Abstract
This study surveyed patients admitted to the emergency department or surgical units at a single hospital to compare an emoji-based pain scale with a conventional numeric rating scale.
Digital platforms provide an opportunity to improve patient experience across culturally and linguistically diverse backgrounds.1 To understand patients’ perception of pain, visual analog scales, such as the Wong-Baker FACES Scale, are used but are not open-source or adapted for digital use.2 Emoji, preloaded on digital platforms, may provide a standardized, no-cost mechanism for patients from diverse backgrounds to report outcomes. Previous studies showed emoji were an effective way to represent anxiety and mood in health care settings.3,4 We compared an emoji-based pain scale with a conventional numeric rating scale.
Methods
To establish the validity of an emoji-based pain scale, we surveyed patients admitted to the emergency department or surgical units at Massachusetts General Hospital from October 2021 to January 2022. The study was approved by the Mass General Brigham institutional review board and verbal informed consent was obtained from patients. Patients’ race and ethnicity were taken from electronic medical records to account for participant diversity. Race categories were African American, American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, White, and other (any race not listed). Ethnicity was assessed as Hispanic/Latinx or non-Hispanic/non-Latinx. A convenience sample was used, and no patient refused the survey. Patients were surveyed regardless of presence of pain.
The emoji-based pain scale was composed of 6 icons (Figure) modeled after the extensively studied and validated Wong-Baker FACES Scale. The numeric rating scale ranged from 0 to 10. To minimize bias, we randomized patients to 1 of 2 groups, rating pain on the emoji-based scale first or numeric rating scale first. The randomization sequence was performed by generating an equally proportionate binary code, assigning numeric as 0 and emoji as 1. For statistical purposes, emoji were assigned a numeric value of 0, 2, 4, 6, 8, and 10. The 11 possible numeric responses were treated as ordinal outcome measures and allocated into 6 categories (0 [0, no pain], 2 [1-2], 4 [3-4], 6 [5-6], 8 [7-8], and 10 [9-10, worst pain]). A weighted Cohen κ accounted for degrees of disagreement between the emoji-based scale and numeric rating scale. To achieve statistical significance for weighted κ with 6 ordinal categories, a sample size of 84 patients was needed to achieve 80% power. We used Stata version 17 (StataCorp) for data analysis. Statistical significance was set at a 2-sided P < .05.
Figure. Depiction of Emoji-Based Visual Analog Scale and Numeric Rating Scale.
Scales were presented to participants in succession without response guidance.
Results
The final sample size was 109 patients. The median age of patients was 65 (IQR, 52-75) years. A total of 47.7% of patients were female, 82.6% were White, and 88.1% were ethnically not Hispanic or Latinx. Among the 98 patients who experienced pain, the types were abdominal (45.9%), chest (13.8%), back (13.8%), and extremity (12.8%). Among 109 patients, 53 patients rated the emoji-based scale first and 56 rated the numeric scale first. The median pain scores using either a numeric pain scale or emoji scale were 4 (IQR, 2-7) and 4 (IQR, 2-8), respectively. The overall agreement between the emoji-based visual analog pain scale and the numeric rating scale was a weighted κ of 0.84 (95% CI, 0.77-0.87; P < .001) (Table). The agreement for the group rating the emoji scale first was a weighted κ of 0.87 (95% CI, 0.82-0.92; P < .001) and for the group rating the numeric scale first was 0.80 (95% CI, 0.74-0.85; P < .001). There was no significant difference between the groups (P = .58).
Table. Patient Ratings of Reported Pain Between the Emoji-Based Visual Analog Scale and Numeric Rating Scale.
| Numeric rating scale | Emoji-based visual analog scale | ||||||
|---|---|---|---|---|---|---|---|
| 0 | 2 | 4 | 6 | 8 | 10 | Total | |
| 0 | 10 | 7 | 0 | 0 | 0 | 0 | 17 |
| 2 | 1 | 13 | 0 | 0 | 0 | 0 | 14 |
| 4 | 0 | 4 | 21 | 0 | 0 | 0 | 25 |
| 6 | 0 | 0 | 10 | 12 | 1 | 0 | 23 |
| 8 | 0 | 0 | 0 | 2 | 18 | 1 | 21 |
| 10 | 0 | 0 | 0 | 1 | 2 | 6 | 9 |
| Total | 11 | 24 | 31 | 15 | 21 | 7 | 109 |
Discussion
This study demonstrated a high level of agreement between an emoji-based visual analog pain scale and a numeric rating scale in a sample of patients in 1 hospital. Easily adapted to digital platforms, emoji are an open-source, visual option that could be a low-cost alternative to the numeric rating scale. Limitations of the study are the lack of a diverse population and use of a convenience sample rather than a random or purposive sample. Further work is needed to validate the emoji-based scale in diverse populations and with different types of scales.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.
References
- 1.Lai D, Lee J, He S. Emoji for the medical community: challenges and opportunities. JAMA. 2021;326(9):795-796. doi: 10.1001/jama.2021.8409 [DOI] [PubMed] [Google Scholar]
- 2.Garra G, Singer AJ, Taira BR, et al. Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients. Acad Emerg Med. 2010;17(1):50-54. doi: 10.1111/j.1553-2712.2009.00620.x [DOI] [PubMed] [Google Scholar]
- 3.Pourmand A, Quan T, Amini SB, Sikka N. Can emoji’s assess patients’ mood and emotion in the emergency department? an emoji based study. Am J Emerg Med. 2020;38(4):842-843. doi: 10.1016/j.ajem.2019.09.008 [DOI] [PubMed] [Google Scholar]
- 4.Setty JV, Srinivasan I, Radhakrishna S, Melwani AM, Dr MK. Use of an animated emoji scale as a novel tool for anxiety assessment in children. J Dent Anesth Pain Med. 2019;19(4):227-233. doi: 10.17245/jdapm.2019.19.4.227 [DOI] [PMC free article] [PubMed] [Google Scholar]