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Am Fam Physician. 2006;74(8):1417-1418

Acute and chronic pain are common complaints but often are treated inadequately. It has been suggested, and even mandated in some settings, to include pain as a “fifth vital sign” based on the hypothesis that recording pain level would improve attention and lead to better management. Mularski and associates evaluated the difference in pain management before and after the implementation of pain as a fifth vital sign, and on improvements in pain management of a group of patients reporting severe pain (i.e., a score of 4 or more on a 10-point scale, with 0 indicating no pain).

The authors performed a retrospective chart review at a Veterans Affairs hospital. Twenty of 100 sequential visits per physician in an internal medicine clinic were randomly selected. Indicators of pain management were used to determine quality of care, focusing on history, physical examination, medication, additional pain treatments, and follow-up. Three composite scores relating to evaluation, treatment, or attention to pain were developed from these indicators.

Patient characteristics in the pre- and postimplementation groups were similar. Pain diagnoses before implementation were made in 64 percent of sampled patients, with 56 percent receiving pain medication prescriptions. Pain level was recorded in 94 patients in the preimplementation group and in 247 in the postimplementation group. The latter represented pain as the fifth vital sign recorded in 82 percent of patients, with 45 percent reporting pain, and 32 percent reporting severe pain.

There was no difference in the pre- and postimplementation groups in terms of composite scores (P > .05) or number of recorded quality indicators. Of patients in the postimplementation group reporting substantial pain, 22 percent had no mention of pain on their records, and 27 percent had no evaluation of pain. Treatment was absent or unchanged in 52 percent. There was no difference in results noted across providers. Pain treatment increased 10-fold when a provider evaluated pain. Pain level, a chief complaint of pain, and a diagnosed pain disorder also were associated with treatment.

The inclusion of pain level as a vital sign had no impact on pain management, which remained unchanged before and after the implementation of pain as the fifth vital sign. In addition, patients reporting severe pain received no attention to their pain in more than one fifth of visits, and more than one half of patients received no new treatment or no change in treatment. The authors conclude that using pain as the fifth vital sign alone is not sufficient for improving pain care, and that other measures to improve evaluation and treatment of pain are needed.

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