The Joint Commission of Accreditation of Healthcare Organizations (JCAHO) announced in August, 1999, new standards for the assessment and management of pain in accredited hospitals and other health care settings. Acknowledging that pain is a co-existing condition with many other diseases and injuries, the standards make pain management an integral part of all treatment plans.

The new standards are published in the 2000–2001 standards manual for the affected JCAHO accreditation programs, and will first be scored for compliance in 2001. The standards apply to nearly 18,000 organizations involved in the direct provision of care.

JCAHO published Pain Assessment and Management: An Organizational Approach to provide an overview of their new pain management standards. The book also provides examples of ways various organizations have successfully implemented pain assessment and management strategies. The book is available through JCAHO's Customer Service Center, (630) 792-5800.

According to the book, the intent of the new standards is to acknowledge that “unrelieved pain has adverse physiological and psychological effects” and state that a pain assessment should include a psychosocial assessment, along with a detailed patient history, physical examination and diagnostic evaluation.

The book also suggests that:

• If a patient has pain, the effects of the pain upon the patient's functioning in daily life, i.e. sleep, appetite, relationships, emotions, concentration, etc., should be explored and that patients should be reassessed regularly.
• The pain and the effectiveness of the pain management plan should be evaluated at every assessment and documented.
• A 0-to-10 pain scale should be utilized to assess pain intensity of adult patients.

The complete case study can be found on pages 66–72 of “Pain Assessment and Management: An Organizational Approach,” available through the Joint Commission on Accreditation of Healthcare Organizations, Customer Service (630-792-5800).

Established initially as a private medical office in 1989, the Pain Management Center of Paducah in Kentucky has evolved over the years into an ambulatory center that manages subacute, chronic, and cancer pain. The Center also includes a subsidiary, Physical Therapy and Psychology, which provides complementary physical therapy, rehabilitation services and psychological services. Persons served include individuals with complaints of enduring pain who have not responded to previous appropriate medical or surgical treatment; were treated inappropriately; or are seeking treatment for the first time for pain that interferes with their physical, psychological, social, and/or vocational functioning.

The 45 employees of the Center include anesthesiologists with subspecialty in pain management, a psychologist, physical therapists, nurses, surgical technicians and administrative personnel, and espouse a multi-disciplinary team approach to pain management. Evidence of that approach is the interdisciplinary team that holds at least monthly conferences for each person receiving treatment in two out of the three components (medical, psychological, and functional management) of the pain program (See Suggested Algorithm for Comprehensive Evaluation and Management of Chronic Pain).

The Pain Management Center's Medical Director, Laxmaiah Manchikanti, M.D., believes that proper procedure management requires the establishment of policies and procedures that meet the criteria of relevant accrediting bodies, such as the Joint Commission. When developing such policies for the Center, the importance of pain assessment was stressed.

As part of pain management, all individuals seeking treatment are given an initial assessment that includes a physical and psychosocial status and health history. (See related story "P-3 Assessment Fits New Pain Patient Protocols.") After an appointment is made, a comprehensive questionnaire is mailed to the persons seeking care with a request to complete it prior to arriving for the initial assessment. The 15-page questionnaire includes a pain [history]; past, family and social [histories]; and medical history. During the initial assessment, the individual served may be assessed for nutritional or functional status, and may undergo diagnostic testing. Persons served are reassessed and reevaluated at follow-up visits, which can occur anywhere from two weeks to two years based on responsiveness to the treatment.

Policies and procedures also address patient/family education, which is an essential component of Paducah's program, as is staff continuing education.

As part of its quality improvement efforts, the Pain Management Center collects data to measure functional outcomes, medical outcomes, disposition at discharge, status of postdischarge functional abilities, appropriate use of medication, effective management of pain, and cost-effective treatment. Data are collected by three means: random chart analysis, a patient satisfaction questionnaire distributed to individuals served after each visit, and an annual patient opinion survey.

A statistician analyzes these data and presents them to the various providers at monthly staff meetings as well as to management at quarterly Quality Management and Improvement meetings. Further requirements in technology, cost savings and improvement in outcome measures are incorporated.

The Pain Management Center maintains that the goals of a pain management practice should be defined and reevaluated on a regular basis, ideally annually, using the principles of the “SWOT”(strengths, weaknesses, opportunities, and threats) analysis to do so.

“Physicians should realize that creating a pain management practice is dramatically different from operating room-based anesthesia or other types of medical or surgical practices,” Manchikanti says. “Building a successful pain management practice takes time and hard work, but it is attainable by any competent physician who is willing to plan for success.”

© Joint Commission: ("Pain Assessment and Management: An Organizational Approach"). Oakbrook Terrace, IL: 2000, pages 66-72. Abridged with permission.

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Late last year, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) released new standards that now require an evaluation of the psychosocial status of patients suffering from pain. (See article "New JCAHO Standards Require Pain Assessment Protocol.") The American Society of Interventional Pain Physicians (ASIPP) recently issued practice guidelines for interventional techniques. The ASIPP guidelines state that “The three crucial components of evaluation and management services are: history, physical examination and medical decision making,” and “Psychological evaluation is an extension of the evaluation process.”

Laxmaiah Manchikanti, MD, a primary author of the ASIPP guidelines, and Medical Director of the Pain Management Center of Paducah, is a strong proponent of psychological assessment as a component of the complete patient evaluation. He states, “When physicians think they can detect the psychological condition of a patient, they are very, very inaccurate, no matter how experienced the physician is.”

Manchikanti believes the P-3^® (Pain Patient Profile) test is probably the best tool presently available to meet the criteria of the JCAHO and ASIPP standards for psychological assessment of pain patients. This article explains how Manchikanti arrived at that conclusion and describes how the Pain Management Center of Paducah has incorporated the P-3 assessment into their pain management protocols.

Addressing Depression, Anxiety, Somatization

The Pain Management Center of Paducah sees patients with chronic pain; most are disabled, approximately 40% are male, 60% female, and as a group are somewhat elderly. Manchikanti and his staff have been using psychological evaluations as part of their protocols for more than ten years. After reviewing the prevalent psychological issues among his patients, Manchikanti found 77% of the patients suffered from depression, 74% from anxiety, 49% from somatization, and 32% had symptom magnification.

From post-treatment evaluations, he found all four of the issues decreased, especially somatization, which decreased from 49% to 30%. As a result of these data, he confirmed that psychological evaluation and management are indeed important parts of chronic pain management.

Though they have used several other tests over the years, Manchikanti and his colleagues eventually selected the P-3 test as their primary assessment. After conducting research that compared P-3 results to results from another test they were using at the same time, they found the results didn't vary much. Because the P-3 assessment measures focus only on depression, anxiety and somatization, in addition to taking less time to administer and costing less to purchase, they decided that administering both tests was unnecessary.

An Integrated Evaluation

An algorithm designed by Manchikanti et al, and reprinted here with permission, integrates psychological assessment into the initial patient evaluation, along with physical, functional assessments and diagnostic testing.

At the first appointment, a nurse takes the patient's medical history and administers the P-3 assessment. All patients are reevaluated with the assessment one year later. Patients receiving Intradiscal Electrothermal Annuloplasty (IDET) treatment are reevaluated after three months, six months and one year after treatment to collect outcomes data.

Cost-Effective, Patient-Friendly, and Based on Pain Patients

Patients only need 10–15 minutes to take the P-3 assessment. The patients like that the test is easy, short, and the questions are not personally intrusive. Previously the entire battery of assessments administered by Manchikanti's staff took four hours; now it lasts just 90 minutes. According to Manchikanti, the resulting significant savings of staff time, transcription time, and examining room time meant the staff can see more patients.

Besides providing significant cost savings and focusing only on depression, anxiety and somatization, P-3 results include a pain patient profile that Manchikanti especially likes. The easy-to-read graph compares the pain patient's results to the results of other pain patients which he finds “very helpful.” Even with patients without psychological issues, the test can be useful. He notes that certain personality tests won't give proper value if the patient doesn't suffer from a psychological disorder.

Meeting JCAHO Standards

According to Manchikanti, JCAHO is mainly interested in depression and anxiety, have some interest in somatization, but no interest in personality. “This (the P-3 assessment) will be the best test to meet that criteria,” says Manchikanti. “Without going into specific psychopathology, we are now able to assess the psychological condition of the patient.”

The ASIPP guidelines are published in the January, 2001 issue of Pain Physician magazine, available through ASIPP, (270) 554-9412 or www.asipp.org. JCAHO guidelines are available on the JCAHO website, www.jcaho.org. JCAHO will also answer implementation questions through their website.

To learn more about psychological assessments for use by medical professionals, stop by the Pearson booth at the following conferences:

American Pain Society (APS)
April 19–22, 2001
Phoenix, AZ
www.ampainsoc.org

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