The "comfortable dying" measure: how patient characteristics affect hospice pain management quality scores

All hospices were required by the Centers for Medicare and Medicaid Services (CMS) to collect the "Comfortable Dying" measure in 2012 (National Quality Forum measure #0209). However, it is not known how scores on this measure are affected by patient characteristics. It is important to identify these characteristics so that a hospice's case mix can be taken into account when interpreting its scores.

Our aim was to describe the implementation of the NQF #0209 measure in 10 hospices and to identify patient characteristics associated with scores.

We conducted an electronic health record (EHR)-based retrospective cohort study of patients in 10 hospices in the United States. The main outcome measure was the proportion of patients with pain that made them uncomfortable whose pain was controlled within 48 hours.

A total of 4157 patients were eligible for an initial pain assessment. Of those who reported pain (n=1992), 1152 (58%) reported having their pain controlled on the follow-up assessment. In a multivariable regression model, clustered by hospice, six variables were independently associated with pain control. These included age (adjusted odds ratio [OR] 1.02; 95% confidence interval [CI] 1.02-1.03, p=0.003), a cancer diagnosis (OR 1.37; 95% CI 1.20-1.53, p=0.008), initial care in an inpatient unit (OR 1.28; 95% CI 1.08-1.47, p=0.031), presence of a Foley catheter (OR 1.40; 95% CI 1.15-1.59, p=0.038), use of opioid medication (OR 1.34; 95% CI 1.03-1.74, p=0.027), and higher Palliative Performance Scale (PPS) score (OR 1.02; 95% CI 1.01-1.03, p<0.001). Presence of a Stage 2 pressure ulcer was independently associated with worse pain control (OR 0.63; 95% CI 0.31-0.96, p=0.012).

Several patient characteristics are associated with #0209 pain scores. As hospices are increasingly required to report quality measures, it will be essential to understand how their scores are affected by case mix.