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CME/CE Released: 09/20/2007; Reviewed and Renewed: 10/17/2008; Valid for credit through
10/17/2009
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September 20, 2007 -- In the primary care setting, the pain numeric rating scale to screen for
pain was only moderately accurate in identifying pain in patients, according to the results of a
study reported in the August 1 Online First issue and will appear in the October print issue of the
Journal of General Internal Medicine.
"Universal pain screening with a 0-10 pain intensity numeric rating scale (NRS) has been widely
implemented in primary care," write Erin E. Krebs, MD, MPH, from the Center on Implementing
Evidence-Based Practice, Roudebush Veterans Affairs Medical Center in Indianapolis, Indiana,
and colleagues. "Universal screening in primary care would be useful if it accurately identified
patients with clinically important pain who could potentially benefit from additional pain
assessment and management.... The U.S. Preventive Services Task Force (USPSTF)
recommends that two criteria be met before a screening test is recommended for widespread use:
(1) the test should be sufficiently accurate and capable of detecting a condition earlier than
routine care and, (2) screening and early treatment should improve the likelihood of favorable
patient outcomes."
In this prospective, diagnostic accuracy study, 275 adult clinic patients were enrolled from
September 2005 to March 2006 and were tested for clinically important pain with the use of 2
alternate definitions: pain interfering with functioning (Brief Pain Inventory interference scale
[BPI] ≥ 5) and pain motivating a visit to the clinician or being the patient-reported reason for the
visit.
A pain symptom being the main reason for a visit to the clinician was reported by 22% of
patients, with the most frequently reported pain locations being in the lower extremity (21%) and
back or neck (18%).
As a test for pain that interferes with functioning, the NRS had fair accuracy, with an area under
the receiver operator characteristic (ROC) curve of 0.76. A pain screening NRS score of 1 was
69% sensitive for pain that interferes with functioning (95% confidence interval [CI], 60 - 78),
and multilevel likelihood ratios for scores of 0, 1 to 3, 4 to 6, and 7 to 10 were 0.39 (95% CI,
0.29 - 0.53), 0.99 (95% CI, 0.38 - 2.60), 2.67 (95% CI, 1.56 - 4.57), and 5.60 (95% CI, 3.06 -
10.26), respectively.
Use of the alternate definition of pain that motivates a visit to the clinician yielded similar
results.
Limitations of the study include the absence of a well-established gold standard for clinically
important pain, potential selection bias, and lack of generalizability to all primary care settings.
"The practice of universal pain screening has become widespread despite a lack of published
research evaluating the accuracy and effectiveness of pain screening strategies," the study
authors conclude. "Our results suggest that the most commonly used measure for pain screening
may have only modest accuracy for identifying patients with clinically important pain in primary
care. Further research is needed to determine whether pain screening improves patient outcomes
in primary care."
The Robert Wood Johnson Foundation provided funding for this study through the Clinical
Scholars Program and supported one of its authors. The remaining authors have disclosed
financial relationships with the National Institutes of Health and the Department of Veterans
Affairs.
October 2007;00:000-000.
Clinical Context
Approximately 20% of primary care patients experience chronic pain, and pain screening is
intended to improve the quality of pain management by systematically identifying patients with
pain in clinical settings, but currently there is no commonly accepted gold standard for clinically
important pain. The NRS on which patients rate their pain as 0 ("no pain") to 10 ("worst pain")
has become the most widely used instrument for pain screening. The potential advantages of the
NRS are it is short, easy to administer, and is validated as a measure of intensity of pain in
populations with known pain. However, no studies have evaluated its accuracy as a screening
test to identify patients with clinically important pain.
Study Highlights
Advantages of the NRS for pain screening are it is short, easy to administer, and is
validated as a measure of intensity of pain in populations with known pain.
Compared with measures of functional interference and reason for a visit to the
physician, the NRS has moderate accuracy.
CME/CE Test
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