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Health Services Research & Development

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2006 HSR&D National Meeting Abstract

3073 — Implementation of Pain as the 5th Vital Sign Initiative and Trends in Analgesic Prescriptions

Author List:
Bair MJ (Roudebush VA Medical Center)
Flanagan ME (Roudebush VA Medical Center)
Yeung A (Roudebush VA Medical Center)
Sutherland JM (Roudebush VA Medical Center)
Kroenke K (Indiana University School of Medicine)

In 1999, the Veterans Health Affairs (VHA) began implementation of the “Pain as the 5th Vital Sign” (Pain5thVS) initiative and recommended routine measurement of patients’ pain using a numeric rating scale (0 to 10). The study objectives were to determine the trends in analgesic prescriptions since implementation and whether patients reporting moderate to severe pain were more likely to be prescribed opioid analgesics in the primary care setting.

The study setting was the general medicine clinics at the Roudebush VA Medical Center. Two years of data (2000 – 2002) were extracted from the VHA Information Systems and Technology Architecture (VISTA) computerized patient records. Datasets were created, linked by patient identifiers, and included pain scores, analgesic prescriptions, patients’ demographics, clinic site, prescribing provider, and medication issue dates. Generalized linear models and a repeated measure design were used to model the number of analgesic prescriptions before and after implementation of Pain5thVS initiative and the likelihood of an opioid prescription for a given pain score controlling for variation in the total number of patients, dichotomized status of implementation and time.

Of 25,789 patients, 46% (n=11,806) were prescribed analgesics during the 2-year study period. For those prescribed analgesics, the mean age was 64.8 and 73% were white and 15% African-American. Opioid prescriptions quadrupled and the rate of opioid prescriptions differed by 14.2% after implementation (p<.0001) controlling for time, implementation status, and total number of patients. The proportion of patients receiving opioid analgesics increased steadily as pain severity increased with a concomitant decrease in non-opioids. At a moderate pain score, patients were 1.4 times more likely to be prescribed an opioid compared with a non-opioid analgesic. Those with severe pain were 2.0 to 3.5 times more likely to be prescribed an opioid.

The implementation of Pain5thVS initiative had a significant positive effect on the number of analgesics prescribed in primary care. Furthermore, the pain score was significantly related to the likelihood of an opioid prescription, suggesting that primary care providers are appropriately tailoring analgesic prescribing based on their patients' pain severity.

Future studies should examine the impact of other implementation strategies on improving pain management.

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