The Cancer Pain Practice Index: A Measure of Evidence-Based Practice Adherence for Cancer Pain Management in Older Adults in Hospice Care

Article Outline

• Abstract
• Introduction
• Methods
  • Identification of Relevant Clinical Practice Guidelines
  • Identification of Specific Evidence-Based Practice Recommendations
  • Expert Review and Refinement of Evidence-Based Practice Recommendations
  • Development of an Evidence-Based Practice Indicator List
    • Initial Development
    • Review and Refining
    • Expert Review
  • Development and Validation of the Cancer Pain Practice Index
  • Cancer Pain Practice Index Tool Validation
    • Cancer Pain Practice Index Tool Details
    • Cancer Pain Practice Index Tool Completion and Scoring
    • Cancer Pain Practice Index Reliability
• Discussion
• Acknowledgments
• References
• Copyright

Abstract 

Various clinical practice guidelines addressing pain assessment and management have been available for several years that pertain, at least to some extent, to older patients with cancer. Nonetheless, systematic evaluations or methodologically sound studies of adherence to pain management practice guidelines within Medicare-certified hospice programs are lacking. As part of a larger translating-research-into-practice pain improvement study involving older patients with cancer in hospice programs, we recognized the need to create a valid and reliable tool that can facilitate critical evaluation of hospice medical records for nurse and physician adherence to pain management guidelines to create a consolidated score for comparative and quality improvement purposes. We report the process used to create this tool, named the Cancer Pain Practice Index, and a guide to its use.

Key Words: Cancer pain, older patients, hospice, quality improvement, medical records review scoring tool

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Introduction 

Use of hospice services under the Medicare Hospice Benefit has grown substantially over the last 10 years. The percentage of Medicare decedents receiving hospice care is now close to 40% annually. Within this population, pain and related symptom distress are highly prevalent. Timely and effective pain management is a national health concern that has been targeted as a top research priority¹ and remains a key end outcome measure of effective hospice care espoused by many authoritative sources, including the Centers for Medicare and Medicaid Services (CMS), the National Consensus Project, the National Hospice and Palliative Care Organization (NHPCO), and the National Quality Forum.² Systematic evaluations or methodologically sound studies of adherence to pain management practices within Medicare-certified hospice programs are lacking even though clinical practice guidelines (CPGs) addressing pain assessment and management have been available for several years that pertain—at least to some extent—to older patients with cancer.³, ⁴, ⁵

The absence of established pain practice evaluation methodologies limits our understanding of the extent to which pain guidelines are applied by hospice programs for older patients and patients with cancer. Simply stated, it is hard to improve care and outcomes if what is currently being done is indeterminable. Hospice programs and external regulatory bodies that have an interest in measuring and improving pain-related practices, processes of care, and outcomes, require a validated and readily applicable means to implement quality assessment and performance improvement (QAPI).

A review of the literature yielded limited information specific to evidence-based practice (EBP) adherence in the hospice setting. Mercier et al.⁶ describe tools that might be used to measure discrepancies between prescribing practices and EBP recommendations but do not report on levels of EBP adherence. A number of researchers reported using selected indicators from EBP guidelines as dependent measures of guideline adoption in nonhospice settings,⁷, ⁸, ⁹, ¹⁰ and in settings similar to home-based hospice programs where nurses provide much of the day-to-day care, investigators have evaluated the use of and the adherence to CPGs. For instance, Cunningham¹¹ evaluated advanced practice nursing, guideline use, and pain-related interventions in a home-care setting after hospital discharge after radical prostatectomy. Idell and Grant¹² set out to improve inpatient nursing reassessment of pain using a practice modification methodology based on the National Comprehensive Cancer Network (NCCN) Guidelines and one-on-one feedback of individual staff practices. In a study of opinion leaders regarding cardiac patients, Berner et al.⁷ used five indicators of EBP related to unstable angina. These studies examined individual provider practices and offer some helpful insights into EBP use, but they do not provide an evaluation of overall adoption of evidence-based guideline recommendations.

Two reports of overall adherence to evidence-based pain practice are noted. Du Pen et al.¹³ implemented a previously developed algorithm to determine adherence to evidence-based treatment of cancer pain in community outpatient oncology clinics, whereas Titler¹⁴ details an 18-item Summative Index for Quality of Care in Acute Pain Management for hospitalized older adults. These tools are unique to their respective care settings and populations, and hence, they have limited applicability for determining assessment and treatment of cancer pain in the hospice setting. Thus, it was important to develop a tool that could capture the overall use of evidence-based pain management practices for older adults with cancer in a hospice setting.

The primary goal in creating the Cancer Pain Practice Index (CPPI) was to develop a clinically relevant and applicable tool that measures a representative number of key practices and monitors outcome measures of best practice. The tool would have value as both a quality assessment and performance improvement tool for use by clinical staff in the hospice environment and to serve as a measure of adoption of evidence-based pain practices for the larger research study. The major challenge was to develop a tool that would be both comprehensive and sensitive enough to evaluate and score documentation of adherence to evidence-based pain management practices while being easy to use in a routine clinical setting.

Evaluation of adherence to CPGs related to pain assessment and treatment is confounded by the large number of practice recommendations found in comprehensive guidelines. Nolan and Berwick¹⁵ argue that a single indicator does not reflect the overall adoption of an EBP, but rather, a composite score of behaviors or individual indicators is needed. Titler et al.¹⁴ determined that a summative index of key factors designed to measure the amount of EBPs the patient received was able to reliably discriminate differences in pain management practices in a hospital setting. These observations led us to determine that a valid and reliable summative index tool would be required to evaluate adherence to pain management CPGs of EBPs in the hospice setting. This article describes the development of the CPPI and the process to establish content validity and interrater reliability of this practice assessment tool.

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Methods 

The CPPI is a tool that was developed to measure nurse and physician use of EBPs with older cancer patients receiving community-based hospice services. The need for such a tool became evident as a component of a larger study to determine the effectiveness of a translating-research-into-practice intervention within a randomized, controlled study (Cancer Pain in Elders: Improving Evidence-Based Practices in Hospices. National Cancer Institute, R01CA115363).

Establishment of the CPPI required a number of steps to produce a selection of key indicators that could be identified by chart reviewers that adequately reflect EBPs in the hospice setting. The process was carried out in four phases, with objectives and outcomes identified for each phase. During Phase 1, the researchers identified appropriate EBP guidelines. EBP guidelines define an approach to treatment with the goal of better patient outcomes and integrate the best available research with clinician expertise and client characteristics. Phase 2 moved from the broader EBP guidelines to selection of specific EBP recommendations. Because no EBP guideline existed specific to older adults with cancer receiving hospice service in a community setting, the researchers selected EBPs from a number of relevant EBP guidelines that matched the study population and setting. During Phase 3, the process moved from the EBP level to the identification of EBP indicators, activities that serve as a measurement of the level of the EBP implementation. The final phase then culled the number of identified EBP indicators down to those included on the CPPI.

As the researchers moved through the CPPI-development process, it was important to review and consider all possible options at each level, including EBP guideline, EBP recommendation, or EBP indicator. During each phase, the examination moved from the broader level, considering all possible choices, to a narrowing of items that were specific to older adults with cancer receiving hospice care in a community setting. To summarize, the final development of the CPPI was a multistep process over four discrete phases and a final tool creation and validation step: 1) identification of relevant CPGs; 2) identification of EBPs specific to the identified population and setting; 3) expert review and refinement of selected EBPs; 4) development of an EBP indicator list; and 5) development and validation of the CPPI tool (Table 1).

Table 1. Cancer Pain Practice Index Development: Five-Step Process

Development Phase	Objective	Outcome
Phase I: Guidelines
Step I	Identification of relevant clinical practice guidelines (CPGs)	3.CPGs selected: •American Pain Society (2005) •National Consensus Project (2004) •Acute Guideline, Herr et al. (2006)
Phase II: Evidence-Based Practices
Step II	Identification of specific EB practice recommendations from CPGs	•Selected study population (older adults with cancer) •Selected study setting (community-based hospice) •Initial list of 78 practice recommendations identified
Step III	Expert review and refinement of selected EB practices from CPGs	•0- to 5-point scale used by experts to rate practices (0=not important; 5=extremely important) •Items receiving score 3.5 or less dropped from initial list (6 items) •Similar items combined •More specific items placed as subpoints under general practices •Final list of 21 relevant EB practices
Phase III: Indicators
Step IV	Development of EBP indicator list	•List of 84 potential indicators of EBP drafted •Refined list reduced to include 48 indicators of EBP based on team input •Expert review; final revision made •Six indicator categories established: comprehensive assessment; focused assessment; analgesics; side effects; nonpharmacological therapies; and education
Phase IV: CPPI
Step V	Development and validation of CPPI tool	•Indicator list sent to 17 national pain and hospice experts; asked to identify key indicators •Final list of 11 key indicators identified by experts form CPPI •Interrater and intrarater reliability established

Identification of Relevant Clinical Practice Guidelines 

The study investigators began by searching for available guidelines related to cancer pain and pain in older adults. Two guidelines were identified specific to cancer pain, one developed by the American Pain Society (APS) and one developed by the NCCN. The APS guideline was selected for this project after a thorough review, as the NCCN guideline was deemed too detailed and not necessarily appropriate for the study target population. Limited guidelines were available specific to pain in older adults. Two guidelines were reviewed in this area—the American Geriatrics Society (AGS) Guideline on Persistent Pain in Older Persons and the Evidence-Based Practice Guideline: Acute Pain Management in Older Adults, developed by Herr et al.⁵ Researchers determined that the AGS guideline did not address cancer pain in older adults and the Acute Pain Management Guideline provided more specific age-related recommendations. The only guidelines specific to hospice and palliative care were developed by the National Consensus Project (a task force of the National Hospice and Palliative Care Coalition comprised of four national palliative care organizations) and the National Quality Forum. Neither of these were detailed enough to generate specific performance indicators.

From this search, three guidelines were chosen that collectively provide recommendations relevant to the population identified in the research project: older adults with cancer enrolled in community-based hospice programs. Those guidelines selected include the following:

Identification of Specific Evidence-Based Practice Recommendations 

The research team identified an initial list of 78 potential EBPs from the recommendations included in these guidelines by cross-referencing the three guidelines and selecting items that specifically pertained to the identified population of the research study. Although some of the EBPs on the initial list were included in all three guidelines, many of the items were found in one or two of the guidelines because of their varied focus. The list of 78 EBP recommendations abstracted from the three guidelines may be obtained from the authors.

Expert Review and Refinement of Evidence-Based Practice Recommendations 

Although all EBPs reflect optimal pain care, a smaller number of items was needed for a clinically usable tool. The initial list of 78 EBP recommendations were reviewed by five of the investigators and three additional experts (see Acknowledgments), all knowledgeable in the management of pain in older adults and/or hospice and palliative care, as demonstrated in their publications and by their national recognition as experts on these topics. The reviewers were asked to rate each item on a zero- to five-point scale, with 0 being not important and 5 being extremely important. It was predetermined that only items with a score greater than or equal to 3.5 after averaging ratings would be retained. Through this scoring method and consolidation, we identified 21 fundamental EBPs from which key indicators could be developed, defined as identifiable and discreet clinical actions or events that can and should be documented as part of routine hospice care.

Development of an Evidence-Based Practice Indicator List 

A three-step process was followed to move from the EBP recommendation level and create a manageable list of key indicators. The process included 1) initial development; 2) review and refining; and 3) expert review to determine face and content validity.

The study principal investigator worked with the project director and statistician to formulate a list of specific indicators for each of the 21 EBP recommendations identified during the expert review described earlier. A list of 84 potential indicators that could serve as a measurement of the level of the EBP implementation made up the initial draft of EBP indicators.

The initial draft of indicators was then honed by the research team to consolidate when possible and format to conform (semantically) to conventional documentation practices. The revised EBP indicator list consisted of 48 indicators.

The list of 48 indicators was then sent for review and comment to three experts from across the country in the fields of pain management and hospice care. Their input was used to further refine the list of indicators, which were divided into six categories—comprehensive assessment (admission assessment): 12 indicators; focused assessment (nursing reassessment): 10 indicators; analgesics: 14 indicators; side effects: three indicators; nonpharmacological therapies: two indicators; and education: seven indicators.

Although the list of 48 indicators was useful as a tool for collection of research data, it was determined to be too unwieldy and impractical to use as an audit tool in a “real-life” chart-audit setting. Based on medical record abstraction being completed for the larger study, the average time needed to abstract data from the first two weeks of a patient's hospice experience was two to three hours per medical record, which would not be feasible in a clinical setting. The researchers determined that a brief, yet valid, instrument was needed, which would cover essential content areas from which a summative score could be derived to assess overall provider adherence to EBP performance.

Development and Validation of the Cancer Pain Practice Index 

To create this proposed index, the list of 48 evidence-based indicators was reviewed by 17 experts in pain and hospice/palliative care from across the country, including members of the National Hospice Work Group. The experts were asked independently to consider each of the 48 EBP indicators and select a maximum of 10 key indicators. The key indicators would be those that they believed were the most important indicators of quality evidence-based pain management practice for older adults with cancer delivered in a home hospice setting. The experts were also encouraged to make suggestions about combining indicators, removing indicators from the list, or otherwise consolidating the list to a manageable number. The result was the inclusion of items on the CPPI that were rated as key indicators by at least one-third (i.e., six or more) of the expert panel. The final list of 11 key indicators that comprise the CPPI fall into six discrete categories: comprehensive assessment (admission assessment), three indicators; focused assessment (nursing reassessment), two indicators; analgesics, two indicators; side effects, two indicators; nonpharmacological therapies, one indicator; and education, one indicator (Table 2).

Table 2. CPPI Indicators by Category

Indicators
Comprehensive assessment (admission assessment)
1. Pain assessment completed using a valid culturally sensitivea pain scale (numeric scale, verbal descriptor scale, Faces scale) for patients able to report pain OR using a nonverbal pain scale and/or pain behaviors documented for patients with a cognitive impairment at hospice admission.
2. Patients with pain present at admission with primary components of a comprehensive pain assessment completed within 24 hours of admission (pain intensity, pain location, pain quality, pain duration/pattern, impact of pain on function).
3. Patients with pain present at admission with additional components of comprehensive pain assessment completed within 48 hours of admission. (Detailed pain history, including description of previous and current pain episodes and treatment effectiveness; physical examination, including musculoskeletal and neurological assessment; presence or absence of delirium; things that make pain better; things that make pain worse; and presence of anxiety and depression.)
Focused assessment (nursing reassessment)
4. For patients who can self-report: reports of moderate/severe pain (≥ 5) followed by pain intensity assessment within 24 24 hours.
5. Focused pain assessments that include a reviewb of the pain treatment plan.
Analgesics
6. Patients with admission report of pain as mild (1–4) with order for nonopioid or combination of opioid-nonopioid analgesic within 24 hours of admission OR patients with admission report of pain as moderate (5–6) or greater with order for opioid analgesic within 24 hours of admission OR patients unable to self-report with pain behaviors documented with an order for a nonopioid or opioid analgesic within 24 hours of admission.
7. For patients who can self-report: consecutive pain intensity reports of 5 or greater that are followed by increases of opioid dose or additional analgesic added within 24 hours.
Side effects
8. Patients with an opioid order that have an existing bowel regimen (includes both laxative and stool softener) in place or a new order for a bowel regimen initiated within 24 hours of an opioid order.
9. Patients with opioids ordered who are monitored each day a focused assessment is completed for the five most concerning analgesic-induced side effects (respiratory depression, sedation, nausea and vomiting, constipation, and delirium).
Nonpharmacological therapies
10. Patients with report of pain with any cognitive/behavioral nonpharmacological therapies documented in the following week (e.g., meditation, music, prayer, aromatherapy, imagery) OR patients with report of pain with any physical nonpharmacological therapies documented in the following week (e.g., massage, vibrations, medicated lotions, repositioning, use of hot, use of cold).
Education
11. Patients with documentation of a written pain management plan that includes ALL the following components: the causes of their pain; the types of and rationale for their analgesic meds; specific instructions on how to dose and titrate their analgesic medications; instructions on how to manage analgesic side effects; instructions for storage and safe keeping of medications; who to call if pain is not relieved or increases in intensity or if side effects occur; and when and how to use nonpharmacological approaches to pain management.

©Keela Herr, PhD, RN, AGSF, FAAN; College of Nursing, University of Iowa.

Cancer Pain Practice Index Tool Validation 

The CPPI is used to determine the percent of consensus-derived essential EBPs a patient receives from nurses and physicians based on data present in the hospice medical record. A CPPI score is calculated on an individual patient basis. Each of the 11 indicators on the CPPI may receive one of three scores: met (1), unmet (0), or nonapplicable (N/A). A score of 1 indicates that there was documentation of the EBP in the patient's medical record. A score of 0 indicates that the indicator was applicable, but there was no documented evidence of the EBP. An indicator should receive a score of N/A if it does not apply to the patient's particular situation. For example, if a patient reports a pain score of 3 on a 10-point numeric pain intensity rating scale, Indicators 4 and 7 on the CPPI, which deal with moderate (five to six out of 10) or severe (seven to 10 out of 10) pain, do not apply and should receive a score of N/A; hence, they are not included in the patient's total score.

Although an “all or none” approach was used for single-component practice indicators, as recommended by Nolan and Berwick,¹⁵ for indicators that include multiple subcomponents, such as those pertaining to assessment, an “all or none” threshold was considered an unrealistically high standard. For all indicators that include subcomponents (i.e., CPPI Items 2, 3, 8, and 11), we chose to use a threshold of 75% (of subcomponents documented) as the cutoff to receive a score of 1 for that item on the CPPI. For example, Indicator 2 lists the primary components of a comprehensive pain assessment that need to be completed within 24 hours of admission to hospice. As defined on the CPPI, the components of a comprehensive pain assessment include pain intensity, pain location, pain quality, pain duration/pattern, and the impact of pain on function. To receive 1 point on the CPPI for this indicator, a patient would need to have received at least four of the five assessment components (Table 3). Admittedly, the 75% threshold is arbitrarily established but reflects what the expert consultants considered to be a reasonable set point. Whether or not this threshold will be sensitive enough to correlate with the end outcome, measure of improved pain relief, remains to be tested.

Table 3. Directions for Completion and Scoring of CPPI

General directions

1. Review CPPI indicator to determine if it applies to the patient record under review.

2. Review Scoring Detail column of CPPI for each indictor for specific scoring-related information.

3. Review patient medical record to determine appropriate score for indicator.

4. Enter correct score in the Patient Score column of the CPPI tool as follows: 1.=indicator met; 0=indicator NOT met; N/A=not applicable to patient record under review (note: N/A is not an appropriate response for indicator number 1).

5. Complete for all 11 CPPI indicators.

Scoring directions

1. Determine the total applicable indicators for each patient by subtracting the number of indicators listed as N/A from 11 (the maximum number if all indicators were applicable).

2. Enter the total applicable indicators at the bottom of the tool where indicated.

3. Determine the total patient score by adding the numbers in the Patient Score column on the completed CPPI tool. (Maximum possible is 11.)

4. Enter the total patient score at the bottom of the tool where indicated.

5. Calculate the final CPPI score by dividing the total patient score by the total applicable score to determine a percentage.

6. Enter the CPPI score % at the bottom of the tool where indicated.

©Keela Herr, PhD, RN, AGSF, FAAN; College of Nursing, University of Iowa.

Based on the work of others studying overall adherence to best practices,¹⁵, ¹⁶ a composite measurement approach was selected for scoring the CPPI. The CPPI tool is completed and scored according to the steps indicated in Table 4. Final CPPI scores are reported as a percentage of eligible EBPs a patient received: the higher the percentage on the CPPI, the more recommended EBPs were received by the patient.

Table 4. CPPI Scoring Tool

Indicator	Indicator	Scoring Details (1=Indicator Met; 0=Indicator NOT Met; N/A=Not Applicable)	Patient Score
1	Pain assessment completed using a valid culturally sensitive∗ pain scale (numeric scale, verbal descriptor scale, faces scale) for patients able to report pain OR using a nonverbal pain scale and/or pain behaviors documented for patients with a cognitive impairment at hospice admission. NOTE: ∗Culturally sensitive=translated pain scale and/or interpreter services used.	Applies to ALL patients N/A is NOT a possible response for this indicator
2	Patients with pain present at admission with primary components of a comprehensive pain assessment completed within 24 hours of admission. NOTE: Place a check next to each component noted in the patient medical record. ___ Pain intensity ___ Pain location ___ Pain quality ___ Pain duration/pattern ___ Impact of pain on function	Applies to patients with report of pain at admission or a prior pain diagnosis but denies pain at admission To receive 1 point must have 4 of 5 components completed within 24 hours of admission
3	Patients with pain present at admission with additional components of comprehensive pain assessment completed within 48 hours of admission. NOTE: Place a check next to each component noted in the patient medical record. ___ Detailed pain history including description of previous & current pain episodes & treatment effectiveness. ___ Physical exam, including musculoskeletal & neurological assessment. ___ Presence or absence of delirium. ___ Things that make pain better. ___ Things that make pain worse. ___ Presence of anxiety and depression	Applies to patients with pain To receive 1 point must have 5 of 6 components completed within 48 hours of admission
4	For patients who can self-report: reports of moderate/severe pain (5 or greater) followed by pain intensity assessment within 24 hours.	Applies to patients with pain 5 or greater To receive 1 point all reports of moderate/severe pain must be followed by pain intensity assessment within 24 hours.
5	For patients who can self-report: consecutive pain intensity reports of 5 or greater that are followed by increases of opioid dose or additional analgesic added within 24 hours.	Applies to patients with pain 5 or greater To receive 1 point ALL consecutive pain intensity reports of 5 or greater must be followed by increases of opioid dose or additional analgesic added within 24 hours Credit is given if increase offered but patient refused.
6	Patients with admission report of pain as mild (1–4) with order for nonopioid or combination of opioid-nonopioid analgesic within 24 hours of admission OR patients with admission report of pain as moderate (5–6) or greater with order for opioid analgesic within 24 hours of admission OR patients unable to self-report with pain behaviors documented with an order for a nonopioid or opioid analgesic within 24 hours of admission.	Applies to patients with pain or pain diagnosis at admission
7	Patients with an opioid order who have an existing bowel regimen (includes both laxative and stool softener) in place or a new order for a bowel regimen initiated within 24 hours of an opioid order.	Applies to patients with opioid orders
8	Patients with opioids ordered who are monitored each day a focused assessment is completed for the five most concerning analgesic-induced side effects. ___ Respiratory depression ___ Sedation ___ Nausea and vomiting ___ Constipation ___ Delirium	Applies to patients with opioid orders To receive 1 point must have 4 of 5 components completed each day a focused assessment is completed.
9	Patients with report of pain with any cognitive/behavioral nonpharmacological therapies documented in the following week (e.g., meditation, music, prayer, aromatherapy, imagery) OR patients with report of pain with any physical nonpharmacological therapies documented in the following week (e.g., massage, vibrations, lotions: Ben Gay®, Icy Hot®; repositioning, use of hot, use of cold).	Applies to patients with pain ∗Credit is given if nonpharm treatment suggested but patient refused.
10	Focused pain assessments that include a review∗ of the Pain Treatment Plan. NOTE: ∗Review of Pain Treatment Plan is defined as the documentation regarding the current treatment approaches and maintaining or changing orders, and others, if the patient is following the plan and/or the degree of adherence to the pain treatment plan.	Applies to patients with report of pain or a pain diagnosis To receive 1 point ALL focused pain assessments must include a review of the pain treatment plan
11	Patients with documentation of a written pain management plan that includes ALL the following components: ___ The causes of their pain ___ The types of and rationale for their analgesic meds ___ Specific instructions on how to dose and titrate their analgesic medications ___ Instructions on how to manage analgesic side effects ___ Instructions for storage and safe keeping of medications ___ Whom to call if pain is not relieved or increases in intensity or if side effects occur ___ When & how to use nonpharmacological approaches to pain management	Applies to patients with pain To receive 1 point must have 6 of 7 components completed.
Total.CPPI score NOTE: The higher the CPPI score %, the more Evidence-Based Practices the patient received.		Total applicable indicators Total patient score CPPI score %

^©Keela Herr, PhD, RN, AGSF, FAAN, College of Nursing, University of Iowa.

Two independent raters were trained in the use of the CPPI in an initial one-hour training session, which included review of the CPPI tool, the process for using the CPPI, and criteria for judging evidence of each practice in the medical record. Each rater then completed independent scoring of three medical records to determine areas of discrepancy and/or disagreement in rating. Feedback from these initial reviews led to revision of the CPPI tool format, refinement and clarification of the directions for its use, and development of a “CPPI User Guide” (available from the corresponding author).

The CPPI was then piloted by two trained reviewers on a randomly selected group of 10 patients participating in an institutional review board-approved study. The two raters were experienced with the medical record abstraction process and common issues arising in the interpretation of the EBPs. They also were familiar with the medical record formats of the records selected, based on their prior work with the ongoing study. The patients selected for the CPPI pilot study met the following criteria: 65 years of age or older; newly admitted to hospice with a cancer diagnosis; receiving community-based services from one of 16 community-based hospices in the Midwest. De-identified medical records for each randomly selected patient were obtained from the community-based hospices participating in the ongoing study.

The average time needed to complete the CPPI tool was 25 minutes per record across reviewers, with times ranging from 10 to 45 minutes depending on the level of medical record documentation and number of days of charting available for review. Medical records for the larger study were gathered for the first two weeks of a patient's hospice experience. Because not all patients received hospice service for the total 14-day period, some medical records included less information for review, thus decreasing the time needed to complete the CPPI. Interrater reliability of the CPPI was established at 93%. Intrarater reliability was established by having one trained abstractor reabstract 10 records after a two-week period. Intrarater reliability of the CPPI tool was established at 95%.

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Discussion 

The CPPI has been developed as a tool to determine the use of EBPs in hospices caring for older persons with cancer pain, which could be used for quality improvement, auditing purposes, or research purposes. The process of tool development and the establishment of preliminary reliability and validity have been described.

A number of studies have shown that, if effectively implemented, EBPs can improve patient outcomes and reduce the use of resources.¹⁷, ¹⁸ Titler et al.¹⁸ demonstrated that a Translating Research Into Practice (TRIP) intervention, which assisted in implementing EBPs in pain management, had a measurable effect on nurses' practices in an acute care setting. The current TRIP Cancer Intervention Study⁵ builds on that work and attempts to move the TRIP intervention strategies into the hospice environment. The challenge of any study that examines improvements in use of EBPs is capturing adherence to the practice recommendations either as single indicators of practices or as a composite measure of overall adherence.

Dykes¹⁹ states that “to accurately capture the impact of clinical practice guidelines on practice patterns and patient outcomes, clinician adherence must be measured” (p. 67). Measuring adherence can be achieved in a variety of ways, including clinician self-report of adherence; observation of care provided; patient report of care provided; medical record abstraction; and review of administrative data. There are advantages and disadvantages to each method. Dykes reports that the most common data sources used to study provider adherence were cross-sectional review or retrospective chart review.

There is general agreement that health care documentation is an essential element for the provision of quality patient care and positive patient outcomes and is used in day-to-day practice to justify payment, demonstrate care measures, and comply with regulatory expectations. A variety of authoritative bodies describe the critical importance of nursing care documentation to verify adherence.², ²⁰, ²¹ The CPPI uses medical record data as the source of information on use of EBPs. Other methods are logistically challenging in this setting of care where practices are often administered in the home, self-report accuracy on practices provided has not been validated, and there is considerable variability in formats and types of documentation systems.

The CPPI tool creates a score that reflects the percent of overall adherence to EBPs identified specifically for older adults with cancer receiving hospice care in a community-based setting, regardless of the documentation system. Although the CPPI was developed as a summative index for the specific population described, the indicators reflect good pain care for any patient with cancer pain. The CPPI could be used as a routine QAPI instrument for internal use by hospices or as a process measures evaluation tool to be used by external bodies (e.g., professional groups, such as the NHPCO, the National Association for Home Care, the American Hospice Foundation, or regulatory and accreditation bodies, such as the CMS, the Joint Commission, and Community Home and Hospice Programs).

The use of the CPPI as a measure of EBP does require knowledge of an organization's medical records and location of information regarding EBP use. Considerable time was devoted to learn records and location of data and to assure reliable interpretation of practices.²² If the CPPI were used by a hospice, rather than as part of a research project, knowledge of the documentation system should be stronger and the time to use the CPPI might be shortened once the user was trained in application and interpretation of the tool.

Because of the process used to narrow the scope of the CPPI to the most important EBPs for cancer pain management in older persons, the tool does not reflect adherence to all recommendations in existing guidelines. Further research should examine the relationship between the short CPPI and a more comprehensive list of EBPs reflected in current guidelines. It remains to be determined if meeting CPPI indicators leads to optimal pain outcomes. Additional research is warranted to establish the reliability and validity of the CPPI when administered in the clinical environment by quality improvement staff rather than by trained research assistants and to determine if it discriminates between comparative groups.

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Acknowledgments 

The following reviewers are acknowledged for their contributions: Janet Bull, MD, Chief Medical Officer, Vice President of Clinical Services, Four Seasons, Hendersonville, NC; Malene Davis, President, CEO, Capital Hospice, Falls Church VA; Anna Du Pen, MN, ARNP,^a Hospice of Kitsap County, Bremerton, WA; Mary Ersek, PhD, RN,^a Associate Professor, Associate Director of the Hartford Center of Geriatric Nursing Excellence, University of Pennsylvania School of Nursing, Philadelphia, PA; Betty Ferrell, PhD, RN, FAAN,^a Research Scientist, City of Hope National Medical Center, Duarte, CA; Barbara Head, Instructor, School of Medicine, University of Louisville, Louisville, KY; Jan Jones, President, CEO, Alive Hospice, Nashville, TN; Susan Lasker Hertz, Director of Hospice Services, The Denver Hospice, Denver, CO; Christine Miaskowski, RN, PhD, FAAN, Professor and Associate Dean, UCSF School of Nursing, San Francisco, CA; Judith A. Paice, PhD, RN, Research Professor of Medicine, Northwestern University, Chicago, IL; Maryjo Prince-Paul, PhD, Assistant Professor, Frances Payne Bolton School of Nursing, Case Western University and Hospice of the Western Reserve, Cleveland, OH; Mary K. Sheehan, RN, MSN, MBA, President, CEO, Midwest Palliative & Hospice Care Center, Glenview, IL; Jules Sherman, DO, Chief Medical Officer, Hospice of Dayton, Dayton, OH; Dena Jean Sutermaster, RN, MSN, Director of Education/Research; Hospice and Palliative Care Nurses Association; Janet Snapp, RN, MSN, Vice President of Clinical Services, Hospice of the Bluegrass, Lexington, KY; and Mary Zuccaro, MSN, APRN-BC, Director of Palliative Care Consultations, A Service of Valley Hospice, Inc., Rayland, OH.

Special thanks to Kimberly Bergen, RN, MSN; Catherine Fiala, RN, BSN; and Patricia McNichol, RN, BSN, for their efforts in collecting the medical record data for this study.

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References 

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• a Indicates the experts who reviewed the initial list of 78 EBP recommendations.