Advertisement

Quality Indicators for Pain in Palliative Care

  • Sydney Dy
  • Hsien Seow
Chapter

Abstract

Measuring the quality of pain management is essential for comparing providers, targeting quality improvement efforts, and measuring the impact of quality improvement initiatives in palliative care. Recent development of quality indicators in cancer palliative care and in general palliative care populations has produced a variety of pain management indicators that have been evaluated for feasibility, reliability, and validity. Indicators are available for outpatient, inpatient, intensive care, and hospice settings, and address structure, process, and outcome, as well as the spectrum of care through screening, assessment, treatment, and follow-up. Quality measurement in pain is facilitated by the availability of well-validated pain assessment tools. However, implementation of these indicators is limited by the challenges of assessment in vulnerable populations; lack of consistent documentation of many aspects of pain management in the medical record; and the lack of evidence for correlation between quality indicators and patient outcomes. Further research is needed for pain indicators in children and those who cannot report pain, how to tailor pain quality measurement to different populations and settings, and on better integration of quality measurement and clinical care. More development is also needed on the nonphysical aspects of pain and its management, and interaction between the quality of pain management and other symptoms and domains of palliative care. The collection of patient-reported outcome data and the use of structured electronic medical record (EMR) documentation also have the potential for improving the measurement of the quality of pain management. Measuring the quality of pain management is essential for comparing providers, targeting quality improvement efforts, and measuring the impact of quality improvement initiatives in palliative care. Recent research has produced indicator sets focusing on pain management, in cancer palliative care, and in general palliative care populations that have been evaluated for feasibility, reliability, and validity. Indicator sets are available for outpatient, inpatient, intensive care, and hospice settings, and address the spectrum of care, through screening, assessment, treatment, and follow-up. Quality measurement in pain is facilitated by well-validated pain assessment tools but limited by the challenges of assessment in vulnerable populations, lack of consistent documentation of many aspects of pain management in the medical record, and the lack of evidence for correlation between quality indicators and patient outcomes. Collection of patient-reported outcome data and the use of structured EMR documentation have the potential for improving the future measurement of the quality of pain management.

Keywords

Palliative Care Pain Management Quality Indicator Edmonton Symptom Assessment System National Quality Forum 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. American Medical Association (AMA). (2010). Physician Consortium for Performance Improvement (PCPI). Consortium Measures, 2010. Retrieved, from http://www.ama-assn.org, December 31, 2010.
  2. Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality & Safety in Health Care, 11, 358–364.CrossRefGoogle Scholar
  3. Carolinas Center for Medical Excellence. (2008). Palliative Care Quality Measurement Project (PEACE). Retrieved, from http://www.thecarolinascenter.org/default.aspx?pageid=24, October 11, 2011.
  4. Cleeland, C. S., Gonin, R., Hatfield, A. K., Edmonson, J. H., Blum, R. H., Stewart, J. A., et al. (1994). Pain and its treatment in outpatients with metastatic cancer. The New England Journal of Medicine, 330, 592–596.PubMedCrossRefGoogle Scholar
  5. Connor, S. R., Teno, J., Spence, C., & Smith, N. (2005). Family evaluation of hospice care: results from voluntary submission of data via website. Journal of Pain and Symptom Management, 30(1), 9–17.PubMedCrossRefGoogle Scholar
  6. Donabedian, A. (1988). The quality of care. How can it be assessed? The Journal of the American Medical Association, 260(12), 1743–1748.CrossRefGoogle Scholar
  7. Dy, S. M., Lorenz, K. A., ONeill, S., Asch, S. M., Walling, A. M., Tisnado, D., et al. (2010). Cancer quality-ASSIST supportive oncology quality indicator set: Feasibility, reliability, and validity testing. Cancer, 116(13), 3267–3275.PubMedCrossRefGoogle Scholar
  8. Epstein, R. M., & Street, R. L., Jr. (2007). Chapter 4: Key communication tasks and outcomes: The cancer care continuum. In R. M. Epstein, R. L. Street Jr., R. M. Epstein, R. L. Street Jr., R. M. Epstein, & R. L. Street Jr. (Eds.), Patient-centered communication in cancer care: Promoting healing and reducing suffering (pp. 68–88). Bethesda: National Cancer Institute, NIH Publication No. 07-6225.Google Scholar
  9. Etzioni, S., Chodosh, J., Ferrell, B. A., & MacLean, C. H. (2007). Quality indicators for pain management in vulnerable elders. Journal of the American Geriatrics Society, 55(Suppl 2), S403–S408.PubMedCrossRefGoogle Scholar
  10. Ferrell, B. A., Ferrell, B. R., & Rivera, L. (1995). Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management, 10, 591–598.PubMedCrossRefGoogle Scholar
  11. Fine, P. (2011). Recognition and resolution of ethical barriers to palliative care research. In R. J. Moore (Ed.), Handbook of pain and palliative care. New York: Springer.Google Scholar
  12. Fine, P., Herr, K., Titler, M., Sanders, S., Cavanaugh, J., Swegle, J., Forcucci, C., Tang, X., Lane, K., & Reyes, J. (2010). The cancer pain practice index: A measure of evidence-based practice adherence for cancer pain management in older adults in hospice care. Journal of Pain and Symptom Management, 39(5), 791–802.PubMedCrossRefGoogle Scholar
  13. Grossman, S. A., Sheidler, V. R., Swedeen, K., Mucenski, J., & Piantadosi, S. (1991). Correlation of patient and caregiver ratings of cancer pain. Journal of Pain and Symptom Management, 6, 53–57.PubMedCrossRefGoogle Scholar
  14. Herr, K., Titler, M., Fine, P., Sanders, S., Cavanaugh, J., Swegle, J., Forcucci, C., & Tang, X. (2010). Assessing and treating pain in hospices: Current state of evidence-based practices. Journal of Pain and Symptom Management, 39(5), 803–819.PubMedCrossRefGoogle Scholar
  15. Hooke, C., Hellsten, M. B., Stutzer, C., & Forte, K. (2002). Pain management for the child with cancer in end-of-life care: APON position paper. Journal of Pediatric Oncology Nursing, 19, 43–47.PubMedCrossRefGoogle Scholar
  16. Jacobson, J. O., Neuss, M. N., McNiff, K. K., Kadlubek, P., Thacker, L. R. 2nd, Song, F., et al. (2008). Improvement in oncology practice performance through voluntary participation in the Quality Oncology Practice Initiative. Journal of Clinical Oncology, 26, 1893–1898.PubMedCrossRefGoogle Scholar
  17. Kovach, C. R. (2011). Assessing pain and unmet needs in patients with advanced dementia: The role of the serial trial intervention (STI). In R. J. Moore (Ed.), Handbook of pain and palliative care. New York: Springer.Google Scholar
  18. Lorenz, K. A., Dy, S. M., Naeim, A., Walling, A. M., Sanati, H., Smith, P., et al. (2009). Quality measures for supportive cancer care: The cancer quality-ASSIST (assessing symptoms side effects and indicators of supportive treatment) project. Journal of Pain and Symptom Management, 37(6), 943–964.PubMedCrossRefGoogle Scholar
  19. Lorenz, K. A., Lynn, J., Dy, S., Wilkinson, A., Mularski, R. A., Shugarman, L., et al. (2006). Quality measures for symptoms and advance care planning in cancer: A systematic review. Journal of Clinical Oncology, 24, 4933–4938.PubMedCrossRefGoogle Scholar
  20. Lorenz, K. A., Rosenfeld, K., & Wenger, N. (2007). Quality indicators for palliative and end-of-life care in vulnerable elders. Journal of the American Geriatrics Society, 55(Suppl 2), S318–S326.PubMedCrossRefGoogle Scholar
  21. Miyashita, M., Nakamura, A., Morita, T., & Bito, S. (2008). Identification of quality indicators of end-of-life cancer care from medical chart review using a modified Delphi method in Japan. The American Journal of Hospice & Palliative Care, 25, 33–38.CrossRefGoogle Scholar
  22. Morrison, R. S., Magaziner, J., Gilbert, M., Koval, K. J., McLaughlin, M. A., Orosz, G., et al. (2003). Relationship between pain and opioid analgesics on the development of delirium following hip fracture. Journal of Gerontology Series A: Biological Sciences and Medical Sciences, 58, 76–81.CrossRefGoogle Scholar
  23. Mularski, R. A., Curtis, J. R., Billings, J. A., Burt, R., Byock, I., Fuhrman, C. et al. (2006a). Proposed quality measures for palliative care in the critically ill: A consensus from the Robert Wood Johnson Foundation Critical Care Workgroup. Critical Care Medicine, 34(11), S404–S411.PubMedCrossRefGoogle Scholar
  24. Mularski, R. A., White-Chu, F., Overbay, D., Miller, L. Asch, S.M., Ganzini, L. (2006b). Measuring pain as the 5th vital sign does not improve quality of pain management. Journal of General Internal Medicine, 21, 607–612.PubMedCrossRefGoogle Scholar
  25. National Consensus Project for Quality Palliative Care. (2004). Clinical practice guidelines for quality palliative care. Pittsburgh: National Consensus Project for Quality Palliative Care.Google Scholar
  26. National Quality Forum. (2006). A national framework and preferred practices for palliative and hospice care quality. Washington: National Quality Forum.Google Scholar
  27. National Quality Forum. (2008). Measure evaluation criteria. Washington: National Quality Forum.Google Scholar
  28. Nelson, J. E., Mulkerin, C. M., Adams, L. L., Pronovost, P. J. (2006). Improving comfort and communication in the ICU: A practical new tool for palliative care performance measurement and feedback. Quality & Safety in Health Care, 15, 264–271.CrossRefGoogle Scholar
  29. Pasman, H. R., Brandt, H. E., Deliens, L., & Francke, A. L. (2009). Quality indicators for palliative care: A systematic review. Journal of Pain and Symptom Management, 38(1), 145–156.PubMedCrossRefGoogle Scholar
  30. Rhodes, D. J., Koshy, R. C., Waterfield, W. C., Wu, A. W., & Grossman, S. A. (2001). Feasibility of quantitative pain assessment in outpatient oncology practice. Journal of Clinical Oncology, 19, 501–508.PubMedGoogle Scholar
  31. Ryndes, T., Connor, S., Cody, C., et al. (2000). Report on the alpha and beta pilots of end result outcome measures constructed by the outcomes forum: A joint effort of the National Hospice and Palliative Care Organization and the National Hospice Work Group. Retrieved, from http://www.nhpco.org/, October 10, 2011.
  32. Schulman-Green, D., Cherlin, E. J., McCorkle, R., Carlson, M. D., Pace, K. B., Neigh, J. et al. (2010). Benefits and challenges in use of a standardized symptom assessment instrument in hospice. Journal of Palliative Medicine, 13, 155–159.PubMedCrossRefGoogle Scholar
  33. Seow, H., Snyder, C. F., Mularski, R. A., Shugarman, L. R., Kutner, J. S., Lorenz, K. A., Wu, A. W., & Dy, S. M. (2009a). A framework for assessing quality indicators for cancer care at the end of life. Journal of Pain and Symptom Management, 38(6), 903–912.PubMedCrossRefGoogle Scholar
  34. Seow, H., Snyder, C. F., Shugarman, L. R., Mularski, R. A., Kutner, J. S., Lorenz, K. A., Wu, A. W., & Dy, S. M. (2009b). Developing quality indicators for cancer end-of-life care: Proceedings from a national symposium. Cancer, 115, 3820–3829.PubMedCrossRefGoogle Scholar
  35. Swarm, R., Anghelescu, D. L., Benedetti, C., Blinderman, C. D., Boston, B., Cleeland, C., et al. (2007). National comprehensive cancer network (NCCN). Adult cancer pain. Journal of the National Comprehensive Cancer Network, 5(8), 726–751.PubMedGoogle Scholar
  36. Twaddle, M. L., Maxwell, T. L., Cassell, B., et al. (2007). Palliative care benchmarks from academic medical centers. Journal of Palliative Medicine, 10, 86–98.PubMedCrossRefGoogle Scholar
  37. Walling, A. M., Asch, S. M., Lorenz, K. A., Roth, C. P., Barry, T., Kahn, K. L., & Wenger, N. S. (2010). The quality of care provided to hospitalized patients at the end of life. Archives of Internal Medicine, 170(12), 1057–1063.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2013

Authors and Affiliations

  • Sydney Dy
    • 1
  • Hsien Seow
    • 2
  1. 1.Johns Hopkins UniversityBaltimoreNorway
  2. 2.Juravinski Cancer CenterMcMaster UniversityHamiltonNorway

Personalised recommendations