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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



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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