Just a couple of quick searches:
the three questions in the original survey were:
During this hospital stay, did you need medicinefor pain?
During this hospital stay, how often was your pain well controlled?
During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
On October 1, 2017, the Centers for Medicare & Medicaid Services (CMS) announced they will no longer use results from the pain management portion of the Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey to impact reimbursement rates from the Hospital Value-Based Purchasing (VBP) program*. The Department of Health and Human Services (HHS) determined pain management questions may financially incentivize inpatient hospitals to over prescribe opioids in an effort to eliminate pain and improve survey results.
HHS intends to replace the current questions with questions targeted toward pain management communication similar to those in the Outpatient and Ambulatory Surgery (OAS) CAHPS. HHS will have public comment periods available during development and prior to implementation of the new pain management questions for the HCAHPS. The President’s Commission on Combating Drug Addiction and the Opioid Crisis supported this decision as part of their 56 recommendations released on October 31, 2017.
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*For now, the pain management questions will continue to remain a part of the survey sent to patients and will be used when determining scores for the Hospital IQR program, HCAHPS star ratings, and Hospital Compare overall ratings. However, the scores will not impact reimbursements through the VBP program.
Case
A hospital’s Committee on Patient Quality meets monthly to discuss a strategic plan to address deficiencies in scores on its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results. Dr. Anderson begins the meeting by proposing a new pain management protocol to the group. He references the plateau in pain management scores in the HCAHPS report, warning that the organization will sustain substantial financial penalties by failing to improve in the “patient experience of care” domain. As Dr. Anderson begins to explain the new protocol for pain management and how it will bring about an upward trend in scores, Dr. Parker interjects.
“Can we take a step back for a moment? I understand that patient satisfaction surveys can provide a lot of useful information to our hospital system. But a low rating on—let’s say pain control—doesn’t mean the patient received low-quality care.”
“I agree with what you’re saying, but this is the reality of pay for performance. Plus, there is value in considering patient satisfaction—happier patients are more likely to adhere to our recommendations and return in the future. As you mentioned, we can learn a lot from these surveys—like how helpful it was to have extra volunteer greeters in the lobby to assist patients with finding their way in the hospital,” explains Dr. Anderson.
“I still don’t think it makes sense for Medicare to tie the survey results to our reimbursement,” Dr. Parker counters. “Financial penalties for hospital-acquired infections and preventable readmissions make sense. Public reporting of morbidity and mortality encourages systemic improvements and patient empowerment. But all of these are objective measures. Patient satisfaction just isn’t an objective measure of care quality.”
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Now, as part of the ACA’s Hospital Value-Based Purchasing Program [1], CMS is withholding 1 percent of Medicare payments—30 percent of which is tied to HCAHPS scores—to fund the incentives of the program [4]. The proportion of the payouts that is withheld from hospitals will undoubtedly increase over time. There are similar incentive components in the Physician Quality Reporting System (PQRS). Overall, measurement of and incentives linked to patient experience are increasing [5].
https://www.medscape.com/viewarticle/875980
Pain management specialist Ralph laraiso, MD, commented that patients don’t use the Visual Analogue Scale in the way it was originally developed, “while others have learned to manipulate that scale to obtain the maximum amount of narcotic medications.”
Dr Iaraiso said he relies more on functional status. “Many of these patients have psychosocial issues that will not be relieved by pain pills, but they will not admit to that nor seek appropriate professional services on their own, or, when referred, they are resistant,” he said.
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Pressure to Prescribe?
Survey participants were asked how often they feel pressure to prescribe pain medication in order to keep patient satisfaction levels high.
For physicians, 28% said often; 29%, sometimes; and 6%, always. About a third said they never or rarely felt that pressure. Nurses felt similar pressure. Thirty-percent said they often felt a need to prescribe; 23%, sometimes; and 12%, always. Thirty-five percent said they never or rarely felt pressured to prescribe.
Mary Mavraganes, a registered nurse, said, “often we are forced to give pain medicine per family or patient request.” This can be the wrong move in the elderly, as they “become very confused, which results in falls,” said Mavraganes.
Another registered nurse, Debra Bork, said, “Since the opioid epidemic hit the fan, people want narcotics for every little pain they have and expect to get them.”
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“Government involvement in healthcare, especially HCAHPS, has no real value, but utilizes subjective measures and no outcome data to hijack hospital reimbursement,” commented Allen Coleman, MD, an anesthesiologist. “Pain scores are entirely subjective and leave us treating numbers, which is something good medical students learn not to do in clinical rotations.”
https://www.ashp.org/news/2013/04/26/pharmacists_work_to_boost_patient_satisfaction_scores
“We have an acute pain steering committee [that] is charged with looking at ways to improve pain management,” Ghafoor said. “And they had asked pharmacy specifically to look at some of the medication issues and try to see if there are ways to improve the medication administration up on the floors.”
During a two-month pilot program on the hospital’s oncology and medical–surgical units, Ghafoor reviewed medication administration records for each patient whose pain score was at least 5 out of 10. During multidisciplinary rounds, she recommended ways to maximize these patients’ pain therapy with opiates and other analgesics.
Important to the process was a review of each patient’s medication history, including data on controlled substance use obtained from the state’s prescription drug monitoring program.
“If the patient is missing a medication that they were on [at home], we want to make physicians aware of that so they can order that, because that, a lot of times, contributes to the pain,” Ghafoor said.
In the hospital’s oncology unit, Ghafoor’s efforts resulted in 84% of patients saying the staff always did everything they could to control pain, a 14-percentage-point increase on that HCAHPS measure. On the medical–surgical unit, the score rose from 78% before the pilot program to 91% afterward.
https://www.practicalbioethics.org/files/pains/PAINS-policy-brief-8.pdf
[This article is actually pro 5th Vital Sign]
Unfortunately, in conjunction with embracing Pain as the 5th Vital Sign, many hospitals established standardized protocols with different doses and formulations of pharmacological therapies based on narrowly focused pain scores alone.
https://www.mayoclinicproceedings.org/article/S0025-6196(17)30923-0/fulltext
Abstract
The opioid crisis that exists today developed over the past 30 years. The reasons for this are many. Good intentions to improve pain and suffering led to increased prescribing of opioids, which contributed to misuse of opioids and even death. Following the publication of a short letter to the editor in a major medical journal declaring that those with chronic pain who received opioids rarely became addicted, prescriber attitude toward opioid use changed. Opioids were no longer reserved for treatment of acute pain or terminal pain conditions but now were used to treat any pain condition. Governing agencies began to evaluate doctors and hospitals on their control of patients’ pain. Ultimately, reimbursement became tied to patients’ perception of pain control. As a result, increasing amounts of opioids were prescribed, which led to dependence. When this occurred, patients sought more in the form of opioid prescriptions from providers or from illegal sources. Illegal, unregulated sources of opioids are now a factor in the increasing death rate from opioid overdoses. Stopping the opioid crisis will require the engagement of all, including health care providers, hospitals, the pharmaceutical industry, and federal and state government agencies.
Side article, but interesting:
https://www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-patients/390684/
The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”
This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.
In fact, a national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.
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How far will a hospital go to satisfy a patient? Recently, some have rushed to purchase extra amenities such as valet parking, live music, custom-order room-service meals, and flat-screen televisions. Some are offering VIP lounges to patients in their “loyalty programs.”
And because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply. An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to provide scripts or other resources that boost satisfaction scores. Some institutions have even hired actors to rehearse the scripts with nurses.
Thanks for the research.
The use of the VAS is not very useful to assess pain especially chronic pain, functional assessments are of course much better.
However, most of these studies involve hospital based treatment, post op care, cancer, hospital stays for various illnesses.
The claim the government has made for a while is that the increased opioid overdose rate and death rate correlates with the increased total mg opioids prescribed which mostly comprises outpatient prescriptions for chronic pain. The dogma is that correlation equals causation. But recent analysis of CDC data indicates that the increased overdose rate is due to illicit drugs. There has been some slight recent improvement in overdose deaths (but not overdose attempts) because of narcan. However, with the sharp reduction in prescription opiates of more than 30% we should have seen a greater reduction in overdose deaths and overdose attempts and we have not.
The anti-opioid faction counters by saying that more exposure to opioids causes more addiction. But even that is likely not true becuse addiction rates for opiates and other substances have been essentially stable for years. Trying to completely eliminate exposure to opiates, which is the only way to avoid addiction, is nearly impossible. Even banning its use for cancer and postoperative pain would not likely eliminate exposure in the illicit market.
The same thing was tried 100 years ago with alcohol prohibition and there was very little decrease in alcoholism at the time.
I think the problem here is that suicide rates are up. Opioids are one means of accomplishing that act. However, everyone knows that there are many ways to commit suicide.
So based on this experience, the government should force people to abstain from alcohol and ban opiates. People should convert to Mormon, Islam or Amish, and we need to strengthen families by forbidding divorce.
As they say, abstinence is a virtue, but prohibition is a tyranny.
Exactly
During this hospital stay, did you need medicinefor pain?
During this hospital stay, how often was your pain well controlled?
During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
1978 Bad Motorcycle accident, major roadrash,raw flesh,bones,...
1. NO I had Surgery the very next Morning and when I woke up All the Pain was GONE! I had a little stinging on my thigh where they skinned me alive to do the skin grafting,(1’x2’) but Not Pain.
2. for the first 2 days they gave me a shot of demeral once each day, mostly to calm me down. then another week and I was clean
My pain was the “Go Directly into Shock” and hit the ground wherever you are as soon as the meds wore off. I knew what to expect going in to this and would absolutely do it again, withdrawls sucked, and I would do it again, but so what the Percodan SAVED MY LIFE!!!