Goals and satisfaction with pain management

I came across this paper by Rowland Hazard and colleagues amongst a whole lot of papers lying on my desk (those of you who’ve seen my desk will understand momentous this!). It describes a very useful finding from a study the group conducted on outcome measurement.

There is an enormous focus on patient-centred treatment, with an equally enormous focus from purchasers on outcome measurement – and sometimes the two don’t always see eye to eye.

In this paper Goal Attainment Scaling, which is an approach to measuring outcome that I’ve been in favour of for quite a while, (go here for a full website on it) is compared with ‘traditional’ treatment provider outcome measures to establish which most closely predicts patient satisfaction.

In most well-organised pain management centres, a range of pre- post- and follow-up measures are taken. These vary a whole lot, but often include things like mood, activity avoidance, disability, and pain intensity. As a long-standing critic of only using pen and paper measures of outcome, I’ve often said I’d love to make sure some practical measures that mean something to the person are also included.

Pen and paper measures are correlates of real world outcomes, and often measure intermediate outcomes rather than end-point outcomes. What I mean by this is that there is an assumption that a positive shift on a Beck Depression Inventory is correlated with positive increases in activity and a reduction in disability (so hopefully the person will maybe do more in a day, even consider returning to work). Unfortunately, the correlation between what changes on a questionnaire and what actually happens is not always as linear as we’d like.

So the Goal Attainment Scaling approach is a nice way to anchor ‘real world’ goals against a numeric scale that can then be used for statistical calculations.  There are problems of course with this approach – no-one knows whether the scale is a ratio scale, ordinal scale or something else, but it is usually assumed that you can do parametric statistics the scores.  (those with glazed eyes – go re-read statistics 101!).  Goal attainment scaling takes a goal, attaches a numeric score to an ‘average’ or ‘ok’ achievement, an above average ‘really good’ achievement and a below average ‘didn’t quite make it’ achievement – and monitors this over the course of treatment.

In this paper, an occupational therapist worked with each participant to identify three major and very specific goals by saying ‘What is your goal for [work/recreation/general activities] three months from now?’.  This was checked the next day by another clinician, and amended if necessary, and along with several other measures taken at the same time, was included in all subsequent outcome measurement points.  The paper describes in detail the process used (great if you want to know exactly how to conduct one of these outcome measure studies – if you don’t already!), and one year after completing the pain management programme, partiicpants were asked to complete the same measures.

Hallmarks of a very good study are that they clearly describe each process used in the study, they indicate any difference between those who agreed to participate and those who didn’t, and they also provide information on those who failed to complete all the measures.  This study does all of this, and the language used and methods described mean it’s easy to see how they arrived at their conclusions.

The findings from this study of 86 people who completed all measures showed that goal attainment scaling was a more sensitive measure of satisfaction than outcomes from any other questionnaires (using multiple regression analysis).   Satisfaction with progress was more stronly related to personal functional goal achievement than to more traditional outcome measures including pain, disability, fear-avoidance, lifting, trunk flexibility and treadmill endurance.

Why would we worry about patient satisfaction? Good question if you are only worried about getting someone to go through a process and not as interested in what matters to the person you’re working with. 

Satisfaction with treatment, apart from reducing nonadherence and nonattendance, is associated with how well you as a provider are interacting with the person, it’s also associated with the level of ‘motivation’ a person puts in to his or her own self management (more about this tomorrow!).  It helps us as providers identify the ‘right treatment for the right person at the right time’ – it might help us identify who needs help to re-orient their goals towards achievable ones (especially if pain reduction is what they really want but is not achievable with our current tools).

What I learned from this study was that the systems needed to develop a relevant outcome measurement process are not complex, but the process of setting goals that are important to the person may take more time than we often allow.  Goal setting that relates to what the person wants to achieve takes time, negotiation and careful listening.  If we do it lightly, the goals may very well be things WE want rather than things the person values.

Hazard RG, Spratt KF, McDonough CM, Carayannopoulos AG, Olson CM, Reeves V, Sperry ML, & Ossen ES (2009). The impact of personal functional goal achievement on patient satisfaction with progress one year following completion of a functional restoration program for chronic disabling spinal disorders. Spine, 34 (25), 2797-802 PMID: 19910869



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