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FOR
RESEARCHERS: PERSISTENT SEVERE PAIN IN NURSING HOMES
Data
Source:
Pursuant to
the 1987 Nursing Home Reform Act, since 1991, all Medicare or
Medicaid certified nursing facilities in the country have been
required to conduct regular comprehensive clinical assessments
of each resident. Assessments are performed on admission, upon
significant change, and at least annually, so that there are multiple
assessments of the same individual over time. Under new
regulations, all states have computerized RAI data since July,
1998. In the persistent pain analysis, we utilize the 1999
national repository Minimum Data Set (MDS) data that contains
over 350 discrete data elements - including socio-demographic
information, numerous clinical items (ranging from degree of functional
dependence to cognitive functioning), and a check list for staff
to indicate the presence of the most common geriatric diagnoses.1,2
The reliability
of MDS assessments has been tested repeatedly. Field tests
conducted in 1989 and 1990 revealed high levels of agreement on
the vast majority of MDS items. Moreover, the accuracy of
patient records increased significantly as the result of a 10
state study of 250 facilities while the MDS was being introduced.3
In general, data items measuring physical functioning and
cognitive status constructs are strongly related to research quality
instruments.4
However, not all the items are highly correlated with established
clinical measures. For example, some authors found that
certain behavior and mood items do not correlate well with research
scales.5
By and large, however, when used in accordance with the
training manual, the RAI measures common clinical geriatric phenomenon
similar to the way most established research quality scales do.6
Measures
This study
utilizes version 2.0 of the MDS. Specifically, this study analyses
Section J, titled Health Conditions, which examines the
frequency (none, pain less than daily, and pain daily) and severity
of pain (mild, moderate, or times when the pain is horrible or
excruciating). It is drawn from the "problems, conditions,
signs, and symptoms" section of the assessment instrument.
The MDS users manual defines the intent of this section: “To
record the frequency and intensity of signs and symptoms of pain.
For care planning purposes, this item should be used to identify
indicators of pain as well as to monitor the resident’s response
to pain management.” (1999, MDS manual). The Manual instructs
staff to ask simple direct questions about whether the patient
had experienced pain. Because some residents did not complain
verbally or were unable to speak, the assessors were supposed
to observe these persons for signs of pain, including moaning,
crying, wincing, frowning, or other facial expressions or posturing
such as guarding or protecting an area of the body. If there
is difficulty in determining pain, assessors were instructed to
code for more severe levels of pain. Independent, dual assessment
of pain items in a diverse sample of residents during testing
and revision of the MDS showed an average weighted Kappa (k)
exceeding 0.7.7
Because of
concerns with ascertainment bias, the reported quality indicator
examines pain management among a cohort of persons known to be
in pain at one assessment. The numerator is the number of persons
whose pain has increased to or remains at a level of moderate
daily pain or any episode of excruciating pain. Included
in the denominator are all those nursing home residents who were
noted to be in pain on their first assessment and also had a second
assessment at least 60 but not over 180 days later. For simplicity,
this quality indicator is referred to as persistent severe pain.
In this study,
the national estimates of pain are based on those MDS assessments
done within 60 days of April 1, 1999. This analysis was
stratified for whether the patient had a diagnosis of cancer and
whether the patient was noted to be cognitively intact.
We used an established MDS-based measure of cognitive functioning
to classify residents by degree of cognitive impairment in order
to allow for more equal comparisons of the level of pain.
The Cognitive Performance Scale (CPS) is a 7-level measure of
cognition that is strongly related to standardized measures of
memory and cognition commonly used in research studies.4,6
We conducted
an analysis with the state as the unit of analysis. The rate of
persistent severe pain is adjusted for 1) the rate of patients
with pain on admission among nursing homes in each state and 2)
the rate at which persons are discharged from the nursing homes
in each state. An additional analysis was done to adjust
for the risk of developing pain based on a model including several
patient characteristics (cognitive functioning, ADL, age, gender,
diagnosis, and race). These additional adjustments did not yield
different results, and they are not reported. Adjusted results
are presented only for the US Map; inndividual state reports are
based on unadjusted findings.
Reference
List
1. Morris JN, Hawes C, Fries
BE, et al. Designing the national resident assessment instrument
for nursing homes. Gerontologist. 1990;30:293-307.
2. Morris JN, Hawes C, Murphy
K, et al. Resident Assessment Instrument Training Manual and
Resource Guide. Baltimore, Maryland: Health Care Finacing
Association; 1991.
3. Hawes C, Morris JN, Phillips
CD, Mor V, Fries BE, Nonemaker S. Reliability estimates for the
Minimum Data Set for nursing home resident assessment and care
screening (MDS). Gerontologist. 1995;35:172-8.
4. Morris JN, Fries BE, Mehr
DR, et al. MDS Cognitive Performance Scale. J Gerontol.
1994;49:M174-82.
5. Frederiksen K, Tariot
P, De Jonghe E. Minimum Data Set Plus (MDS+) scores compared with
scores from five rating scales. J Am Geriatr Soc. 1996;44:305-9.
6.
Snowden M, McCormick W, Russo J, et al. Validity and responsiveness
of the Minimum Data Set. J Am Geriatr Soc. 1999;47:1000-4.
7. Fries BE, Hawes C, Morris
JN, Phillips CD, Mor V, Park PS. Effect of the National Resident
Assessment Instrument on selected health conditions and problems
[see comments]. J Am Geriatr Soc. 1997;45:994-1001.
Data
Table:
To view the
data table in PDF format, click
here.
To download the data table in Excel format, click
here.
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