FACT SHEET No.

14

Using Outcomes to Improve Pain Care After Surgery:

Real-Time, Short- Term, and Long-Term
Assessing the quality of pain management includes evaluating structures, processes, and outcomes [15].
Outcomes, for the most part, reflect the results of processes and structures. This Fact Sheet focuses on
describing outcomes to make treatment decisions at point-of-care for individual patients, those used for
quality improvement (QI) initiatives such as enhanced recovery after surgery programs, and those used
for research. Measurement of outcomes is also increasingly required for accountability (performance
measures) that in some countries is linked to financial incentives for health-care systems.

Quality care has been defined as the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current professional
knowledge [9]. There is currently no consensus definition as to what constitutes high-quality
perioperative pain management. This gap reflects a lack of agreement as to what are desired health
outcomes in this context, how and when to measure them, and which thresholds should be used to
judge quality [10,12].

Outcomes of importance related to the management of pain caused by surgery may differ based on the
perspective of the observer (whether it is the patient, a clinician, an administrator, or a researcher), time
(near to and far from the time of surgery), and the available resources, including staffing and
technology. Examples of outcomes include, among others:

Patient-reported outcomes (PROs); e.g., pain intensity, interference with function, adverse
effects, quality of life, satisfaction, quality of recovery, development of chronic pain
Clinical outcomes; e.g., complications, analgesic consumption, mortality
Health economic outcomes; e.g., costs of resource utilization and interventions (manpower,
equipment, and disposables) in ambulatory environments compared with inpatient ones and
private versus state-run health-care systems

______________________________________________________________________________________________________________________________

Copyright 2017 International Association for the Study of Pain. All rights reserved.

IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.
Outcome Measurement for Treatment Decisions at Point-of-Care, in Real Time

To help guide treatment decisions in clinical practice, several PROs should be used to assess a patients
pain status and the impacts of the host of factors that affect their experience of pain (type of procedure,
genetics, sociodemographic characteristics, mood, fatigue, and previous and current drug therapy).
These outcomes should address the overarching goal of early functional recovery. Core outcome
measures should be simple. They may include:

patient report of pain severity

pain interference with function (e.g. movement in or out of bed and with sleep)
presence and severity of adverse effects
how the patient perceives the treatment received (e.g. satisfaction, wish for more effective pain
treatment).

Outcome targets should, when possible, include no worse than mild pain [9] and minimal interference
with function from pain and from pain treatments.
The dynamic nature of postoperative pain necessitates repeated measurements of pain. Basing
treatment decisions on single ratings of pain intensity (e.g., worst or least) is not associated with
improved care [3] and has been linked to reports of overtreatment and serious adverse events [2].

Various pain assessment questionnaires are available, but research has not demonstrated a single best
tool or an optimal frequency to apply it to assess and reassess postoperative pain [8].

A pain trajectory can capture the dynamic nature of a patients pain. A pain trajectory is a graphical
representation of a patients pain intensity scores over the observation period. Compared with a single
pain score, trajectories draw attention to the speed of onset of initial pain relief, the consistency of pain
relief, and the overall amount of pain relief achieved [4,5].

In clinical situations where pain assessments are carried out routinely, the primary data for creating
trajectories already exist. Awareness about this technique and knowledge of how to interpret the
findings are needed.

Outcome Measurement for Quality Improvement [7]

QI initiatives depend upon providing the right information at the right time to the right group of people.
A clinical data registry can offer information about quality and safety of treatment for a group or groups
of patients at the ward, hospital, and even national or international level. Providers can use the data to:

Track their own performance and the impact of interventions, thereby identifying clinical
weaknesses and strengths, and apply this information to allocate improvement resources in a
data-driven fashion
Compare performance with other institutions (benchmarking)

______________________________________________________________________________________________________________________________

Copyright 2017 International Association for the Study of Pain. All rights reserved.

IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.
Registry information may be more generalizable because it does not exclude complex patients.

PAIN OUT (www.pain-out.eu) is an international perioperative registry [13, 14] and is endorsed
by IASP
The Collaborative Health Outcomes Information Registry (CHOIR) (www.choir.stanford.edu) is
currently developing an acute module for assessing quality of perioperative pain in the USA

Outcome Measurement for Research

Including clinically important patient-centered outcomes using standardized, valid measurement

instruments is essential in perioperative research. [1]

The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT)
group offers a core set of outcome measures for designing and implementing randomized
controlled perioperative pain studies [6,11].
Big Data registries provide opportunities for epidemiological and clinical research

Outcome Measurement for Accountability: Assessing Health-Care System Performance

Performance indicators are publicly reported back to the health-care purchaser/consumer and can be
used to channel market demand toward systems with the best performance. Few such indicators
currently exist for pain. Examples that include pain items are the U.S. Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) (www.hcahpsonline.org) and the Picker Institute inpatient
surveys in the UK (www.pickereurope.org/).

Robust assessment of health-care performance must also consider pain after discharge because the
current emphasis on shortened hospital stays for enhanced recovery protocols risks pain problems after
surgery (e.g., chronic postsurgical pain) being under-recognized in the community.

REFERENCES

1. Boney O, Moonesinghe S, Myles PS, Grocott MPW. Standardizing endpoints in perioperative research. Can J Anaesth
2016;63:159-168.
2. Vila H Jr, Smith RA, Augustyniak MJ, Nagi PA, Soto RG, Ross TW, Cantor AB, Strickland JM, Miguel RV, The efficacy and
safety of pain management before and after implementation of hospital-wide pain management standards: is patient
safety compromised by treatment based solely on numerical pain ratings? Anesth Analg 2005;101:47480.
3. Hadjistavropoulos T, MacNab Y, Lints-Martindale A, Martin R, Hadjistavropoulos H. Does routine pain assessment
result in better care? Pain Res Manag, 2009;14:,211-6.
4. Chapman CR, Donaldson GW, Davis JJ, Bradshaw DH. Improving individual measurement of postoperative pain: the
pain trajectory. J Pain. 2011;12(2):257-62.
5. Kannampallil T, Galanter WL, Falck S, Gaunt MJ, Gibbons RD, McNutt R, Odwazny R, Schiff G, Vaida AJ, Wilkie DJ,
Lambert BL. Characterizing the pain score trajectories of hospitalized adult medical and surgical patients: a
retrospective cohort study. Pain. 2016;157(12):2739-2746.

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Copyright 2017 International Association for the Study of Pain. All rights reserved.

IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.
 6. Cooper SA, Desjardins PJ, Turk DC et al. Research design considerations for single-dose analgesic clinical trials in acute
pain: IMMPACT recommendations Pain 2016;157(2):288-301.
7. Gordon DB, Polomono R, Pellino, TA, Turk DC, McCracken L, Sherwood G, Farrar J, Paice J, Wallace M, Strassels S.
Psychometrics of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ) for Quality
Improvement of Acute and Cancer Pain Management. J of Pain 2010;11(11):1172-1186.
8. Gordon DB, DeLeon-Casasola OA, Wu CL, Sluka K, Brennan T, Chou R. Research gaps on practice guidelines for acute
perioperative pain management in adults: findings from a review of the evidence for an American Pain Society clinical
practice guideline. J Pain 2016;17(2):158-66.
9. Lohr K.N. Medicare . A Strategy for Quality Assurance. Washington, DC: National Academy Press, 1990.
10. Malhotra A, Mackey S. Outcomes in pain medicine: a brief review. Pain Ther 2012;1(1):5.
11. McGrath PJ, Walco GA, Turk DC et al. Core outcome domains and measures for pediatric acute and chronic/recurrent
pain clinical trials: PedIMMPACT recommendations. J Pain 2008;9(9):771-83.
12. Moore RA, Straube S, Aldington D. Pain measures and cut-offs - 'no worse than mild pain' as a simple, universal
outcome. Anaesthesia. 2013;68(4):400-12.
13. Rothaug J, Zaslansky R, Schwenkglenks M, Korman M, Alvin A, Backstrom, R, Brill S, Bucholz IM, Engle C, Fletcher D,
Foror L, Funk P, Gerbershagen HJ, Gordon DB, Konrad C, Kopf A, Leykin Y, Pogatzki-Zahn E, Puig M, Rawal N, Taylor
RS, Ullrich K, Volk T, Yahiaoui-Doktor M, Meissner W. Patients perceptions of post-operative pain management:
validation of the International Pain Outcomes questionnaire (IPO). J Pain 2013;14(11):1361-1370.
14. Zaslansky R, Rothaug J, Chapman CR, Bckstrm R, Brill S, Fletcher D, Fodor L, Gordon DB, Komann M, Konrad C,
Leykin Y, Pogatski-Zahn E, Puig MM, Rawal N, Ullrich K, Volk T, Meissner W. PAIN OUT: the making of an international
acute pain registry. Eur J Pain 2015;19:490-502.
15. Donabedian, A. The quality of care: How can it be assessed? JAMA 1988;260 (12): 17438.

AUTHORS
Deb Gordon RN, DNP, FAAN
Departments of Anesthesiology & Pain Medicine
Co-Director, Harborview Integrated Pain Care Program
University of Washington
Seattle, Wash., USA

Winfried Meissner, MD
Project Coordinator, PAIN-OUT/QUIPS
Dep. of Anesthesiology and Intensive Care
University Hospital FSU Jena
Jena, Germany

Ruth Zaslansky, DSc

Scientific Manager, PAIN-OUT
Jena University Hospital
Dept. of Anesthesiology and Intensive Care
Jena, Germany

REVIEWERS

Jane Quinlan, MB, BS, FRCA, FFPMRCA

Consultant in Anaesthetics and Pain Management
Nuffield Division of Anaesthetics
Oxford University Hospitals NHS Foundation Trust
Oxford, United Kingdom

______________________________________________________________________________________________________________________________

Copyright 2017 International Association for the Study of Pain. All rights reserved.

IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.
Narinder Rawal, MD, Ph.D., FRCA (Hon), EDRA
Professor, Department of Anaesthesiology and Intensive Care
rebro University
rebro, Sweden

About the International Association for the Study of Pain

IASP is the leading professional forum for science, practice, and

education in the field of pain. Membership is open to all professionals
involved in research, diagnosis, or treatment of pain. IASP has more
than 7,000 members in 133 countries, 90 national chapters, and 20
Special Interest Groups.

As part of the Global Year Against Pain After Surgery, IASP offers a series of Fact Sheets that cover
specific topics related to postsurgical pain. These documents have been translated into multiple
languages and are available for free download. Visit www.iasp-pain.org/globalyear for more
information.

______________________________________________________________________________________________________________________________

Copyright 2017 International Association for the Study of Pain. All rights reserved.

IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the
study of pain and translate that knowledge into improved pain relief worldwide.