Introduction

In 2000, the Joint Commission and the Agency for Healthcare Research and Quality endorsed pain as “the fifth vital sign” in an attempt to tackle the nationwide problem of the under-treatment of pain [1]. The new standards and criteria for pain management essentially implied that patients should be pain free, leading to a drastic increase in opioid prescriptions. According to the Centers of Disease Control and Prevention, the use of prescription opioids has quadrupled since 1999, and the USA consumes more than 90% of the world’s opioids [2]. While the Joint Commission has begun to revise its pain standards to address this current opioid epidemic, the fact remains that changing patients’ perceptions of pain and how it should be treated is much more challenging. One way to address this crisis is through education of the public and modifications to patient satisfaction surveys, which ultimately may be at the heart of the problem.

Overall, physicians want what is best for their patients. This is why patient-centered care is at the forefront of medical centers across the country. Yet, this concept is often confused with patient-dictated care, as physicians are prescribing certain medications and allowing for procedures and testing that are unnecessary or against sound medical judgment, all because the patient asks for it [3]. Since they are partly accessed by patient satisfaction surveys, physicians and medical centers may submit to their patients’ wishes in the hopes of getting higher scores. Patient satisfaction surveys can also tie into financial incentives and promotion opportunities, possibly furthering compromising their decision-making. Press Ganey surveys are a leading provider of patient experience measurements. Their surveys include questions regarding doctor, nurse, and patient communication, cleanliness, and overall hospital rating [4]. However, certain pain management questions, such as “I was satisfied with the way my doctor treated my pain,” may place physicians and medical centers in a difficult position [5]. Many patients have specific expectations when visiting medical centers and may believe that all they need to relieve their pain is a pill [3]. If physicians do not give opioids to address the pain and offer non-opioid treatment instead, it may negatively affect patient satisfaction scores. No place is this more apparent than in pain management centers. In fact, Press Ganey surveys from 4,274,639 patients from 17,685 sites nationwide showed average scores for pain management were the lowest amongst 50 different specialties [6].

Academic pain management centers are often referred the most difficult patients to treat. Many patients have already failed multiple treatments or are under the impression that they are being referred for opioid management. Therefore, we questioned whether academic pain management centers are in a unique position to be cast negatively on patient satisfaction surveys.

Methods

A survey was provided to members of the American Association of Pain Program Directors (AAPPD) from March 2017 through April 2017. The survey was administered through Survey Monkey, Inc. after IRB approval (IRB-HSR #19732). Forty-seven responses were received from approximately 93 programs. The survey contained three questions (see Table 1). Participants were asked about how their program performed on annual Press Ganey surveys. Press Ganey surveys are sent out to patients to gather comprehensive patients’ feedback to optimize the patient and clinician experience. Press Ganey survey data is analyzed and reported to the hospital system. The hospital system may report the analyzed data to each academic department/division. Individual departments/divisions can be ranked according to their scores. Thus, survey participants reported on their divisions’ ranked performance. Participants were also asked if they felt pain divisions were more likely to receive a lower ranking and if so why and whether or not they received pressure from administration to improve their rankings. All data was then entered into an excel sheet and descriptive analysis was performed. Data was presented as numbers and percent.

Table 1 Survey questions
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Results

Recipients responded to question 1 “How does your program perform on Press Ganey Surveys compared to other programs in your institution” as follows: 28% (13/46) stated that their Press Ganey scores were almost always worse than practices they are compared to; 21% (10/46) reported they performed slightly worse than other practices; 26% (12/46) reported they performed about equal to other practices; 15% (7/46) stated they performed slightly better than other practices; and 9% (4/46) stated they almost always perform better compared to other practices (see Fig. 1).

Fig. 1
figure 1

How does your program perform on Press Ganey Surveys compared to other programs at your institution?

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Ninety four percent (44/47) of respondents stated they felt that pain practices are uniquely positioned to be case negatively as compared to other practices, while only 6% (3/47) did not feel as though this were true (see Fig. 2). The majority of the program directors (77%) indicated that conservative writing of opioids and inability to realistically meet the expectations of the patients to become pain free was to blame (23%).

Fig. 2
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Do you think pain medicine practices are uniquely positioned to be cast negatively on patient satisfaction surveys as compared to other practices?

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In regard to feeling pressured from administration to improve patient satisfaction scores, 46% (22/47) reported they always receive pressure from administration, 36% (17/47) stated they receive some pressure from their administration, 11% (5/47) stated they rarely receive pressure from their administration, and 6% (3/47) stated they never receive pressure from their administration (see Fig. 3).

Fig. 3
figure 3

Do you receive pressure from administration to improve patient satisfaction?

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Discussion

There is no denying the fact that the opioid epidemic must be addressed, and the use of prescription opioids needs to decrease. Opioid prescribing increased dramatically during the past decades. There are many potential reasons for the increased prescribing including the introduction of pain as the 5th vital sign, overprescribing of opioid medications secondary to ease of prescribing and better insurance coverage than alternative therapies, targeted marketing, lack of medical education related to proper opioid prescribing, and perhaps the introduction of patient satisfaction surveys [7]. In 2011, the Institute of Medicine (IOM) stated that there needed to be improvement in delivering consistent quality care to all patients. They thus called for a plan to improve measures in 6 areas including safety, effectiveness, patient centeredness, timeliness, efficiency, and equitableness [8]. The IOM also called for tracking these measures for which patient satisfaction became a proxy [7]. Shortly thereafter, Congress directed the Center for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality to create the Hospital Consumer of Healthcare Providers and Systems (HCAHPS) Survey that essentially evaluated patient satisfaction [9]. Three of the survey questions asked about pain control and how well providers manage patients with pain. While it is a laudable goal to measure and improve patients’ experiences, there is no evidence to equate patients’ perception of their health care, including pain control, with quality of care.7. Furthermore, HCAPHS scores began to be included as part of payment incentives with those reporting good scores receiving financial benefits [10]. This may have resulted in physicians feeling obligated to treat pain more aggressively [11, 12]. In fact, a recent study in JAMA suggests that denying patients requests for pain medication resulted in lower patient satisfaction scores [13]. Furthermore, a study by Sites et al. in 2018 demonstrated a link between moderate and high-dose opioid prescribing and increased patient satisfaction [14].

However, while these studies suggest a link between patient satisfaction scores and opioid prescribing, the literature regarding this topic is conflicting. For instance, one study asserted that a patient’s perception of the physician’s engagement and concern impacted patient satisfaction scores more than any other factor, thus failing to find a connection between patient satisfaction surveys and opioid prescriptions [3]. They found that questions like: “Listened to you carefully about your questions and concerns”; “Treated you with courtesy and respect”; and “Helped you with your problem” were the strongest predictors of patient satisfaction scores [3]. While the literature on the actual impact opioid prescribing has on patient satisfaction is conflicting, there appears to be the perception that there is a link amongst academic pain physicians.

Our survey suggests that there is a perception amongst pain physicians at academic medical centers that decreased opioid prescribing is associated with lower patient satisfaction scores on these types of surveys. Seventy-seven percent of physicians in our survey indicated that decreased opioid prescribing was a contributing factor in low scores. Given that 83% of the respondents indicated they felt pressure from administrators to improve patient satisfaction scores, the reality and/or perception of the link between opioid prescribing and patient satisfaction is concerning in that it may influence physicians prescribing habits contributing further to the opioid epidemic. The difficulty of treating/curing chronic pain was also indicated to be a factor in low patient satisfaction scores by 23% of respondents. Physicians reported that patients often expect complete alleviation of their pain which is often not achievable in the context of chronic pain.

In order to address this epidemic, public education of opioid addiction and a revised patient satisfaction system needs to be considered. Patients must understand that pain management does not equate to the elimination of pain but rather to the increase of function and the decrease of pain to tolerable levels. Physicians are accountable as well and must realize that high patient satisfaction does not lead to better outcomes. A prospective cohort study from 2000 to 2007 indicated that while patient satisfaction was associated with decreased emergency room visits, it actually led to increased in-patient admissions, higher overall healthcare and prescription drug costs, and increased mortality [1]. Furthermore, according to the Centers of Disease Control and Prevention, although the use of prescription opioids has quadrupled since 1999, the amount of self-reported pain has not changed [14]. Thus, it may be counterproductive to have patient satisfaction surveys linked to physician and medical center assessment and financial incentives.

Luckily, there appears to be changes on the horizon. In January of 2018, CMS directed HCAPHS to change their 3 pain-related questions: [1] During this hospital stay, did you need medicine for pain?; [2] During this hospital stay, how often was your pain well controlled?; [3] During this hospital stay, how often did the hospital staff do everything they could do to help your pain? [15]. The new questions are as follows: [1] during your hospital stay did you have pain?; [2] during your hospital stay did the hospital staff talk to you about how much pain you had?; [3] during this hospital stay, how often did hospital staff talk with you about how to treat your pain? [16] The hope is that the revised questions focus less on “fixing” the pain and more on assessing compassion and awareness of patients’ pain. In addition, these questions are no longer linked to financial reimbursement from the federal government to hospitals. While the questions might not be tied to financial incentives from the federal government, individual institutions or departments can still incentivize physician performance on patient satisfaction surveys.

Regardless of how the patient satisfaction system changes, opioid use in pain management settings still needs to be balanced. Although the Joint Commission’s standards for pain may have led to unintended consequences, it did manage to improve pain management in some areas. This is especially true for patients with chronic and painful conditions. While the use of prescription opioids must decrease, it is important to not neglect or stigmatize patients who may actually need adjunctive opioid therapy [1]. Future goals should consist of finding a balance between proper opioid prescribing to help those whom may truly benefit without incentivizing prescribers with financial or other benefits.

Limitations

Limitations of this study include lack of investigation regarding the use of ultrasounds guided nerve blocks and their impact on patient satisfaction particularly in regard to acute pain. When performed properly the use of such blocks can increase patient satisfaction. However, results of such procedures may vary based on the experience of the clinic and clinician thus can also result in decreased patient satisfaction for acute pain control. Future studies on this topic would be warranted.

Conclusion

Overall, pain management divisions rank lower on patient satisfaction surveys than other divisions within the institution. These divisions may receive pressure from their administration to improve their scores. Judicious opioid prescribing is perceived to contribute to lower patient satisfaction.