The Quality of Medical Care Provided to Vulnerable Older Patients with Chronic Pain

Published in: Journal of the American Geriatrics Society, v. 52, no. 5, May 2004, p. 756-761

Posted on RAND.org on December 31, 2003

by Joshua Chodosh, David Solomon, Carol P. Roth, John T. Chang, Catherine MacLean, Bruce Ferrell, Paul G. Shekelle, Neil S. Wenger

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OBJECTIVES: To assess the quality of chronic pain care provided to vulnerable older persons. DESIGN: Observational study evaluating 11 process-of-care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999. SETTING: Two senior managed care plans. PARTICIPANTS: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed-care plans. Measurements: Percentage of quality indicators satisfied for patients with chronic pain. RESULTS: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2-year period. One hundred twenty-three patients (33%) had medical record documentation of a new episode of chronic pain during a 13-month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow-up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase-selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity. CONCLUSION: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow-up, and attention to potential toxicities of therapy.

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