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International Journal for Quality in Health Care Advance Access originally published online on August 1, 2007
International Journal for Quality in Health Care 2007 19(5):274-280; doi:10.1093/intqhc/mzm032
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© The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

Pain management in a medical walk-in clinic: link between recommended processes and pain relief

Noelle Junod Perron and Patrick Bovier

General Internists, Medical Outpatient Clinic, Department of Community Medicine, University Hospitals of Geneva, Switzerland

Address reprint requests to: Noelle Junod Perron, Medical Outpatient Clinic, Department of Community Medicine, University Hospitals of Geneva, 24 rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland, Tel: +41 22 372 96 36; Fax: +41 22 372 96 00; E-mail: noelle.junod{at}hcuge.ch


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
 References
 
Background. While most recommended pain management practices have been developed for hospitalised patients, little is known about their relevance for ambulatory patients presenting with acute pain.

Objective. In this study, we explored the relationship between patients' reported use of recommended pain management practices and pain relief in outpatients.

Mehtod. 703 adult patients who presented with pain at the medical walk-in clinic of the University Hospitals of Geneva, Switzerland, were included in a mailed cross-sectional survey. They completed a self-administered questionnaire with specific items on self reports of pain and pain management processes.

Main outcome measures. Patient's self reports on pain and pain management processes.

Results. Of the 703 patients presenting with pain, 40% reported complete pain relief after their visit at the medical walk-in clinic. After adjustment for age, sex, origin, general health and intensity of pain, patients' self-report of complete pain relief was associated with availability of medical doctors (OR = 5.6; 95% CI 2.1–14.7 for excellent vs. poor availability), availability of nurses (OR = 2.6; 95% CI 1.2–6.0 for excellent vs. poor availability), waiting < 10 min for pain medication (OR = 4.6; 95% CI 2.2–9.8), regular assessment of pain (OR = 1.7; 95% CI 1.02–2.7) and having received information about pain and its management (OR = 3.0; 95% CI 1.8–4.9).

Conclusions. Self-reported pain relief was associated with more frequent use of recommended pain management processes. These recommendations initially developed for hospitalized patients should also be encouraged for ambulatory care patients.

Keywords: pain management, pain relief, walk-in clinic

Studies on pain management have shown that pain is commonly experienced by a majority of patients. However, pain is unsatisfactorily managed in general medical, surgical, or oncology wards [1, 2], and emergency departments [3–6] despite international guidelines on management of chronic and acute pain and implementation of educational programs [7]. Several explanations have been suggested: health care professionals may underestimate patients' pain intensity, use inappropriate analgesics [8], underestimate or question the efficacy of applying pain management guidelines in their everyday practice [7]; patients and health care professionals may fear addiction related to the use of some pain medication [9, 10] or believe that analgesia will interfere with making a diagnosis [11, 12]; finally institutions may show little commitment in trying to change health professionals' attitudes towards pain [7].

A recent study performed in a large general teaching hospital showed that self-reported pain relief was more frequent among hospitalized patients when various processes to manage pain had been used, such as regular pain assessment, modification of pain treatment when ineffective, timely delivery of pain treatment and appropriate information about pain and its management [13]. The authors concluded that hospitals should be encouraged to apply these practices more consistently.

In ambulatory settings, little is known about the relationship between recommended pain management processes and pain relief. Most studies have been conducted in emergency settings with patients in acute pain and explored the relationship between pain management processes and patients' satisfaction. Pain relief was only weakly associated with improved satisfaction with pain management [14]. Patients reported higher satisfaction with pain management when they had received a treatment for pain [15]. Regular pain assessment was also found to be important [16]. Contrasting with these results, other authors have found that a decrease of pain intensity by appropriate care, measured with a visual analogical scale, did not correlate with higher satisfaction regarding pain management [17]. So far none has explored the relationship between the use of recommended pain management processes and pain relief in outpatients.

In this study, we explored whether the use of recommended pain management processes initially developed for hospitalized patients would also be associated with increased pain relief among outpatients attending a walk-in clinic of a large teaching hospital.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 Conclusion
 Acknowledgements
 References
 
Setting
This study was conducted at the medical walk-in clinic of the University Hospitals of Geneva, a 2200-bed public teaching hospital in Switzerland. The medical walk-in clinic is located in the emergency department building. Patients attend the emergency department either spontaneously or because they are referred by their primary care doctor. They are triaged by specialized nurses to either walk-in clinics (medical, surgical or psychiatric) or the emergency rooms according to the severity of their complaints. The medical walk-in clinic provides ambulatory care to ~15 000 patients every year and is open from 8 AM to 11 PM 7 days a week. Less than 10% of patients are hospitalized. Care is delivered by residents generally enrolled in a 12-month training program in primary care medicine.

Study design and sample
We used the data of 703 patients presenting with pain at the medical walk-in clinic to study the link between the use of recommended processes and pain relief. These data were collected as part of a quality improvement program following a multifaceted intervention on pain management [18]. All patients completed a specific questionnaire addressing pain management processes, based on the Picker instrument (P) [19, 20] and new items (N) developed by the members of the Geneva University Hospitals Pain Management Network [13]. Patients presenting with pain at the medical walk-in clinic were identified with the question: ‘Were you in pain during your consultation at the walk-in clinic?’ Because some patients who answered ‘no’ to this question or who skipped it nevertheless described pain intensity, or reported having asked for pain medication elsewhere in the questionnaire, answers to these questions were also used to identify patients presenting with pain at the medical walk-in clinic. As a quality improvement project involving minimal risk to participants, the study was exempted from formal review by the local research ethics committee.

Study variables
The main outcome variable was patient's self-reported pain relief (N) (‘Overall, was your pain relieved during your visit at the walk-in clinic?’). The answers ‘yes, to some extent’ and ‘no’ were grouped and compared with ‘yes, completely’.

The main predictor variables used were patient's reports of the following aspects of pain management (Table 1): availability of doctors and/or nurses (P), waiting time < 10 min before a requested pain medication was brought to the patient (P), regular pain assessment (N), use of a pain assessment tool (N), administration of analgesics during consultation (N), modification of pain treatment when current treatment proved ineffective (N) and having received enough information about pain and its management (N). We chose these different predictors because patients' experience of pain management in the walk-in clinic may be influenced not only by efficient therapy but also by the attitude of health care professionals towards patients. Additional variables included patient's sex, age, citizenship, educational level, the general health item of the Short Form health survey [21] and the intensity of pain.


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  		Table 1 Association between self-reported pain and medical factors in 703 outpatients presenting with pain at a medical walk-in clinic

 
Statistical analysis
Descriptive statistics (frequency tables, means, standard deviations and quartiles) were used to describe socio-demographic characteristics of the patients. Chi-squared and linear trend tests were used to study how overall pain relief varied according to patient characteristics and use of recommended pain management processes. Significant factors in the univariate analysis were used in logistic regression models to identify multivariate predictors of pain relief. We also included important determinants of pain relief that have been identified by others, such as sex, age, origin, perceived health and intensity of pain [4, 5, 10]. Finally, we counted how many significant medical care processes identified in the multivariate analysis were reported as implemented by each patient reporting complete pain relief, and computed the proportions of patients by count. In this analysis, we combined very good and excellent, and poor and fair availability of health professionals. All statistical tests were two-sided with a significance level of 0.05. Statistical analyses were performed using SPSS 11 (Chicago, IL, USA).


   Results
Top
 Abstract
 Methods
 Results
Discussion
 Conclusion
 Acknowledgements
 References
 
The mean age of patients presenting with pain was 39.9 years (SD 15.6; quartiles: 28–38–49) and 57% (397/704) were women. Most patients were Swiss or from the European community (34 and 31%, respectively). Pain was more frequently reported by patients that were non-Swiss, had lower education level, and worst perceived general health (Table 2). Pain was reported as severe by 58% respondents, moderate by 32% and mild by 11%. According to the ICPC-2 classification [22], 32% (223/703) of patients presented with musculo-squeletal complaints, 17% (122/703) with abdominal pain, 16% (113/703) with ear-nose-throat complaints, 8% (55/703) with uro-genital complaints, 7% (52/703) with headache, 6% (40/703) with skin problems and 4% (31/703) with thoracic pain. None of these patients had orthopedic or traumatic diagnoses that are usually managed in the surgical walk-in clinic.


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  		Table 2 Characteristics associated with pain and pain management among outpatient attending a medical walk-in clinic (n = 924)

 
Seventy three percent (505/691) of the patients with pain reported regular pain assessment and 48% (325/683) noticed the use of a pain assessment tool. Half of the patients (49%, 343/695) received a pain medication during their stay at the walk-in clinic. Pain treatment was considered as sufficient to relieve pain by 53% (175/328) and had been modified for 51% of the patients (78/153) when ineffective. More than half of the patients (53%; 153/287) reported waiting < 10 min before a requested pain medication was brought. Seventy percent (287/410) of the patients reported having received enough medication during their stay at the walk-in clinic. Forty-one percent of the patients (281/681) considered having received enough information about pain and its management, and 52% (349/675) about how to manage and treat pain at home. Patients considered overall staff availability to be good to very good (mean score 3.4 (SD 1) for both medical and nursing staff on a five-point Likert scale) and 50% (339/674) considered that health care professionals did everything to relieve them from pain.

Forty percent (262/656) reported complete pain relief after their visit at the walk-in clinic. Self-reported pain relief did not vary according to patients' age, gender, citizenship and educational level, but was less frequently reported by patients with fair or poor general health self-assessment and more severe pain (Table 2).

Multivariate predictors of pain relief
A multivariate analysis including patient's age, sex, origin, general health and intensity of pain as independent variables showed that five medical factors remained associated with complete self-reported pain relief: doctors' and nurses' availability, waiting < 10 min for pain medication, regular assessment of pain and having received information about pain and its management (Table 3).


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  		Table 3 Multivariate analysis of medical care factors associated with pain relief (multivariate logistic regression models)

 
When none of these factors was reported, only 11% of patients reported complete pain relief but when all were reported, almost 80% did (Fig. 1) (linear trend test: P < 0.001).


Figure 1
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  		Figure 1 Relation between the number of recommended pain management processes reported by patients and self-reported complete pain relief (processes included in the score calculation: very good or excellent availability of medical doctors; very good or excellent availability of nurses; waiting time to receive a pain medication of 10 min or less; regular assessment of pain; definitively received information about pain and its management).

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
Conclusion
 Acknowledgements
 References
 
We found that use of recommended pain management processes during emergency care at a medical walk-in clinic was associated with more frequent reports of pain relief among outpatients. A majority of patients said they experienced pain (76%), many of whom had inadequate pain relief (60%). Pain relief was more common in outpatients who reported they had received information about pain and its management, regular assessment of pain, short waiting time to receive pain medication and satisfactory doctors' and nurses' availability.

Influence of pain management activities on patient outcomes has been described for acute and chronic pain in hospital care [13]. As far as we know, there are no studies assessing such correlation for acute pain in ambulatory settings. Our study shows that prevalence of pain was as high among patients attending a medical walk-in clinic as in hospital settings. More than two-thirds of the patients presented with pain and more than half of them rated it as severe. Surprisingly, use of a pain assessment tool or administration of pain medication was not associated with pain relief. It suggests that health care professionals' attitude towards pain, their ability to communicate and inform in an appropriate way are perceived by outpatients as more important than these purely technical processes. The fact that pain relief correlated with a short waiting time to receive pain medication but not with the administration of pain medication further supports the idea that patients may be more sensitive so health staff responsiveness and concern about their pain than to the pain medication itself. Moreover, complete pain relief may be an unrealistic outcome to achieve in a walk-in clinic, where outpatients stay only for a limited period of time. Indeed some authors have found that patients were more satisfied when they feel health care providers are paying high attention to pain management [1, 9]. A primary care study conducted among chronic pain patients also showed that improved doctor–patient communication and general information about pain increased patients' knowledge and satisfaction about pain treatment as well as pain treatment effectiveness [23]. Health care providers' attitude seems therefore more important than pain relief itself. Other studies performed in the emergency department and other settings have found little correlation between pain relief and patient satisfaction [9, 17].

Finally, in our study, pain intensity, patients' age, origin and health self-assessment did not change the association between pain management processes and pain relief. These results are consistent with the medical literature that reports conflicting results about the influence of pain and patient characteristics on pain management practices and outcomes [24–29].

Our study has several limitations. Despite two reminders during mail surveys, the rate of non-respondents remained high (44%), raising the issue of differential associations among non-responding patients. Moreover, submitting a questionnaire in French may have further limited the spectrum of patients included in the study and prevented the exploration of possible confounding in pain management outcomes related to lack of proficiency in French. Another limitation is the fact that our survey questionnaire was filled in by patients several weeks (2–6 weeks later) after they attended the walk-in clinic, raising the issue of recall bias. However, retrospective assessment appears to be valid for a 3-month period in ambulatory settings [30]. Agreement between patient report and staff documentation of the use of a pain assessment tool and administration of pain medication was poor (k = 0.29 and k = 0.30, respectively), with either staff omitting to document pain intensity and administration of pain medication or patients overestimating use of such processes in more than half of the cases. Anecdotic experience in the walk-in clinic suggests that physicians often give pain medication to the patient and nurses tend to ask about pain intensity without documenting it in the medical file. Moreover, patients were quite reliable in reporting the absence of pain management: < 10% of patients did not report any use of a pain assessment tool and 6% of patients denied having received a medication whereas such processes were documented in their medical file. Our results may also have been influenced by the Hawthorn effect. However, we believe that it was not the case because clinicians were not informed about the time of the surveys and patients received the questionnaire at least 2–6 weeks after their visit at the walk-in clinic. Finally, as with any cross-sectional study, causal interpretation of our findings must be done cautiously.

A major strength of our study is that we evaluated pain management processes and outcomes through patients' perspectives, whereas most studies on pain management assessment are generally based on analysis of medical files. The American Pain Society (APS) stresses the need to assess patients' perspectives with regard to pain management outcomes [31, 32]. The patient is an important source regarding the effectiveness of pain relief [1] and assessment of pain management should not be limited to documentation of pain intensity and delivery of pain medication. Furthermore, we collected information about pain management among a fairly large group of outpatients to allow exploration of even weak associations.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusion
Acknowledgements
 References
 
Our study showed that use of pain management processes usually recommended for hospitalized patients was associated with more frequent self-reported pain relief among outpatients, regardless of their pain intensity or general health. These findings underline the importance of regular assessment of pain, short waiting time before receiving a pain medication, delivery of enough information about pain and its management and availability of health professional in daily practice. These recommendations should continue to be included in any educational program aiming at improving pain management in hospital and outpatient care.


   Acknowledgements
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
References
 
The authors wish to thank the Quality of Care program of the University Hospitals of Geneva who funded this work, Olivia Zehfus and Paola D'Ipolito, RN, for the data collection; Agnès Hazard, RN, Yves-Cédrix Cottier, MD and Valérie Piguet, MD, for collaborating on the quality improvement project; Professor Hans Stalder, MD, for his useful comments on a prior version of the manuscript and all the members of the medical staff of the walk-in clinic for their continuing support throughout this project.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
 References
 

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Accepted for publication June 21, 2007.


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This Article
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