Oncology: Medical and Radiation – Plan of Care for Pain

Strengths:

• The developer cites evidence regarding the incident rate of over 1.9 million cancer cases in 2023 and the prevalence of pain among cancer patients during treatment. There is a logic model linking the process where providers document a plan of care for cancer patients undergoing chemotherapy or radiation, optimizing pain management therapies which leads to improved function by way of symptom control and pain management, thereby improving the quality of life of the cancer patient.
• The developer also cites a systematic review which found that 55% of patients undergoing anticancer treatment reported pain. The impact of severe pain on mental health, employment and financial outcomes, relationships and overall quality of life is highlighted by the developer.
• The developer cites evidence regarding reports of insufficient pain management adherence rate to pain documentation (84%) and reassessment (43%) within an hour of medication administration, discrepancies in prescribed pain treatments and reported pain intensity among cancer patients.
• The developer cites clinical practice guideline recommendations for effective oncologic management of a cancer patient. This guideline recommends:
  • Consistently reassessing pain to ensure effective treatment with minimal side effects.
  • Tailoring analgesic therapy to consider diagnosis, safety, and patient goals.
  • Maintaining regular follow-ups, monitoring medication use and adjusting pain plan as needed to meet specific goals.
  • Using pain intensity rating scale to comprehensively assess pain and also identify the cause of the pain.
  • Clearly communicating and agreeing upon a care plan to manage expectations and outcomes.
• The developer cites disparities in opioid access and dosage among different racial groups, noting that Black and Hispanic patients were less likely to receive opioids than White patients (Black, -4.3 percentage points, 95% CI; Hispanic, -3.6 percentage points, 95% CI) and received lower daily doses (Black, -10.5 MMED, 95% CI; Hispanic, -9.1 MMED, 95% CI).
• Additionally, the developer highlights the decline in performance rates from MIPS-Quality program data reflecting calendar years 2019-2021:
  Individual Clinician Performance - mean performance rate in 2019 was 0.86|0.79 in 2020|0.69 in 2019
  Practice Performance - mean performance rate in 2019 was 0.83|0.69 in 2020|0.70 in 2021

Limitations:

• Although no direct patient input on the meaningfulness of the measure, the developer cites a 2022 study reporting that the study's patient and caregiver panel placed emphasis on the importance of routine pain screening, management, and follow-up.

Rationale:

There is a business case supported by credible evidence depicting a link between health care processes to desired outcomes for cancer patients. Actions providers can take to reach the desired outcome are outlined. Additionally, a gap in care remains that warrants this measure.

Pain is a difficult qualifier in medicine - it's subjective. 

And clouded by the "5th vital sign" fiasco of recent decades. 

Cancer pain is recognized as real and these patients likely suffer from the flux away from opiates in the setting of the current recognized crisis.

Copy from staff notes I also found helpful:

• The developer cites evidence regarding the incident rate of over 1.9 million cancer cases in 2023 and the prevalence of pain among cancer patients during treatment. There is a logic model linking the process where providers document a plan of care for cancer patients undergoing chemotherapy or radiation, optimizing pain management therapies which leads to improved function by way of symptom control and pain management, thereby improving the quality of life of the cancer patient.
• Additionally, the developer highlights the decline in performance rates from MIPS-Quality program data reflecting calendar years 2019-2021:
  Individual Clinician Performance - mean performance rate in 2019 was 0.86|0.79 in 2020|0.69 in 2019
  Practice Performance - mean performance rate in 2019 was 0.83|0.69 in 2020|0.70 in 2021

While having a treatment plan in place for cancer-related pain is an admirable goal, the current definition within the measure is quite broad: "use of opioids, nonopioid analgesics, psychological support, patient and/or family education, referral to a pain clinic, or reassessment of pain at an appropriate time interval."

As such, it is not clear to me that having any plan in place to treat the patient's pain, even if it is medically the wrong plan, is any better than not having a plan.  

Some of the comments have mentioned the opiate epidemic suggesting that there might be a reduction in valid medications to cancer patients. The  NCCN Panel recommendations address history of opioid abuse, psychological issues, etc. In doing so, it does not ignore the clinical possibilities/ realities. This measure has no effect on the administration of the plan and it is not appropriate to criticize it for what it cannot do.
 

My bigger concern is that the measure only requires that a plan is in place at the time the data was collected. I understand that PQM lacks the ability to verify that a treatment plan is appropriate. To do so would be seen in a poor light by the participating providers. However I would like to see this measure find a way to verify that treatment plans are implemented. This could be accomplished by finding a way to indicate if a treatment plan was reviewed. While this might be difficult to tie patient by patient, It might be possible to tabulate and track the total number of pain plan reviews.

There has been an increase in reporting entities for the three years the program has results. This is encouraging. The scores fluctuated some so I am giving the most recent results the most focus.

In the 2021 report,  51 of the 138 entities had Pearson score below .64. The patient encounters for these lowest providers comprises 53,103 patients. The providers who had a rating of 0 represented 14,461 patients, So on the face of it, very many patients included in the measures results for 2021 appeared not to have a pain management plan. This is very disconcerting. Period.
 

Monitoring pain intensity is undoubtably valuable to patient care.  However, simply asking a patient about their pain intensity without requiring the clinician to develop plan to address elevated pain is inadequate. This is evidenced by data provided by the measure steward, as well Oncology Care Model data showing that although practices tend to perform high on measures associated with collecting a pain score, avoidable pain continues to be one of the most prevalent reasons for hospital ED visits.  Performance benchmarks indicate high performance for practices and individual clinicians asking about pain levels, but we know that pain is a persistent, unmanaged issue for a large percentage of patients with cancer.   Given the current state of our inadequate pain management and high performance on existing measures, perhaps a more relevant quality measure would be: 1) A combined quality measure to assess both pain intensity and plan of care for pain, or 2) A patient-reported outcome measure indicating pain improvement within a certain time period of follow up.

Given incidence of cancer, this is an important measure. 

As a patient/caregiver this quality measure is very important as it discusses encounters with cancer patients receiving chemotherapy or radiation who report having pain with a documented plan of care to address this pain. I realize this measure only addresses a plan of care being developed and monitored, not that the plan adequately addresses the pain the patient is having. 

From the developer:

“However, many oncology patients report insufficient pain control. (9) A retrospective chart review analysis found an 84 percent adherence to the documentation of pain intensity and 43 percent adherence to pain re-assessment within an hour of medication administration. (10) An observational study found that over half of its cancer patients had a negative pain management index score, indicating that the prescribed pain treatments were not commensurate with the pain intensity reported by the patient.”

The same information is used to support the importance of this measure as  Measure 384 (companion measure). Citations are provided to support the large incidence of cancer, the importance and impact of pain control, and the lack of congruence between reported pain level and treatment.  This measure, like 384, is incorporated in practice guidelines. Clearly, this measure has face validity.  However, there are no citations supporting a connection between having a plan of care and adequate pain control. Since this measure has been in use for a number of years and according to the measure developers, has been selected by a large number of practices for MIPS and other quality programs, it seems appropriate to provide literature and data that support the association between having a plan of care and the outcomes in the logic model. 

The authors outline the importance of standardizing documentation of the pain management plan for patients undergoing chemotherapy and/or radiation therapy who report pain. 

Measure developers address the importance of this measure for a sub-group of oncology patients who receive radiation therapy treatment and those who receive a chemotherapy administration procedure.  Since the endorsement of this measure in 2017, an increasing number of oncology patients receive other forms of treatments that are not addressed by the developers.  Cancer patients receiving other treatment modalities also experience pain and the developers could consider expanding this measure to include these other sub-groups of oncology patients as additional populations in the reported rate of this measure.

Instead of two process measures (0383 and 0384) combine into one measure; pain assessed and on the plan of care. It would be less burdensome for sites.

Agree with PQM staff comments

What is the data in support of the position that having a documented plan in place leads to better patient outcomes? 

The information provided adequately summarizes the reason this measure is important and identifies that gaps in the target population currently exist. Because the cohorts change considerably over the years 2019, 2020, and 2021, comparisons of means and distributions across years are not possible.

I also agree with a comment from another member that the definition of a plan is too broad. Currently a documented plan is defined as "A documented plan of care may include: use of opioids, nonopioid analgesics, psychological support, patient and/or family education, referral to a pain clinic, or reassessment of pain at an appropriate time interval." Is there any relevant medical evidence to narrow this definition further?

Literature review, including patient-identified areas of concern related to cancer treatments, are supportive of this measure importance.

Concur with this staff analysis: 

There is a business case supported by credible evidence depicting a link between health care processes to desired outcomes for cancer patients. Actions providers can take to reach the desired outcome are outlined. Additionally, a gap in care remains that warrants this measure. Would like to have seen something about patient input on meaningfulness of measure. The cited 2022 study affirms the intent of the measure but is not the same as patient feedback on the measure.