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Pain assessment by patient is the rule in clinical trials, but may not be in clinical practice. We examined studies comparing patient and professional assessment of pain in clinical practice using published studies (1990-2016; ≥20 patients), in English, comparing pain assessment within 24 hours by patient and healthcare professional. A difference of at least 10% of the maximum score was considered significant. We judged quality on sampling method, blinding, and study size.Eighty studies (20,496 patients) provided data from a range of settings and locations; most (51%) used unbiased sampling, and most (68%) were blind or probably blind. Nine studies with ≥500 patients involved 58% of patients; 60 with <200 patients involved 25%. Large studies were more likely to use comprehensive or random sampling, and blinding of patient and professional.Underestimation of pain by professional compared to patient was reported by 62/80 studies (78%), while there was no difference in 17 (21%), and overestimation in one (1%). Underestimation was reported in 75% of large studies (>500 patients), 91% of mid-sized studies (200-400), and 78% of small studies (<200). High quality studies (blind, comprehensive or random sampling, >200 patients) consistently reported underestimation (10/11; 91%). The extent of underestimation tended to increase with pain severity.Professionals consistently tend to underestimate pain as compared to assessment by the patient. This tendency is more pronounced with more severe pain, and the extent of underestimation can be large. It is likely that this contributes to under-treatment of pain.

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