Related Studies
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A Standardized Quality Assessment System to Evaluate Pain Detection and Management in the Nursing Home.
Mary P. Cadogan, John F. Schnelle, N.R. Al-Samarrai, Noriko Yamamoto-Mitani, Georgina Cabrera, Dan Osterweil, Sandra F. Simmons, in the Journal of the American Medical Directors Association 2005;6(1):1-9.
Pain in nursing home residents is reported to be under-diagnosed and under-treated, yet few studies have used objective criteria to measure the quality of nursing home care related to pain. This study was designed to fill this gap by field testing standardized resident interview and medical record review protocols to assess and score quality indicators relevant to pain assessment, management and treatment. The researchers completed medical record reviews for 542 residents in 30 nursing homes and used the data to score 12 indicators related to pain assessment, management, and response to treatment. They also completed a seven-item pain interview with 478 residents who were rated by NH staff as cognitively aware.
The study found that the quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of the participating residents reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; however, more than 50% of the residents reporting symptoms of chronic pain on interview had nurse pain scores of zero for four consecutive weeks prior to interview.
According to the authors, the study results “illustrate how the evaluation of pain care quality based on medical record review alone will result in an incomplete picture,” one that underestimates pain prevalence. Use of a simple resident interview like the one tested here leads to more accurate conclusions about detection, assessment, and management of pain. The authors estimate that 80% of nursing home residents can reliably self-report pain presence.
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Using the Minimum Data Set to Select Nursing Home Residents for Interview about Pain.
Lily Chu, John F. Schnelle, Mary P. Cadogan, Sandra F. Simmons, in the Journal of the American Geriatrics Society 2004; 52(12):2057-2061.
This study, conducted in 33 nursing homes, found that a majority of residents, including the most cognitively impaired residents, can provide meaningful reports of the pain they are experiencing when asked four simple questions:
The study was designed to determine whether a cognitive performance measure derived from the MDS could accurately identify nursing home residents capable of reliably responding to the pain interview. Results showed that increases in residents’ MDS recall scores, which are calculated from four items on the MDS, were positively associated with increases in the residents’ ability to answer all interview questions. Yet even among the most cognitively impaired residents, those with recall scores of 0, 52% were able to complete the interviews, and to do so reliably.
The study found that of the 262 residents who reported chronic pain in interviews with research staff, only 100 (38.2%) had recent MDS documentation of pain. Moreover, as a resident’s cognitive impairment increased, nursing home staff were increasingly less likely to document pain presence on the MDS, a finding that suggests that the staff are using subjective criteria to evaluate pain among residents.
Given the study’s finding that a high percentage of residents can reliably report pain presence, the authors recommend that nursing home staff be instructed to “ask all residents directly about pain in a simple manner (e.g., “Do you have pain anywhere right now?”) before elaborating on details (e.g., location, intensity) or resorting to less direct behavioral methods.”
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A Minimum Data Set Prevalence of Pain Quality Indicator: Is it Accurate and Does it Reflect Differences in Care Processes?
Mary P. Cadogan, John F. Schnelle, Noriko Yamamoto-Mitani, Georgina Cabrera, and Sandra F. Simmons, in Journal of Gerontology: Medical Sciences 2004; 59A(3):281-285.
Federal regulations require nursing homes to complete resident assessments periodically using the Minimum Data Set (MDS) assessment protocol. Results are used to generate quality indicators (QI) in a number of clinical areas for each facility, which consumers can then use to compare nursing homes. But the use of QIs as a measure of quality of care is controversial due in part to concerns about the accuracy of staff-generated MDS data.
This study, conducted in 16 nursing homes, collected independent data that showed that the MDS quality indicator for “prevalence of pain” does indeed accurately discriminate between facilities. Interpretation of the pain indicator requires caution, however. Rather than reflecting poor quality, a high prevalence of pain according to the MDS was associated with better pain assessment and treatment care processes. This study reports results from eight nursing homes that scored in the upper 75th percentile on the prevalence of pain QI and eight nursing homes that scored in the lower 25th percentile for the same QI. Research staff collected data through interviews with 255 residents and medical record reviews.
In high prevalence homes, 47% of the participating residents had pain documented on their most recent MDS and the same percentage reported symptoms of chronic pain during interviews with research staff. By contrast, in low prevalence homes, 9% of the participating residents had pain documented on their most recent MDS, but 27% reported chronic pain symptoms in interviews.
On every measure of pain-related care quality independently evaluated in this study (see our pain care quality indicators), nursing homes with a high reported prevalence of pain on the MDS performed better than nursing homes with low MDS pain prevalence. One explanation, according to the authors, is that a higher prevalence of pain among residents sensitizes nursing home staff to the need for better overall care for pain.
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The Effects of a Controlled Exercise Trial on Pain in Nursing Home Residents.
Sandra F. Simmons, Bruce A. Ferrell, John F. Schnelle, 2002, in Clinical Journal of Pain. 18:380-385.
Does exercise alleviate pain among nursing home residents, as it has been shown to do in arthritis sufferers? Findings from this study suggest it does not; indeed, exercise may tend to increase pain in this frail population. This randomized controlled study evaluated the effects of an exercise and toileting intervention on pain among 51 incontinent residents in one nursing home. Four times a day, five times a week, for 32 weeks, research staff provided residents with incontinence care and then helped them either to walk or, if non-ambulatory, to wheel their chairs and to repeat sit-to-stands. Pain was measured at baseline and again at 32 weeks using resident interviews and physical performance assessments.
There were significant differences between intervention and control groups on all physical performance measures over time, with the intervention group remaining stable and the control group showing a significant decline in sit-to-stand, walking, and wheelchair propulsion endurance. While both groups expressed mild to moderate pain complaints at baseline, over time there were no significant changes in pain complaints attributable to the exercise intervention. There was, however, a trend for pain reports to increase in the intervention group.
These preliminary findings suggest that exercise alone may be ineffective for pain management among incontinent residents. Care providers should consider that exercise to improve physical function may increase pain complaints, thereby requiring pre-emptive analgesia, other pain control strategies, or modified exercise techniques. These findings also suggest that residents may be more likely to experience pain during physical movement as opposed to when they remain sedentary.
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- A Standardized Quality Assessment System to Evaluate Pain Detection and Management in the Nursing Home
- Using the Minimum Data Set to Select Nursing Home Residents for Interview about Pain
- A Minimum Data Set Prevalence of Pain Quality Indicator: Is it Accurate and Does it Reflect Differences in Care Processes?
- The Effects of a Controlled Exercise Trial on Pain in Nursing Home Residents
A Standardized Quality Assessment System to Evaluate Pain Detection and Management in the Nursing Home.
Mary P. Cadogan, John F. Schnelle, N.R. Al-Samarrai, Noriko Yamamoto-Mitani, Georgina Cabrera, Dan Osterweil, Sandra F. Simmons, in the Journal of the American Medical Directors Association 2005;6(1):1-9.
Pain in nursing home residents is reported to be under-diagnosed and under-treated, yet few studies have used objective criteria to measure the quality of nursing home care related to pain. This study was designed to fill this gap by field testing standardized resident interview and medical record review protocols to assess and score quality indicators relevant to pain assessment, management and treatment. The researchers completed medical record reviews for 542 residents in 30 nursing homes and used the data to score 12 indicators related to pain assessment, management, and response to treatment. They also completed a seven-item pain interview with 478 residents who were rated by NH staff as cognitively aware.
The study found that the quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of the participating residents reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; however, more than 50% of the residents reporting symptoms of chronic pain on interview had nurse pain scores of zero for four consecutive weeks prior to interview.
According to the authors, the study results “illustrate how the evaluation of pain care quality based on medical record review alone will result in an incomplete picture,” one that underestimates pain prevalence. Use of a simple resident interview like the one tested here leads to more accurate conclusions about detection, assessment, and management of pain. The authors estimate that 80% of nursing home residents can reliably self-report pain presence.
Back to Top
Using the Minimum Data Set to Select Nursing Home Residents for Interview about Pain.
Lily Chu, John F. Schnelle, Mary P. Cadogan, Sandra F. Simmons, in the Journal of the American Geriatrics Society 2004; 52(12):2057-2061.
This study, conducted in 33 nursing homes, found that a majority of residents, including the most cognitively impaired residents, can provide meaningful reports of the pain they are experiencing when asked four simple questions:
- Do you have pain anywhere right now?
- Does pain ever keep you from sleeping at night?
- Does your pain ever keep you from participating in activities/doing things you enjoy?
- Do you have pain every day?
The study was designed to determine whether a cognitive performance measure derived from the MDS could accurately identify nursing home residents capable of reliably responding to the pain interview. Results showed that increases in residents’ MDS recall scores, which are calculated from four items on the MDS, were positively associated with increases in the residents’ ability to answer all interview questions. Yet even among the most cognitively impaired residents, those with recall scores of 0, 52% were able to complete the interviews, and to do so reliably.
The study found that of the 262 residents who reported chronic pain in interviews with research staff, only 100 (38.2%) had recent MDS documentation of pain. Moreover, as a resident’s cognitive impairment increased, nursing home staff were increasingly less likely to document pain presence on the MDS, a finding that suggests that the staff are using subjective criteria to evaluate pain among residents.
Given the study’s finding that a high percentage of residents can reliably report pain presence, the authors recommend that nursing home staff be instructed to “ask all residents directly about pain in a simple manner (e.g., “Do you have pain anywhere right now?”) before elaborating on details (e.g., location, intensity) or resorting to less direct behavioral methods.”
Back to Top
A Minimum Data Set Prevalence of Pain Quality Indicator: Is it Accurate and Does it Reflect Differences in Care Processes?
Mary P. Cadogan, John F. Schnelle, Noriko Yamamoto-Mitani, Georgina Cabrera, and Sandra F. Simmons, in Journal of Gerontology: Medical Sciences 2004; 59A(3):281-285.
Federal regulations require nursing homes to complete resident assessments periodically using the Minimum Data Set (MDS) assessment protocol. Results are used to generate quality indicators (QI) in a number of clinical areas for each facility, which consumers can then use to compare nursing homes. But the use of QIs as a measure of quality of care is controversial due in part to concerns about the accuracy of staff-generated MDS data.
This study, conducted in 16 nursing homes, collected independent data that showed that the MDS quality indicator for “prevalence of pain” does indeed accurately discriminate between facilities. Interpretation of the pain indicator requires caution, however. Rather than reflecting poor quality, a high prevalence of pain according to the MDS was associated with better pain assessment and treatment care processes. This study reports results from eight nursing homes that scored in the upper 75th percentile on the prevalence of pain QI and eight nursing homes that scored in the lower 25th percentile for the same QI. Research staff collected data through interviews with 255 residents and medical record reviews.
In high prevalence homes, 47% of the participating residents had pain documented on their most recent MDS and the same percentage reported symptoms of chronic pain during interviews with research staff. By contrast, in low prevalence homes, 9% of the participating residents had pain documented on their most recent MDS, but 27% reported chronic pain symptoms in interviews.
On every measure of pain-related care quality independently evaluated in this study (see our pain care quality indicators), nursing homes with a high reported prevalence of pain on the MDS performed better than nursing homes with low MDS pain prevalence. One explanation, according to the authors, is that a higher prevalence of pain among residents sensitizes nursing home staff to the need for better overall care for pain.
Back to Top
The Effects of a Controlled Exercise Trial on Pain in Nursing Home Residents.
Sandra F. Simmons, Bruce A. Ferrell, John F. Schnelle, 2002, in Clinical Journal of Pain. 18:380-385.
Does exercise alleviate pain among nursing home residents, as it has been shown to do in arthritis sufferers? Findings from this study suggest it does not; indeed, exercise may tend to increase pain in this frail population. This randomized controlled study evaluated the effects of an exercise and toileting intervention on pain among 51 incontinent residents in one nursing home. Four times a day, five times a week, for 32 weeks, research staff provided residents with incontinence care and then helped them either to walk or, if non-ambulatory, to wheel their chairs and to repeat sit-to-stands. Pain was measured at baseline and again at 32 weeks using resident interviews and physical performance assessments.
There were significant differences between intervention and control groups on all physical performance measures over time, with the intervention group remaining stable and the control group showing a significant decline in sit-to-stand, walking, and wheelchair propulsion endurance. While both groups expressed mild to moderate pain complaints at baseline, over time there were no significant changes in pain complaints attributable to the exercise intervention. There was, however, a trend for pain reports to increase in the intervention group.
These preliminary findings suggest that exercise alone may be ineffective for pain management among incontinent residents. Care providers should consider that exercise to improve physical function may increase pain complaints, thereby requiring pre-emptive analgesia, other pain control strategies, or modified exercise techniques. These findings also suggest that residents may be more likely to experience pain during physical movement as opposed to when they remain sedentary.
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