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Pain occurs frequently with disease and is prevalent in older people. Population-based studies suggest that 25% to 40% of community-dwelling elders have pain-related problems. Studies have reported as high as a twofold increase in painful conditions in persons older than 60 years of age relative to younger persons. The prevalence is even greater among residents of long-term care facilities, where as many as 71% to 83% of residents have at least one pain-associated problem. The consequences and costs of pain in elderly persons are substantial. The association of pain with depression, social isolation, sleep disturbance, gait impairment, and increased use of health services with their attendant costs is well documented. Chronic pain means different things to different patients and physicians. For the purposes of this review, chronic pain is defined as "persistent or episodic pain of a duration or intensity that adversely affects the function or well-being of the patient". Although pharmacologic treatment with traditional analgesics is the most common form of pain treatment in older patients, the use of complementary and alternative medications and nonpharmacologic interventions also must be considered, especially when results with the former are felt to be less than satisfactory or the burden of potential adverse effects outweighs the benefits. While patients desire relief of symptoms, complete relief for patients with chronic pain is often unobtainable, and treatment decisions require that patients and physicians continually weigh the risks against the benefits. This review describes quality indicators developed to measure the quality of care associated with chronic pain management in vulnerable elders. These indicators do not pertain to management of cancer pain or treatment of pain that is acute in nature. Although few experts disagree that painful conditions should be treated, less consensus exists on specific treatments for particular conditions. For this reason, indicators have been proposed for the general management of chronic pain in areas in which evidence is strong or a consensus among experts exists. For the following reasons, indicators for specific pharmacologic therapies for specific conditions were not proposed: 1) highly prevalent conditions, such as osteoarthritis, with good evidence for specific therapies are addressed elsewhere; 2) for most painful conditions, definitive evidence favoring one pain therapy over another is lacking; and 3) because the information physicians need to make optimal therapeutic decisions is complex, implementation of indicators to measure the quality of such decisions on the basis of medical records or patient perceptions is problematic. This review focuses on screening, general management, and follow-up of chronic painful conditions and identifies indicators that may be applied to the evaluation of quality of care for vulnerable elders with chronic pain. Methods: The methods for developing these quality indicators, including literature review and expert panel consideration, are detailed elsewhere. For pain management, the structured literature review identified 7297 titles, from which relevant abstracts and articles were identified. On the basis of the literature and the authors' expertise, 16 potential quality indicators were proposed. Results: Of the 16 potential quality indicators for management of chronic pain, 6 were judged to be valid by the expert panel process, and one new indicator was created by the panel; 2 were merged into indicators in other sections, and 8 were rejected We describe the literature summaries that support each of the indicators judged to be valid by the expert panel process.

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Originally published in: Annals of Internal Medicine, v.135, no. 8, pt. 2, October 16, 2001, pp. 731-735.

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