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

METRICS

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 and 2 ). 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 adjunctive therapies.

 

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 nonterminal illness.³

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  

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 treatments.²⁰

Palliative Care  

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).  

 

Metrics Overload?

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.

 

CONCLUSION

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.  

REFERENCES

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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 10, 2014.
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.
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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.
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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, 2014.
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.
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