Quality Indicators for Pain in Palliative Care

  • Kathleen A. LeeEmail author
  • Rachelle Bernacki
  • Joshua Lakin


Measuring the quality of pain management is essential for demonstrating the value of providers’ efforts to control this burdensome symptom. Measuring pain management is also critical for developing and evaluating quality improvement initiatives in palliative care. Groups have recently developed quality indicators for pain management and tested them for feasibility, reliability, and validity in both cancer and general palliative care populations in various care settings. These indicators address structure, process, and outcomes throughout the spectrum of care. Measurement of pain management is facilitated by the availability of well-validated pain assessment tools. However, indicator implementation is limited by assessment challenges in vulnerable populations, inconsistent documentation of pain management aspects in the medical record, inaccessible relevant data in current electronic medical records (EMRs) and data sets, and lack of evidence for correlation between quality indicators and patient outcomes. We need further research for establishing pain indicators in children and patients who cannot report pain, tailoring pain measurement to different populations and settings, and improving integration of quality measurement into clinical care. We also need more development on indicators of nonphysical aspects of pain and its management. Last, we need to assess how pain management quality interacts with other palliative care symptoms and domains, as well as opioid misuse, a related important issue. The collection of patient-reported outcome data within routine clinical workflow and national/regional quality improvement collaborations establishing quality benchmarks have the potential to address some issues and improve the measurement as well as quality of pain management.


  1. American Society for Clinical Oncology (ASCO). Quality Oncology Practice Initiative (QOPI) Measures. (2017). Accessed 30 June 2017.
  2. Basch, E. (2017). Patient-reported outcomes – Harnessing patients’ voices to improve clinical care. New England Journal of Medicine, 376(2), 105–108.CrossRefGoogle Scholar
  3. Blackhall, L. J., Alfson, E. D., & Barclay, J. S. (2013). Screening for substance abuse and diversion in Virginia hospices. Journal of Palliative Medicine, 16(3), 237–242.CrossRefGoogle Scholar
  4. Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality & Safety in Health Care, 11, 358–364.CrossRefGoogle Scholar
  5. Carmichael, A., Morgan, L., & Del Fabbro, E. (2016). Identifying and assessing the risk of opioid abuse inpatients with cancer: An integrative review. Substance Abuse and Rehabilitation, 7, 71–79.PubMedPubMedCentralGoogle Scholar
  6. Centers for Medicare & Medicaid Services. (2016, November 17). Current Measures, Hospice Quality Reporting Program. Accessed 30 June 2017.
  7. Claessen, S. J., Francke, A. L., Belarbi, H. E., Pasman, H. R., van der Putten, M. J., & Deliens, L. (2011). A new set of quality indicators for palliative care: Process and results of the development trajectory. Journal of Palliative Medicine, 42(2), 169–182.Google Scholar
  8. Cleeland, C. S., Gonin, R., Hatfield, A. K., Edmonson, J. H., Blum, R. H., Stewart, J. A., et al. (1994). Pain and its treatment in outpatients with metastatic cancer. The New England Journal of Medicine, 330, 592–596.CrossRefGoogle Scholar
  9. Connor, S. R., Teno, J., Spence, C., & Smith, N. (2005). Family evaluation of hospice care: Results from voluntary submission of data via website. Journal of Pain and Symptom Management, 30(1), 9–17.CrossRefGoogle Scholar
  10. De Roo, M. L., Leemans, K., Claeseen, S. J., Cohen, J., Pasman, H. R. W., Deliens, L., et al. (2013). Quality indicators for palliative care: Update of a systematic review. Journal of Pain and Symptom Management, 46(4), 556–572.CrossRefGoogle Scholar
  11. Donabedian, A. (1988). The quality of care. How can it be assessed? The Journal of the American Medical Association, 260(12), 1743–1748.CrossRefGoogle Scholar
  12. Dy, S. M., Lorenz, K. A., ONeill, S., Asch, S. M., Walling, A. M., Tisnado, D., et al. (2010). Cancer quality-ASSIST supportive oncology quality indicator set: Feasibility, reliability, and validity testing. Cancer, 116(13), 3267–3275.CrossRefGoogle Scholar
  13. Dy, S. M., Kiley, K. B., Ast, K., Lupu, D., Norton, S., McMillan, S. C., et al. (2015). Measuring what matters: Top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association. Journal of Pain and Symptom Management, 44(4), 773–781.CrossRefGoogle Scholar
  14. Dy, S. M., Herr, K., Bernacki, R. E., Kamal, A. H., Walling, A. M., Ersek, M., & Norton, S. A. (2016). Methodological research priorities in palliative care and hospice quality measurement. Journal of Pain and Symptom Management, 51(2), 155–162.CrossRefGoogle Scholar
  15. Eagar, K., Watter, P., Currow, D. C., Aoun, S. M., & Yates, P. (2010). The Australian Palliative Care Outcomes Collaboration (PCOC)-measuring the quality and outcomes of palliative care n a routine basis. Australian Health Review, 34, 186–192.CrossRefGoogle Scholar
  16. Epstein, R. M., & Street, R. L., Jr. (2007). Chapter 4: Key communication tasks and outcomes: The cancer care continuum. In R. M. Epstein & R. L. Street Jr. (Eds.), Patient-centered communication in cancer care: Promoting healing and reducing suffering (pp. 68–88). Bethesda: National Cancer Institute NIH Publication No. 07-6225.Google Scholar
  17. Etzioni, S., Chodosh, J., Ferrell, B. A., & MacLean, C. H. (2007). Quality indicators for pain management in vulnerable elders. Journal of the American Geriatrics Society, 55(Suppl 2), S403–S408.CrossRefGoogle Scholar
  18. Fain, K. M., Alexander, G. C., Dore, D. D., Segal, J. B., Zullo, A. R., & Castillo-Salgado, C. (2017). Frequency and predictors of analgesic prescribing in U.S. nursing home residents with persistent pain. Journal of American Geriatrics Society, 65, 286–293.CrossRefGoogle Scholar
  19. Ferrell, B., Connor, S. R., Dahlin, C. M., Fine, P. G., Hutton, N., Leenay, M., et al. (2007). The National Agenda for quality palliative care: The National Consensus Project and the National Quality Forum. Journal of Pain and Symptom Management, 33(6), 737–744.CrossRefGoogle Scholar
  20. Fine, P., & Grebauer, S. (2019). Recognition and resolution of ethical barriers to palliative care research. In R. J. Moore (Ed.), Handbook of pain and palliative care (2nd ed.). New York: Springer.Google Scholar
  21. Fine, P., Herr, K., Titler, M., Sanders, S., Cavanaugh, J., Swegle, J., et al. (2010). The cancer pain practice index: A measure of evidence-based practice adherence for cancer pain management in older adults in hospice care. Journal of Pain and Symptom Management, 39(5), 791–802.CrossRefGoogle Scholar
  22. Greco, M., Roberto, A., Corli, O., Deandrea, S., Bandieri, E., Cavuto, S., et al. (2014). Quality of cancer pain management: An update of a systematic review of undertreatment of patients with cancer. Journal of Clinical Oncology, 32(36), 2149–2154.CrossRefGoogle Scholar
  23. Grossman, S. A., Sheidler, V. R., Swedeen, K., Mucenski, J., & Piantadosi, S. (1991). Correlation of patient and caregiver ratings of cancer pain. Journal of Pain and Symptom Management, 6, 53–57.CrossRefGoogle Scholar
  24. Hanson, L. C., Scheunemann, L. P., Zimmerman, S., Rokoske, F. S., & Schenck, A. P. (2010). The PEACE project review of clinical instruments for hospice and palliative care. Journal of Palliative Medicine, 13(10), 1253–1260.CrossRefGoogle Scholar
  25. Hanson, L. C., Rowe, C., Wessell, K., Caprio, A., Winzelberg, G., Beyea, A., et al. (2012). Measuring palliative care quality for seriously ill hospitalized patients. Journal of Palliative Medicine, 15(7), 798–804.CrossRefGoogle Scholar
  26. Herr, K., Titler, M., Fine, P., Sanders, S., Cavanaugh, J., Swegle, J., Forcucci, C., & Tang, X. (2010). Assessing and treating pain in hospices: Current state of evidence-based practices. Journal of Pain and Symptom Management, 39(5), 803–819.CrossRefGoogle Scholar
  27. Hooke, C., Hellsten, M. B., Stutzer, C., & Forte, K. (2002). Pain management for the child with cancer in end-of-life care: APON position paper. Journal of Pediatric Oncology Nursing, 19, 43–47.CrossRefGoogle Scholar
  28. Jacobson, J. O., Neuss, M. N., McNiff, K. K., Kadlubek, P., Thacker, L. R., 2nd, Song, F., et al. (2008). Improvement in oncology practice performance through voluntary participation in the Quality Oncology Practice Initiative. Journal of Clinical Oncology, 26, 1893–1898.CrossRefGoogle Scholar
  29. Jung, K., LePendu, P., & Iyer, S. (2015). Functional evaluation of out-of-the-box text-mining tools for data-mining tasks. Journal of American Medical Informatics Association, 22, 121–133.Google Scholar
  30. Kamal, A. H., Gradison, M., Maguire, J. M., Taylor, D., & Abernethy, A. P. (2014). Quality measures for palliative care in patients with cancer: A systematic review. Journal of Oncology Practice, 10(4), 281–287.CrossRefGoogle Scholar
  31. Kamal, A. H., Hanson, L. C., Casarett, D. L., Dy, S. M., Pantilat, S. Z., Lupu, D., et al. (2015a). The quality imperative for palliative care. Journal of Pain and Symptom Management, 49(2), 243–253.CrossRefGoogle Scholar
  32. Kamal, A. H., Kavalieratos, D., Bull, J., Stinson, C. S., Nicolla, J., & Abernathy, A. (2015b). Usability and acceptability of the QDACT-PC, an electronic point-of-care system for standardized quality monitoring in palliative care. Journal of Pain and Symptom Management, 50(5), 615–621.CrossRefGoogle Scholar
  33. Kamal, A. H., Harrison, K. L., Bakitas, M., Dionne-Odom, J. N., Zubkoff, L., Akyar, I., et al. (2015c). Improving the quality of palliative care through national and regional collaboration efforts. Cancer Control, 22(4), 396–402.CrossRefGoogle Scholar
  34. Kamal, A. H., Bull, J., Kavalieratos, D., Nicolla, J. M., Roe, L., Adams, M., et al. (2016a). Development of the quality data collection tool for prospective quality assessment and reporting in palliative care. Journal of Palliative Care, 19(11), 1148–1155.Google Scholar
  35. Kamal, A. H., Bull, J., Ritchie, C. S., Kutner, J. S., Hanson, L. C., Friedman, F., et al. (2016b). Adherence to measuring what matters measures using point-of-care data collection across diverse clinical settings. Journal of Pain and Symptom Management, 51(3), 497–503.CrossRefGoogle Scholar
  36. Kelley, A. S., Covinsky, K. E., Gorges, R. J., McKendrick, K., Bollens-Lund, E., Morrison, R. S., et al. (2017). Identifying older adults with serious illness: A critical step toward improving the value of health care. Health Services Research, 52(1), 113–131.CrossRefGoogle Scholar
  37. Leemans, K., Deliens, L., Van den Block, L., Vander Stichele, R., Francke, A. L., & Cohen, J. (2017). Systematic quality monitoring for specialized palliative care services: Development of a minimal set of quality indicators for palliative care study (QPAC). American Journal of Hospice and Palliative Care, 34(6), 532–546.CrossRefGoogle Scholar
  38. Lindvall, C., Forsyth, A., Barzilay, R., & Tulsky, J. (2017). Natural language processing: An opportunity to make chart data come alive in palliative care research, AAHPM conference paper session abstract. Journal of Pain and Symptom Management, 53(2), 385.CrossRefGoogle Scholar
  39. Lorenz, K. A., Lynn, J., Dy, S., Wilkinson, A., Mularski, R. A., Shugarman, L., et al. (2006a). Quality measures for symptoms and advance care planning in cancer: A systematic review. Journal of Clinical Oncology, 24, 4933–4938.CrossRefGoogle Scholar
  40. Lorenz, K. A, Lynn, K., Dy, S., Hughes, R., Mularski, R. A., Shugarman, L. R., et al. (2006b). Cancer care quality measures: Symptoms and end-of-life care. Evidence Report/Technology Assessment No. 137 (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-02-003). AHRQ Publications No. 06-E0011. Rockville: Agency for Healthcare Research and Quality.Google Scholar
  41. Lorenz, K. A., Rosenfeld, K., & Wenger, N. (2007). Quality indicators for palliative and end-of-life care in vulnerable elders. Journal of the American Geriatrics Society, 55(Suppl 2), S318–S326.CrossRefGoogle Scholar
  42. Lorenz, K. A., Dy, S. M., Naeim, A., Walling, A. M., Sanati, H., Smith, P., et al. (2009). Quality measures for supportive cancer care: The cancer quality-ASSIST (assessing symptoms side effects and indicators of supportive treatment) project. Journal of Pain and Symptom Management, 37(6), 943–964.CrossRefGoogle Scholar
  43. Makris, U. E., Abrams, R. C., Gurland, B., et al. (2014). Management of persistent pain in the older patient: A clinical review. Journal of American Medical Association, 312(8), 825–836.CrossRefGoogle Scholar
  44. Measuring What Matters, American Association of Hospice and Palliative Medicine. (2015). Accessed 30 June 2017.
  45. Morrison, R. S., Magaziner, J., Gilbert, M., Koval, K. J., McLaughlin, M. A., Orosz, G., et al. (2003). Relationship between pain and opioid analgesics on the development of delirium following hip fracture. Journal of Gerontology Series A: Biological Sciences and Medical Sciences, 58, 76–81.CrossRefGoogle Scholar
  46. Moschinski, K., Kuske, S., Andrich, S., Stephan, A., Gnass, I., Sirsch, E., et al. (2017). Drug-based pain management for people with dementia after hip or pelic fractures: A systematic review. BMC Geriatrics, 17(1), 1–15.CrossRefGoogle Scholar
  47. Mularski, R. A., Curtis, J. R., Billings, J. A., Burt, R., Byock, I., Fuhrman, C., et al. (2006a). Proposed quality measures for palliative care in the critically ill: A consensus from the Robert Wood Johnson Foundation Critical Care Workgroup. Critical Care Medicine, 34(11), S404–S411.CrossRefGoogle Scholar
  48. Mularski, R. A., White-Chu, F., Overbay, D., Miller, L., Asch, S. M., & Ganzini, L. (2006b). Measuring pain as the 5th vital sign does not improve quality of pain management. Journal of General Internal Medicine, 21, 607–612.CrossRefGoogle Scholar
  49. Nakazawa, Y., Kato, M., Yoshida, S., Miyashita, M., Morita, T., & Kizawa, Y. (2016). Population-based quality indicators for palliative care programs for cancer patients in Japan: A Delphi study. Journal of Pain and Symptom Management, 51(4), 652–661.CrossRefGoogle Scholar
  50. National Consensus Project for Quality Palliative Care. (2004). Clinical practice guidelines for quality palliative care. Pittsburgh: National Consensus Project for Quality Palliative Care.Google Scholar
  51. National Consensus Project for Quality Palliative Care. (2013). Clinical practice guidelines for quality palliative care (3rd ed.). Pittsburgh: National Consensus Project for Quality Palliative Care.Google Scholar
  52. National Hospice and Palliative Care Organization. (2016). Performance measures. Accessed 30 June 2017.
  53. National Quality Forum. (2006). A national framework and preferred practices for palliative and hospice care quality. Washington, DC: National Quality Forum. Accessed 30 June 2017.
  54. National Quality Forum (2016a). A national framework and preferred practices for palliative and hospice care quality. Washington, DC: National Quality Forum. Accessed 30 June 2017.
  55. National Quality Forum. (2016b). Measure evaluation criteria. Washington, DC: National Quality Forum. Accessed 30 June 2017.
  56. National Technical Information Service. (2016). Limited death access MasterFile. Washington, DC: United States Department of Commerce. Accessed 30 June 2017.
  57. Nelson, J. E., Mulkerin, C. M., Adams, L. L., & Pronovost, P. J. (2006). Improving comfort and communication in the ICU: A practical new tool for palliative care performance measurement and feedback. Quality & Safety in Health Care, 15, 264–271.CrossRefGoogle Scholar
  58. Palliative Care Outcomes Collaboration. (2013). National benchmarks and targets. Version 3. Accessed 30 June 2017.
  59. Pantilat, S. Z., Marks, A. K., Bischoff, K. E., Bragg, A. R., & O’Riordan, D. L. (2017). The palliative care quality network: Improving the quality of caring. Journal of Palliative Medicine, 20(8), 862–868.CrossRefGoogle Scholar
  60. Pasman, H. R., Brandt, H. E., Deliens, L., & Francke, A. L. (2009). Quality indicators for palliative care: A systematic review. Journal of Pain and Symptom Management, 38(1), 145–156.CrossRefGoogle Scholar
  61. Payne, T. H., Corley, S., Cullen, T. A., Gandhi, T. K., Harrington, L., & Kuperman, G. J. (2015). Report of the AMIA HER-2020 Task Force on the status and future direction of EHRs. Journal of the American Medical Informatics Association, 22(5), 1102–1110.CrossRefGoogle Scholar
  62. Pinkerton, R., & Hardy, J. R. (2017). Opioid addiction and misuse in adults and adolescent patients with cancer. Internal Medicine Journal, 47(6), 632–636.CrossRefGoogle Scholar
  63. Quill, T., & Abernathy, A. (2013). Generalist plus specialist palliative care-creating a more sustainable model. The New England Journal of Medicine, 368(13), 1173–1175.CrossRefGoogle Scholar
  64. Rhodes, D. J., Koshy, R. C., Waterfield, W. C., Wu, A. W., & Grossman, S. A. (2001). Feasibility of quantitative pain assessment in outpatient oncology practice. Journal of Clinical Oncology, 19, 501–508.CrossRefGoogle Scholar
  65. Ryndes, T., Connor, S., Cody, C., Merriman, M., Bruno, S., Fine, P., et al. (2000). Report on the alpha and beta pilots of end result outcome measures constructed by the outcomes forum: A joint effort of the National Hospice and Palliative Care Organization and the National Hospice Work Group. Accessed 30 June 2017.
  66. Schenck, A. P., Rokoske, F. S., Durham, D. D., Cagle, J. G., & Hanson, L. C. (2014). Quality measures for hospice and palliative care: Piloting the PEACE measures. Journal of Palliative Medicine, 17(7), 769–775.CrossRefGoogle Scholar
  67. Schulman-Green, D., Cherlin, E. J., McCorkle, R., Carlson, M. D., Pace, K. B., Neigh, J., et al. (2010). Benefits and challenges in use of a standardized symptom assessment instrument in hospice. Journal of Palliative Medicine, 13, 155–159.CrossRefGoogle Scholar
  68. Seow, H., Snyder, C. F., Mularski, R. A., Shugarman, L. R., Kutner, J. S., Lorenz, K. A., et al. (2009a). A framework for assessing quality indicators for cancer care at the end of life. Journal of Pain and Symptom Management, 38(6), 903–912.CrossRefGoogle Scholar
  69. Seow, H., Snyder, C. F., Shugarman, L. R., Mularski, R. A., Kutner, J. S., Lorenz, K. A., et al. (2009b). Developing quality indicators for cancer end-of-life care: Proceedings from a national symposium. Cancer, 115(17), 3820–3382.CrossRefGoogle Scholar
  70. Snyder, C. F., Aaronson, N. K., Choucair, A. K., Elliott, T. E., Greenhalgh, J., Halyard, M. Y., et al. (2012). Implementing patient-reported outcomes assessment in clinical practice: A review of the options and considerations. Quality Life Research, 21(8), 1305–1314.CrossRefGoogle Scholar
  71. Swarm, R., Anghelescu, D. L., Benedetti, C., Blinderman, C. D., Boston, B., Cleeland, C., et al. (2007). National comprehensive cancer network (NCCN). Adult cancer pain. Journal of the National Comprehensive Cancer Network, 5(8), 726–751.PubMedGoogle Scholar
  72. Tan, P. D., Barclay, J. S., & Blackhall, L. J. (2015). Do palliative care clinics screen for substance abuse and diversion? Results from a national survey. Journal of Palliative of Medicine, 18(9), 752–757.CrossRefGoogle Scholar
  73. Twaddle, M. L., Maxwell, T. L., Cassell, B., Liao, S., Coyne, P., Usher, B. M., et al. (2007). Palliative care benchmarks from academic medical centers. Journal of Palliative Medicine, 10, 86–98.CrossRefGoogle Scholar
  74. Van Riet, P. J., Vernooji-Dassen, M., Droes, R. M., Radbruch, L., Vissers, K., & Engels, Y. (2014). Consensus on quality indicators to assess the organization of palliative cancer and dementia care applicable across national healthcare systems and selected by international experts. BMC Health Services Research, 14(396), 1–10.Google Scholar
  75. Walling, A. M., Asch, S. M., Lorenz, K. A., Roth, C. P., Barry, T., Kahn, K. L., et al. (2010). The quality of care provided to hospitalized patients at the end of life. Archives of Internal Medicine, 170(12), 1057–1063.CrossRefGoogle Scholar
  76. Walling, A. M., Asch, S. M., Lorenz, K. A., Malin, J., Roth, C. P., Barry, T., et al. (2012). The quality of supportive care among inpatients dying with advanced cancer. Support Care Cancer, 20, 2189–2194.CrossRefGoogle Scholar
  77. Walsh, A. F., & Broglio, K. (2016). Pain Management in the Individual with serious illness and comorbid substance use disorder. Nursing Clinics of North America, 51, 433–447.CrossRefGoogle Scholar
  78. Zubkoff, L., Lorenz, K. A., Lanto, A. B., Sherbourne, C. D., Goebel, J. R., Glassman, P. A., et al. (2010). Does screening for pain correspond to high quality care for veterans? Journal of General Internal Medicine, 25(9), 900–905.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Kathleen A. Lee
    • 1
    Email author
  • Rachelle Bernacki
    • 1
  • Joshua Lakin
    • 1
  1. 1.Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Division of Adult Palliative CareBostonUSA

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