and Answers about
the Facts on Dying research findings
Findings Regarding Pain Management
in Nursing Homes
is this data from?
reported research uses the National Repository Data of the
Minimum Data Set (MDS). As of 1998, version 2.0 of the MDS
for all nursing home residents was collected electronically
by the Health Care Financing Agency. The MDS collects information
on the demographic characteristics, functioning, as well
as pain frequency and severity. The data in this report
uses 1999 repository data. We examined pain management among
those persons who were in or entered a nursing home around
April 1, 1999.
completes the MDS in nursing homes? How does that impact the
results of this research?
MDS is completed by nursing home staff. Previous research
has shown that health care providers tend to underestimate
the rate of pain. Because of this, we believe that these
results most likely represent an underestimation of the
true pain burden.
did you choose to examine persistent pain?
on two pain assessments ensures that the nursing home staff
had time to effectively treat the patient's pain. We believe
that persistent pain greater than daily moderate pain represents
inadequate pain management and is an important target for
are there two rates - 14.7% and 41.2%?
our findings based on the outcomes of those persons in pain
at their first assessment who also had a second pain assessment
60-180 days later. To understand the impact on the entire
nursing home population, we report the rate of persistent
severe pain among all patients in a nursing
home for two assessments. Our findings indicate that about
one in seven persons (14.7%) in a nursing home for two assessments
has persistent severe pain.
rate of 41.2% represents the proportion of persons in pain
at the second assessment among those who were noted
to be in pain on their first MDS assessment. This
was done to lessen the effect of ascertainment bias on these
results. That is, staff have already noted that pain is
a problem with these patients.
did you compare states on the rate of pain management?
map that contrasts pain management
was adjusted for 1) the rate at which nursing home residents
are discharged from nursing homes in that state and 2) the
rate at which nursing homes in that state admit patients
who have pain at the time of admission. An additional adjustment
that was completed for patient characteristics (age, gender,
function, and cognitive status) did not change the state
rates of persistent pain.
caution in state comparisons. A low rate of reported pain
by nursing home staff may reflect inadequate pain assessment.
However, a high rate of persistent pain indicates that pain
is being assessed but not palliated. The wake up call
from this data is that every state has an important opportunity
to improve pain management.
should be done in response to these data?
and foremost, these results indicate that there is an important
opportunity to improve and enhance the quality of medical
care for this frail and older population. We urge
patients, families, and policy makers to consider the following
Patients and family members must ask nursing
homes about their pain treatment policies Do they
regularly assess pain as a fifth vital sign?
What efforts has that nursing home taken to be aware of
and improve pain management? For more information, click
here to view Choices and Conversations,
a consumer guide to end-of-life care.
Persistent pain in nursing homes should be a quality
indicator that is publicly reported. Federal and state nursing
home surveyors should assess the quality of pain management
at the time of annual inspection of nursing homes. We call
on the Centers for Medicare
& Medicaid Services (formerly the Health Care Financing
Administration) and local peer review organizations to work
with nursing homes to improve pain management in the next
While we all should be concerned about the
appropriate use of opiates, failure to treat severe pain
is a medical concern that is as important as preventing
the abuse of opiates.
further questions, please e-mail Dr.
Joan M Teno.