Prevalence of pain in adults admitted to Catalonian hospitals: A cross-sectional study

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European Journal of Pain 10 (2006) 721–731

Prevalence of pain in adults admitted to Catalonian hospitals:A cross-sectional study

A. Vallano a,*, J. Malouf b, P. Payrulet a,J.E. Banos b, on behalf of the Catalan Research Group for Studying Pain in Hospital 1

a Fundacio Institut Catala de Farmacologıa, Servicio de Farmacologıa Clınica, Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona,

Passeig Vall d’ Hebron no. 119-129, 08035 Barcelona, Spainb Departament de Ciencies Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain

Received 4 July 2005; received in revised form 7 November 2005; accepted 24 November 2005Available online 18 January 2006

Abstract

Objective: To survey the prevalence of pain in patients admitted to different hospitals of Catalonia and to describe which factors arerelated to pain.Methods: A cross-sectional study was performed in 1675 patients from fifteen hospitals in Catalonia (Spain). Clinical and demo-graphic data, as well as the existence of pain intensity evaluations and analgesic therapy, were obtained from medical charts. Char-acteristics of pain were given by patients after being interviewed by trained interviewers. The main-outcome measure was theexistence of pain (at the interview, in the previous 24 h, at the admission and at any time after admission) that was assessed by avisual analogue scale (VAS). The relationship of prevalence of pain to patients’ characteristics was carried out by means of a multi-ple-logistic-regression model with pain presence as the dependent variable of interest.Results: A great variability in the prevalence and intensity of pain among different hospitals was observed. At the time of the inter-view, 48.5% (95% CI: 46.1–50.9%) of the patients had pain and the median VAS was 40 mm (range: 10–100 mm), and the prevalenceof pain during the previous 24 h was similar (47.6%; 95% CI: 45.2–50%). At admission, 26.7% (95% CI: 24.6–28.8%) of patients werein pain, whereas 62% (95% CI: 59.7–64.3%) reported having pain at some time during their stay. Pain intensity annotations wereabsent in 51.3% (95% CI: 47.9–54.7%) of the medical records of the patients with pain. The factors associated with pain were youn-ger age, female gender, presence of surgery, orthopaedic surgery wards, large hospital and prescribed analgesics.Conclusion: A high prevalence of clinically relevant pain in in-patients was found as well as a great variability according to type ofpatients, clinical wards and hospitals. This study gives clear evidence of the lack of adequate management of pain in the majority ofthe hospitals and calls for the implementation of organisational and educational measurements that may settle this epidemicproblem.� 2005 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All

rights reserved.

1090-3801/$32 � 2005 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights

reserved.

doi:10.1016/j.ejpain.2005.11.003

* Corresponding author. Tel.: +34 93 428 30 29; fax: +34 93 489 41 09.E-mail address: [email protected] (A. Vallano).

1 Josep Maria Arnau de Bolos, Ramon Puig Treserra, Cristina Aguilera Martın, Xavi Vidal Guitart (Fundacio Institut Catala de Farmacologia,Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona); Sılvia Mateu Escudero (Hospital de la Santa Creu i Sant Pau, UniversitatAutonoma de Barcelona); Joan Albert Arnaiz Gargallo, Xavier Carne Cladellas (Hospital Clınic de Barcelona); Joan Costa i Pages (HospitalUniversitari Germans Trias i Pujol de Badalona); Maria Dolors Pelegrı Isanta (Hospital de Viladecans); Pere Comas Casanova (Hospital deFigueres); Carme Busquets Julia, Fina Parramon Vila (Hospital Universitari de Girona ‘‘Dr. Josep Trueta’’); Magı Farre Albaladejo (InstitutMunicipal d’Investigacio Medica, Universitat Autonoma de Barcelona); Montserrat Canellas Arsegol (Corporacio Sanitaria Parc Taulı de Sabadell);Antonio Moreno Matamala (Hospital Universitari de Bellvitge); Enric Turon (Hospital de Vilafranca del Penedes); Susana Garcıa Bermudez(Hospital de Terrassa); Marıa Rull i Bertomeu (Hospital Universitari de Tarragona ‘‘Joan XXIII’’); Pilar Baxarias Gascon (Fundacio Puigvert), andJordi Castellnou (Hospital Verge de la Cinta de Tortosa).

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722 A. Vallano et al. / European Journal of Pain 10 (2006) 721–731

Keywords: Pain; Pain measurements; Cross-sectional studies; Epidemiologic studies; Outcome assessment (Health Care); Quality of health care

Sample of patients in hospitals

(n=2,593) (36.6%)

Patients excluded and not

evaluated1

(n = 918)(12.6%)

Sample of evaluated patients in hospitals

(n = 1,675) (23%)

Registered patients in hospitals

(n=7,272)

1. Introduction

Several studies have shown that pain is a very com-mon event in the general population of Western coun-tries, it impairs these people’s personal and social lifeand conveys a loss of their quality of life (Andersenand Worm-Pedersen, 1987; Bassols et al., 1999; Boschet al., 1990; Brattberg et al., 1989; Browser et al.,1993; James et al., 1991; Stenbach, 1986). In in-patients, pain is also an important problem beyondpersonal suffering as it is associated with longer hospi-tal stays because it delays successful recovery andtherefore increases the use of hospital resources(Levenson et al., 1992). Several studies have analysedpain prevalence in selected samples of patients, suchas those afflicted with postoperative pain (Parkhouseet al., 1961; Vallano et al., 1999) or pain secondaryto medical illnesses (Donovan et al., 1987; Marks andSachar, 1973). Nevertheless, few studies have evaluatedthe prevalence of pain in all in-patients (Constantiniet al., 2002; Visentin et al., 2005) and most of themhave been conducted in a single hospital or only in asmall number of centres (Abbot et al., 1992; Canellaset al., 1993; Salomon et al., 2002; Whelan et al.,2004). This fact limits the external validity of theresults, as they may be influenced by the idiosyncraticcharacteristics of each hospital.

Several small-sized studies (Canellas et al., 1993; Val-lano et al., 1999) have shown a high prevalence of painin in-patients in Catalonia, a well-defined area in theNortheast of Spain with a population of almost sevenmillion people. Nevertheless, there are no studiesdescribing the current prevalence and determinants ofpain among a large population of hospitalised patientsin Catalonia in order to know the actual magnitude ofthis problem and then to plan and deliver specificactions to improve it.

The purpose of this paper is to report the preva-lence of pain in hospitalised patients and describe thefactors related to pain in a large sample of hospitalsin Catalonia.

1Reasons for non-assessment and exclusion

333 patients were out of the ward at the moment of interview 247 patients were in an unspecified poor clinical condition or with a severe illness 226 patients had cognitive, hearing or speech disorders including dementia 56 patients refused to be interviewed and to participate in the study 38 patients did not understand Spanish 18 patients were younger than 18 years old

Fig. 1. Flow chart of patients considered for participating in the study.

2. Methods

2.1. Characteristics of the study population

The study was carried out in patients from fifteenhospitals of Catalonia. A cross-sectional study with aconsecutive sampling of all patients admitted to eachhospital, until fulfilling the predetermined sample size

for each hospital, in one day (from January 1, 2002 toSeptember 31, 2003) was performed (see below in statis-tical analysis). Only patients younger than 18 years ofage, those admitted to critical care units and thoseunable to be interviewed by cognitive disorders or lackof knowledge of Spanish or who refused to participatein the study were excluded (Fig. 1).

2.2. Data collection

Demographic and clinical characteristics of patients(age, gender, education, diagnosis), and the existenceof written pain intensity evaluations and of analgesictreatment were obtained from medical charts. Pain fea-tures (presence, intensity, location) were obtaineddirectly from patients. In addition, characteristics ofhospitals were also collected from the local collabora-tors at each centre. Investigators asked the patients forthe presence and intensity of pain at four distinct peri-

A. Vallano et al. / European Journal of Pain 10 (2006) 721–731 723

ods: at the time of the interview, during the previous24 h, at admission to hospital and during his/her stay.Patients were also asked to rate the slightest pain andworst pain suffered during their stay. Pain intensitywas assessed by means of a visual analogue scale(VAS) of 100 mm, and in some of the results the per-centage of patients with a VAS score higher than30 mm (clinically relevant pain) and the percentage ofpatients with a VAS score higher than 60 mm (severepain) was calculated. The hospitals were classifiedaccording to their size as large (>600 beds), medium(300–600 beds) or small (<300 beds) hospitals. The cen-tres were divided into teaching and non-teaching hospi-tals if they had established residency programmes.

2.3. Ethical considerations

The study was approved by the Ethical Committeefor Clinical Research of each centre. All patientsincluded in this study were informed of the aims andcharacteristics of the study and gave their writteninformed consent to participate.

2.4. Statistical analysis

EPISTAT software was used to calculate the numberof patients of each hospital to be included in the study.The sampling design was a stratified sample (with hospi-tals as strata) and the sample selected in each hospitalwas proportional to its size. The premises consideredfor calculating the sample were a pain prevalence in50% of patients (according to the results of a pilotstudy), a maximum difference of 10% between the prev-alence of pain in the sample and in the population, and alevel of statistical significance of 95%. Proportions andcorresponding 95% confidence intervals (95% CI) wereused, and continuous variables were presented asmean ± standard deviation (SD) if they were normallydistributed, or median with minimum and maximumvalues if not. The relationship between categorical vari-ables was analysed using the Pearson v2 test, and differ-ences between continuous variables were compared bymeans of ANOVA for normally distributed variables.A Bonferroni correction for multiple testing wasapplied. In the statistical analysis P < 0.0005 was chosenas the significance level for hypothesis testing. To iden-tify predictors of pain, a multiple-logistic- regressionmodel with pain presence at the time of the interviewas the dependent variable of interest was performed.Potential predictors included in the model as indepen-dent variables were: age, sex, presence of surgery, useof analgesic therapy, clinical ward and type of hospital.From the final model, an odds ratio (OR) and corre-sponding 95% CI were calculated. Statistical analysiswas performed using SPSS software (SPSS Inc; Chicago,IL).

3. Results

3.1. Demographic and clinical characteristics of patients

A total of 1675 patients were included in the study.When considered by type of hospital, 1112 (66.4%) ofthese patients were recruited from large-sized, 235(14%) from medium-sized and 328 (19.6%) from small-sized hospitals. Ten centres were teaching hospitalsand seven were public hospitals. Fig. 1 shows a flowchart detailing the process of inclusion of patients andthe causes for their exclusion. Demographic and clinicalcharacteristics of patients are shown in Table 1. Themean age (SD) of the patients was 58.4 (18.3) yearsold [median 62; range: 18–98], 51.6% were men (95%CI: 49.2–53.9%) and they had a median of 8 years ofeducation (range: 0–30). Most patients were admittedto medical or surgical wards. There were 33.4% (95%CI: 31.1–35.7%) of patients who had been submittedto surgery, and 14.8% (95% CI: 13.1–16.5%) wereafflicted with cancer. The most frequent diagnoses wererelated to musculoskeletal (18.4%; 95% CI: 16.5–20.3%)or gastrointestinal disorders (17.4%; 95% CI: 15.6–19.2%). The most frequent painful sites were abdomen(12.4%; 95% CI: 10.8–14%), legs and hip (11%; 95%CI: 9.5–12.5%), back (6%; CI 95% 4.9–7.1%) and chest(5.7%; 95% CI: 4.6–6.8%).

3.2. Pain assessment

3.2.1. Pain at the time of the interview and in the previous

24 h

At the time of the interview, 48.5% (95% CI: 46.1–50.9%) of the patients reported being in pain, and thisfigure was similar to that of patients in pain during theprevious 24 h (47.6%; 95% CI: 45.2–50%). At the timeof the interview, the median score of pain intensity inpatients with pain was 40 mm (range: 10–100 mm) with52.9% of these patients (95% CI: 49.5–56.3%) scoring apain intensity higher than 30 mm and 19.7% (95% CI:17–22.4%) higher than 60 mm, according to VAS.

3.2.2. Pain when admitted to hospital and during their

stay

When patients were admitted to hospital, 26.7% (95%CI: 24.6–28.8%) had pain, whereas 62% (95% CI: 59.7–64.3%) reported it at some time during their stay. A totalof 70.8% of patients (95% CI: 68.0–73.6%) communi-cated their pain to nurses or physicians, but 29.2%(95% CI: 26.4–32.0) of the patients who had pain atsome time during their stay in the hospital did not.

3.2.3. Prevalence of pain by patients’ demographic and

clinical characteristicsTable 2 summarises the relation of prevalence of

pain to characteristics of patients. In most evaluations,

Table 1Demographic and clinical characteristics of patients

Patients’ characteristics Number ofpatients (N = 1675)

% (95% CI)

Age18–40 years 351 21.0 (19.0–23.0)41–60 years 441 26.3 (24.2–28.4)61–70 years 364 21.7 (19.7–23.7)71–80 years 371 22.1 (20.1–24.1)>80 years 146 8.7 (7.3–10.0)

GenderMale 864 51.6 (49.2–53.9)Female 811 48.4 (46.0–50.8)

EducationPrimary (1–8 years) 736 43.9 (41.5–46.3)Middle and high(>8 years)

939 56.1 (53.7–58.5)

WardsMedicine andspecialities

705 42.1 (39.7–44.5)

General surgeryand specialities

501 29.9 (27.7–32.1)

Orthopaedics andrehabilitation

288 17.2 (15.4–19.0)

Gynaecology andobstetrics

181 10.8 (9.3–12.3)

SurgeryYes 559 33.4 (31.1–35.7)No 1116 66.6 (64.3–68.9)

CancerYes 248 14.8 (13.1–16.5)No 1427 85.2 (83.5–86.9)

TraumaYes 154 9.2 (7.8–10.6)No 1521 90.8 (89.4–92.2)

DeliveryYes 100 6.0 (4.8–7.1)No 1575 94.0 (92.9–95.1)

Diagnosis by systemMusculoskeletal 308 18.4 (16.5–20.3)Gastrointestinal 292 17.4 (15.6–19.2)Respiratory 205 12.2 (10.6–19.2)Cardiovascular 196 11.7 (10.2–13.2)Gynaecology 176 10.5 (9.0–12.0)Urology 142 8.5 (7.2–9.8)Other 356 21.3 (19.3–23.3)


prevalence was higher in younger patients than in olderones and women scored higher than men. No differ-ences were seen when patients were analysed by educa-tional level, using 8 years as a cut-off. When clinicalwards were considered, those with surgical patients(61.2%; 95% CI: 57.2–65.2%) had, in general, higherpain-prevalence rates than medical patients (42.2%;95% CI: 39.3–45.1%). Surgical procedures, traumasand deliveries were clearly associated with higher painprevalence, but cancer patients did not report sufferingmore pain than those without this illness.

3.2.4. Pain intensity by demographic and clinical

characteristics

Table 3 shows the relation of pain-intensity scores ofclinically relevant pain and severe pain according to thepatients’ demographic and clinical characteristics. Themedian score of the worst pain intensity was 70 mm(range 10–100 mm) in patients with pain during theirstay in hospital, 84.5% (CI 95%: 82–87%) of them scor-ing pain intensity higher than 30 mm, and 56% higherthan 60 mm (CI 95%: 52.6–59.4%). The median scoreof the slightest pain intensity was 40 mm (range 10–100 mm) in the patients with pain during their stay inthe hospital, 50.9% of whom scored pain intensityhigher than 30 mm (CI 95%: 47.5–54.3%), and 17%higher than 60 mm (CI 95%: 14.4–19.6%). Youngerpatients scored higher than older patients in the variableThe worst pain during stay, but no differences were seenin the other variables. Female patients scored consis-tently higher than men, and no differences were seenwhen patients were analysed by educational level.Again, patients from surgical wards gave higher scoresthan those from medical wards, with those of orthopae-dics and rehabilitation as well as gynaecology andobstetrics scoring the highest. More patients scored theworst pain intensity higher than 30 mm in the orthopae-dic surgery ward (53.6%; 95% CI 47.9–59.4%) than inthose in general surgery and surgical specialities wards(40.1%; 95% CI: 36.7–45.3%) and in internal medicineand medical specialities wards (33.3%; 95% CI: 29.7–36.7%). More post-operative patients scored the worstpain intensity higher than 30 mm (51.5%; 95% CI:47.4–55.6) than did non-postoperative patients (37%;95% CI: 32.9–38.3%). Patients who underwent surgicalprocedures had higher relevant pain scores comparedwith those who did not in Pain at the time of interview

and The worst pain during their stay. For instance,post-operative patients scored pain intensity higher than30 mm (31.5%; 95% CI: 27.6–35.3%) than those who didnot undergo surgery (22.8%; 95% CI: 20.3–25.3%). Can-cer patients only scored higher in The worst pain during

stay in VAS scores higher than 60 mm. Trauma patientsgave the highest scores in all variables. Women whodelivered babies had higher scores in VAS > 30 mm atThe worst pain during stay, as compared with womenwho did not. Differences were also observed when diag-noses were compared.

3.3. Written records of pain intensity assessment and

analgesic treatment in medical charts

When medical charts were reviewed, no written painintensity assessments were found in 55% of them (95%CI: 52.6–57.4%) as well as in 51.3% (95% CI: 47.9–54.7%) of those from patients who reported pain atthe time of the interview. Table 4 shows written recordsof pain assessment according to the demographic and

Table 2Prevalence of pain and characteristics of patients

Patients’ characteristics Pain at the timeof interview% (95% CI)

Pain in theprevious 24 h% (95% CI)

Pain duringstay% (95% CI)

Pain at admission% (95% CI)

Age18–40 years 58.4 (53.2–63.6) 55.8 (50.6–61.0) 76.6 (72.2–81.0) 23.4 (19.0–27.8)41–60 years 48.3 (43.6–53.0) 47.8 (43.1–52.5) 61.7 (57.2–66.2) 23.6 (19.6–27.6)61–70 years 47.8 (42.7–52.9) 48.1 (43.0–53.2) 58.0 (52.9–63.1) 23.1 (18.8–27.4)71–80 years 43.7 (38.6–48.7) 42.6 (37.6–47.6) 54.7 (49.6–59.8) 24.8 (20.4–29.2)>80 years 39.7 (31.8–47.6) 39.0 (31.1–46.9) 56.2 (48.1–64.2) 37.7 (29.8–45.6)

p < 0.0005 p < 0.0005 p < 0.0005 ns

GenderMale 42.9 (39.6–46.2) 42.2 (38.9–45.5) 57.5 (54.2–60.8) 26.0 (23.1–28.9)Female 54.5 (51.1–57.9) 53.4 (50.0–56.8) 66.7 (63.5–69.9) 23.7 (20.8–26.6)

p < 0.0005 p < 0.0005 p < 0.0005 ns

EducationPrimary (1–8 years) 48.4 (44.8–52.0) 47.4 (43.8–51.0) 60.3 (56.8–63.8) 23.1 (20.1–26.1)Middle and high (>8 years) 48.7 (45.5–51.9) 47.8 (44.6–51.0) 63.3 (60.2–66.4) 26.3 (23.5–29.1)

ns ns ns ns

WardMedicine and specialities 39.0 (35.4–42.6) 39.0 (35.4–42.6) 53.8 (50.1–57.5) 24.1 (20.9–27.3)General surgery and specialities 47.9 (43.5–52.3) 48.3 (43.9–52.7) 61.1 (56.8–65.4) 29.9 (25.9–33.9)Orthopaedics and rehabilitation 63.9 (58.3–69.4) 60.4 (54.7–66) 77.1 (72.2–81.9) 35,4 (29.9–49.9)Gynaecology and obstetrics 63.0 (56.0–70.0) 59.1 (51.9–66.3) 72.4 (66.2–77.2) 14.4 (9.3-19.5)

p < 0.0005 p < 0.0005 p < 0.0005 p < 0.0005

SurgeryYes 61.2 (57.2–65.2) 59.0 (54.9–63.1) 72.8 (69.1–76.5) 18.8 (15.6–22.0)No 42.2 (39.3–45.1) 41.4 (38.5–44.3) 56.5 (53.6–59.4) 28.0 (25.4–30.6)

p < 0.0005 p < 0.0005 p < 0.0005 ns

CancerYes 49.2 (43.0–55.4) 49.6 (43.5–55.9) 59.7 (53.6–65.8) 23.0 (17.8–25.2)No 48.4 (45.8–51.0) 47.3 (44.7–49.9) 62.4 (59.9–64.9) 25.2 (22.9–27.4)

ns ns ns ns

TraumaYes 69.5 (67.3–71.7) 65.6 (63.3–67.9) 85.1 (83.4–86.8) 37.7 (35.4–40.0)No 46.4 (44.0–48.8) 45.8 (43.4–48.2) 59.6 (57.2–61.9) 23.6 8 (21.6–25.6)

p < 0.0005 p < 0.0005 p < 0.0005 p < 0.0005

DeliveryYes 68.0 (58.9–77.1) 65.0 (55.6–74.3) 79.0 (71.0–87.0) 25.8 (17.1–34.4)No 47.3 (44.8–49.8) 46.5 (44.0–49.0) 60.9 (58.5–63.3) 10.0 (8.5–11.5)

p < 0.0005 p < 0.0005 p < 0.0005 ns

Diagnosis by systemMusculoskeletal 63.6 (58.2–69.0) 61.4 (56.0–66.8) 77.3 (72.6–82.0) 30.8 (25.6–36.0)Gastrointestinal 41.4 (35.7–47.0) 41.8 (36.1–47.5) 59.9 (54.3–65.5) 36.3 (30.8–41.8)Respiratory 31.7 (25.3–38.1) 33.2 (26.7–39.6) 47.8 (41.0–54.6) 15.1 (10.2–20.0)Cardiovascular 40.3 (33.4–47.2) 40.3 (33.4–47.2) 54.6 (47.6–61.2) 31.1 (24.6–37.6)Gynaecology 60.8 (53.6–68.0) 58.0 (50.7–65.3) 73.3 (66.8–79.8) 14.2 (9.0–19.4)Urology 45.1 (36.9–53.3) 45.8 (37.6–54.0) 54.2 (46.0–62.4) 14.1 (8.4–19.8)Other 50.8 (45.6–56.0) 48.6 (43.4–53.8) 60.1 (55.0–65.2) 22.2 (17.9–26.5)

p < 0.0005 p < 0.0005 p < 0.0005 p < 0.0005

Total 48.5 (46.1–50.9) 47.6 (45.2–50.0) 62.0 (59.7–64.3) 26.7 (24.6–28.8)

ns, not significant.


clinical characteristics of the patients. Pain intensityassessments were present in 42% (95% CI: 37.9–46.1)of the post-operative, and in 63.7% (CI 95%: 57.7–69.7%) of cancer patients. When wards were considered,the frequency of written pain intensity assessments was

higher in internal medicine and medical specialities(49.9%; 95% CI: 42.7–50.1%), as well as in general sur-gery and surgical specialities wards (56.1%; 95% CI51.7–60.4%), than in orthopaedic surgery (27.1%; 95%CI: 21.1–33.1%) or gynaecology and obstetrics wards

Table 3Pain intensity by characteristics of patients

Patients’characteristics

Pain at the time of interview The worst pain during stay The least pain during stay

VAS > 30 mm% (95% CI)

VAS > 60 mm% (95% CI)

VAS > 30 mm% (95% CI)

VAS > 60 mm% (95% CI)

VAS > 30 mm% (95% CI)

VAS > 60 mm% (95% CI)

Age18–40 years 27.9 (23.2–32.6) 10.8 (7.5–14.5) 52.4 (47.2–57.6) 37.6 (32.5–42.7) 21.7 (17.3–25.9) 8.3 (5.4–11.2)41–60 years 25.6 (21.5–29.7) 8.2 (5.6–10.8) 42.4 (37.8–47.0) 28.6 (24.4–32.8) 20.4 (20.0–28.0) 5.7 (3.5–7.9)61–70 years 27.5 (22.9–32.1) 11.8 (8.5–15.1) 41.8 (36.7–46.9) 28.0 (23.4–32.6) 20.6 (16.4–24.7) 8.0 (5.2–10.8)71–80 years 23.5 (19.2–27.8) 8.9 (6.0–12.8) 31.5 (26.8–36.2) 18.6 (14.6–22.6) 20.2 (16.1–24.3) 7.0 (4.4–9.6)>80 years 21.9 (15.2–28.6) 6.8 (2.7–10.9) 31.5 (24.0–39.0) 17.8 (11.6–24.0) 17.1 (11.0–23.2) 3.4 (0.5–6.3)

ns ns p < 0.0005 p < 0.0005 ns ns

GenderMale 21.6 (18.9–24.3) 8.2 (6.4–10.0) 36.6 (30.4–36.7) 24.4 (25.1–27.3) 17.0 (14.5–19.5) 5.6 (4.1–7.1)Female 30.0 (26.8–33.1) 11.0 (8.8–13.1) 45.6 (42.2–49.0) 30.1 (26.9–33.3) 23.9 (21.0–26.8) 8.1 (6.2–10.0)

p < 0.0005 ns p < 0.0005 ns p < 0.0005 ns

EducationPrimary (1–8 years) 26.4 (23.2–29.6) 10.2 (8.0–12.4) 40.9 (37.3–44.4) 26.0 (22.8–29.2) 20.4 (17.5–23.3) 6.9 (5.1–8.7)Middle and high(>8 years)

25.1 (22.3–27.9) 9.1 (7.3–10.9) 41.0 (37.8–44.1) 28.1 (25.2–31.0) 20.3 (17.7–22.9) 6.7 (5.1–8.3)

ns ns ns ns ns nsWard

Medicine andspecialities

21.3 (18.3–24.3) 8.7 (6.6–10.8) 33.2 (29.7–36.7) 24.1 (20.9–27.3) 17.7 (14.9–20.5) 6.0 (4.2–7-7)

General surgeryand specialities

23.6 (19.9–27.3) 8.8 (6.3–11.3) 40.1 (35.8–44.4) 25.7 (21.9–29.5) 20.2 (16.7–23.7) 6.8 (4.6–9.0)

Orthopaedics andrehabilitation

40.3 (34.6–46.0) 14.6 (10.5–18.7) 53.5 (47.7–59.3) 34.0 (28.5–39.5) 28.8 (23.6–34.0) 10.1 (6.6–13.6)


25.4 (19.1–31.7) 7.2 (3.4–11.0) 53.6 (46.3–60.9) 32.0 (25.2–38.8) 17.7 (12.1–23.3) 5.0 (1.8–8.2)

p < 0.0005 ns p < 0.0005 ns ns ns

SurgeryYes 31.5 (31.1–39.1) 10.0 (7.5–12.5) 51.5 (47.4–55.6) 30.2 (26.4–34.0) 22.7 (19.2–26.2) 6.6 (4.0–8.0)No 22.8 (26.1–31.5) 9.3 (9.1–9.5) 35.7 (32.9–38.5) 25.6 (23.0–28.2) 19.2 (16.9–21.5) 7.2 (5.7–8.7)

p < 0.0005 ns p < 0.0005 ns ns ns

CancerYes 26.6 (21.1–32.1) 10.1 (6.3–13.8) 44.0 (37.8–50.2) 33.0 (28.0–39.8) 23.0 (17.8–28.2) 7.3 (4.1–10.5)No 25.5 (23.2–27.8) 9.5 (8.0–11.0) 40.4 (37.8–43.0) 26.0 (23.7–28.3) 19.9 (17.8–22.0) 6.7 (5.4–8.0)

ns ns ns ns ns ns

TraumaYes 44.8 (36.9–52.6) 14.9 (9.3–20.5) 61.0 (53.3–68.7) 37.7 (30.0–45.3) 34.4 (26.9–41.9) 11.0 (6.1–15.9)No 23.7 (21.6–25.8) 9.0 (7.6–10.4) 38.9 (36.4–41.3) 26.1 (23.9–28.3) 18.9 (16.9–20.9) 6.4 (5.2–7.6)

p < 0.0005 ns p < 0.0005 ns p < 0.0005 ns

DeliveryYes 23.0 (14.7–31.2) 6.0 (1.3–10.6) 59.0 (49.4–68.6) 36.0 (26.6–45.4) 19.0 (11.3–26.7) 6.0 (1.3–10.6)No 25.8 (23.6–28.0) 9.8 (8.3–11.3) 39.8 (37.4–42.2) 26.6 (24.–28.8) 20.4 (18.4–22.4) 6.9 (5.6–8.1)

ns ns p < 0.0005 ns ns ns

Diagnosis by systemMusculoskeletal 39.0 (33.5–44.4) 14.0 (10.1–17.9) 54.5 (48.9–60.1) 34.4 (29.1–39.7) 27.9 (22.9–32.9) 9.4 (6.1–12.7)Digestive 23.3 (18.4–28.1) 7.5 (4.5–10.5) 33.2 (27.8–38.6) 20.9 (16.2–25.6) 21.2 (16.2–25.6) 5.8 (3.1–8.5)Respiratory 15.1 (10.2–20.0) 3.4 (0.9–5.9) 28.8 (22.6–35.0) 19.5 (14.1–24.9) 13.2 (8.6–17.8) 2.4 (0.9–4.5)Cardiovascular 22.4 (16.5–28.2) 10.7 (6.4–15) 32.1 (25.6–38.6) 23.0 (17.1–28.9) 16.8 (15.6–22.0) 8.2 (4.4–12.0)Gynaecology 23.9 (17.6–30.2) 6.3 (2.7–9.9) 53.4 (46.0–60.8) 31.8 (24.9–38.7) 18.8 (13.0–24.6) 4.5 (1.5–7.5)Urology 19.0 (12.5–25.4) 7.0 (2.8–11.2) 34.5 (26.7–42.3) 22.5 (15.6–29.4) 15.5 (9.5–21.4) 4.2 (0.9–7.5)Other 27.5 (22.9–32.1) 12.9 (9.4–16.4) 22.7 (18.3–27.0) 32.3 (27.4–37.2) 21.9 (17.6–26.2) 9.3 (6.3–12.3)

p < 0.0005 p < 0.0005 p < 0.0005 p < 0.0005 ns ns

Total 25.7 (23.6–27.8) 9.6 (8.2–11.0) 41.0 (38.6–43.4) 27.2 (25.1–29.3) 20.4 (18.5–22.3) 6.8 (5.6–8.0)



Table 4Presence of pain intensity evaluation in medical charts

Patients’ characteristics Patients in hospitals% (95% CI)

Patients with painat the time of theinterview % (95% CI)

Patients with painduring stay% (95% CI)

Age18–40 years 35.3 (30.3–40.3) 38.5 (31.8–45.2) 39.8 (33.9–45.6)41–60 years 44.0 (39.4–48.6) 45.5 (38.8–52.2) 46.0 (40.1–51.9)61–70 years 47.5 (42.4–52.6) 51.7 (42.3–59.1) 50.2 (43.4–56.9)71–80 years 49.1 (44.0–54.2) 56.8 (49.2–64.4) 52.7 (45.8–59.6)>80 years 57.5 (49.1–65.1) 65.5 (53.3–77.7) 63.4 (53.0–73.8)

p < 0.0005 p < 0.0005 ns

GenderMale 47.1 (43.8–50.4) 53.6 (48.5–58.7) 51.1 (46.7–55.5)Female 43.2 (39.8–46.6) 44.6 (40.0–49.2) 44.9 (40.7–49.1)

ns ns ns

EducationPrimary (1–8 years) 42.0 (38.4–45.6) 44.4 (39.3–49.6) 43.7 (30.1–48.3)Middle and high (>8 years) 47.7 (38.8–45.2) 52.1 (47.5–56.7) 51.0 (47.0–55.0)

ns ns ns

WardMedicine and specialities 49.8 (46.1–53.6) 58.9 (53.1–64.7) 56.2 (51.2–61.2)General surgery and specialities 56.1 (51.7–60.4) 63.3 (57.2–69.4) 60.1 (55.5–66.5)Orthopaedics and rehabilitation 27.1 (22.0–32.2) 25.5 (19.2–31.8) 27.9 (22.0–33.8)Gynaecology and obstetrics 26.0 (19.6–32.4) 30.7 (22.2–39.2) 29.0 (21.2–36.8)

p < 0.0005 p < 0.0005 p < 0.0005

SurgeryYes 42.0 (37.9–46.1) 42.7 (37.1–47.9) 43.0 (38.2–47.8)No 46.8 (43.9–49.7) 53.1 (48.6–57.6) 51.0 (47.1–54.9)

ns ns ns

CancerYes 63.7 (57.7–69.7) 70.5 (62.4–78.6) 68.9 (61.4–76.4)No 42.0 (39.4–44.6) 44.9 (41.2–48.6) 44.4 (41.1–47.7)

p < 0.0005 p < 0.0005 p < 0.0005

TraumaYes 36.4 (28.8–44.0) 35.5 (26.4–44.6) 38.2 (29.9–46.5)No 46.1 (43.6–48.6) 50.7 (47.0–54.4) 49.3 (46.0–52.5)

ns ns ns

DeliveryYes 23.0 (14.7–31.2) 27.9 (17.2–38.6) 26.6 (16.9–36.3)No 46.6 (44.1–49.1) 50.6 (47.0–54.2) 49.6 (46.4–52.8)

p < 0.0005 p < 0.0005 p < 0.0005

Diagnosis by systemMusculoskeletal 31.5 (26.3–36.7) 32.7 (26.2–39.3) 33.2 (27.2–39.2)Digestive 64.7 (59.2–70.2) 75.2 (67.5–82.9) 68.6 (61.7–75.5)Respiratory 48.8 (42.0–55.6) 63.2 (51.4–74.8) 59.2 (49.5–68.9)Cardiovascular 55.6 (48.6–62.7) 69.6 (59.5–79.7) 62.6 (53.4–71.8)Gynaecology 33.0 (26.0–39.9) 38.3 (29.1–47.5) 36.4 (28.1–44.7)Urology 43.0 (34.9–51.1) 60.9 (48.9–72.9) 55.8 (44.7–66.9)Other 50.8 (35.1–45.3) 35.9 (24.2–47.6) 38.8 (32.3–45.3)

p < 0.0005 p < 0.0005 p < 0.0005

Total 45.5 (42.8–47.6) 48.7 (45.3–52.1) 47.9 (44.9–50.9)



(26%; 19.6–32.4%). Analgesic treatment was prescribedfor 70% of patients (95% CI: 67.8–72.2%) and the med-ian of different analgesics prescribed was 1 (range 0–4).When presence of pain at the time of the interviewwas compared with prescribed analgesic treatment, it

was observed that 21.4% (95% CI: 19.4–23.4%) ofpatients had neither pain nor were they prescribed anal-gesic treatment, 30.1% (95% CI: 27.9–32.3%) did nothave pain and had prescribed analgesic treatment,39.9% (95% CI: 37.5–42.2%) had pain as well as


prescribed analgesic treatment and 8.6% (95% CI: 7.3–9.9%) of the patients had pain but were not prescribedanalgesic treatment.

3.4. Pain and type of hospitals

A statistically significant heterogeneity in records ofpain intensity in medical or nursing records of patients(0–87%) among different hospitals was observed(Fig. 2). A great variability in the prevalence of painamong different hospitals was also observed (Fig. 3),from 31.1% (95% CI: 17.5–44.6%) to 67.8% (95% CI:60.2–75.3%), as well as in pain intensity (Fig. 4). Theprevalence of pain was higher in large hospitals(52.2%; 95% CI: 49.3–53.1%) than in medium and smallones (41.4%; CI 95%: 37.3–45.5%), as well as was theproportion of patients with pain intensity higher than30 mm (large hospitals: 28.4%; 95% CI: 25.7–31%; med-ium and small hospitals: 20.2%; 95% CI 16.9–23.5%).No differences between the teaching and non-teachinghospitals were observed.

3.5. Factors related to prevalence of pain

Table 5 shows factors associated with pain at the timeof the interview in the hospitals according to a logistic-regression model. The factors associated with a highprevalence of pain at the moment of the interview wereage (younger patients), gender (women), surgery (pres-ence), type of clinical ward (orthopaedic surgery andrehabilitation), type of hospital (large centres) and num-ber of prescribed analgesics (more analgesics). However,the presence of a cancer diagnosis and years of educa-tion were not associated.

4. Discussion

This study confirms the high prevalence of pain inhospitals and that the intensity of pain is often clinicallyrelevant. For instance, one out of every two patients sur-veyed in our sample of hospitals reported pain and twoout of every three patients scored their pain higher than30 mm, according to VAS. This is the first study that hasassessed pain prevalence from a large sample of the hos-pitals in our country, regardless of the diagnosis atadmission. Although there are some studies which haveevaluated the prevalence of pain in all patients admittedto hospitals of different countries, most of them havebeen carried out in a single centre (Abbot et al., 1992;Bourgeois et al., 2002; Canellas et al., 1993; Donovanet al., 1987; Durieux et al., 2001; Jeanfaivre et al.,2003; Johnston et al., 1992; Ranfray et al., 2003; Salo-mon et al., 2002; Whelan et al., 2004), and only a fewhave studied its prevalence in several centres of a well-defined region or country (Bruster et al., 1994; Constan-

tini et al., 2002; Visentin et al., 2005). In a previous studyin Catalonia, Canellas et al. found a prevalence of painat interview of 55% among all hospitalised patients, butonly one hospital was analysed (Canellas et al., 1993).Constantini et al. surveyed 4709 in-patients, from 30Italian hospitals, and found that 43% experienced painat the time of the interview and 60% in the previous24 h (Constantini et al., 2002). However, a more surpris-ing finding was the very high prevalence of pain found inanother study, because 91% of patients reported pain atinterview (Visentin et al., 2005). In a prospective cohortstudy of 5584 hospitalised patients, 59% had pain duringtheir hospital stay (Whelan et al., 2004). All of thesestudies have reported a remarkably high prevalence ofpain in most of the studied hospitals.

One of the factors contributing to the high prevalenceof pain could be the scarce use of pain intensity annota-tions in medical records. Only half of the patients withpain have registered their intensity in medical recordsin our study. This finding points out that pain in hospi-tal still tends to be underestimated, and therefore is notassessed, and generally is treated inadequately as hadalready been emphasised in earlier studies (Abbotet al., 1992; Donovan et al., 1987). Other factors associ-ated with pain in our study were age, gender, surgery,type of clinical wards, type of hospital and prescribedanalgesics. Significant age differences have been reportedin other studies (Constantini et al., 2002; Visentin et al.,2005; Whelan et al., 2004), but the literature is rathercontradictory on this point and the range of age withthe highest pain is quite variable. We found a higherprevalence of pain among young people, such as Con-stantini et al., described (Constantini et al., 2002), but,in contrast, other studies reported an increased preva-lence of pain in older patients (Visentin et al., 2005;Whelan et al., 2004). These opposing results might beexplained by differences of the painful conditions, thediagnosis and prognostic co-morbidity, and the medicalcare of patients. A higher prevalence and a greater inten-sity of pain in women, compared to men, was observed.Treatment of pain has been found to differ between menand women, although published evidence in the scien-tific literature on this association is contradictory aswell. Several epidemiological studies have reportedhigher prevalence of pain in women (Abbot et al.,1992; Constantini et al., 2002; Piguet et al., 1998; Whe-lan et al., 2004) that is coincident with experimental,electrically-induced pain in healthy young patients inwhich women typically report a lower pain thresholdthan men (Walker and Carmody, 1998). On the con-trary, other studies found a higher prevalence of painin males (Visentin et al., 2005) that could be due tothe fact that women were treated more frequently thanmen. The association between surgery and higher painprevalence is well known and has already been reportedrepeatedly (Abbot et al., 1992; Constantini et al., 2002;

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

%%pa

tien

tspa

tien

ts

Hospitalspain at the time of interview pain during stay in hospital

Fig. 3. Prevalence of pain at the time of the interview and pain duringtheir stay in the different hospitals.

Table 5Determinant factors associated with pain at interview in hospitals

Odds ratios (95% CI)

Age>70 years Reference strata40–70 years 1.34 (1.06–1.69)18–39 years 1.65 (1.21–2.2.6)

GenderMale Reference strataFemale 1.37 (1.11–1.70)

SurgeryNo Reference strataYes 1.73 (1.34–2.23)

WardInternal medicineand medical specialities

Reference strata

General surgery andsurgical specialities

1.06 (0.81–1.38)

Orthopaedics surgeryand rehabilitation

1.74 (1.21–2.44)


1.43 (0.94–2.18)

Hospital sizea

Medium and Small Reference strataLarge 1.48 (1.19–1.83)

Number of prescribedanalgesics

0 Reference strata1 2.27 (1.74–2.97)2 3.15 (2.35–4.21)

a Hospital size: large (>600 beds), medium (300–600 beds) and small(<300 beds).

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

VAS > 30 mm at the time of the interviewVAS > 30 mm worst pain at any time during stay

%pa

tien

ts

Hospitals

Fig. 4. Pain intensity of the patients at the time of the interview andpain during their stay in the different hospitals.

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

% p

atie

nts

Hospitals

Fig. 2. Written records of pain intensity assessment in the medicalcharts of patients in the different hospitals at the time of the interview.


Donovan et al., 1987) but, in contrast, we did not findan increased prevalence of pain in patients with cancer.We did not find differences in pain prevalence betweenpatients admitted to wards of internal medicine andother medical specialities and patients admitted to gen-eral surgery and other surgical specialities; however,patients admitted to orthopaedic and rehabilitation ser-vices had a higher prevalence of pain, probably because

traumatic or orthopaedic problems are some of the mostpainful conditions (Beaussier, 1998). Another interestingfinding in our study was the observation of the huge dif-ferences and heterogeneity in the prevalence of painamong the fifteen hospitals. This result stresses the lim-itations and difficulties in generalising from one centreto another. No studies have analysed the characteristicsof the hospitals which increase or reduce the prevalenceof pain. In our study, patients in large-sized hospitalshad more pain than patients in smaller hospitals. Thisfinding may reflect different types of populations admit-ted to each hospital, and the variability of clinical set-tings. We believe these data deserve further studies.

Despite growing research into the complex physiol-ogy of pain, the development of acute- and chronic-painservices, the availability of effective analgesic technolo-gies, such as patient-controlled analgesia, and theincreasing educational efforts and interest in pain man-agement, a concomitant improvement of analgesic effec-tiveness in clinical practice has not occurred. Forinstance, the results reported here are similar to thosepublished by Canellas et al. in 1993 in a study performedin one hospital of Catalonia (Canellas et al., 1993). Dif-ferent barriers to pain management had been identifiedsuch as a lack of knowledge, non-facilitative attitudes,


inconsistent leadership, poor working relationships, cul-tural and religious biases, physicians’ fears of legalrepercussions and a lack of resources (Brockopp et al.,1998; Clarke et al., 1996; Jiang et al., 2001). Gaps inknowledge, negative attitudes toward prescribing opioiddrugs, inadequate assessment skills, and timidity in pre-scribing are important barriers for pain management(Von Roenn et al., 1993). The problem begins withlow priority being given to pain treatment in medicalschools and residency training programmes (Von Roennet al., 1993). However, although it is still recognised thatpoor knowledge of pain control by all healthcare profes-sionals is one of the major barriers to improving painmanagement, contemporary studies show that other,more subtle, barriers can just as effectively inhibit atimely and effective response to patients’ reports of pain.These barriers are not just the ones created by poorknowledge, myth and misconception; the most powerfulbarriers to change may be the institutional ones that canbe entrenched within hospital policies and nursingbehaviour (Mann and Redwood, 2000), as nurses playa crucial role in the control of pain. Staff nurses’ percep-tions of barriers to pain management are due to a lackof educational preparation, inadequacy of clinical prac-tice skills, organisational aspects, and institutional con-straints such as workload and lack of staff (Brockoppet al., 1998; Clarke et al., 1996; Schafheutle et al.,2001). Patient-related barriers also influence and includecommunication, psychological, and attitudinal issues(Brockopp et al., 1998; Clarke et al., 1996; Mann andRedwood, 2000). Finally, health-care-system barriersthemselves can pose barriers to effective pain relief inthe form of practical constraints (Clarke et al., 1996;Mann and Redwood, 2000). Future studies shouldsearch for the most effective strategies for overcomingall of these obstacles.

Our study has several limitations that are worth not-ing as well. Although the study was multicentre, the par-ticipating hospitals were not all hospitals in the definedarea. Only a limited number of hospitals, with specificcharacteristics of the patients and the health profession-als concerning pain, accepted to participate. Nonethe-less, the most important teaching and public hospitalsof our area were included in the study. These hospitalswere those pertaining to the Catalonian National HealthService (Institut Catala de la Salut) as well as the mainprivate hospitals supported with public funds. Althoughour results cannot be generalised for other settings, theydo agree with those from other studies already discussedand support the evidence that many patients suffer painin hospitals and that this pain often goes unrecognised.Patients included in the study were not all patients admit-ted to hospital because only adult patients were includedin the study, without cognitive alterations and notseverely ill. Therefore, patients in paediatrics, intensivecare and emergency rooms were not represented in our

sample. Nevertheless, this is a minority of patientsadmitted to hospitals of the study, and our results arerepresentative of adult patients without cognitive altera-tions and not severely ill, which are the majority ofpatients admitted to participant hospitals. Other addi-tional limitations were that we did not have an aetiolog-ical diagnosis of pain nor did we analyse the chronologyof pain and the co-morbidity of patients. Further studiesanalysing the contributions of these factors might pro-vide added insights for predicting and managing pain.

In conclusion, this study reports that pain is a com-mon and clinically relevant experience often unrecogn-ised in patients admitted to hospital. Several factorsare related to pain prevalence like age, gender, clinicalwards, existence of previous surgery, presence of analge-sic treatments and type of hospital. The present studyhas established the situation of pain in the hospitals ofour area and has defined a health problem that shouldbe corrected by both organisational and educationalactions. At this moment, activities against pain in hospi-tal should be considered as a medical care priority byhealth authorities to confront and to settle the problemsdescribed herein.

Acknowledgements

This work was supported by a Grant (056/09/2000)from the Catalan Agency of Research and MedicalTechnologies. The authors thank the nurses and physi-cians of each ward of every hospital where the studywas carried out for their help and patience. This studywas only made possible by the participation of patientswho were suffering from painful ailments during theirhospital stay. We express our greatest gratitude to themfor their collaboration. This manuscript was read andcorrected by a native English-speaking Instructor ofEnglish of our University.

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Prevalence of pain in adults admitted to Catalonian hospitals: A cross-sectional study