Reprinted with Permission
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.
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 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.
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.
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
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