Hospice and pain management in nursing home residents with cancer

Background: The prevalence of untreated pain in nursing home residents with cancer is unacceptably high. Hospice may increase the likelihood of receiving pain management at the end of life. Objectives: To estimate whether receipt of hospice in nursing homes increases the receipt of pain management for nursing home residents with cancer at the end of life. Methods: We conducted a cross-sectional study on a national sample of Medicare decedents who had cancer and were nursing home residents during the last 90 days of life in 2011–2012. We used the last Minimum Data Set (MDS) 3.0 assessment before death and the Medicare Beneficiary Summary File to measure hospice use, pain, and pain management at the last MDS assessment. We matched residents with cancer and in pain who received hospice care to residents in pain not receiving hospice care on nursing home facility and time from last MDS assessment to death. The primary outcomes were receipt of pharmacologic pain management including scheduled and PRN analgesics and non-pharmacologic pain management. Conditional logistic models were used to estimate the association between hospice use and pain management. Results: In matched analyses, untreated pain was uncommon (2.9% in hospice users and 5.6 in non-hospice users), though there was an absolute difference of 15.4% in scheduled analgesics use between hospice and non-hospice users (71.5% vs. 56.1%, respectively). Hospice use was associated with receipt of scheduled analgesics (adjusted Odds Ratio(aOR): 1.85, 95% Confidence Interval(CI):1.73–1.97), PRN medication (aOR: 1.31, 95% CI:1.20–1.43), and non-pharmacologic pain management (aOR: 1.18, 95% CI:1.11–1.26). Conclusions: Untreated pain at the end of life among nursing home residents with cancer was unusual. Hospice use was associated with increased pain management in nursing home residents with documented pain. Further work to examine the type and effectiveness of pain management strategies used is warranted

Pain and Pharmacologic Pain Management in Long-Stay Nursing Home Residents

Prior studies estimate that \u3e40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set (MDS) 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after these important initiatives of: 1) prevalence and correlates of persistent pain; and 2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in United States NHs between 2011-2012 with 2 MDS assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios estimates (APR) and 95% confidence intervals (CI).The prevalence of persistent and intermittent pain was 19.5% and 19.2% respectively but varied substantially by age, gender, race/ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated or undertreated. Racial/ethnic minorities (non-Hispanic blacks vs. whites, APR=1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs. no/mild APR=1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in five NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed

The Effects of a Plyometric Training Program on Jump Performance in Collegiate Figure Skaters: A Pilot Study

International Journal of Exercise Science 9(2): 175-186, 2016. Plyometric training has been implemented to increase jump height in a variety of sports, but its effects have not been researched in figure skating. The purpose of this study was to determine the effects of a plyometric training program on on-ice and off-ice jump performance. Six collegiate figure skaters (19.8±1.2 years; 164.7±4.9 cm; 60.3±11.6 kg) completed a six-week sport-specific plyometric training program, consisting of low to moderate intensity plyometric exercises, while eight collegiate figure skaters (21.1±3.9 years; 162.6±6.0 cm; 60.4±6.1 kg) served as the control group. Significant increases were found for vertical jump height, standing long jump distance, (F = 31.0, p \u3c 0.001), and flight time (F = 11.6, p = 0.007). No significant differences were found for self-reported jump evaluation (p = 0.101). Six weeks of plyometric training improved both on-ice and off-ice jump performance in collegiate figure skaters, while short-term skating training alone resulted in decreases. These results indicate that figure skaters could participate in off-ice plyometric training

Association of a Communication Training Program With Use of Antipsychotics in Nursing Homes

Importance: Off-label antipsychotic prescribing in nursing homes (NHs) is common and is associated with increased risk of mortality in older adults. Prior large-scale, controlled trials in the NH setting failed to show meaningful reductions in antipsychotic use. Objective: To quantify the influence of a large-scale communication training program on NH antipsychotic use called OASIS. Design, Setting, and Participants: This investigation was a quasi-experimental longitudinal study of NHs in Massachusetts enrolled in the OASIS intervention. Participants were residents living in NHs between March 1, 2011, and August 31, 2013. The data were analyzed from December 2015, to March 2016, and from November through December 2016. Exposures: The OASIS educational program targets all NH staff (direct care and nondirect care) using a train-the-trainer model. The program goals were to reframe challenging behaviors of residents with cognitive impairment as the communication of unmet needs, to train staff to anticipate resident needs, and to integrate resident strengths into daily care plans. Main Outcomes and Measures: This study used an interrupted time series model of facility-level prevalence of antipsychotic medication use, other psychotropic medication use (antidepressants, anxiolytics, and hypnotics), and behavioral disturbances to evaluate the intervention\u27s effectiveness in participating facilities compared with control NHs in Massachusetts and New York. The 18-month preintervention (baseline) period was compared with a 3-month training period, a 6-month implementation period, and a 3-month maintenance period. Results: This study included 93 NHs enrolled in the OASIS intervention (27 of which had a high prevalence of antipsychotic use) compared with 831 nonintervention NHs. Among OASIS facilities, prevalences of atypical antipsychotic prescribing were 34.1% at baseline and 26.5% at the study end (absolute reduction of 7.6% and relative reduction of 22.3%) compared with a drop of 22.7% to 18.8% in the comparison facilities (absolute reduction of 3.9% and relative reduction of 17.2%). In the OASIS implementation phase, NHs experienced a reduction in antipsychotic use prevalence among OASIS facilities (-1.20%; 95% CI, -1.85% to -0.09% per quarter) greater than that among non-OASIS facilities (-0.23%; 95% CI, -0.47% to 0.01% per quarter), resulting in a net OASIS influence of -0.97% (95% CI, -1.85% to -0.09%; P = .03). A difference in trend was not sustained in the maintenance phase (difference of 0.93%; 95% CI, -0.66% to 2.54%; P = .48). No increases in other psychotropic medication use or behavioral disturbances were observed. Conclusions and Relevance: Antipsychotic use prevalence declined during OASIS implementation of the intervention, but the decreases did not continue in the maintenance phase. Other psychotropic medication use and behavioral disturbances did not increase. This study adds evidence for nonpharmacological programs to treat behavioral and psychological symptoms of dementia

Hospice Use and Pain Management in Elderly Nursing Home Residents With Cancer

CONTEXT: Pain management is suboptimal in nursing homes. OBJECTIVES: To estimate the extent to which receipt of hospice in nursing homes (NHs) increases the receipt of pain management for residents with cancer at the end of life. METHODS: Study participants included Medicare beneficiaries with cancer who were NH residents in the last 90 days of life in 2011-2012 (n = 78,160). Residents in pain on hospice were matched to like residents without hospice by facility, type of pain assessment (self-report/staff assessment), and weeks until death (9064 matched strata, 16,968 unique residents). Minimum Data Set 3.0 provided information on residents\u27 pain prevalence and receipt of pain management (scheduled analgesics, as needed [pro re nata {PRN}] medication, nonpharmacologic interventions). We developed conditional logistic models to estimate the association between hospice use and pain management, stratified by self-reported and staff-assessed pain. RESULTS: We found that pain prevalence was higher in residents using hospice versus those without hospice (e.g., residents who self-reported pain: hospice: 59.9%, 95% CIs = 59.3%-60.5%; nonhospice: 50.0%, 95% CI = 49.4%-50.6%). In matched analyses, untreated pain was uncommon (self-reported pain: 2.9% and 5.6% in hospice users and nonusers, respectively). Hospice use was associated with receipt of scheduled analgesics (self-reported: adjusted odds ratio = 1.85, 95% CI = 1.73-1.971) and PRN medication (self-reported: adjusted odds ratio = 1.31, 95% CI = 1.20-1.43). Pain prevalence and the association between hospice and pain management were similar in residents with staff-assessed pain. CONCLUSION: Untreated pain at the end of life among residents with cancer in NHs is unusual. Hospice is associated with increased pain management among those with documented pain

Long-acting opioid initiation in US nursing homes

PURPOSE: To estimate the proportion of residents newly initiating long-acting opioids in comparison to residents initiating short-acting opioids and examine variation in long-acting opioid initiation by region and resident characteristics. METHODS: This cross-sectional study included 182 735 long-stay nursing home residents in 13 881 US nursing homes who were Medicare beneficiaries during 2011 to 2013 and initiated a short-acting or long-acting opioid (excluding residents \u3c 50 years old, those with cancer, or receiving hospice care). Medicare Part D prescription claims were used to identify residents as newly initiating short-acting or long-acting opioids, defined as having a prescription claim for an opioid with no prior opioid prescriptions in the preceding 60 days. We estimated the overall proportion of initiators prescribed long-acting opioids. Regional variation was examined by mapping results by state and hospital referral regions. Logistic models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Two percent of opioid initiators were prescribed long-acting opioids. State variation in long-acting opioid initiation ranged from 0.6% to 7.5% (5th-95th percentiles: 0.6-6.4%). Resident characteristics associated with increased long-acting opioid initiation included severe physical limitations (vs none/mild limitations; aOR: 2.13, 95% CI: 1.92-2.37) and pain (staff-assessed vs no pain; aOR: 1.59 95% CI: 1.40-1.80), whereas being non-White was inversely associated (non-Hispanic black vs non-Hispanic white; aOR: 0.70, 95% CI: 0.62-0.79). CONCLUSION: United States nursing home residents predominantly initiate short-acting opioids in accordance with Center for Disease Control and Prevention guidelines. Documented variation by geographic and resident characteristics suggests that improvements are possible

Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Residents

BACKGROUND/OBJECTIVES: Overall and long-term opioid use among older adults have increased since 1999. Less is known about opioid use in older adults in nursing homes (NHs). DESIGN: Cross-sectional. SETTING: U.S. NHs (N = 13,522). PARTICIPANTS: Long-stay NH resident Medicare beneficiaries with a Minimum Data Set 3.0 (MDS) assessment between April 1, 2012, and June 30, 2012, and 120 days of follow-up (N = 315,949). MEASUREMENTS: We used Medicare Part D claims to measure length of opioid use in the 120 days from the index assessment (short-term: \u3c /=30 days, medium-term: \u3e 30-89 days, long-term: \u3e /=90 days), adjuvants (e.g., anticonvulsants), and other pain medications (e.g., corticosteroids). MDS assessments in the follow-up period were used to measure nonpharmacological pain management use. Modified Poisson models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for age, gender, race and ethnicity, cognitive and physical impairment, and long-term opioid use. RESULTS: Of all long-stay residents, 32.4% were prescribed any opioid, and 15.5% were prescribed opioids long-term. Opioid users (versus nonusers) were more commonly prescribed pain adjuvants (32.9% vs 14.9%), other pain medications (25.5% vs 11.0%), and nonpharmacological pain management (24.5% vs 9.3%). Long-term opioid use was higher in women (aPR = 1.21, 95% CI = 1.18-1.23) and lower in racial and ethnic minorities (non-Hispanic blacks vs whites: APR = 0.93, 95% CI = 0.90-0.94) and those with severe cognitive impairment (vs no or mild impairment, aPR = 0.82, 95% CI = 0.79-0.83). CONCLUSION: One in seven NH residents was prescribed opioids long-term. Recent guidelines on opioid prescribing for pain recommend reducing long-term opioid use, but this is challenging in NHs because residents may not benefit from nonpharmacological and nonopioid interventions. Studies to address concerns about opioid safety and effectiveness (e.g., on pain and functional status) in NHs are needed

Commonly Initiated Opioids and Risk of Fracture Hospitalizations in United States Nursing Homes

OBJECTIVES: The aim of this study was to estimate the comparative safety of initiating commonly used opioids among older, long-stay United States nursing home residents with fracture hospitalizations. METHODS: We conducted a new-user retrospective cohort study of nursing home residents initiating short-acting oxycodone, hydrocodone, or tramadol by merging the 2011-2013 Minimum Data Set 3.0 to Medicare hospitalization and pharmacy claims. Residents ( \u3e /= 65 years, no cancer or hospice use) contributed treatment episodes ( \u3e 120 days with no prior opioid claims) and were followed for 180 days until incident fracture hospitalization (hip, femur, humerus, pelvis, radius/ulna), death (competing risk), treatment changes (e.g., discontinuation), or administrative censoring. Competing risks models with inverse probability of treatment weighting were used to estimate subdistribution hazard ratios (HRSD) and 95% confidence intervals (CI). RESULTS: Overall, 110,862 residents contributed 134,432 treatment episodes: 14,373 oxycodone; 69,182 hydrocodone; and 50,877 tramadol initiators. The incidences of fracture hospitalizations per 100 person-years were 9.4 (95% CI 7.5-11.7) for oxycodone, 7.9 (95% CI 7.1-8.8) for hydrocodone, and 5.0 (95% CI 4.3-5.7) for tramadol initiators. In weighted models, oxycodone initiators had a similar rate of fractures to hydrocodone initiators (HRSD 1.08, 95% CI 0.79-1.48). Tramadol initiators had lower fracture rates than hydrocodone initiators (HRSD 0.67, 95% CI 0.56-0.80). CONCLUSIONS: The lower rate of fractures that we documented among tramadol initiators compared with hydrocodone initiators is consistent, albeit attenuated compared with prior studies among community-dwelling older adults. However, overall fracture rates were lower than in community settings, potentially due to the limited risk of falling in this population with limited mobility

Geographic Variation in the Initiation of Commonly Used Opioids and Dosage Strength in United States Nursing Homes

OBJECTIVES: To examine and quantify geographic variation in the initiation of commonly used opioids and prescribed dosage strength among older US nursing home residents. METHODS: We merged 2011 Minimum Data Set 3.0 to Medicare claims and facility characteristics data to conduct a cross-sectional study among long-stay nursing home residents who initiated short-acting opioids commonly used in nursing homes (oxycodone, hydrocodone, or tramadol). We examined geographic variation in specific opioids initiated and potentially inappropriate doses ( \u3e /=50 mg oral morphine equivalent/d) across hospital referral regions (HRR). Multilevel logistic models quantified the proportional change in between-HRR variation and associations between commonly initiated opioids and inappropriate doses after adjusting for resident characteristics, facility characteristics, and state. RESULTS: Oxycodone (9.4%) was initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varied dramatically between HRRs (range, 0%-74.5%). In total, resident/facility characteristics and state of residence, respectively explained 84.1%, 58.2%, 59.1%, and 46.6% of the between-HRR variation for initiating oxycodone, hydrocodone, tramadol, and inappropriate doses. In all cases, state explained the largest proportion of between-HRR variation. Relative to hydrocodone, residents initiating oxycodone were more likely (adjusted odds ratio, 5.00; 95% confidence interval, 4.57-5.47) and those initiating tramadol were less likely (adjusted odds ratio, 0.28; 95% confidence interval, 0.25-0.31) to be prescribed potentially inappropriately high doses. CONCLUSIONS: We documented extensive geographic variation in the opioid and dose initiated for nursing home residents, with state explaining the largest proportion of the observed variation. Further work is needed to understand potential drivers of opioid prescribing patterns at the state level