The Journal of Pain, Vol 7, No 4 (April), 2006: pp 272-280

Available online at www.sciencedirect.com

Using the American Pain Society’s Patient Outcome

Questionnaire to Evaluate the Quality of Postoperative Pain
Management in a Sample of Norwegian Patients
Alfhild Dihle,* Sølvi Helseth,* Ulf E. Kongsgaard,† Steven M. Paul,‡ and
Christine Miaskowski‡
*Faculty of Nursing, Oslo University College, Oslo, Norway.
†
Department of Anaesthesia and Intensive Care, Norwegian Radium Hospital, Oslo, Norway.
‡
Department of Physiological Nursing, University of California, San Francisco, California.

Abstract: In the United States, quality improvement (QI) approaches have been used to evaluate
pain management. However, the use of QI approaches to evaluate the quality of patient care is just
emerging in many European countries. The purposes of this study, using the American Pain Society’s
QI Standards, were: to describe changes over time, in pain severity, in pain interference with function,
and in the doses of analgesics administered; to describe patients’ level of satisfaction with postop-
erative pain management; and to determine the relationships between pain severity and patient
outcomes. Results from a sample of patients who underwent orthopedic surgery suggest that
undertreatment of pain persists across the first 5 postoperative days and that pain’s level of
interference with function decreases significantly between the third and fifth postoperative days. As
in other studies, despite high pain intensity scores, patients reported high levels of satisfaction with
postoperative pain management.
Perspective: Findings suggest that the undertreatment of pain results in significant decrements in
function over the first 5 postoperative days. Future studies designed to improve the quality of post-
operative pain management need to use multimodal approaches and evaluate not only pain intensity,
but improvements in function as critical outcome measures.
© 2006 by the American Pain Society
Key words: Postoperative pain, pain management, analgesics, patient satisfaction, quality improve-
ment, patient outcomes, quality of patient care.

A
lthough effective pain treatment is available for
acute postoperative pain, studies continue to re-
port that many patients receive less than optimal
pain management.4,29,35,36,39 Inadequate postoperative
pain relief leads to negative physiologic and psychologic
consequences and delayed convalescence12,24,26,33 and,
based on findings from a recent systematic review,32 may
contribute to the development of chronic pain. There-
fore, evaluation of the quality of pain management is
important not only to make clinicians aware of its under-
Received April 22, 2005; Revised September 30, 2005; Accepted Novem-
ber 3, 2005.
This study was supported financially by Oslo University College.
Address reprint requests to Alfhild Dihle, Assistant Professor, Faculty of
Nursing, Oslo University College, Pb. 4 St. Olavs plass, N-0130 Oslo Nor-
way. E-mail: alfhild.dihle@su.hio.no
1526-5900/$32.00
© 2006 by the American Pain Society
doi:10.1016/j.jpain.2005.11.005
treatment, but also to encourage them to develop strat-
egies for improvement.
In 1991, the American Pain Society (APS) published
quality assurance standards for the relief of acute and
cancer pain2 and provided a Patient Outcome Question-
naire (POQ) that could be adapted to assist in efforts to
improve the quality of acute and cancer pain manage-
ment. Several studies used the original or modified ver-
sions of this questionnaire9,10,19,27,30,37 and consistently
found that patients reported high levels of satisfaction
with pain management despite significant levels of pain
and long waiting periods for pain medication. In 1995,
the APS Quality Improvement (QI) guidelines were re-
vised based on published reports and clinical experi-
ence.3 The main revisions included the addition of 5
items on how pain interferes with function from the
Brief Pain Inventory14and 7 items from the Patient Barri-
ers Questionnaire38 to the POQ. In addition, clinicians

272
ORIGINAL REPORT/Dihle et al
were encouraged to evaluate the quality of pain man-
agement in both inpatient and outpatient settings.
A recent review19 reported on 20 studies conducted in
the United States that evaluated the quality of pain man-
agement. Five of these studies used the revised APS ques-
tionnaire. However, only 2 of these 5 studies were pub-
lished.28,29 Based on the analysis of these 20 QI studies,
Gordon et al19 noted that patients’ ratings of both pain
severity and its impact on function were high and had
remained the same for over 7 years. In addition, in all 20
studies, patients reported high levels of satisfaction with
pain management despite severe pain. In the 8 QI studies
that used the items from the Patient Barriers Question-
naire, patients’ beliefs about pain management did not
vary by level of satisfaction. In 75% of these studies,
analgesic prescriptions and administrations were exam-
ined, but detailed information on analgesics adminis-
tered was not reported in any of the studies. Of note, of
the 20 QI studies done to date, all were cross-sectional
studies. Recently, Chung and Lui13 reported the results of
a QI study of postoperative pain management in Hong
Kong. While this study used the 1995 version of the APS
POQ, they did not report information on either the in-
terference or barrier items.
No studies have been conducted in Europe utilizing the
1995 version of the APS POQ. Furthermore, no studies,
either in the United States or internationally, have re-
ported detailed information on the administration of
analgesic medications or provided data on changes in
quality indicators over time. Therefore, the purposes of
the study of a sample of patients from Norway who un-
derwent orthopedic surgery were: to describe changes
over time, in pain severity, in pain interference with
function, and in the doses of nonopioid and opioid an-
algesics administered; to describe patients’ level of satis-
faction with postoperative pain management; and to de-
termine the relationships between pain severity and
patient outcomes (ie, interference with function and pa-
tient satisfaction with pain management).
Materials and Methods
Sample and Setting
This study used a repeated measures design to describe
the quality of postoperative pain management in a sam-
ple of patients who underwent orthopedic surgery. One
hundred seventy-six patients admitted to a local hospital
in Oslo, Norway, were invited to participate in the study.
The participants were adult inpatients between 18 and
80 years of age; were able to read, write and understand
Norwegian; and underwent hip or knee replacement. Of
176 consecutive participants approached in an 8-month
period, 12 were not eligible (8 did not have surgery, 2
required additional surgeries, and 2 were cognitively im-
paired). In addition, 43 patients declined to participate, 6
withdrew from the study, 5 questionnaires were not re-
turned, 6 were completed incorrectly, and 2 were re-
turned blank. Therefore, the participation rate for the
study was 62.2% (102/164). Of those 62 patients who did
not participate, 54 were female and 8 were male; 28 and
273
34 underwent hip or knee replacement, respectively; and
their mean age was 70.3 years (SD ⫽ 8.78). No differences
in types of surgery were found between those who did
and did not participate. However, participants were sig-
nificantly younger (65.0 years vs 70.3 years; P ⬍ .0001)
and were more likely to be male (43.1% vs 12.9%; P ⬍
.0001) than nonparticipants. The final sample consisted
of 102 patients who provided data on postoperative day
(POD) 1, 100 patients on POD3, and 91 patients on POD5.
Instruments
Baseline Information
Patients completed a demographic questionnaire pre-
operatively to obtain information on age, sex, previous
surgery, and use of analgesic medication prior to sur-
gery.
Pain Intensity Measures on POD1
To reduce respondent burden on POD1, patients only
provided ratings of pain now, as well as worst and aver-
age pain in the past 24 hours using 0-to-10 numeric rat-
ing scales (NRSs). In addition, patients were asked to rate
the level of pain that required pain medication. Pain
intensity scores were assessed using 0 (no pain) to 10
(worst pain possible) NRSs, which is a valid and reliable
approach to assess pain intensity.11,21,23,41
Pain Experiences on POD3 and POD5
The Norwegian version of the American Pain Society’s
POQ (APS-POQ-N) was administered on POD3 and POD5.
The APS POQ was translated using international guide-
lines,6,20 including forward and backward translation by
professional bilingual translators, independent review
by a panel of clinical nurse experts in pain management,
a meeting of the experts to develop consensus on some
difficult items, and pilot testing of the final version of the
instrument. The initial item on the questionnaire asked
patients if they had experienced any pain in the past 24
hours. If the patients responded yes, they completed the
remainder of the APS-POQ-N.
Part 1, modified from the Brief Pain Inventory (BPI),14
asked patients to rate pain now, as well as pain at its
worst and on average in the past 24 hours, using 0-to-10
NRSs. In addition, patients were asked to rate the level of
pain that required pain medication. Part 2, also modified
from the BPI, asked patients to rate how much their pain
interfered with function (activity, mood, walking, sleep,
and relations with others), using 0-to-10 NRSs (0 ⫽ does
not interfere; 10 ⫽ completely interferes). Part 3 assessed
patients’ satisfaction with pain treatment overall, and
nurses’ and physicians’ responsiveness to their pain, us-
ing a 6-point Likert scale that ranged from “very dissat-
isfied” to “very satisfied.” Part 4 asked patients to pro-
vide information on perceived waiting time for
analgesics (from 10 minutes or less to ⬎60 minutes, asked
for but never received, or never asked) as well to answer
a question about their perception of the waiting time
between a complaint that pain medication was not
working and receipt of a different or stronger medica-
274 Quality of Postoperative Pain Management in Norwegian Patients

tion (⬍1 hour to ⬎24 hours). Part 5 addressed patients’ Demographic and Clinical
Table 1.
perceptions of barriers or beliefs about pain manage- Characteristics of the Sample
ment (cannot control pain, addiction, good patients
avoid talking about pain, side effects, distracts physician, MEAN SD
tolerance, progression of disease) using items from the Age (years) 65.0 9.34
Patient Barriers Questionnaire.38 These items were rated n %
using a 6-point scale (0 ⫽ do not agree at all to 5 ⫽ agree Gender
very much). The last item required a yes/no response, if Female 58 56.9
the patient was informed about the importance of pain Male 44 43.1
treatment and reporting when s/he was in pain. Previous surgery
The reliability of the Norwegian version of the APS Yes 87 85.3
POQ in this sample was estimated using Cronbach’s al- No 15 14.7
pha coefficients. Reliability estimates were .84 for the Analgesics prior to surgery
pain intensity subscale, .78 for the pain interference sub- Yes 71 71.0
No 29 29.0
scale, .59 for the satisfaction subscale, and .79 for the
Type of surgery
beliefs about pain and pain management subscale.
Total hip replacement 47 46.1
Total knee replacement 55 53.9
Data Collection Procedures
The study was approved by the National Regional Abbreviations: POD, postoperative day; SD, standard deviation.
Committee for Medical Research Ethics in Norway. Pa-
tients were recruited by the head nurse or her/his assis- using the Bonferroni procedure to control the overall
tant, when they were admitted to the ward. The head alpha level of the 3 possible pairwise contrasts at .05. The
nurse explained the study procedures and obtained writ- P values presented for each pairwise contrast was ad-
ten informed consent and then gave the patients the justed so that values of less than .05 indicate statistical
study questionnaires. The patients completed the ques- significance. Pearson’s product moment correlation co-
tionnaires preoperatively as well as on POD1, POD3, and efficients were calculated to determine the relationships
POD5 and returned the completed questionnaires in between pain intensity scores and patient outcomes (ie,
sealed envelopes to one of the nursing staff. In addition, interference with function and patient satisfaction with
patients’ medical records were reviewed to obtain infor- pain management). In all other analysis, a P value of ⬍.05
mation on the types and doses of analgesics adminis- was considered statistically significant.
tered over a 24-hour period on POD1, POD3, and POD5 as
well as the patient’s diagnosis and type of surgery. Results
Data Analysis Sample Demographics
All data were entered and analyzed in SPSS 12.0. De- The demographic and clinical characteristics of the pa-
scriptive statistics were generated on all demographic tients are summarized in Table 1. Of the 102 patients
and surgical characteristics. Analgesic medications were who participated in the study, 56.9 % were female, with
categorized into paracetamol, weak opioids (eg, parac- a mean age of 65.0 years (range 40 to 80), and 46.1%
etamol and codeine, dextropropoxyphene), or strong underwent total hip replacement. The majority of the
opioids (eg, ketobemidon). All opioid analgesics were patients (85.3%) had undergone a previous surgery and
converted to oral morphine equivalents per 24 hours. had been treated with analgesics (71%) prior to surgery.
The total dose of opioid analgesics administered per 24 On POD3, 83.3% reported that they had experienced
hours for each postoperative day was calculated as the pain in the previous 24 hours, and on POD5 the percent-
sum of the weak opioid dose and the strong opioid dose age decreased to 69.7%.
in oral morphine equivalents per 24 hours. In addition,
patients were categorized into whether or not they had Pain Intensity Scores
received a nonsteroidal antiinflammatory drug (NSAID) Figure 1A illustrates the pain intensity scores for all of
on each postoperative day. Owing to the skewed distri- the available study participants on POD1 (n ⫽ 102), POD3
bution of the satisfaction items, the scale was collapsed (n ⫽ 85), and POD5 (n ⫽ 68). Figure 1B illustrates changes
from 6 responses to 4 responses, ie, all of the dissatisfac- over time of pain intensity scores for the 63 patients who
tion responses as 1 response, slightly satisfied, satisfied, reported pain intensity scores for all 3 assessments. Sig-
and very satisfied, to provide cells large enough for nificant decreases, over time, were found in pain now
meaningful comparisons. (F(2,122) ⫽ 14.33; P ⬍ .0001), average pain (F(2,124) ⫽
Repeated measures analysis of variance was used to 25.98; P ⬍ .0001), and worst pain (F(2,124) ⫽ 20.84; P ⬍
determine changes over time in pain intensity scores, in .0001). No differences were found, over time, in patients’
pain’s level of interference with function, and in doses of ratings of the severity of pain that required an analgesic.
analgesics administered. All data are presented as mean
and standard deviation. If the overall test of change was Analgesic Administration
significant, the 3 possible pairwise contrasts (POD1 vs Figure 2A illustrates the doses of paracetamol admin-
POD3, POD1 vs POD5, and POD3 vs POD5) were done istered to the study participants on POD1 (n ⫽ 91), POD3
ORIGINAL REPORT/Dihle et al 275

(n ⫽ 100), and POD5 (n ⫽ 91). Figure 2B illustrates A.

changes over time in the doses of paracetamol adminis-
4000
tered to the 87 patients who participated in the study for

Dose of paracetamol (mg)

all 3 assessments. No differences were found in the total
doses of paracetamol administered over time.
3000
Nonsteroidal antiinflammatory drugs were adminis-
tered to 26.5% of the patients on POD1, to 42.2% of the
patients on POD3, and to 47.1% of the patients on POD5.
2000
The most frequently used NSAIDs were rofecoxib, di-
clofenac, and celecoxib.
Figure 3A illustrates for POD1, POD3, and POD5 the
1000
doses of weak opioids (n ⫽ 93, 97,and 90, respectively),
strong opioids (n ⫽ 86, 25, and 11, respectively), and the
total dose of opioid (expressed in oral morphine equiva-
0
lents per 24 hours; n ⫽ 98, 98, and 91, respectively) ad- Day 1 Day 3 Day5
ministered to study participants.
Figure 3B illustrates changes over time in the doses of B.
opioid analgesics administered. A total of 84 patients
received a weak opioid analgesic on all 3 postoperative 4000

Dose of paracetamol (mg)

days that were assessed, and this dose increased signifi-
cantly over time (F(2,166) ⫽ 11.60; P ⬍ .0001). Only 9
3000

Pain now
A. Average pain 2000
10 Worst pain
Analgesic needed

8 1000
Pain intensity

6
0
Day 1 Day 3 Day 5
4
Figure 2. (A) Doses of paracetamol administered to study par-
ticipants on POD1 (n ⫽ 91), POD3 (n ⫽ 100), and POD5 (n ⫽ 91).
2 (B) Changes in the doses of paracetamol administered to the 87
patients who participated in the study for all three assessments.
All values are plotted as mean ⫾ standard deviation.
0
Day 1 Day 3 Day 5

B.
Pain now
patients received a strong opioid on all 3 postoperative
10 Average pain days and this dose decreased significantly over time
Worst pain (F(2,16) ⫽ 16.87; P ⬍ .0001). The total dose of opioid
8 Analgesic needed decreased significantly over time (F(2,176) ⫽ 37.01; P ⬍
.0001) in the 89 patients who received opioids on all 3
Pain intensity

postoperative days. It should be noted that 4 patients

6
had complete medication data for both weak and strong
opioids on all 3 postoperative days, and that is why the
4 sample size for total dose of opioid is 89.

2
0 in pain’s level of interference with general activity, walk-
Day 1 Day 3 Day 5
Figure 1. (A) Pain intensity scores for all of the available study
participants on POD1 (n ⫽ 102), POD3 (n⫽85), and POD5 (n⫽68).
(B) Changes in pain intensity scores for the 63 patients who
reported pain intensity scores for all 3 assessments. All values
are plotted as meean ⫾ standard deviation. Significant pairwise
contrasts were for pain now (day 1 ⬎ days 3 and 5), average pain
(day 1 ⬎ day 3 ⬎ day 5), and worst pain (day 1 ⬎ day 3 ⬎ day 5).
Interference With Function
As shown in Table 2, significant decreases were found
ing ability, and relations with other as well as in mean
interference scores between POD3 and POD5. No differ-
ences were found in the mood and sleep interference
items. As shown in Table 3, on POD3 significant positive
correlations were found between the majority of the
pain intensity scores and interference items. On POD5,
stronger positive correlations were found between the
276 Quality of Postoperative Pain Management in Norwegian Patients

Weak opioids majority of the pain intensity scores and the various in-
Strong opioids
terference items.
Total dose of opioid
A.
120 Patient Satisfaction With Postoperative
Milligrams of opioid analgesic

Pain Management on POD3 and POD5

100 As shown in Table 4, the majority of the patients who
completed the survey were satisfied or very satisfied with
80
all aspects of pain management on both postoperative
days. Of note, on POD3 significant negative correlations
60
were found only between patients’ ratings of their sat-
40 isfaction with the nurses’ responsiveness to their pain
and their ratings of pain now (r ⫽ ⫺.36; P ⫽ .001) and
20 average pain (r ⫽ ⫺.35; P ⫽ .001). On POD5, significant
negative correlations were found between patients’ rat-
0 ings of their satisfaction with the nurses’ responsiveness
Day 1 Day 3 Day 5
to their pain and their ratings of pain now (r ⫽ ⫺.35; P ⫽
.004) and average pain (r ⫽ ⫺ 30; P ⫽ .01). In addition,
B.
Milligrams of opioid analgesic

140
120
100
80
60
40
20
0 higher dissatisfaction scores.
Day 1 Day 3
Figure 3. (A) For POD1, POD3, and POD5, the doses of weak
opioids (n ⫽ 93, 97, and 90, respectively) and strong opioids (n ⫽
86, 25, and 11, respectively) and the total dose of opioid (ex-
pressed in oral morphine equivalents per 24 hours; n ⫽ 98, 98,
and 91, respectively) administered to the study participants. (B)
Changes in the doses of weak opioid (n ⫽ 84) and strong opioid
(n ⫽ 9) and total dose of opioid (n ⫽ 89) for all patients who
received these types of analgesic medications on all three days
that were assessed. All values are plotted as mean ⫾ standard
deviation. Significant pairwise contrasts were for weak opioids
(day 1 ⬍ days 3 and 5), strong opioids (day 1 ⬎ days 3 and 5), and
total dose of opioid analgesics (day 1 ⬎ days 3 and 5).
Weak opioids
Strong opioids significant negative correlations were found between
Total dose of opioid patients’ ratings of their satisfaction with physicians’ re-
sponsiveness to their pain and their ratings of pain now
(r ⫽ ⫺.38; P ⫽ .004), worst pain (r ⫽ ⫺.42; P ⫽ .001), and
average pain (r ⫽ ⫺.39; P ⫽ .003). Of note, only on POD5
were significant negative correlations found between
patients’ ratings of overall satisfaction with pain man-
agement and their ratings of pain now (r ⫽ ⫺.34; P ⫽
.005), worst pain (r ⫽ ⫺.27; P ⫽ .03), and average pain (r
⫽ ⫺.34, p ⫽ .005). These negative correlations indicate
that higher pain intensity scores were associated with
Day 5 Waiting times for pain medication and for changes in
analgesic prescriptions were evaluated on POD3. The
majority of the patients (88%) reported a wait time of 20
minutes or less to receive a pain medicine. Forty-seven
percent indicated that the pain medication was not ef-
fective and that they required a higher dose or a differ-
ent pain medication. Of those patients, 89% received a
higher dose or a different medication in less than 1 hour.
Patients were also asked if they had been told by a nurse
or a physician that pain treatment was very important
and to tell them when they were in pain. Eighty-eight
percent of the patients reported that they had received
the information, 11% indicated they had not, and 1 per-
son could not remember.

Differences in Patients’ Ratings of How Pain Interfered With Functions Between

Table 2.
Postoperative Days 3 and 5
DAY 3 DAY 5

ITEM MEAN SD MEAN SD STATISTIC

General activity (n ⫽ 58) 4.55 2.47 3.16 2.53 F(1,57) ⫽ 13.96; P ⬍ .0001
Mood (n ⫽ 61) 2.85 2.55 2.20 2.46 F(1,60) ⫽ 3.42; P ⫽ .07
Walking ability (n ⫽ 59) 4.85 2.82 3.66 2.81 F(1,58) ⫽ 11.61; P ⫽ .001
Relations with others (n ⫽ 61) 2.49 2.46 1.89 2.32 F(1,60) ⫽ 4.98; P ⫽ .03
Sleep (n ⫽ 61) 4.74 2.59 3.98 2.45 F(1,60) ⫽ 3.90; P ⫽ .053
Mean interference score (n ⫽ 61) 3.87 1.83 2.98 1.94 F(1,60) ⫽ 15.85; P ⬍ .0001

Abbreviation: SD, standard deviation.

ORIGINAL REPORT/Dihle et al 277

Correlations Between Pain Intensity Scores and Interference With Function Scores on
Table 3.
Postoperative Days 3 and 5
MEAN
RELATIONS WITH INTERFERENCE
GENERAL ACTIVITY MOOD WALKING ABILITY OTHERS SLEEP SCORE

PAIN INTENSITY DAY 3 DAY 5 DAY 3 DAY 5 DAY 3 DAY 5 DAY 3 DAY 5 DAY 3 DAY 5 DAY 3 DAY 5

Pain now .21 .60*** .34** .46*** .15 .52*** .42*** .35** .30** .42*** .39*** .61***
Pain worst .35*** .48*** .30** .38** .23* .40** .36*** .26* .48*** .40** .47*** .50***
Pain average .39*** .64*** .39*** .52*** .29** .54*** .41*** .42*** .39*** .45*** .50*** .67***
Pain intensity when an .24* .44*** .15 .25* .29** .35** .11 .21 .40*** .22 .33** .39**
analgesic was needed

***P ⱕ .001; **P ⬍ .01; *P ⬍ .05 (all 2-tailed tests).

Patients’ Beliefs About Postoperative
Pain Management
As shown in Table 5, based on the reports from POD3
patients reported only modest levels of agreement
(means 1.37-2.35) with all 7 statements. The highest level
of agreement (2.35 ⫾ 1.84) was for the statement, “peo-
ple get addicted to pain medicine easily.”
Discussion
This study is the first to evaluate the quality of postop-
erative pain in a European country using the quality im-
provement standards recommended by APS.3 In addi-
tion, this study is the first to use multiple measurements
of pain intensity, interference with function, analgesic
medication, and satisfaction to evaluate for changes in
the quality of postoperative pain management over
time.
Findings from this study need to be interpreted and
understood within the context of postoperative pain
management in Norway, where, at the time of data col-
lection, no national standards were available on effec-
tive postoperative pain management. This lack of stan-
dards contrasts sharply with the Pain Standards that
were implemented in health care institutions in the
United States that undergo accreditation by the Joint
Commission on Accreditation of Health Care Organiza-
tions.7,8 However, it should be noted that the Norwegian
Medical Association has approved Guidelines for Pain
Management in Norway.31 These guidelines are in the
process of being implemented. The data presented in
this paper may be representative of baseline data on the
quality of postoperative pain management in Norway
that can be used for comparative purposes.
Pain intensity ratings from this relatively homoge-
neous sample of orthopedic patients were similar to
those reported for more heterogeneous samples of post-
operative patients.10,19,27 Once again, the findings from
this study demonstrate that postoperative pain is under-
treated, with high ratings of pain intensity and low an-
algesic doses administered. The findings suggest that the
undertreatment of postoperative pain persists across the
first 5 postoperative days (Fig 1A). Although, as expected
for postoperative pain, all pain intensity scores de-
creased over time (Fig 1B), 25% of the patients in this
study continued to have an average pain score of greater
than 5, and 53% had a worst pain score of greater than 5
on the fifth postoperative day.
With regard to analgesic medications administered,
approximately 90% to 98% of the patients received the
same dose of paracetamol over the 3 postoperative as-
sessments. However, the majority of the patients re-
ceived only 50% of the paracetamol dose that was pre-
scribed in the standing orders for postoperative
management (Fig 2A). Nonsteroidal antiinflammatory
drugs were prescribed individually for each patient, and
only 26.5% of the patients received a dose on POD1. This
percentage increased to approximately 50% on POD3
and POD5. It is not clear why so few patients received an
NSAID in the postoperative period, because the combi-

Table 4. Patients’ Ratings of Overall Satisfaction With Pain Management, as Well as Their Level
of Satisfaction With How Nurses (RN) and Physicians (MD) Responded to Their Reports of Pain
DAY 3 DAY 5

LEVEL OF OVERALL, RN, MD, OVERALL, RN, MD,

SATISFACTION n (%) n (%) n (%) n (%) n (%) n (%)

Dissatisfied 1 (1.3) 0 (.0) 2 (2.9) 2 (3.0) 2 (3.0) 2 (3.5)

Slightly satisfied 9 (10.8) 4 (4.8) 5 (7.3) 6 (9.0) 3 (4.5) 10 (17.5)
Satisfied 27 (32.5) 14 (16.9) 27 (39.1) 25 (37.3) 13 (19.4) 16 (28.1)
Very satisfied 46 (55.4) 65 (78.3) 35 (50.7) 34 (50.7) 49 (73.1) 29 (50.9)
278
Table 5. Patients’ Level of Agreement With Beliefs About Postoperative Pain Management (0 ⴝ
Do Not Agree at All to 5 ⴝ Agree Very Much)
STATEMENT
1. Pain medicine cannot really control pain.
2. People get addicted to pain medicine easily.
3. Good patients avoid talking about pain.
4. It is easier to put up with pain than with the side effects that come from pain medicine.
5. Complaints of pain could distract a physician from treating my underlying illness.
6. Pain medicine should be “saved” in case the pain gets worse.
7. The experience of pain is a sign that the illness is getting worse.
Abbreviation: SD, standard deviation.
nation of paracetamol and an NSAID is suggested to en-
hance analgesia and to have an opioid sparing ef-
fect.22,25
Although strong opioids are recommended for the ef-
fective management of pain in the immediate postoper-
ative period,1,15 only 84.3% (86/102) received a strong
opioid on POD1. This percentage decreased to 25% and
12% of the sample on POD3 and POD5, respectively. In
addition, the mean dose of strong opioid administered
per 24 hours, on all 3 days, was equivalent to only 30 mg
oral morphine. This finding contrasts sharply with the
higher percentage of patients who received weak opi-
oids (primarily paracetamol and codeine or dextro-
propoxyphene) on POD3 and POD5 (97% and 98%, re-
spectively). Again as with the strong opioids, the average
dose of weak opioid administered to these patients in a
24-hour period was equivalent to 30 mg oral morphine.
The total dose of opioids on POD1 was equivalent to
approximately 60 mg oral morphine and on the 2 subse-
quent days to approximately 40 mg oral morphine in a
24-hour period. The high pain intensity scores might be
partially explained by the low doses of analgesics that
were administered to these patients. It should be noted
that routine management of postoperative pain in this
hospital consisted of around-the-clock administration of
paracetamol or a weak opioid together with pro re nata
administration of intravenous opioids. No patients in this
study had a patient-controlled analgesia device or re-
ceived epidural analgesia.
Findings from this study suggest that whereas mean
pain interference scores, as well as interference with
general activity, walking ability, and relations with other
people decreased over time (Table 3), patients with
higher pain intensity scores reported significantly higher
interference scores. In fact, the strongest correlations
(range .26-.67) were found on POD5, when only 12% of
the patients received a dose of a strong opioid. The in-
terference scores reported by the patients in this study
were slightly lower than those reported in previous stud-
ies with more heterogeneous samples of hospitalized pa-
tients.19 It should be noted that the interference scores
for mood and sleep did not decrease over time. Although
the interference scores for mood were in the mild range,
the scores for sleep were in the moderate range. Taken
Quality of Postoperative Pain Management in Norwegian Patients
MCNEILL ET AL, 1998
CURRENT STUDY STUDY29
MEAN (SD) MEAN (SD)
2.25 (2.07) 2.05 (2.04)
2.35 (1.84) 2.74 (1.83)
1.37 (1.75) 1.48 (1.87)
1.89 (1.73) 1.71 (1.87)
1.55 (1.74) 1.42 (1.79)
1.62 (1.80) 1.10 (1.66)
1.95 (1.82) 2.41 (1.96)
together, these findings support the conclusions made
by Gordon et al19 that pain interference scores should be
monitored as an indicator of the quality of postoperative
pain management. Future studies need to determine if
pharmacologic and nonpharmacologic interventions
that result in decreases in pain intensity scores reduce
pain interference scores.
As has every other study of the quality of pain manage-
ment in hospitalized patients,19 patients in this study
reported high satisfaction scores in the setting of signif-
icant postoperative pain. This study did evaluate for
changes in satisfaction scores over time and found high
satisfaction scores across the postoperative period. Con-
sistent with previous reports,19 higher pain intensity
scores were associated with higher dissatisfaction scores.
This patient satisfaction measure remains an unreliable
indicator of the quality of postoperative pain manage-
ment and should not be used for this purpose in future
studies.
Only one study29 has reported scores for the individual
items from the pain beliefs section of the APS POQ. This
study evaluated the pain experience of 122 hospitalized
patients of whom 68% had had surgery. Although direct
comparisons of the patients’ ratings are not possible ow-
ing to the differences in the patient samples the scores
on the various barrier items were fairly similar (Table 5).
In both of these studies, the highest level of agreement
was with the item about addiction (item 2). This area may
need to be evaluated and addressed more carefully in
the preoperative education of patients.
Although this study is the first in Europe using the
APS POQ from 1995 to evaluate for changes in the
quality of pain management over the first 5 postoper-
ative days, several limitations need to be noted. The
patients who chose to participate in this study were
somewhat younger and included more men. This re-
sponse bias may have decreased the pain intensity rat-
ings, because women are more likely to report higher
pain scores than men.5,34 However, as suggested in the
study of Aubrunet al,5 gender differences in pain in-
tensity may disappear in older patients (age ⬎75
years). The generalizability of the study findings are
limited because of the homogeneous patient sample
and because the collection of data occurred in a single
ORIGINAL REPORT/Dihle et al
institution. As with any longitudinal study, missing
data did occur.
Despite these limitations, the findings from this study
suggest that postoperative pain is not well managed and
results in interference with functions that are critical for
postoperative recovery (eg, walking ability). As part of a
systematic approach to improve the quality of postoper-
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