Article

Variation in Pain Medication Use in End-of-Life Care

Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado 80045, USA.
Journal of palliative medicine (Impact Factor: 2.06). 05/2010; 13(5):501-4. DOI: 10.1089/jpm.2009.0406
Source: PubMed

ABSTRACT Pain is a common and distressing symptom at the end of life that medications can help relieve. We sought to explore variation in approaches to pharmaceutical management of pain among hospice-eligible patients and to determine if variation was explained by patient or site of care characteristics. Variation in medication use may suggest areas for best practices or quality improvement in medication use in end-of-life care.
We conducted a secondary analysis of randomized trial data, examining use of five medication classes: opiates, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant pain medications (tricyclics and antiseizure), stimulants, and antianxiety medications in 16 study sites nationwide. Descriptive statistics were generated for patient-level data and by site. Unadjusted and adjusted odds ratios were calculated to compare patient and location of care characteristics with each medication class use by site.
We found variation in medication use was not predicted by most patient characteristics or location of care (home versus facility). Use of all types of pain medications decreased with age (odds ratio [OR] 0.75 [0.63-0.90]). Medication use varied between sites: a range of 14%-83% of patients were on different types of opiates, 0%-40% on NSAIDS, 20%-69% on benzodiazepines, 0%-25% on adjuvant medications, and 0%-23% were on acetaminophen at any time during the data collection period.
Pain and adjuvant medication use differs widely by site of care. Further research is needed to determine the extent to which provider and patient choice contribute to prescribing variation, and to explore associations between patient symptoms, medication variation, and patient care quality.

Download full-text

Full-text

Available from: Sunny Linnebur, Feb 17, 2015
0 Followers
 · 
93 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The paper determines a cost function for a network of wideband code division multiple access (WCDMA) frequency division duplex (FDD) base transceiver stations (BTS) for the purpose of dimensioning a software defined radio (SDR) implementation. An SDR architecture is proposed and the cost function is expressed in terms of cell diameter and signal processing load. The cost function is developed in terms of a large number of system parameters. Based on certain assumptions, a cell diameter is determined which minimizes the cost function and therefore provides the minimal computational complexity SDR.
    Spread Spectrum Techniques and Applications, 2004 IEEE Eighth International Symposium on; 10/2004
  • [Show abstract] [Hide abstract]
    ABSTRACT: Opiates are commonly used for symptoms at the end of life (EOL). Little is known about the decision-making process physicians go through when deciding to prescribe opiates for their EOL patients. The study's objective was to explore physician factors affecting EOL opiate prescribing. Qualitative study of 38 physicians in the Denver area in the specialties of outpatient and inpatient medicine, geriatrics, oncology, and palliative care. Semi-structured qualitative interviews by trained interviewers asked physicians about their knowledge, attitudes, and experiences in prescribing opiates, reasons for prescribing opiates, barriers to prescribing opiates, changes in prescribing habits, and perceived patient factors that influence prescribing. Interviews were analyzed using ATLAS.ti qualitative analysis software and independently coded by two reviewers. We found a spectrum of beliefs ranging from the viewpoint that opiates are underused at EOL to overused. We found five key themes: practices in when and how to use opiates, barriers to prescribing, personal experiences drive prescribing, social meaning of opiates, and differences in the role of physician. Physicians interviewed described experiences, both personal and professional, that influenced their opiate-prescribing habits. All respondents expressed positive experiences with prescribing opiates in being able to ease patients' suffering at EOL and to improve their functionality and quality of life. Differences in prescribing habits, attitudes, and experiences of physicians influence opiate prescribing, which may lead to over- and underprescribing. Knowledge, barriers, and fears about EOL opiate prescribing need to be addressed to ensure EOL patients are receiving appropriate symptom relief.
    Journal of palliative medicine 03/2011; 14(5):567-72. DOI:10.1089/jpm.2010.0505 · 2.06 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Many cancer patients die in the hospital, in spite of their preference to end their lives at home. Internal Medicine wards are poorly equipped to care for dying patients. Staff members have no specific training in palliative care, and the organization of the ward lacks flexibility. The entire staff (physicians and nurses) of the Internal Medicine ward of our hospital took part in a specially designed training program, and a protocol for end-of-life care (EOL-care) was implemented to improve the comfort of patients with terminal cancer. The aim of this study was to analyze the impact of this protocol on clinical practice in the ward, in terms of the number of interventions and the degree of control of key symptoms. Materials and methods The EOL-care protocol, which was established in cooperation with the Sue Ryder Foundation, was a modified version of the Liverpool Care Pathway. The main objective was to ensure the comfort of the dying patient through judicious discontinuation of all non-essential medications and interventions, frequent and systematic assessment of the key symptoms, and greater emphasis on communication with the patient and his/her caregivers. We compared 82 unselected cases managed with conventional care, representing the 20% of the deaths that occurred in 2007-2008 in our ward (controls), and 27 consecutive cancer patients cared for with the EOL-care protocol between May 2009 and February 2010 (cases). Results Patients in the case group received fewer interventions than controls (catheterization rate: 0% vs 19.4%; invasive procedure rate: 0% vs 8.5%; parenteral nutrition: 0% vs 3.6%), but they obtained almost complete relief of symptoms (pain, dyspnea, respiratory tract obstruction by secretions, agitation, nausea/vomiting). The most prominent result was pain relief: systematic checks revealed persistent pain in only 2.9% of the EOL-care group versus 59.7% of the controls during the last 48 hours of life. Discussion This observational study provides evidence that the quality of EOL-care for cancer patients can be improved, even in non-specialized departments, through organizational rather than technological interventions.
    Italian Journal of Medicine 06/2012; DOI:10.1016/j.itjm.2011.08.004