Does receipt of hospice care in nursing homes improve the management of pain at the end of life?

OBJECTIVES: To compare analgesic management of daily pain for dying nursing home residents enrolled and not enrolled in Medicare hospice.
DESIGN: Retrospective, comparative cohort study.
SETTING: Over 800 nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota. PARTICIPANTS: A subset of residents with daily pain near the end of life taken from a matched cohort of hospice (2,644) and nonhospice (7,929) nursing home residents who had at least two resident assessments (Minimum Data Sets (MDSs)) completed, their last between 1992 and 1996, and who died before April 1997. The daily pain subset consisted of 709 hospice and 1,326 nonhospice residents. MEASUREMENTS: Detailed drug use data contained on the last MDS before death were used to examine analgesic management of daily pain. Guidelines from the American Medical Directors Association (AMDA) were used to identify analgesics not recommended for use in managing chronic pain in long-term care settings. The study outcome, regular treatment of daily pain, examined whether patients received any analgesic, other than those not recommended by AMDA, at least twice a day for each day of documented daily pain (i.e., 7 days before date of last MDS).
RESULTS: Fifteen percent of hospice residents and 23% of nonhospice residents in daily pain received no analgesics (odds ratio (OR) = 0.57, 95% confidence interval (CI) = 0.45-0.74). A lower proportion of hospice residents (21%) than of nonhospice residents (29%) received analgesics not recommended by AMDA (OR = 0.65, 95% CI =0.52-0.80). Overall, acetaminophen (not in combination with other drugs) was used most frequently for nonhospice residents (25% of 1,673 prescriptions), whereas morphine derivatives were used most frequently for hospice residents (30% of 1,058 prescriptions). Fifty-one percent of hospice residents and 33% of nonhospice residents received regular treatment for daily pain. Controlling for clinical confounders, hospice residents were twice as likely as nonhospice residents to receive regular treatment for daily pain (adjusted odds ratio = 2.08, 95% CI = 1.68-2.56).
CONCLUSION: Findings suggest that analgesic management of daily pain is better for nursing home residents enrolled in hospice than for those not enrolled in hospice.The prescribing practices portrayed by this study reveal that many dying nursing home residents in daily pain are receiving no analgesic treatment or are receiving analgesic treatment inconsistent with AMDA and other pain management guidelines. Improving the analgesic management of pain in nursing homes is essential if high-quality end-of-life care in nursing homes is to be achieved.