PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2012 COUNCIL MEETING. RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
26(12)
SUBMITTED BY:
Andrew Fenton, MD, FACEP
Roneet Lev, MD, FACEP
California Chapter
SUBJECT:
Patient Satisfaction Scores and Pain Management
PURPOSE: Work with appropriate agencies and organizations to exclude complaints from ED patients with
chronic non-cancer pain from patient satisfaction surveys; oppose new core measures relating to chronic pain
management in the ED; continue to promote timely, effective treatment of acute pain while supporting treating
physicians’ rights to determine individualized care plans for patients with pain; and bring patient satisfaction
scores and pain management to the AMA for national action.
FISCAL IMPACT: Budgeted staff time.
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WHEREAS, Prescription painkiller abuse is considered an epidemic by the Centers for Disease Control
with 15,000 deaths in 2008, and drug overdose has become the number one cause of accidental deaths in the
United States; and
WHEREAS, The misuse and abuse of prescription painkillers were responsible for more than 475,000
emergency department visits in 2009, a number that doubled in just five years; and
WHEREAS, A 2011 study, in the Clinical Journal of Pain (March/April 2011 – Volume 27, Issue 3),
states that the abuse of prescription painkillers in the USA resulted in $42 billion in lost productivity and $8.2
billion in criminal justice costs; and
WHEREAS, According to the CDC, in the last decade, sales of controlled prescription drugs have
increased 300%, and more than 12 million Americans reported using prescription painkiller nonmedically, a tenfold increase in the past ten years; and
WHEREAS, While the United States is 4.6% of the world population, it is responsible for 80% of global
opioid supply and 99.9% of the hydrocodone supply. The United States is also responsible for 99% of
hydrocodone consumption, and 80% of oxycodone consumption; and
WHEREAS, Current patient satisfaction surveys follow the 2001 Joint Commission pain management
standards and the Congressional Declaration that 2001-2010 be the “Decade of Pain Control”; and
WHEREAS, Patient satisfaction surveys that are methodologically and statistically sound can be a valid
measure of the patient’s perception of health care value, and patient outcome can be related to patient satisfaction;
and
WHEREAS, A recent study in Archives of Internal Medicine (March 2012 –Volume 172, Issue 5),
showed that higher patient satisfaction was associated with more spending on prescription medications and higher
patient mortality; and
WHEREAS, Patients with a history of chronic pain frequently visit the emergency department for
exacerbations of chronic pain and often request prescription pain medications; and
Resolution 26(12) Patient Satisfaction Scores and Pain Management
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WHEREAS, Current surveys that use pain scores to measure patient satisfaction place pressure on
physicians to increase opiate prescribing for individual patients during a time that physicians are paradoxically
under simultaneous pressure to reduce prescribing for the sake of public health; and
WHEREAS, Beginning in 2012, CMS will institute a new Core Measure that applies to outpatient
settings that links payment to pain management for fractures and there are plans for more Core Measures in the
future related to patient satisfaction and pain management; therefore be it
RESOLVED, That ACEP work with appropriate agencies and organizations, including hospitals, to
exclude emergency department patients with chronic non-cancerous pain complaints from patient satisfaction
surveys; and be it further
RESOLVED, That ACEP oppose any new Core Measure that relates to chronic pain management in the
emergency department; and be it further
RESOLVED, That ACEP continue to promote timely, effective treatment of acute pain while supporting
the rights of treating physicians to determine the best individualized care plan for patients who report pain; and be
it further
RESOLVED, That ACEP bring the subject of patient satisfaction scores and pain management to the
American Medical Association for national action.
Background
This resolution calls for the College to work with appropriate agencies and organizations to exclude complaints
from emergency department (ED) patients with chronic non-cancer pain from patient satisfaction surveys; to
oppose new core measures that relate to chronic pain management in the ED; to continue to promote timely,
effective treatment of acute pain while supporting treating physicians’ rights to determine individualized care
plans for patients with pain; and to bring the subject of patient satisfaction scores and pain management to the
American Medical Association for national action.
The 2012 ACEP “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the
Emergency Department” http://www.acep.org/clinicalpolicies/, addresses four critical questions: (1) the utility of
state prescription drug monitoring programs in identifying patients at high-risk for opioid abuse; (2) use of
opioids for acute low back pain; (3) effectiveness of short-acting schedule II versus short-acting schedule III
opioids for treatment of new-onset acute pain; and (4) the benefits and harms of prescribing opioids on discharge
from the ED for acute exacerbation of noncancer chronic pain. This guideline acknowledges the increase in opioid
deaths, recognizes the difficulties emergency physicians face in treating pain appropriately while avoiding adverse
events, identifies the literature (and lack of literature) related to the four critical questions, and offers some
guidance on prescribing opioids at ED discharge for acute pain and acute exacerbation of noncancer chronic pain.
At the same time, it recognizes the importance of the individual physician’s judgment, and provides information
for individuals and groups such as state chapters to work within their states and institutions to develop opioid
guidelines appropriate for their locations. This clinical policy was funded by the Centers for Disease Control and
Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury.
This clinical policy is posted on the ACEP Web site, was highlighted in several communications to the
membership, and will publish in the Annals of Emergency Medicine in October 2012. The guideline identifies
some of the state and chapter activities that have already occurred related to opioid prescribing in the ED. The
guideline was also distributed to all ACEP state chapters and The Joint Commission for their information.
The ACEP policy statement, “Optimizing the Treatment of Pain in Patients with Acute Presentations”
http://www.acep.org/Content.aspx?id=48089 supports all patients being treated appropriately for pain with
prompt, safe, and effective pain management.
Resolution 26(12) Patient Satisfaction Scores and Pain Management
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The ACEP policy statement, “Electronic Prescription Monitoring” http://www.acep.org/Content.aspx?id=82648
supports the use of electronic prescription monitoring systems that ensure access to legitimate use of controlled
substances, protect patient privacy, provide liability protection for the practitioner, are voluntary, minimize
burdensome requirements on the physician, have linkages to other locations, are easily accessible and navigable
by practitioners around the clock, are not used to evaluate physician’s practice, and allow physicians to monitor
their own prescribing patterns and to identify potential unauthorized use.
In 2004, ACEP developed a CME monograph, “Pain Management in the Emergency Department,” which
reviewed available management options and provided additional information to assist emergency physicians in
improving ED pain management.
ACEP offers resource information for all state chapters and serves as the central data collection center for sharing
information, such as state activities related to opioid prescribing.
The Emergency Medicine Practice Committee (EMPC) in June 2011 developed the information paper
“Emergency Department Patient Satisfaction Surveys.” This paper provides the history of patient satisfaction
surveys, the methodologies used, the limitations and utilization of survey data and information on improving
patient satisfaction. Members of the EMPC have worked with Press Ganey to address member concerns about
patient satisfaction surveys including reliability and sampling. Currently, the Centers for Medicare and Medicaid
Services (CMS) is contracting with the RAND Corporation to develop a survey of patient experiences with ED
services. Input from the College was requested and will be provided.
In 2009, the American Medical Association (AMA) House of Delegates adopted the “Principles for the Public
Release and Accurate Use of Physician Data.” The document states: “Because of the difficulty in determining
whether responses to patient satisfaction surveys are a result of the performance of a physician …or other factors
out of the control of the physician, the use of patient satisfaction data is not appropriate for incentive or tiering
mechanisms. As in physician profiling programs, it is important that programs that publicly rate physicians on
patient satisfaction notify physicians of their rating and provide a chance for the physician to appeal that rating
prior to its publication”
ACEP Strategic Plan Reference
Goal 2 – Improve Quality, Patient Safety, and Efficiency.
Fiscal Impact
None other than budgeted staff time.
Prior Council Action
Amended Resolution 29(10) Prescription Electronic Monitoring adopted. Supported creation of a policy
regarding the use of web-based prescription monitoring programs in every state, that utilization of the prescription
monitoring program be at the practitioner’s discretion, that physicians not be required to submit information to
prescription monitoring programs or to report potential prescribed medication abuse to the authorities, and that
ACEP support re-authorization of federal funding for the National All Schedules Prescription Electronic
Reporting (NASPER) system and adequate funding for intra-state linkages of databases with access by practicing
physicians.
Substitute Resolution 22(09) Patient Satisfaction Surveys adopted. Directed ACEP to disseminate information to
educate members about patient satisfaction surveys including how emergency physicians armed with more
knowledge can assist hospital leaders with appropriate interpretation of the scores and encourage hospital and
emergency physician partnership to create an environment conducive to patient satisfaction.
Resolution 26(12) Patient Satisfaction Scores and Pain Management
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Substitute Resolution 21(04) Pain Control adopted. Directed ACEP to study the JCAHO requirements for pain
assessment and treatment as it relates to the ED and provide information and feedback to the JCAHO with regard
to their pain management requirements.
Prior Board Action
June 2012, approved “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the
Emergency Department.”
October 2011, approved the policy statement “Electronic Prescription Monitoring.”
June 2011, reviewed the information paper “Emergency Department Patient Satisfaction Surveys.”
September 2010, approved the policy statement “Patient Satisfaction Surveys.”
Amended Resolution 29 (10) Prescription Electronic Monitoring.
June 2010, rescinded the policy statement “Pain Management in the Emergency Department.”
June 2009, approved policy statement “Optimizing the Treatment of Pain in Patients with Acute Presentations.”
Substitute Resolution 22(09) Patient Satisfaction Surveys.
March 2004, approved the policy statement “Pain Management in the Emergency Department.”
Substitute Resolution 21(04) Pain Control.
Background Information Prepared By: Margaret Montgomery, RN, MSN
Emergency Medicine Practice Manager
Rhonda Whitson, RHIA
Clinical Practice Manager
Reviewed by: Marco Coppola, DO, FACEP, Speaker
Kevin Klauer, DO, EJD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director