US Pharm. 2014;39(3):18-21.
Health encompasses physical, mental, emotional, and social well being and the ability to adapt to one’s environment.1,2
Pain in older adults can alter, at times significantly, this
multidimensional dynamic state of health by affecting each one of these
domains (TABLE 1
). While pain in elderly
patients can often be reliably detected and effectively treated, studies
have indicated that compared to the general population, patients with
multiple comorbidities, which are common in the elderly, are more likely
to experience poorly coordinated care, cost barriers, and inadequate
communication from care providers.3-5
While implementing a holistic approach to
care that includes pain management is difficult in most healthcare
systems owing to time constraints, one study found that some providers
are able to do so.6 However, patients noted differences in
the quality of care from provider to provider, in addition to
differences between care settings and hospital units.6
Providing consistent quality care in a care environment that is
stretched to capacity is challenging; it requires attention in order to
optimize the patient experience.6 It is critical that
appropriate pain-management metrics, services, and policies be developed
with a keen understanding of the elderly population so that health
systems struggling with budgets may optimize quality of care while at
the same time striving for fiscal efficiency.6
Much attention has been drawn to clinical
specialties regarding measurement of and reporting on the quality of
care delivered to patients, an area termed metrics.7 It has been noted that merely defining the right indicators of quality is not sufficient to close the feedback loop.7
Rather, how this information can be used effectively—by way of feeding
back data—to improve care is the question of paramount interest.7,8
Researchers in specialty areas have identified the potential metrics by
which the quality of service delivered can not only be reported, but
also evaluated.7 This article will focus on how metrics can be applied to pain management in seniors.
PAIN IN SENIORS
Pain may be underrecognized in
individuals with cognitive or sensory impairments; this may also be the
case in those with language or speech difficulties. Further, pain is
frequently undertreated in cognitively impaired patients.3 In
older adults, untreated or undertreated pain may result in various
consequences that have the potential to significantly affect
functionality, independence, and quality of life (TABLES 1
Many practicing healthcare providers do not receive adequate
pain-management training, and new and updated information regarding pain
management is not widely disseminated or understood.9 It has become clear that pain management should follow a process (TABLE 3
and is enhanced when quality features are included in the pain
management system, including the use of a multidisciplinary approach (TABLE 4
Pharmacists can continue to effectively contribute to the
geriatric-focused pain-management process by recognizing untreated or
undertreated pain in seniors; carrying out pain assessments on an
ongoing basis; contributing to age-appropriate treatment plans with
targeted, individualized pharmaceutical care plans; and monitoring
age-associated renal and hepatic considerations. Further, pharmacists
can educate healthcare providers regarding the nuances of analgesic and
Of note, there are no specific laboratory tests for pain;
pain is always subjective and best diagnosed based on patient
description and history. However, with regard to persistent pain, it may
be helpful in diagnosing the etiology to investigate history and/or
diagnostic proof of past trauma (e.g., CT) or present disease (e.g.,
autoantibodies).10-14 Vitamin D levels, thyroid-stimulating antibodies, and vitamiin B12 levels are laboratory tests that may be considered.10-14
Pain Management in Long-Term Care
While pain in and of itself is not a normal part of aging,
disorders that can cause persistent pain become more common with
advancing age.3 In the long-term care setting, pain is a
common occurrence with approximately 45% to 80% of nursing home patients
having some persistent pain; however, the pain is sometimes
underrecognized and undertreated. In nursing facilities, non-cancer pain
accounts for 97% of pain complaints; treatment of persistent noncancer
pain has been found to be inconsistent, especially among those with
Researchers studying persistent severe
pain found that in one study in the United States, 14.7% of 2.2 million
nursing home patients were in persistent pain; moreover, 41.2% who
reported some pain at a first assessment were in severe pain 60 to 180
days later.3 Among patients with advanced cancer, 40% to 50%
have moderate-to-severe pain, while 25% to 30% have very severe or
excruciating pain. The majority of patients indicated that pain that
impairs their functioning affects them most.3
Pharmacists are encouraged to contribute
to the development of pain-management metrics, services, and policies
that serve these vulnerable seniors in settings such as those that
deliver long-term, palliative, postsurgical, and hospice care. An
example of pain metrics used in a palliative care program can be found
below (see Palliative Care and RESOURCES
PAIN-MANAGEMENT SYSTEM: MEASURES FOR ASSESSMENT
A systematic effort is needed to recognize and treat pain in the long-term care setting.3 Knowledgeable
healthcare providers of many disciplines who are educated regarding
appropriate pain care should be available to perform an adequate
evaluation, select pertinent interventions, and evaluate the patient’s
responses to pain-management efforts.3 Selection of important
measures for assessing process outcomes of a pain-management system may
be informed by consideration of several quality features of a
successful system of care (TABLE 4).
Cleeland et al indicate that
operationalizing these features and selecting specific measures or
indicators of process and outcome may be a reasonable approach to
establishing the effectiveness of a pain-management system of care.15 For medication-use outcome measures, see Reference 16.
METRICS IN ACTION
Medication reconciliation (MR), the
review and updating of medication lists when a patient meets with a
healthcare provider, is standard-of-care in most hospitals and is well
accepted as a good metric.17 MR occurs at various transitions
(i.e., admission, transfer, discharge), involves a spectrum of pharmacy
expertise, and may include all patients or focus on targeted high-risk
(i.e., for adverse drug events, rehospitalizations) individuals.
Further, MR is an expectation of The Joint Commission in the U.S. and of
Accreditation Canada.18 (See RESOURCES
for literature supporting its widespread adoption and discussing future challenges.)
End-of-Life Care Metrics
Reported aggressive care interventions at
the end of life (ACE) are considered metrics of suboptimal quality in
end-of-life care; these interventions are modifiable by
palliative-medicine consultation.19 One study evaluated the
association of inpatient palliative medicine consultation with ACE
scores and direct inpatient hospital costs of patients with gynecologic
malignancies.19 The specific metrics utilized to tabulate ACE
scores were ICU admission, hospital admission, emergency room visit,
death in an acute care setting, chemotherapy at the end of life, and
hospice admission <3 days. The researchers found that timely
palliative-medicine consultation (defined as exposure to inpatient
consultation ≥30 days before death) was associated with lower ACE scores
and direct hospital costs. While this study was conducted as a
retrospective review of medical records of patients who died from their
primary gynecologic malignancies, the researchers suggest prospective
evaluation is needed to validate the impact of palliative-medicine
consultation on quality of life and healthcare costs.19 Other
ACE metrics include ventilator use, pulmonary artery monitor use,
cardiac catheterization, and dialysis; surgical procedure codes in
Medicare’s MEDPAR file and the U.S. Department of Veteran's Afairs
patient treatment files (PTF) have been used to identify these
The application of metrics in palliative care practice is thoroughly discussed in a presentation given by Morrison and Weissman.21
Measuring quality through structure (e.g., presence of a palliative
care program, credentialing of palliative-medicine professionals);
process (e.g., appropriate referral for palliative care, concurrent
laxative treatment with opioid therapy [see Reference 22]); and outcome
(e.g., reduction in symptom distress, improved quality of life) are
outlined in the presentation. Metric domains, including operational,
clinical, customer, and financial, are also presented.
Are Biometric Approaches Practical?
Biometric approaches utilize hardware devices to quantify
physical function, capacities, or movement; they are frequently useful
in injury litigation cases or in federal or state disability decisions
(e.g., forSocial Security Disability or Workers’ Compensation)
addressing questions concerning functional capacities.16 According
to the Veterans Health Administration (VHA) National Pain Management
Strategy, while biometric approaches to physical capacity measurement
are appealing (owing to their comprehensive nature and precision), they
are not suitable for general use as pain outcomes measures since they:16
Require administration times of 3 to 4 hours or more
Incur hardware costs of approximately $12,000 to $100,000 plus additional fees for each completed assessment
Were designed to
assess work-related performance (i.e., functional capacities) rather
than physical capacities per se; tasks utilized for testing may not be
relevant to a VHA patient population (e.g., multiple disabilities, low
rates of employment, sedentary lifestyles).
According to McEvoy, metrics overload is bad medicine; while quality is a “worthy goal” and “metrics do matter” (TABLE 5),
the process should not be so distracting to healthcare providers that
they “must focus on lists and box-checking rather than patients.”17
McEvoy further emphasizes that it should not be overlooked that
“metrics are chosen because they are measureable, not because they are
proxies for excellence.”17 Of note, in developing quality
programs, managing the metrics should not be so burdensome that in
striving for quality and fiscal efficiency, excessive and unreasonable
manpower and costs are required.
Understanding the consequences of
untreated and undertreated pain in older adults, the quality features of
a successful and integrated pain-management system, and the link
between structure, process, and outcome indices can assist pharmacists
with the operational metrics required to assist programs in ensuring
quality, fiscal responsibility, sustainability, and growth.
1. World Health Organization. Nolte E, McKee M., eds. Caring for People With Chronic Conditions: a Health System Perspective. Berkshire, England: Open University Press, 2008.
2. Canguilhem G. The Normal and the Pathological. Brooklyn, NY: Zone Books, 1989.
3. Pain management in the long-term care
setting: percentage of patients with periodic documented assessment by nursing staff of effectiveness of pain management. U.S.
Department of Health and Human Services. Agency
for Healthcare Research and Quality. National Quality Measures
Clearinghouse. Completed May 17, 2005; reaffirmed November 21, 2012.
www.qualitymeasures.ahrq.gov/content.aspx?id=26742. Accessed February
4. Schoen C, Osborn R, How SK, et al. In
chronic condition: experiences of patients with complex health care
needs, in eight countries, 2008. Health Affairs. 2009; 28:w1-w16.
5. Burgers JS, Voerman GE, Grol R. Quality and
coordination of care for patients with multiple conditions: results from
an international survey of patient experience. Evaluation and the Health Professions. 2010;33:343-364.
6. Kuluski K, Hoang SN, Schaink AK, et al. The care delivery experience of hospitalized patients with complex chronic disease. Health Expect. 2013;16:e111-e123.
7. Benn J, Arnold G, Wei I, et al. Quality indicators in anaesthesia. Br J Anaesth. 2012;109:80-91.
8. Levitan D. Study suggests need for actionable pain metrics. Policy & Management. Pain Medicine News. 2007;05:05.
9. Baumann TJ, Strickland JM, Herndon CM. Pain management. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: McGraw-Hill Inc; 2011:1045-1059.
10. Twycross RG. Pain and analgesics. Curr Med Res Opin. 1978;5:497-505.
11. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pain. 5th ed. Glenview, IL: American Pain Society; 2003.
12. Turner NK, Hooten WM, Schmidt JE, et al. Prevalence of
clinical correlates of vitamin D inadequacy among patients with chronic
pain. Pain Med. 2008;9:979-984.
13. Hagen K, Bjoro T, Zwart J, et al. Do
high TSH levels protect against chronic musculoskeletal complaints? The
Nord-Trondelag Health Study (HUNT). Pain. 2005;113:416-421.
14. Bernard MA, Nakonezny PA, Kashner TM. The effect of
vitamin B12 deficiency on older veterans and its relationship to health.
J Am Geriatr Society. 1998;46:1199-1206.
15. Cleeland CS, Reyes-Gibby CC, Schall M, et al. Rapid
improvement in pain management: the Veterans Health Administration and
the institute for healthcare improvement collaborative. Clin J Pain. 2003;19(5):298-305.
16. National VA Pain Outcomes Working Group. VHA Pain
Outcomes Tool Kit. National VA Pain Management Coordinating Committee.
Department of Veteran Affairs. Washington, DC. February 2003.
www1.va.gov/PAINMANAGEMENT/Clinical_Resources.asp Accessed February 19,
17. McEvoy V. Why “metrics” overload is bad medicine. Wall Street Journal. February 13, 2014: A11.
18. Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012.172:1057-1068.
19. Nevadunsky NS, Gordon S, Spoozak L,
et al. The role and timing of palliative medicine consultation for women
with gynecologic malignancies: association with end of life
interventions and direct hospital costs. Gynecol Oncol. 2014;132:3-7.
20. Richardson SS, Sullivan G, Hill A, et al. Use of
aggressive medical treatments near the end of life: differences between
patients with and without dementia. Health Serv Res. 2007; 42(1 pt 1):183-200.
21. Morrison RS, Weissman DE. Using metrics to grow your
palliative care program. New York, NY: Center to Advance Palliative
Care; 2009. Presented at AAHPM Annual Meeting; Boston, MA; March 2010.
www.capc.org/ Accessed February 19, 2014.
22. Zagaria ME. Preemptive treatment of constipation when opioids are initiated. US Pharm. 2012;37(1):21-24.
23. American Medical Directors Association. We Care: Tool Kit for Implementation of the Clinical Practice Guideline for Pain Management [binder]. Columbia MD: American Medical Directors Association (AMDA); 2004:various pages.
To comment on this article, contact email@example.com.