these tools may be more readily adopted into clinical practice.
authors.affiliation: University of Michigan Health Systems, Department of Anesthesiology, Mott Children's Hospital, Ann Arbor, Michigan 48109-0211, USA. terriv@umich.edu
authors.forename: Terri
authors.initials: T
authors.lastname: Voepel-Lewis
authors.forename: Shobha
authors.initials: S
authors.lastname: Malviya
authors.forename: Alan R
authors.initials: AR
authors.lastname: Tait
authors.forename: Sandra
authors.initials: S
authors.lastname: Merkel
authors.forename: Roxie
authors.initials: R
authors.lastname: Foster
authors.forename: Elliot J
authors.initials: EJ
authors.lastname: Krane
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Davis
mesh_terms: D002648:Child; D002652:Child Behavior; D003072:Cognition Disorders / Q000150:complications* / Q000523:psychology; D005240:Feasibility Studies; D006801:Humans; D015588:Observer Variation; D010147:Pain Measurement / Q000379:methods*; D010149:Postoperative Pain / Q000150:complications / Q000175:diagnosis* / Q000523:psychology; D011594:Psychometrics; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D014481:United States; D014741:Video Recording