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

Authors

  • Joshua Chodosh MD, MSHS,

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • David H. Solomon MD,

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • Carol P. Roth RN, MPH,

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • John T. Chang MD, MPH,

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • Catherine H. MacLean MD, PhD,

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • Bruce A. Ferrell MD,

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • Paul G. Shekelle MD, PhD,

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • Neil S. Wenger MD, MPH

    1. From the *Greater Los Angeles VA Healthcare System, Los Angeles, California; Divisions of Geriatrics, General Internal Medicine, and §Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, California; andRAND Health, Santa Monica, California.
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  • Dr. Chodosh is a Veterans Affairs Career Development Awardee and received support on this project from the Claude Pepper Older Americans Independence Center. Dr. Shekelle is a Senior Research Associate of the Veterans Affairs Health Services Research and Development Service. This project was supported by a contract from Pfizer Inc to RAND.

  • This work was presented at the 2001 AGS National Meeting and received the Presidential Poster Award for Best in Health Services Research.

Address correspondence to Joshua Chodosh, MD, MSHS, UCLA Geriatrics, 10945 Le Conte Ave, Suite #2339, Los Angeles, CA 90095. E-mail: jchodosh@mednet.ucla.edu

Abstract

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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