Two-Step Screening Process Associated with Increased Diagnosis of Chronic Pain


A new study finds a 2-step chronic pain screening process helped identify patients in primary care with previously undocumented chronic pain.

Daren R. Anderson, MD

Daren R. Anderson, MD

Although chronic pain affects more than 20% of the United States population, there are notable challenges in pain treatment, including data showing severe pain disproportionately affects medically underserved patients.

A new study evaluated the implementation of a 2-step process in a multisite Federally Qualified Health Center (FQHC) to screen for chronic pain, as well as the association with function reported by patients.

The team, led by Daren R. Anderson, MD, Community Health Center Inc, found the 2-step chronic pain screening process was simple to implement and helped identify patients in primary care with previously undocumented chronic pain.


The team conducted a cross-sectional observational study at a statewide, multisite FQHC with approximately 100,000 patients.

A total of 68 primary care practitioners (PCPs) and 58 medical assistants (MAs) from 13 practice sites implemented the process between July 2018 - June 2019. Patients were aged ≥18 years with a primary care visit during the study period.

Investigators used a validated, chronic pain screening tool with the question “In the past 3 months, how often did you have pain?”.

After the question was proposed, answer choices included “never”, “some days”, “most days”, “every day”, and “don’t know”.

After 90 days, a 3-question PEG (pain, enjoyment of life, general activity) functional assessment for patients with chronic pain was asked until the patient screened negative for chronic pain.

The team noted an average PEG response of ≥7 on a 0 - 10 scale was considered severe pain interference.

Patient demographics, including age, sex, self-reported race/ethnicity, primary insurance, and preferred language, were taken from the electronic health record.


Data show a total of 31,600 patients (81.3%) were screened for chronic pain under the new 2-step process, with a mean age of 46.2 years. Most patients were aged 35 - 54 years old (n = 12,987).

In addition, the patients were 58.3% female (n = 18,436), 46.9% Hispanic (n = 14,809), and 58.4% (n = 18,442) had Medicaid insurance.

In the patients assessed, the team noted 10,262 patients (32.5%) screened positive for chronic pain and 9701 patients (94.5%) with the positive results completing PEG function assessment.

In the 9701 patients who completed PEG assessment, 5735 (59.1%) of patients reported severe impairment, with a PEG ≥7 score.

This included more than half of all patients in all age groups (59.9%) and with public insurance (Medicare 61.5%, Medicaid 61.0%).

They noted 4257 (43.9%) patients were not diagnosed with a chronic painful condition in the year before screening.

As a result, the investigators observed that patients with severe functional impairment without an existing diagnosis were more likely to have a new pain diagnosis on the date of screening or within 90 days (1333 of 2250; 59.2%).

In addition, investigators found workflow observations and interviews identified clinical decision support, time comprehension, and attitudes about normalizing pain as key themes of the intervention.

Although the clinician care team found workflow acceptable, they had issues with lengthy administration time of the test, comprehension of PEG questions, and comprehensive limits as barriers to implementation.

“Some patients were unfamiliar with the concept of pain interference and ‘did not understand the PEG questions without examples,’ requiring MAs to ‘break down and simplify’ questions to elicit a response,” investigators wrote.


Investigators noted that the 2-step screening and functional assessment process might be implemented in the future across a large safety-net practice.

“Future research should examine patients’ perceptions of this chronic pain screening and functional assessment process to ascertain whether patients feel that pain interference is an important and relevant aspect of their pain and whether they perceive the new process as beneficial to their care,” investigators concluded.

The study, “Evaluation of a Chronic Pain Screening Program Implemented in Primary Care,” was published online in JAMA Network Open.

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