The impact of standard postoperative opioid prescribing guidelines on racial differences in opioid prescribing: A retrospective review

BACKGROUND

Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing.

METHODS

This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan-Jun 2018) versus postintervention (Jan-Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service.

RESULTS

A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5-36.5). There was no significant difference in 2019 (-8 morphine milligram equivalents, 95% confidence interval -20.5 to 4.6).

CONCLUSION

Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.

Racial and Ethnic Inequities in Postpartum Pain Evaluation and Management

OBJECTIVE

To evaluate whether the frequency of pain assessment and treatment differed by patient race and ethnicity for women after cesarean birth.

METHODS

We performed a retrospective cohort study of all women who underwent cesarean birth resulting in a liveborn neonate at a single institution between July 1, 2014, and June 30, 2016. Pain scores documented and medications administered after delivery were grouped into 0-24 and 25-48 hours postpartum time periods. Number of pain scores recorded, whether any pain score was 7 of 10 or greater, and analgesic medication administered were calculated. Models were adjusted for propensity scores incorporating maternal age, body mass index, gestational age, nulliparity, primary compared with repeat cesarean delivery, classical hysterotomy, and admission to the neonatal intensive care unit.

RESULTS

A total of 1,987 women were identified, and 1,701 met inclusion criteria. There were 30,984 pain scores documented. Severe pain (7/10 or greater) was more common among black (28%) and Hispanic (22%) women than among women who identified as white (20%) or Asian (15%). In the first 24 hours after cesarean birth, non-Hispanic white women had more documented pain assessments (adjusted mean 10.2) than, black, Asian, and Hispanic women (adjusted mean 8.4-9.5; P<.05). Results at 25-48 hours were similar, compared with non-Hispanic white women (adjusted mean 8.3). Black, Asian, and Hispanic women and women who were identified as other all received less narcotic medication at 0-24 hours postpartum (adjusted mean 5.1-7.5 oxycodone tablet equivalents; P<.001-.05), as well as at 25-28 hours postpartum.

CONCLUSION

Racial and ethnic inequities in the experience, assessment and treatment of postpartum pain were identified. A limitation of our study is that we were unable to assess the role of patient beliefs about expression of pain, patient preferences with regards to pain medication, and beliefs and potential biases among health care providers.

Disparities in TKA Outcomes: Census Tract Data Show Interactions Between Race and Poverty

BACKGROUND

Race is an important predictor of TKA outcomes in the United States; however, analyses of race can be confounded by socioeconomic factors, which can result in difficulty determining the root cause of disparate outcomes after TKA.

QUESTIONS/PURPOSES

We asked: (1) Are race and socioeconomic factors at the individual level associated with patient-reported pain and function 2 years after TKA? (2) What is the interaction between race and community poverty and patient-reported pain and function 2 years after TKA?

METHODS

We identified all patients undergoing TKA enrolled in a hospital-based registry between 2007 and 2011 who provided 2-year outcomes and lived in New York, Connecticut, or New Jersey. Of patients approached to participate in the registry, more than 82% consented and provided baseline data, and of these patients, 72% provided 2-year data. Proportions of patients with complete followup at 2 years were lower among blacks (57%) than whites (74%), among patients with Medicaid insurance (51%) compared with patients without Medicaid insurance (72%), and among patients without a college education (67%) compared with those with a college education (71%). Our final study cohort consisted of 4035 patients, 3841 (95%) of whom were white and 194 (5%) of whom were black. Using geocoding, we linked individual-level registry data to US census tracts data through patient addresses. We constructed a multivariate linear mixed-effect model in multilevel frameworks to assess the interaction between race and census tract poverty on WOMAC pain and function scores 2 years after TKA. We defined a clinically important effect as 10 points on the WOMAC (which is scaled from 1 to 100 points, with higher scores being better).

RESULTS

Race, education, patient expectations, and baseline WOMAC scores are all associated with 2-year WOMAC pain and function; however, the effect sizes were small, and below the threshold of clinical importance. Whites and blacks from census tracts with less than 10% poverty have similar levels of pain and function 2 years after TKA (WOMAC pain, 1.01 ± 1.59 points lower for blacks than for whites, p = 0.53; WOMAC function, 2.32 ± 1.56 lower for blacks than for whites, p = 0.14). WOMAC pain and function scores 2 years after TKA worsen with increasing levels of community poverty, but do so to a greater extent among blacks than whites. Disparities in pain and function between blacks and whites are evident only in the poorest communities; decreasing in a linear fashion as poverty increases. In census tracts with greater than 40% poverty, blacks score 6 ± 3 points lower (worse) than whites for WOMAC pain (p = 0.03) and 7 ± 3 points lower than whites for WOMAC function (p = 0.01).

CONCLUSIONS

Blacks and whites living in communities with little poverty have similar patient-reported TKA outcomes, whereas in communities with high levels of poverty, there are important racial disparities. Efforts to improve TKA outcomes among blacks will need to address individual- and community-level socioeconomic factors.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Recovery Symptoms and Mood States in Thai CABG patients

Recovery symptoms and related mood states during early recovery after coronary artery bypass graft surgery (CABG) have never been assessed in Thailand. This cross-sectional descriptive correlational study was to identify the relationships between frequency of recovery symptoms and mood states of a convenience sample of 91 Thai CABG patients during 2 weeks after discharge. Standardized tools/procedures were used to measure the variables of interest. The most common recovery symptoms were chest and leg incision pain, having trouble sleeping, and neck and shoulder or back discomfort. The most common mood states were confusion, anxiety, and anger, respectively. In addition, Thai CABG patients who had more frequent recovery symptoms also had greater negative mood disturbance. These findings provide a beginning explanation about the phenomena of recovery symptoms and mood states in a specific culture, Thai CABG patients.

Acute postoperative pain relief with immediate-release tapentadol: randomized, double-blind, placebo-controlled study conducted in South Korea

OBJECTIVE

To broaden the ethnic groups in which tapentadol IR is evaluated for treating acute postoperative pain to include Asians.

METHODS

In this phase 3, multicenter, double-blind, randomized study, 352 Korean adults with moderate-to-severe pain following hallux valgus surgery received tapentadol IR 50 or 75 mg or placebo orally every 4-6 hours for 72 hours. Patients requesting other (rescue) analgesics during this period were discontinued for lack of efficacy. The primary endpoint, sum of pain intensity difference (SPID) over 48 hours, was evaluated based on the difference between tapentadol IR and placebo in least squares (LS) mean change from baseline using analysis of covariance (ANCOVA). Secondary endpoints included the time to first rescue medication use and the distribution of responder rates.

RESULTS

A treatment effect, favoring tapentadol IR, was observed for SPID48 (p < 0.001 for both doses vs. placebo, ANCOVA). The between-group difference (vs. placebo) in LS means of SPID48 was 76.4 (95% CI: 51.0, 101.7) for tapentadol IR 50 mg and 90.6 (95% CI: 65.1, 116.1) for tapentadol IR 75 mg. Time to first rescue medication use was delayed for tapentadol IR (p < 0.001 for both doses vs. placebo; log-rank test). The distribution of responders at 12, 24, 48, and 72 hours favored tapentadol IR (p ≤ 0.001 for both doses vs. placebo; Cochran-Mantel-Haenszel test). Dizziness, nausea, and vomiting were each reported in ≥ 10% tapentadol-treated patients and at an incidence ≥ 2-fold higher vs. placebo. The study findings may be limited by study drug dosing every 4 to 6 hours and frequent monitoring during treatment, neither of which mimic pain treatment in clinical practice. However, any potential bias based on this systematic monitoring of patients would be mitigated by the randomized, double-blind nature of the study, with all treatment groups similarly affected by such biases, if any.

CONCLUSIONS

Tapentadol IR reduced acute pain intensity, significantly more than placebo, after orthopedic surgery in Korean patients.

CLINICAL TRIAL REGISTRATION

NCT01516008.

Influence of CYP3A5*3 polymorphism and interaction between CYP3A5*3 and CYP3A4*1G polymorphisms on post-operative fentanyl analgesia in Chinese patients undergoing gynaecological surgery

BACKGROUND AND OBJECTIVE

Fentanyl is metabolised by cytochrome P450 (CYP) 3A4 and CYP3A5. Our previous work demonstrated that the CYP3A4*1G polymorphism significantly affects the post-operative fentanyl analgesic effect in Chinese women undergoing gynaecological surgery. However, whether CYP3A5*3, a frequent single nucleotide polymorphism of CYP3A5 in Chinese people, affects the post-operative analgesic effect of fentanyl is unclear. In this study, we assessed the influence of the CYP3A5*3 polymorphism and the interaction of the CYP3A5*3 and CYP3A4*1G polymorphisms on post-operative fentanyl analgesia in Chinese women undergoing gynaecological surgery.

METHODS

We enrolled 203 women scheduled for abdominal total hysterectomy or myomectomy under general anaesthesia. Intravenous fentanyl patient-controlled analgesia was provided post-operatively for adequate analgesia. Pain scores and fentanyl consumption were recorded 24 h post-operatively. Midazolam was used as a probe drug, and CYP3A activity was measured by plasma ratio of 1'-hydroxymidazolam to midazolam 1 h after intravenous administration of 0.1 mg kg-1 midazolam. Blood samples were genotyped for the CYP3A5*3 polymorphism.

RESULTS

The frequency of the CYP3A5*3 allele was 72.4% in 203 patients. CYP3A activity did not differ among CYP3A5*3 genotypes. Fentanyl consumption 24 h post-operatively was lower with CYP3A5*1/*3 and CYP3A5*3/*3 polymorphisms than with CYP3A5*1/*1, but the differences were not statistically significant. However, combined with CYP3A4*1G polymorphism, post-operative fentanyl consumption at 24 h was significantly lower for the CYP3A5*1/*3 or CYP3A5*3/*3 group than the CYP3A5*1/*1 group.

CONCLUSION

CYP3A5*3 is not the main genetic factor contributing to interindividual variation in the post-operative analgesic effect of fentanyl in Chinese women undergoing gynaecological surgery; an interaction between CYP3A5*3 and CYP3A4*1G polymorphisms can significantly influence the post-operative effect.

Ethnic and gender differences in the functional disparities after primary total knee arthroplasty

BACKGROUND

The benefits of TKA have been well documented. Whether these benefits apply equally across gender and ethnic groups is unclear. Given the underuse of TKA among certain demographic groups, it is important to understand whether gender or ethnicity influence pain and function after TKA.

QUESTIONS/PURPOSES

We determined (1) the influence of race, gender, and body mass index (BMI) on primary TKA functional scores and ROM before gender-specific implants; and (2) whether comorbidities influenced ROM and functional scores.

PATIENTS AND METHODS

We reviewed all 202 patients who underwent primary TKAs in 2004. We contacted 185 of the 202 patients, including 90 African-Americans, 87 Caucasians, four Asians, and four Hispanics (55 men, 130 women). Their average age was 66 years, and average BMI was 34.4 (range, 20-55). Knee Society scores (KSS) and ROM, patient demographics, and the Charlson Comorbidity Index (CCI) were recorded. Minimum followup was 24 months (average, 29.1 months; range, 24-60.3 months).

RESULTS

African-Americans had longer delays to presentation, higher BMI, and worse 2-year KSS. Women (all races) had higher BMI and worse preoperative flexion/arc ROM. African-American women had worse final ROM and had similar final gains in ROM (postoperative minus preoperative ROM) after controlling for confounders.

CONCLUSIONS

Gender and race affected functional KSS and ROM variables. The worse results experienced by African-American women may be attributable to a longer delay to presentation. However, the scores and motion were high for all subgroups, and underuse of TKA in women and African-Americans cannot be justified based on a perception of lesser functional gains.

How military nurses rationalize their postoperative pain assessment decisions

AIM

This paper is a report of a study to explore how military nurses rationalize their postoperative pain assessment decisions, particularly when these differ from patients' pain self-reports.

BACKGROUND

Postoperative pain is a complex phenomenon influenced by many factors that make assessment difficult. Nurses are taught to believe what patients say about their pain. However, their attitudes to pain are influenced by their cultural background and they may disagree with patients' self-reports. Military nurses belong to a military culture with different pain attitudes that may also influence their postoperative pain assessment.

METHOD

An ethnomethodological ethnography study was carried out in 2003. A purposive sample of 29 British military surgical/orthopaedic Registered Nurses were interviewed to identify their taken-for-granted assumptions and commonsense cultural knowledge surrounding postoperative pain assessment. The data were analysed using a systematic process of inductive reasoning aided by Non-numerical, Unstructured Data for Indexing, Searching and Theorizing (QSR N6, NUD*IST).

FINDINGS

Participants told two distinct stories in their postoperative pain narratives. The first, the cultural story, described how military nurses normally assess postoperative pain and revealed taken-for-granted assumptions surrounding this assessment. However, when military nurses believe that patients over- or under-report their pain, the cultural story was challenged through a collective story in which nurses used their commonsense knowledge to account for these differences.

CONCLUSION

Postoperative pain assessment within a military culture is complex, but all nurses need to be aware that their socialization into different nursing cultures may influence their attitudes to postoperative pain assessment.

Lumbar spine surgery in Israeli Arabs and Jews: a comparative study with emphasis on pain perception

BACKGROUND

Surgery for spinal stenosis is a frequent procedure in elderly patients. Presentation, hospital course, and outcome of disease including pain perception may vary among patients of different ethnic origin.

OBJECTIVES

To evaluate whether differences in various medical indicators can explain differences in pain perception between two ethnic groups.

METHODS

We conducted a case-control study on the experience of two spinal units treating a mixed Arab and Jewish population, and compared the data on 85 Arab and 189 Jewish patients undergoing spinal lumbar surgery.

RESULTS

Arab patients were younger (P = 0.027), less educated (P < 0.001), had a higher body mass index (P = 0.004) and included a higher proportion of diabetics (P = 0.013). Preoperative pain intensity (P = 0.023) and functional disability (P = 0.005) were more prominent, and factors associated with pre- or postoperative pain perception differed between the two ethnic groups. Despite these differences, results on follow-up were similar with respect to pain perception and level of disability.

CONCLUSIONS

A better understanding of ethnic differences is crucial for predicting surgery outcomes.

Nurses' assessment of pain in surgical patients

AIM

This paper reports a study to compare nurses' ratings of pain intensity and suffering (affect) in adult surgical patients with patients' own ratings of these variables, and to investigate whether pain ratings were influenced by cultural and ethnic differences.

BACKGROUND

Studies show that postoperative pain continues to be under-treated in a large proportion of cases. The problem may be partly due to inaccurate pain assessment by nurses.

METHOD

A convenience sample of 95 patients and 95 nurses in adult surgical units was selected from four hospitals in Jerusalem, Israel in 2003-2004. A questionnaire was administered to each patient by the researcher. The questionnaire included: (a) a Hebrew translation of the Short-Form McGill Pain Questionnaire for pain sensation, pain affect, and present pain intensity at rest and on movement; (b) visual analogue scales for overall pain intensity, suffering, and satisfaction with treatment; and (c) demographic and cultural data. Within a few minutes of the patient completing the questionnaire, a nurse who had been allocated to care for that patient made an independent assessment of the patient's pain. The nurse then left the patient's room and filled in the same questionnaire.

FINDINGS

Nurses significantly underestimated all dimensions of pain on the above scales, but accurately assessed patient treatment satisfaction. There were no statistically significant effects for cultural and ethnic differences in pain assessment. Both types of clinical area where nurses worked and nurses' level of nursing education were found not to influence their assessment.

CONCLUSION

The findings have implications for the management of postoperative pain by highlighting the need for more accurate pain assessment. Further research is required to elucidate the way in which nurses and patients conceptualize pain and to understand better the process of pain assessment in clinical nursing practice.

The Alternate Forms Reliability of the Oucher Pain Scale

The purpose of this study was to determine the adequacy of the alternate forms reliability of three versions of the Oucher pain scale. Because the original large-sized posters were unwieldy for use by nurses with children in clinical settings, it became necessary to reduce it in size. To determine whether the resulting tools were psychometrically equivalent to the original versions of the Oucher, this study was undertaken. In a group of 3- to 12-year-old children who underwent surgical or dental procedures ( n = 137), scores were obtained after the procedure on small and large versions of the Oucher. The order of presentation of the two different Ouchers was randomized. Findings revealed that correlation coefficients between the scores provided for the small and large versions of the Oucher were strong, positive, and significant for the Caucasian, African-American, and Hispanic versions in 3- to 12-year-old children. These results provided evidence of the adequacy of the alternate forms reliability of these scales.

Post operative pain experiences of central Australian aboriginal women. What do we understand?

OBJECTIVE

The aim of this study was to explore the postoperative pain experiences of Central Australian Aboriginal women and the subsequent interpretation of that pain experience by non-Aboriginal female nurses.

DESIGN

Qualitative study using grounded theory methodology.

SETTING

Postoperative surgical setting of a Central Australian regional hospital.

SUBJECTS

Five Aboriginal female clients who had undergone a surgical procedure, eight non-Aboriginal female nurses and four Aboriginal female health workers employed by a Central Australian regional hospital.

RESULTS

Aboriginal women have culturally appropriate ways of expressing and managing pain that are not well understood by non-Aboriginal female nurses. In addition, the Aboriginal women inappropriately endow non-Aboriginal nurses with the same powers and skills expected of healers from their culture. This phenomenon resulted in the non-Aboriginal nurses lacking the cultural insight and the appropriate knowledge and tools required to assess and manage the postoperative pain of Central Australian Aboriginal women effectively or efficiently.

CONCLUSIONS

Non-Aboriginal nurses have a profound knowledge deficit about the postoperative pain experiences of Central Australian Aboriginal women. This deficit is evident through the use of culturally inappropriate and unreliable pain assessment strategies and tools and the misinterpretation of traditional pain relief strategies, such as the use of pituri, rubbing and centreing. The findings of this study suggested that nurse/client interactions related to language and role interpretation were in cultural conflict. The nurses expected the Aboriginal women to adopt pain behaviours as understood from the nurses' culture. The nurses anticipated that the client would contribute to their own care by communicating pain experiences in ways that are familiar and are believed to be universal. The Aboriginal women expected the nurses to conduct business similar to that of their own traditional tribal healers, 'to see within' and to 'just know'.

Gender and pain upon movement are associated with the requirements for postoperative patient-controlled iv analgesia: a prospective survey of 2,298 Chinese patients

PURPOSE

To investigate prospectively the influence of patient characteristics upon, and the association of postoperative measurements with, the requirements for postoperative morphine and the assessment of resting pain and pain upon movement in Chinese patients.

METHODS

From January 1998 to December 1999, patients receiving patient-controlled iv morphine subsequent to general anesthesia and surgery at our institute (Kaohsiung Veterans General Hospital), were enrolled in the study. Demographic data (such as gender, age, weight, height and education level) and postoperative measurements, including pain scores at rest or during movement, sedation scores and morphine consumption, were recorded.

RESULTS

In total 2,298 patients were recruited. Females consumed significantly less morphine via patient-controlled analgesia (PCA) in the first three postoperative days than was the case for males (P <0.05). Gender was the strongest predictor for postoperative morphine requirements. Postoperative pain upon movement was another effective predictor for morphine requirement (P <0.05). Age, body height, body weight, education and operation sites were not associated with morphine consumption.

CONCLUSION

Gender and postoperative pain upon movement are the major factors influencing morphine requirement for patient-controlled iv morphine analgesia during the first three postoperative days in Chinese patients.

Pain management outcomes for hospitalized Hispanic patients

The purposes of the study were to describe outcomes of pain management and predictors of patient satisfaction in a minority sample. By using a survey design, 3 instruments were used to collect data: (1) The American Pain Society's Patient Outcome Questionnaire-Modified, a 16-item self-report tool about pain and patient satisfaction; (2) a demographic form; and (3) the Pain Management Index. The sample consisted of 104 hospitalized Hispanic inpatients in a Rio Grande Valley hospital. Mean ratings for current and average pain were moderate, whereas severe mean ratings were reported for worst pain. High interference caused by pain was found for walking and sleep. Patients were satisfied with pain management. However, a negative correlation was found between satisfaction and current pain intensity (r = -.49, p = .001). Pain Management Index scores revealed that 36% of the participants were inadequately treated for pain; also, negative correlations with age indicated less effective management for elders. Reliability estimates for tool subscales were greater than 0.70 except for the Beliefs subscale (0.63). By using logistic regression, satisfaction with pain management was predicted by general pain in the last 24 hours (odds ratio = 4.02), pain-related interference with mood (odds ratio = 7.31), and age (odds ratio = 1.8). Clinical implications include the need to apply standardized guidelines, such as those from the Agency for Health Care Policy and Research, and to educate patients, particularly minority elders, about pain management approaches. The emergence of Hispanics as the fastest growing minority group increases the need for research regarding pain management outcomes to plan more effective intervention.

Communicating pain and pain management needs after surgery

This descriptive study explored how patients communicate their pain and pain management needs after surgery. Thirty postoperative patients were interviewed. The majority described avoiding or delaying communicating their pain at some point during their hospitalization. Reasons for decreased pain communication included not wanting to complain; not wanting to take the provider away from other patients; avoiding unpleasant analgesic side effects; and not wanting to take "drugs." Postoperative patients may be unclear about their role in pain management. Pain management communication problems identified in this study could be used to design intervention studies to improve pain communication and consequent pain relief.

Stalked by the past: the influence of ethnicity on health

Ethnicity impacts the course of illness and medical treatment. There are enormous ethnic differences in care delivered to patients who are treated for pain. However, in addition to these social forces, there are enormous ethnic differences in physiological response to stimuli as diverse as diet, exposure to agonist infusions, or habitual patterns of response to stressors. The author's clinical research studies on this topic for the last 20 years are reviewed in this article.

Jordanian nurses' roles in the management of postoperative pain in the postanesthesia care unit

One of the most important patient care issues for nurses is pain because of its significant impact on patients' well-being. Therefore, the main purpose of this exploratory study was to describe the role of Jordanian nurses in the management of postoperative pain in the PACU. A convenience sample of 42 postoperative patients was included in this study. Forty-two nurse-patient encounters involving 20 different nurses were observed during data collection. Findings from this study indicated that nurses in Jordan pay little attention to the area of assessment and management of postoperative pain. Cultural issues were discussed in light of the perception of pain and management of postoperative pain among Jordanian patients. Recommendations related to nursing practice, education, and research were developed to improve the quality of nursing care provided to postoperative patients in Jordan.

Postoperative pain management in the non-Hispanic white and Mexican American older adult

The purpose of this study was to assess use of pain relief measures and satisfaction with postoperative pain management among non-Hispanic white and Mexican American older adults after abdominal surgery. Findings revealed interpatient and intraethnic diversity, endorsing the importance of careful patient assessment and examining patient satisfaction for quality assurance/improvement.

[Cultural effect on postoperative pain]

The objective of this study was to describe the influence of culture on 12 surgical patients. The data was collected by interviews and the analysis was based on the framework of the qualitative methodology. The results showed four categories of influence: the type of pain, the expectancy by pain, the meaning of the pain and the pain management. The meaning apprehended is suffering and was verbalized by metaphors. The study considers the importance of the cultural comprehension about pain by the nurse.

The use of pain measurement scales in the Zimbabwean context

OBJECTIVE

Although pain intensity is difficult to assess and quantify, different assessment tools have been developed for this purpose. The most widely used are verbal and numerical pain rating scales. This study aimed to establish the reliability in the Zimbabwean setting of four standardised scales.

DESIGN

The study used a prospective, descriptive cross sectional design.

SUBJECTS

The subjects were 40 females inpatients of the two government maternity units in Harare who had undergone caesarian section, one to three days prior to participation.

MAIN OUTCOME MEASURES

Each subject responded twice to four scales, the Visual Analogue, the Box Numerical, the Hewer and the McGill verbal descriptive scales with a one hour interval between each response.

RESULTS

The Spearman's rank correlation showed significant positive correlations between each pain rating scale for the whole sample for the first responses. There were non significant correlations between the first and second responses for each scale for those with seven years or less years of education. There were positive significant correlations between first and second responses on each scale for those with more than seven years of education.

CONCLUSIONS

Both the numerical and verbal scales measure the same construct of pain experience. The scales are reliable when used with the more educated of the Zimbabwean population. It is recommended that the scales should not be used on a population who have less than seven years of education. More research is needed to determine the validity of pain scales within the Zimbabwean context.

Factors affecting the assessment of postoperative pain: a literature review

The report of the Royal College of Surgeons and College of Anaesthetists has stimulated much interest in the relief of pain following surgery. Despite the development of new techniques such as patient controlled analgesia, pre-emptive analgesia and complementary techniques that have helped to improve the situation, the role of pain assessment remains central. This literature review discusses the standard of nurses' assessment and looks at the factors suggested to influence nurses' assessment of pain.

Survey of postoperative pain in University Hospital Kuala Lumpur

One hundred and eighty-three patients undergoing surgery were interviewed twenty-four hours following surgery to assess the quality of pain relief they received in the immediate postoperative period. Interviews were conducted using a standard questionnaire for all patients. They were asked to (1) rate the quality of pain relief they obtained on a Visual Pain Analogue Scale (VPAS-0 being no pain and 10 being the worst imaginable pain); (2) state whether they were happy and satisfied with the pain relief they received; (3) if dissatisfied, they were asked to give their reasons. 37.7% (69 patients) had moderate to severe pain--pain score greater than 6 on the VPAS. Most of these patients had undergone abdominal or major orthopaedic surgery. 32.7% (60 patients) were unhappy with their postoperative pain control. The main reasons for complaint from the patients were that analgesic injections were either not given promptly or were not given at all. The survey also highlighted the inadequate under-administration of narcotic injections in the postoperative period despite orders being written up. It showed there is an urgent need for setting up an Acute Pain Service for better postoperative pain control. An anaesthesiology based Acute Pain Service was started in October 1992.

Differences in postoperative pain severity among four ethnic groups

Subjects (N = 543) reporting on acute postoperative dental pain were classified into four major ancestral groups: Asian (N = 96), black American (N = 65), European (N = 296), and Latino (N = 88). Pain severity was measured using a 10-cm visual analogue scale following a standardized operative procedure. The subjects of European descent reported significantly less severe pain than those of black American or Latino descent. They also reported less pain than Asians, although this finding did not reach significance. Evaluation of covariates, including gender, age, education, generation in the United States, and difficulty of the surgical extraction, demonstrated that gender was significant, with men reporting less pain than women regardless of ancestry. Possible implications of these findings are discussed in terms of potential differences in physiology, in addition to social learning.

The adequacy and scope of Roy's adaptation model to guide cross-cultural pain research

The purpose of this study was to examine the adequacy (operational, empirical, and pragmatic) and scope of the Roy adaptation model and the gate control theory of pain to guide the cross-cultural study of pain. The sample consisted of 60 Mexican-American and Anglo-American women undergoing elective cholecystectomy. The conceptual-theoretical-empirical structure developed by Fawcett and Downs (1986) provided the framework for designing the study. Operational adequacy was determined by examining the reliability and validity of the empirical indicators used; it was judged adequate. Empirical adequacy was evaluated by comparing empirical data to hypothesized expectations. Only some of the conceptual-theoretical relational statements were supported. Pragmatic adequacy was assessed by determining whether innovative practice strategies might be derived from the data; several were recommended. Finally, the scope was determined by examining the variables identified by the model and several additional variables. Scope was judged adequate to the current stage of the model's development.

Evaluation of the pain response by Mexican American and Anglo American women and their nurses

This study examined the relationship between ethnicity and pain. The study addressed three major research questions. The first question asked whether there was a significant difference in Mexican American women's and Anglo American women's response to cholecystectomy pain. Secondly, the nurses' attribution of pain to each of the two ethnic groups was compared. Finally, the patient's evaluation of the pain being experienced was compared to the nurse's evaluation of the pain the patient was experiencing. The sample consisted of 60 patient subjects and 60 nurse responses. Data were collected at two major teaching hospitals in southern California. Patient pain was measured using the McGill Pain Questionnaire, amount of analgesics and three physiological measures. The nurse's assessment of patient pain was measured using the Present Pain Intensity scale. MANOVA was used to analyse differences between the two ethnic groups on all measures of pain and no significant differences were found between the two ethnic groups on any of the measures of pain. However, nurses judged the two ethnic groups' pain response differently, assigning more pain to Anglo Americans. Finally, a dependent t-test was used to compare nurses' and patients' evaluation of pain. There were significant differences. Nurses evaluated the patients' pain as being less than patients did. Pearson product-moment correlations were used to examine the relationship between pain and sample characteristics of both patients and nurses. For the nurses, pain was significantly related to the patient's education, place of birth, language and religion.

Inter-ethnic differences in postoperative pethidine requirements

A preliminary study of 24 hours' postoperative analgesia using a patient-controlled analgesia technique was undertaken in eight European and fourteen Asian adult patients. All patients had upper abdominal surgery and received weight-related doses of pethidine postoperatively via a Cardiff Palliator. Both groups had a similar degree of analgesia as assessed by visual analogue score but the Asian patients were more sedated in the postoperative period. The Asian patients made 24% fewer demands for analgesia and had a smaller mean (SD) pethidine consumption, 7.62 (2.04) mg.kg-1, compared with the European patients, 9.97 (2.14) mg.kg-1, (P less than 0.05) during the first 24 hours. Further research is necessary to determine whether the smaller requirement for analgesia in Asian patients is a result of pharmacokinetic or pharmacodynamic differences.