Gaps in Standardized Postoperative Pain Management Quality Measures: A Systematic Review

Abstract

Objective:

The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum (NQF) endorsed measures.

Background Data:

Postoperative pain is an important clinical time-point as poor pain control can lead to patient suffering, chronic opiate use and/or chronic pain. Quality measures can guide best practices, but it is unclear if there are measures for managing pain after surgery.

Methods:

The NQF Quality Positioning System (QPS), Agency for Healthcare Research and Quality (AHRQ) Quality Indicators, and Centers for Medicare & Medicaid Services (CMS) Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 – March 11, 2020.

Results:

Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and five were endorsed by NQF. The NQF measures were not specific to postoperative pain management. Three of the non-endorsed measures, were specific to postoperative pain.

Conclusions:

The dearth of published postoperative pain management quality measures, especially NQF-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

Mini-Abstract

The absence of postoperative pain management quality measures represents a gap in the field. More endorsed measures are needed to foster better care.

INTRODUCTION

Millions of surgical procedures are performed annually in the US and many patients experience moderate to severe postoperative pain,¹ which is often inadequately managed.² Poor postoperative pain control can delay recovery time, increase risk of chronic pain, hospital readmissions, and increase medical costs.^3–6 Multiple pain treatment modalities exist, including pharmaceutical (opioid and non-opioid) and non-pharmaceutical interventions.⁷ Opioids are commonly prescribed for acute postoperative pain and can serve as a gateway to chronic opioid use and misuse.^{8, 9}

Opioids are currently a first-line treatment of postoperative pain,¹⁰ yet regimens using multiple agents that target different pain relieving mechanisms – so called “multimodal analgesia”- have been associated with improved pain outcomes and reduced opioid consumption in clinical trials.^11–18 For example, multimodal analgesia regimens that include nonsteroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen have been shown to reduce early pain intensity and morphine consumption.^{19, 20} For these reasons, postoperative pain management guidelines often recommend multimodal analgesia for postoperative pain.^{21, 22}

For clinical guidelines to best translate into improved care, providers and systems must be able to measure their performance. This guideline assessment is performed when quality measures undergo strict endorsement procedures. This is done by organizations, such as the National Quality Forum (NQF) or Center for Medicare and Medicaid Services (CMS). Endorsed measures are often used for monitoring, quality improvement, public reporting, and pay for performance programs.

There is strong evidence that the endorsement of a quality measures results in improved healthcare outcomes. To date, NQF has endorsed more than 50 measures that address surgical care, including perioperative safety, general surgery, and a range of specialties, including cardiac, cardiothoracic, colorectal, ocular, orthopedic, urogynecologic, and vascular surgery. ²³ Surgery quality measurement has been important for stakeholders such as patients and payers to make informed healthcare decisions. For example, in adult cardiac surgery composite measures related to risk-adjusted mortality and morbidity are used to classify thoracic programs into 1-, 2-, and 3-star programs that may lead to financial or reputational penalties.²⁴ However, many surgical domains lack outcome quality measures because these outcomes are either not available or not feasible to collect, such as patient-reported outcomes following prostatectomy.²⁵

In this study, we undertook a systematic review to evaluate the quality and availability of postoperative pain management measures. We gathered evidence from several databases, including PubMed, Trip, ProQuest, and quality measure search tools to identify pertinent measures. This comprehensive analysis of postoperative pain quality measures – and the lack thereof can inform policy initiatives and development of necessary measures.

METHODS

We conducted a systematic review to identify postoperative pain management quality measures in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol was registered in the International prospective register of systematic reviews (PROSPERO). This study included only publicly available aggregate data and therefore exempt from ethics approval.

Search Strategy

Quality Measure Selection Criteria

We identified healthcare quality measures focused on postoperative pain management. We focused on Donabedian-based measures (structural, process, and outcomes). To be included in the study, measures were focused on postoperative pain management, which include pharmacological and non-pharmacological interventions {desai;Tedesco), pain assessment, as well as pain-related outcomes (e.g., function) in the inpatient and post-discharge settings. In the quality measure databases (i.e., CMS, NQF, and AHRQ), we assumed that retrieved results were that of a quality measure.

Databases

We first searched the three quality measure databases and identified all measures, which were applicable to postoperative pain management (as defined in the Quality Measure Selection Criteria section above)”. We first searched quality measure databases made available by the NQF (Quality Positioning System (QPS)), AHRQ (Quality Indicators), and CMS (Measures Inventory Tool) in November 2019. We then conducted a systematic literature review by searching PubMed for primary sources of evidence, ProQuest, and Trip for gray literature and secondary sources of evidence such as systematic reviews and clinical practice guidelines. From these sources we identified potentially relevant pain measures and then investigated whether they specifically addressed postoperative pain management or if they were endorsed by NQF or CMS.

Search Criteria

We used the following terms for NQF, AHRQ, and CMS quality measure search tools: pain, pain management, opioid, postoperative opioid, postoperative pain, postsurgical pain, perioperative pain, discharge pain, gabapentin, pregabalin, analgesia, and function.

For the systematic literature review databases (ProQuest, Trip, PubMed), the following search string was used: ((“postoperative pain” OR “post operative pain” or “perioperative pain” or “peri operative pain” OR “discharge pain”) AND (surgery OR surgeo* OR surgi*)) AND (Quality metric* OR Quality indicator* OR Quality measure*). For ProQuest, we filtered our search by: Dissertations & Theses, Reports, Books, Newspapers. Results in non-healthcare subject areas were filtered out, such as securities analysis, capital formation, private equity, venture capital, acquisitions & mergers. For Trip, we selected the filter for “All Secondary Sources of Evidence. We excluded sources in which the subject areas were not relevant to the topic or not in the English language (eTable 1 in Supplement). To obtain the most recent quality measures, the search timeframe for the search was March 11, 2015 – March 11, 2020.

Patients, Interventions, Comparators, And Outcomes

We followed the PICO framework (patients, interventions, comparators, outcomes) for this study. These include (P) patients who underwent surgery, (I)/(C) perioperative and discharge pain quality measures, including but not limited to pain assessment, pharmacological and non-pharmacological interventions, adverse risk assessment, patient outcomes, and patient education (O) the outcome of this study is availability of published quality measures that address postoperative pain management as detailed in (I)/(C).

Study Design

We first searched the three quality measure databases and identified all measures, which are potentially applicable to postoperative pain management. The search criteria included the title of quality measure and measure details, including denominator (e.g., surgical population), numerator (e.g., (pain assessment, intervention, education, outcomes), and setting (e.g., not home health or palliative care)

We then conducted a systematic literature review to further identify quality measures used in research publications, clinical practice guidelines, and gray literature. The search string included terms for postoperative pain, pain management, and quality measures. The publication title, abstract and contents and availability of related quality measures were assessed. If there was no abstract or the abstract was unclear on whether the publication may include quality measures, the body of the publication was searched for sections on postoperative pain management, and whether specific quality measures were included. Two independent investigators (JMJ, DG) reviewed titles, abstracts, portions of the publications, and quality measure documentation to identify pertinent quality measures.

Study Analysis and Synthesis

Once relevant measures were compiled based on the previously outlined criteria, measures were further assessed for endorsement status. Main results include measures focused on postoperative pain regardless of endorsement status. All other quality measures deemed important to pain management, regardless of endorsement status are included in supplement material.

RESULTS

Figure 1 displays the search results from NQF, AHRQ, and CMS quality measure databases. The results yielded a total of 19 potentially relevant general pain management quality measures, only 5 of which are endorsed by NQF (eTable 2 in supplement). Two were specific to functionality. None of the NQF-endorsed measures were specific for the treatment of postoperative pain. Thirteen measures were not NQF-endorsed, and 3 of these were specific to postoperative pain (Table 1), while the others are potentially relevant, but do not specifically mention postoperative pain (eTable 3 in the Supplement).

Figure 1:

Postoperative Pain Quality Measures from the National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), and Centers for Medicare & Medicaid Services (CMS) search tools

Table 1.

Postoperative Pain Quality Measures, Identified from Quality Measure Databases (Not Endorsed by NQF)

Steward	Quality Measure	Measure Type	Perioperative/Inpatient	Post-discharge	Development Stage	NQF ID	CMS CMIT ID
American Society of Anesthesiologists	Multimodal Pain Management Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.	Process	Yes	No	Fully Developed	None	6043
TBD, Developer: Brigham and Women’s Hospital	High-dose opioid prescribing practices after hospital discharge following total hip (THA) or total knee arthroplasty (TKA) in previously opioid naive patients This eCQM measures the percentage of opioid naive patients, aged 18 years or older, who were prescribed an average daily dose >= 90 morphine milligram equivalents (MME) for the duration of their post-operative opioid prescriptions, up to a maximum period of 90 days after hospital discharge following an elective primary THA or TKA procedure.	Process	No	Yes	Field Testing	None	6105
TBD, Developer: Brigham and Women’s Hospital	Opioid extended use rate following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) This electronic measure will estimate the proportion of patients (Medicare Fee-For-Service beneficiaries) 65 years of age and older who demonstrates post-operative opioid extended use following THA and/or TKA. The target population is patients 65 years or older, are enrolled in fee-for-service (FFS) Medicare and discharged from Partners HealthCare (PHS) hospitals following THA/TKA.	Process	No	Yes	Concept	None	6107

Figure 2 displays the search results from the systematic literature review. The publication search yielded 1,328 publications, of which 206 were identified as pertinent. Among the pertinent results, only 3 postoperative pain quality measures were identified, none of which are endorsed by NQF (Table 3). The remaining search results did not yield postoperative pain management quality measures, but rather were procedure-specific clinical practice guidelines and Enhanced Recovery After Surgery (ERAS) protocols without accompanying quality measures. These results also yielded original studies and systematic reviews on effectiveness of specific surgical techniques or pharmacological and non-pharmacological interventions to reduce postoperative pain in the inpatient setting. Guidance on post-discharge pain management and opioid prescribing recommendations was lacking.

Figure 2:

Postoperative Pain Quality Measures from ProQuest, Trip, PubMed

Table 3.

Postoperative Pain Quality Measures, Identified from Systematic Review Databases (Not Endorsed by NQF)

Title	Organization	Year	Quality Measures	Measure Type
Call to Action: Adult Opioid Postoperative Prescribing35	MN Health Collaborative	2019 (update in 2020)	Benchmarks for maximum dose (morphine milligram equivalent, MME) for individual procedures.	Not specified
Quality Measures to Reduce Opioid Use After Common Soft Tissue Hand and Wrist Procedures36	Hand Surgery Quality Consortium	2020	Patients undergoing CTR, trigger finger release, first dorsal compartment release, or ganglion cyst excision who are counseled [on opioid use]	Process
Quality Measures to Reduce Opioid Use After Common Soft Tissue Hand and Wrist Procedures36	Hand Surgery Quality Consortium	2020	Patients without opioid prescriptions in 90 days before CTR, trigger finger release, first dorsal compartment release, or ganglion cyst excision who do not fill prescription for opioid medication within 30 days after surgery	Outcome

Endorsed Measures

The five NQF-endorsed pain management measures included four process measures and one outcomes measures (eTable 2). Only one of these measures is specifically applicable to the inpatient setting (NQF 3316e: Safe Use of Opioids - Concurrent Prescribing (eCQM)), which assesses concurrent prescribing of two or more opioids or an opioid and benzodiazepine at discharge. This measure does not specify the population setting (e.g., surgical, non-surgical). The other measures were not for a specific setting; the care setting was listed as “Other, Outpatient Services”. The focus of the process measures was on high opioid dosage and opioid prescriptions from multiple providers. The target population for these three measures are dual-eligible Medicare and Medicaid beneficiaries.

Evidence Synthesis

The results returned very few quality measures specific to postoperative pain management and none nationally endorsed by NQF or CMS (Table 1). Pain measures endorsed by the NQF (eTable 2) do not specifically address postoperative pain management.

Discussion

Providing evidence-based care is a priority for healthcare providers and systems. Endorsed quality measures that are based on critically appraised and scientifically proven evidence drive high-value, quality care. In this study, we aimed to identify key quality measures for management of postoperative pain, an important clinical problem as poor management has many adverse impacts. Through a systematic review and quality measure database search, we identified 20 pain management quality measures. Of these twenty measures, three were specific to postoperative pain management. Five of the twenty measures were endorsed by NQF but none of these specifically addressed postoperative pain management. These results indicate a lack of measures to guide and promote quality postoperative pain management.

There were three non-endorsed quality measures related to postoperative pain identified in this review: one related to multimodal analgesia and two related to opioid prescribing. These measures are consistent with current evidence that suggests multimodal analgesia improves patient outcomes and reduces opioid use compared to opioid-alone pain regimes.¹⁹ One opioid related quality metrics targets opioid naive patients undergoing surgery and promotes limiting morphine equivalents in this population. This is an important quality metric, as recent studies suggest that 3-10% of opioid naïve surgical patients continue to request opioids one year post discharge – even for low-risk surgeries.²⁶ Another postoperative opioid related non-endorsed quality metric measures opioid refills. The endorsement of these measures would support their systematic monitoring and surveillance which would provide essential evidence related to effective pain management practices.

Quality measures are of increasing importance in the healthcare field to guide evidence-based care and support a value-based payment system. However, for postoperative pain management, we found a lack of evidence-based quality measures. This gap in evidence inhibits effective monitoring and surveillance of clinical practice. ²⁷ Ideally, quality measures should include the three Donabedian aspects of quality: structure, process, and outcomes.²⁸ For postoperative pain management, process measures are often used as a proxy for outcomes, such as opioid prescribing patterns to assess quality of post-operative pain management. Indeed, these proxies are not an ideal measurement. However, in face of the opioid crisis, the reduction or replacement of opioids as an element of post-operative pain management may be considered as another indicator of “good” quality. Though decreasing opioids is important, opioids are only a small aspect of postoperative pain management. Measures focused on other aspects of pain management are needed, as adequate pain relief is important to surgical recovery.^{7, 19} Comprehensive postoperative pain management measures may be useful. Such measures could include use of pain management consultations, pharmacological and non-pharmacological interventions, patient outcomes and patient and family education .²⁹ Specific measures for clinically complex patient groups will be important, especially since factors other than surgical pain, such as comorbidities, preoperative pain, substance abuse, and mental health disorders are associated with poor pain outcomes.^{30, 31}

In our search for patient-reported quality measures, we searched for measures related to a patient’s functional status. There are patient-reported quality measures related to changes in functional status after surgery. However none of these are associated with functional status related to pain. Pain after surgery is an important outcome and the community must come to a consensus on pain management outcome measures. Then the supporting evidence can be gather to develop an appropriate quality metric.

The absence of postoperative pain management quality measures represents a gap in the field. There are many potential reasons for the gap in evidence including the traditional focus on pain reduction as opposed to pain management; subjectivity of pain; and a lack of evidence, particularly for post discharge pain management. Research on methods and outcomes of discharge planning and follow-up are scarce and insufficient to provide strong guidance on optimal methods.³² Given that surgery causes pain and adequate pain management is critical for best outcomes and to minimize the risk of opioids, surgery specific quality measures backed by strong evidence need to be prioritized. These measures will ensure patients are getting the most safe, effective and evidence-based pain treatment services that include multimodal options.²⁹ Postoperative quality measures can also quantify quality of care for quality improvement, public reporting, and external benchmarking/performance measurement.

There are limitations to this study. It is beyond the scope of this study to recommend specific quality measures to accompany clinical guidelines, yet it is a crucial area of future research. Three measures relevant to postoperative pain were identified yet not endorsed. The endorsement of these measures could allow nation-wide monitoring and surveillance of postoperative pain clinical practices. In addition, health systems may be developing and implementing their own protocols and quality measures, which is required by The Joint Commission.^{33, 34} Since internal quality measures are not necessarily captured in the databases used in our study, it is unclear which measures are being used by individual institutions and how measures compare across institutions. Although it is possible internal quality measures are published as part of a research study, we did not find any such publications in our systematic review. This is also an important area of future research, to identify which measures institutions are using and to develop appropriate measures that can be standardized across institutions.

CONCLUSION

Perioperative pain management is an important clinical moment. Poor pain management has many adverse consequences and inhibits recovery. While opioids may be necessary to manage pain, it is important to quantify postoperative opioid prescribing in the context of other pain treatment modalities, and tie those back to quality of care and patient outcomes. We sought to identify and publish available postoperative pain quality measures yet found no endorsed measures and only limited quality measures reported in the literature. The major gaps highlighted in this study present an opportunity for the development and implementation of valid measures to improve the quality of postoperative pain management.