Measuring pain as the 5th vital sign does not improve quality of pain management

A dor como quinto sinal vital: utilização da escala de avaliação por enfermeiros de um hospital geral

Pesquisa descritiva, que objetivou descrever as impressões dos enfermeiros sobre o uso de uma escala visual analógica de avaliação da dor em adultos. Os dados foram coletados por meio de um questionário aplicado a 14 enfermeiros de um hospital e analisados mediante análise temática, resultando em seis categorias: a avaliação da dor e sua importância; a avaliação da dor oportunizando humanização do cuidado; a escala da dor medindo subjetividade; a avaliação da dor oportunizando humanização do cuidado; a aplicação da escala orientando a tomada de decisões e a evolução do cuidado e; a dor como quinto sinal vital. O uso da escala possibilitou que os enfermeiros percebessem a dor como o quinto sinal vital, permitiu-lhes acompanhar a eficácia do cuidado e humanizá-lo. Pode-se inferir que a avaliação da dor por meio de uma escala facilita a tomada de decisões do enfermeiro, favorecendo o cuidado atento às necessidades do paciente.

Documentation of pain care processes does not accurately reflect pain management delivered in primary care

BACKGROUND

Researchers and quality improvement advocates sometimes use review of chart-documented pain care processes to assess the quality of pain management. Studies have found that primary care providers frequently fail to document pain assessment and management.

OBJECTIVES

To assess documentation of pain care processes in an academic primary care clinic and evaluate the validity of this documentation as a measure of pain care delivered.

DESIGN

Prospective observational study.

PARTICIPANTS

237 adult patients at a university-affiliated internal medicine clinic who reported any pain in the last week.

MEASURES

Immediately after a visit, we asked patients to report the pain treatment they received. Patients completed the Brief Pain Inventory (BPI) to assess pain severity at baseline and 1 month later. We extracted documentation of pain care processes from the medical record and used kappa statistics to assess agreement between documentation and patient report of pain treatment. Using multivariable linear regression, we modeled whether documented or patient-reported pain care predicted change in pain at 1 month.

RESULTS

Participants' mean age was 53.7 years, 66% were female, and 74% had chronic pain. Physicians documented pain assessment for 83% of visits. Patients reported receiving pain treatment more often (67%) than was documented by physicians (54%). Agreement between documentation and patient report was moderate for receiving a new pain medication (k = 0.50) and slight for receiving pain management advice (k = 0.13). In multivariable models, documentation of new pain treatment was not associated with change in pain (p = 0.134). In contrast, patient-reported receipt of new pain treatment predicted pain improvement (p = 0.005).

CONCLUSIONS

Chart documentation underestimated pain care delivered, compared with patient report. Documented pain care processes had no relationship with pain outcomes at 1 month, but patient report of receiving care predicted clinically significant improvement. Chart review measures may not accurately reflect the pain management patients receive in primary care.

Assessment and management of acute pain in adult medical inpatients: a systematic review

OBJECTIVE

To review the literature addressing effective care for acute pain in inpatients on medical wards.

METHODS

We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions.

RESULTS

We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion.

CONCLUSIONS

Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.

Problems of quality and equity in pain management: exploring the role of biomedical culture

OBJECTIVES

To explore how social scientific analyses of the culture of biomedicine may contribute to advancing our understanding of ongoing issues of quality and equity in pain management.

DESIGN

Drawing upon the rich body of social scientific literature on the culture of biomedicine, we identify key features of biomedical culture with particular salience for pain management. We then examine how these cultural features of biomedicine may shape key phases of the pain management process in ways that have implications not just for quality, but for equity in pain management as well.

SETTING AND PATIENTS

We bring together a range of literatures in developing our analysis, including literatures on the culture of biomedicine, pain management and health care disparities.

MEASURES

We surveyed the relevant literatures to identify and inter-relate key features of biomedical culture, key phases of the pain management process, and key dimensions of identified problems with suboptimal and inequitable treatment of pain.

RESULTS

We identified three key features of biomedical culture with critical implications for pain management: 1) mind-body dualism; 2) a focus on disease vs illness; and 3) a bias toward cure vs care. Each of these cultural features play a role in the key phases of pain management, specifically pain-related communication, assessment and treatment decision-making, in ways that may hinder successful treatment of pain in general -- and of pain patients from disadvantaged groups in particular.

CONCLUSIONS

Deepening our understanding of the role of biomedical culture in pain management has implications for education, policy and research as part of ongoing efforts to ameliorate problems in both quality and equity in managing pain. In particular, we suggest that building upon the existing the cultural competence movement in medicine to include fostering a deeper understanding of biomedical culture and its impact on physicians may be useful. From a policy perspective, we identify pain management as an area where the need for a shift to a more biopsychosocial model of health care is particularly pressing, and suggest prioritization of inter-disciplinary, multimodal approaches to pain as one key strategy in realizing this shift. Finally, in terms of research, we identify the need for empirical research to assess aspects of biomedical culture that may influence physician's attitudes and behaviors related to pain management, as well as to explore how these cultural values and their effects may vary across different settings within the practice of medicine.

Epidural versus intravenous fentanyl for postoperative analgesia following orthopedic surgery: randomized controlled trial

CONTEXT AND OBJECTIVE

Controversy exists regarding the site of action of fentanyl after epidural injection. The objective of this investigation was to compare the efficacy of epidural and intravenous fentanyl for orthopedic surgery.

DESIGN AND SETTING

A randomized double-blind study was performed in Hospital São Paulo.

METHODS

During the postoperative period, in the presence of pain, 29 patients were divided into two groups: group 1 (n = 14) received 100 microg of fentanyl epidurally and 2 ml of saline intravenously; group 2 (n = 15) received 5 ml of saline epidurally and 100 microg of fentanyl intravenously. The analgesic supplementation consisted of 40 mg of tenoxicam intravenously and, if necessary, 5 ml of 0.25% bupivacaine epidurally. Pain intensity was evaluated on a numerical scale and plasma concentrations of fentanyl were measured simultaneously.

RESULTS

The percentage of patients who required supplementary analgesia with tenoxicam was lower in group 1 (71.4%) than in group 2 (100%): 95% confidence interval (CI) = 0.001-0.4360 (P = 0.001, Fisher's exact test; relative risk, RR = 0.07). Epidural bupivacaine supplementation was also lower in group 1 (14.3%) than in group 2 (53.3%): 95% CI = 0.06-1.05 (P = 0.03, Fisher's exact test; RR = 0.26). There was no difference in pain intensity on the numerical scale. Mean fentanyl plasma concentrations were similar in the two groups.

CONCLUSION

Intravenous and epidural fentanyl appear to have similar efficacy for reducing pain according to the numerical scale, but supplementary analgesia was needed less frequently when epidural fentanyl was used.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00635986.

Age and sex trends in long-term opioid use in two large American health systems between 2000 and 2005

OBJECTIVE

To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems.

DESIGN

Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18-44, 45-64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2).

PATIENTS

Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000).

RESULTS

Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35-50% increase). Per-patient daily doses did not increase.

CONCLUSIONS

No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.

Prior conditions influencing nurses' decisions to adopt evidence-based postoperative pain assessment practices

Over the past 30 years, postoperative pain relief has been shown to be inadequate. To provide optimal postoperative pain relief, it is imperative for nurses to use evidence-based postoperative pain assessment practices. This correlational descriptive study was conducted to identify factors, termed prior conditions, that influenced nurses' decisions to adopt three evidence-based postoperative pain assessment practices. A convenience sample of nurses who cared for adult postoperative patients in two Midwestern hospitals were surveyed, and 443 (46.9%) nurses responded. The previous practice and innovativeness of nurses were supportive of adoption of the three practices. Nurses felt that patients received adequate pain relief, which is unsupportive of adoption of the three practices because there is no impetus to change. Nurses who perceived the prior conditions as being supportive of adoption of pain management practices used multiple sources to identify solutions to clinical practice problems, and those who read professional nursing journals were more likely to have adopted the three practices and were more innovative. The number of sources used to identify solutions to clinical practice problems, previous practices, and innovativeness were predictive of nurses' adoption of the three evidence-based postoperative pain assessment practices. Nurses need to be encouraged to use multiple sources, including professional nursing journals, to identify solutions to clinical practice problems. Innovative nurses may be considered to be opinion leaders and need to be identified to promote the adoption of evidence-based postoperative pain assessment practices. Further exploration of the large unexplained variance in adoption of evidence-based postoperative pain assessment practices is needed.

Does routine pain assessment result in better care?

BACKGROUND

Although a variety of national organizations such as the Canadian Pain Society, the American Pain Society and the Joint Commission on Accreditation of Health Care Organizations have advanced the idea that pain should be assessed on a routine basis, there is little evidence that systematic pain assessment information is used routinely by clinicians even when it is readily available.

OBJECTIVE

To determine whether systematic pain assessment information alters medical practitioners' clinical practices.

METHODS

A population of seniors with complex medical problems who were evaluated by case coordinators was studied. Case coordinators were assigned to either an experimental or control patient assessment condition. Control condition patients were assessed as usual. In the experimental condition, a psychometrically valid pain assessment battery as well as the Geriatric Depression Scale - Short Form (because depression and chronic pain are frequently comorbid) were integrated into the routine case coordination assessment. A summary of the results of the depression and pain assessments was subsequently sent to physicians via mail and fax. Patients were also given copies of the assessment summaries and were asked to discuss these with their physicians. Physicians' medication prescriptions were monitored over time through the database of the provincial ministry of health.

RESULTS

At the end of the study, no significant differences between experimental and control patients were found with respect to medications prescribed or patient self-reports of pain. Nonetheless, there was a significant relationship between Geriatric Depression Scale -- Short Form scores and pain medications prescribed for patients in the experimental condition. Moreover, indexes of overall pain intensity did not change significantly over time.

CONCLUSIONS

The findings do not support the idea that the availability of systematic pain assessment information leads to change in clinician's medication practices. As such, educational interventions and public policy initiatives are needed to ensure that treatment providers do not only gather but also use pain assessment information.

Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error

Current strategies to reduce excess pain among hospitalized patients remain inadequate. New, effective approaches are urgently needed. In this prospective observational study of a performance-improvement intervention, we studied the effect of computer-generated, real-time alerts used by nurses on the rate of a medical error in pain management defined as lack of reassessment within 120 minutes from the last observation of severe pain. We also studied duration of severe pain events and frequency of treatment of opioid-related adverse effects. Analyses of 51,619 consecutive observations of severe pain were performed in monthly intervals. Significant decrease in error rate (delayed pain reassessment) was observed postintervention (mean+/-standard error [SE]: 35.8%+/-0.7%) compared with preintervention rate (56.2%+/-1.4%, P<0.0001). Among 6305 unique severe pain events examined during four months pre- and postintervention, time to resolution of severe pain decreased significantly (median time preintervention [January 2006] of 195 minutes compared with median time postintervention of 117, 106, and 101 minutes [January, April, and June 2007], P<0.0001). Hospital-wide, unanticipated monthly naloxone administration decreased postintervention (mean+/-SE: 1.48+/-0.21 per month per 1000 inpatients) compared with preintervention (2.69+/-0.35, P=0.0130). Hospital-wide implementation of real-time, computer-generated alerts identifying instances of delayed pain reassessment resulted in sustained reduction of error rate and faster resolution of severe pain without oversedation.

Implications of IASP Core Curriculum for Pre-Registration Physiotherapy Education

There are concerns about the effectiveness of health professionals when they are working with people who have pain.Health professionals have reported a lack of confidence when working with people with complex pain conditions.Review of pain education in health professional training may improve clinical practice.The International Association for the Study of Pain curricula can be useful in developing pain education initiatives.The up-dated IASP core curriculum appears to be a useful resource for curriculum designers of pre-registration physiotherapy programmes, while the IASP discipline-specific curriculum is in need of revision.

Putting pain assessment into practice: why is it so painful?

OBJECTIVE

To explore some of the reasons for poor compliance with the use of standardized pain assessment tools in clinical practice, despite numerous guidelines and standards mandating their use.

METHODS

First, a review of research and clinical audit literature on the effects of standardized pain assessment tools on patient or process outcomes was conducted, and findings were critiqued. Second, a synthesis of recent literature on the biopsychosocial mechanisms of human detection and recognition of pain in others was presented. Third, the implications for pain assessment in pediatric clinical settings were discussed.

RESULTS

There is a lack of good-quality evidence for the efficacy, effectiveness or cost-benefit of standardized pain assessment tools in relation to pediatric patient or process outcomes. Research suggests that there may be greater variability than previously appreciated in the ability and motivation of humans when assessing pain in others. It remains unknown whether pain detection skills or motivation to relieve pain in others can be improved or overcome by standardized methods of pain assessment.

DISCUSSION

Further research is needed to understand the intra- and interpersonal dynamics in clinical assessment of pain in children and to test alternative means of achieving diagnosis and treatment of pain. Until this evidence is available, guidelines recommending standardized pain assessment must be clearly labelled as being based on principles or evidence from other fields of practice, and avoid implying that they are 'evidence based'.

Has pain management in cancer patients with bone metastases improved? A seven-year review at an outpatient palliative radiotherapy clinic

The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating=0], mild [rating=1-4], moderate [rating=5-6] or severe [rating=7-10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28-95) and the median Karnofsky Performance Status was 70 (range 10-100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.

Evaluation of a web-based palliative care pain management module for housestaff

The objectives of this study were to determine internal medicine residents' knowledge of outpatient palliative care pain management, describe the association of level of training with knowledge, and evaluate the impact on knowledge of a web-based, interactive, evidence-based educational module. We developed the module using established educational principles, based on review of other educational materials, guidelines, and the medical literature. The module included pretest and post-test questions, case studies, didactic sections, and web links. Six hundred twelve housestaff in 35 training programs in 19 states completed the module during the 2005-2006 academic year (196 [32.0%] postgraduate year [PGY]-1, 200 [32.7%] PGY-2, and 216 [35.3%] PGY-3). The mean pretest score was 54.4% (range 31.1%-84.6%); scores were lowest for specific pain management knowledge questions, including appropriate titration of breakthrough opioid doses (mean 31.1% correct) and appropriate initial use of opioids (40.7% correct). Pretest scores were not significantly different by level of training (52.2% for PGY-1 and 56.7% for PGY-3). The mean post-test score was 72.8%, a statistically significant increase from the pretest overall (P<0.001) and for seven of the 10 learning objectives (P<0.001). These findings indicate that housestaff lacked knowledge in many areas of palliative care pain management, and knowledge did not increase with time spent in residency. The large increase in test scores after the module suggests that this may be an effective component of a comprehensive palliative care curriculum.

Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines

Intractable pain, headache or otherwise, is a devastating and life-controlling experience. The need to effectively and aggressively control pain is a fundamental tenet of clinical care. In the past several years, increasing advocacy for continuous opioid therapy has become an important, if not controversial, theme in the development of treatment guidelines and teaching programs. Ironically, the increasing willingness of physicians to prescribe scheduled opioids for their headache and pain patients has occurred in the absence of compelling data demonstrating efficacy or long-term safety. To the contrary, two meta-analyses on chronic noncancer pain (CNCP) and one long-term uncontrolled study on headache patients demonstrate a relatively small number of patients benefiting from the treatment. Recent neuroscience data on the effects of opioids on the brain raise serious concern for long-term safety and also provide the basis for the mechanism by which chronic opioid use might induce progression of headache frequency and severity. Significant adverse effects, including influence on sexual hormonal balances, physical and psychological dependence, the development of opioid-induced hyperalgesia, and cardiac arrhythmia and sudden death that can be seen with standard dosages of methadone, make a strong argument against widespread use of continuous opioid therapy (COT) in otherwise healthy young and middle-aged headache patients. We believe that COT should be used in rare circumstances for chronic headache patients, and propose initial guidelines for selecting patients and monitoring treatment. The physician should be well versed in the details of opioid prescribing, administration, and monitoring, and should be prepared to discontinue opioids when clinical justification, patient behavior, or failure to achieve therapeutic goals make discontinuance necessary.

Symptom Assessment in Palliative Care: A Need for International Collaboration

This article describes the research strategy for the development of a computerized assessment tool as part of a European Union (EU)–funded project, the European Palliative Care Research Collaborative (EPCRC). The EPCRC is funded through the Sixth Framework Program of the EU with major objectives to develop a computer-based assessment and classification tool for pain, depression, and cachexia. A systematic approach will be applied for the tool development with emphasis on multicultural and multilanguage challenges across Europe. The EPCRC is based on a long lasting collaboration within the European Association for Palliative Care Research Network. The ongoing change in society towards greatly increased use of communication as well as information transfer via digital systems will rapidly change the health care system. Therefore, patient-centered outcome assessment tools applicable for both clinic and research should be developed. Report of symptoms via digital media provides a start for face-to-face communication, treatment decisions, and assessment of treatment effects. The increased use of electronic media for exchange of information may facilitate the development and use of electronic assessment tools and decision-making systems in oncology. In the future, patients may find that a combination of a face-to-face interview plus a transfer of information of subjective symptoms by electronic means will optimize treatment.

Evidence-Based Standards for Cancer Pain Management

High-quality management of cancer pain depends on evidence-based standards for screening, assessment, treatment, and follow-up for general cancer pain and specific pain syndromes. We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Providers should routinely screen for the presence or absence and intensity of pain and should perform descriptive pain assessment for patients with a positive screen, including assessment for likely etiology and functional impairment. For treatment, providers should provide pain education, offer breakthrough opioids in patients receiving long-acting formulations, offer bowel regimens in patients receiving opioids chronically, and ensure continuity of opioid doses across health care settings. Providers should also follow up on patients after treatment for pain. For metastatic bone pain, providers should offer single-fraction radiotherapy as an option when offering radiation, unless there is a contraindication. When spinal cord compression is suspected, providers should treat with corticosteroids and evaluate with whole-spine magnetic resonance imaging scan or myelography as soon as possible but within 24 hours. Providers should initiate definitive treatment (radiotherapy or surgical decompression) within 24 hours for diagnosed cord compression and should follow up on patients after treatment. These standards provide an initial framework for high-quality evidence-based management of general cancer pain and pain syndromes.

The fifth vital sign--what does it mean?

Acute pain is reported as a presenting symptom in over 80% of physician visits. Chronic pain affects an estimated 76.2 million Americans--more than diabetes, heart disease, and cancer combined. It has been estimated to be undertreated in up to 80% of patients in some settings. Pain costs the American public more than $100 billion each year in health care, compensation, and litigation. That's why pain was officially declared "The Fifth Vital Sign." Henceforth the evaluation of pain became a requirement of proper patient care as important and basic as the assessment and management of temperature, blood pressure, respiratory rate, and heart rate. The numeric pain scale certainly has a place in care and in pain management; however, it is important to assess the patient's communication and self-management style and to recognize that patients, like pain, are on a continuum with varied styles of communication and adaptation. It is easy to get lost in the process, even when the process is initiated with the best of intentions. In the quest for individualized medicine, it might be best to keep pain assessment in the individualization arena.

Accuracy of the pain numeric rating scale as a screening test in primary care

BACKGROUND

Universal pain screening with a 0-10 pain intensity numeric rating scale (NRS) has been widely implemented in primary care.

OBJECTIVE

To evaluate the accuracy of the NRS as a screening test to identify primary care patients with clinically important pain.

DESIGN

Prospective diagnostic accuracy study

PARTICIPANTS

275 adult clinic patients were enrolled from September 2005 to March 2006.

MEASUREMENTS

We operationalized clinically important pain using two alternate definitions: (1) pain that interferes with functioning (Brief Pain Inventory interference scale > or = 5) and (2) pain that motivates a physician visit (patient-reported reason for the visit).

RESULTS

22% of patients reported a pain symptom as the main reason for the visit. The most common pain locations were lower extremity (21%) and back/neck (18%). The area under the receiver operator characteristic curve for the NRS as a test for pain that interferes with functioning was 0.76, indicating fair accuracy. A pain screening NRS score of 1 was 69% sensitive (95% CI 60-78) for pain that interferes with functioning. Multilevel likelihood ratios for scores of 0, 1-3, 4-6, and 7-10 were 0.39 (0.29-0.53), 0.99 (0.38-2.60), 2.67 (1.56-4.57), and 5.60 (3.06-10.26), respectively. Results were similar when NRS scores were evaluated against the alternate definition of clinically important pain (pain that motivates a physician visit).

CONCLUSIONS

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 evaluate whether pain screening improves patient outcomes in primary care.

The cancer worry chart: a single-item screening measure of worry about developing breast cancer

BACKGROUND

Brief pictograph measures of health functioning have clinical value to office-based practice. Many women with a close family history of breast cancer will experience worry about their risk of developing breast cancer that influences decision-making and can interfere with health-related functioning.

PURPOSE

To develop a clinically - useful triage measure of breast cancer worry for the field setting of office based practice.

METHODS

DESIGN

qualitative pilot testing followed by mailed survey.

SURVEY SAMPLE

women registered with the Cancer Genetics Network who have a first or second-degree family history of breast cancer and no personal history of any cancer. Novel measure: single pictograph item modeled upon the Dartmouth COOP Charts. Comparison gold-standard measure: four-item Cancer Worry Scale (CWS).

RESULTS

Pilot testing: participants found the item to be easily understood, rapidly completed and unobtrusive. Quantitative: 469 women responded (78% response rate); the Cancer Worry Chart demonstrated strong correlation to the CWS (Pearson correlation coefficient: 0.66, P < 0.001); Receiver operator curve identified favorable characteristics (AUC = 0.86) of the Cancer Worry Chart for identifying cancer worry-related mood or social role dysfunction.

CONCLUSIONS

The new Cancer Worry Chart is a valid triage measure for breast cancer worry.