Patient perception of pain care in the United States: a 5-year comparative analysis of hospital consumer assessment of health care providers and systems.

BACKGROUND: The necessity of aggressive pain management in the hospital setting is becoming increasingly evident. It has been shown to improve patient outcomes, and is now an avenue for Medicare to assess reimbursement. In this cohort analysis, we compared the March 2008 to the December 2012 Hospital Consumer Assessment of Health Plans Survey (HCAHPS) reports in order to determine if pain management has improved in the United States after this national standardized survey was created. OBJECTIVE: To evaluate whether pain perception would improve in the 2012 report relative to the 2008 report. STUDY DESIGN: Statistical analyses were conducted with the HCAHPS report to compare pain control in regards to hospital type, hospital ownership, and individual hospitals. Using the question, "How often is your pain controlled?," T-tests were used to compare each hospital type. Hospital ownerships were assessed via analysis of variance (ANOVA) testing. T-tests were conducted to track the difference of hospital performance between the 2008 and the 2012 report. Paired management data were obtained from hospitals that participated in both reports and were assessed using paired T-tests. SETTING: This survey was administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge from any hospital reporting to Centers for Medicare and Medicaid (CMS) across the US. LIMITATIONS: Limitations of this study include response bias, recall bias, and there may be bias related to types of people likely to respond to a survey, but this is inherent to data that is collected on a voluntary response. Additionally, a 3% increase in the number of patients rating their pain as always well-controlled, while statistically significant, admittedly may not be clinically significant. In addition, the raw data collected is adjusted for the effects of patient-mix. The statistical analyses performed to derive the final quarterly HCAHPS reports are unavailable to us and therefore we cannot comment on how individual factors such as age, sex, race, and education or the interaction of the aforementioned affect responses about the patient's perception on how well their pain was controlled between 2008 and 2012. RESULTS: Two thousand three hundred and ninety five hospitals reported pain management data in both 2008 and 2012. In 2012, hospitals improved their ability to "always control a patients pain" by 3.07% (P < 0.0001) in comparison to the baseline March 2008 report, which was statistically significant. According to the 2012 data, the discrepancy in pain management between acute care hospitals and critical access hospitals was 3.33% which was statistically significant (P < 0.05). Government hospitals were shown to manage pain better at baseline, but all 3 types of ownership improved their pain scores between the 2 reports which was shown to be statistically significant (P < 0.01). DISCUSSION: The HCAHPS survey is a national public standardized report used as a way to compare care in the United States. Patient pain perception has improved between the 2008 and 2012 reports. Further studies are needed to evaluate critical care hospitals.

Carbon monoxide releasing molecule-2 attenuates the anticoagulant and amplifies the hypofibrinolytic effects of hypothermia in human plasma in vitro.

Hypothermia is known to contribute to coagulopathy in trauma and other major surgical procedures. Although the effects of hypothermia on coagulation have been characterized, the effects on fibrinolysis remained to be elucidated. Thus, our goals were to discern the effects of hypothermia on fibrinolysis in human plasma, and secondarily determine if a new procoagulant/antifibrinolytic molecule, carbon monoxide releasing molecule (tricarbonyldichlororuthenium (II) dimer; CORM-2) would modify thrombus growth/disintegration under hypothermic conditions. Normal plasma was exposed to 0 or 100 µmol/l CORM-2, with coagulation activated by tissue factor and fibrinolysis initiated with 100 U/ml tissue-type plasminogen activator. Plasma samples were exposed to 37°, 35°, 33°, 31°, 29°, or 27°C (n = 6 per temperature/CORM-2 concentration). Thrombus growth/disintegration kinetics were monitored with thrombelastography until clot lysis time occurred. Hypothermia significantly prolonged the onset and decreased the velocity of clot growth in plasma without decreasing clot strength. Although hypothermia did not affect the time to onset of fibrinolysis, it did significantly decrease the velocity of lysis. The addition of CORM-2 significantly increased the velocity of clot growth and clot strength at all temperatures tested compared with unexposed plasma. Further, CORM-2 addition significantly prolonged the onset of fibrinolysis and diminished the velocity of lysis. Hypothermia resulted in slower growing, slower lysing thrombi in normal plasma. CORM-2 enhanced coagulation and markedly attenuated fibrinolysis at all temperatures tested. Further investigation is warranted to determine if CORM-2 administration can improve hemostasis in preclinical models of hypothermia and trauma.