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Questions and Answers about
the Facts on Dying research findings


National Findings Regarding Pain Management
in Nursing Homes

  1. Where is this data from?

    The 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.


  1. Who completes the MDS in nursing homes? How does that impact the results of this research?

    The 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.


  1. Why did you choose to examine persistent pain?

    Relying 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 improvement.


  1. Why are there two rates - 14.7% and 41.2%?

    We describe 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. 

    The 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.


  1. How did you compare states on the rate of pain management?

    The 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.

    We urge 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.


  1. What should be done in response to these data?

    First 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 steps.

    1.      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.

    2.      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 decade.

    3.      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. 


For further questions, please e-mail Dr. Joan M Teno.


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