Oncology: Medical and Radiation - Pain Intensity Quantified

Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified

Copyright 2023 American Society of Clinical Oncology. All Rights Reserved.

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This measure is intended to have one reporting rate, which aggregates the following populations into a single performance rate for reporting purposes: 
- Population 1: Visits for patients with a diagnosis of cancer who are currently receiving chemotherapy 
- Population 2: Visits for patients with a diagnosis of cancer who are currently receiving radiation therapy

For the purposes of this measure, a single performance rate can be calculated as follows:
Performance Rate = (Numerator 1 + Numerator 2)/ (Denominator 1 + Denominator 2)

An estimated 1,806,590 new cases of cancer were projected to be diagnosed in the US in 2020 (NIH, 2020). Pain is a commonly occurring symptom for cancer patients as 30% to 50% (510,000 to 850,000 each year based on current statistics) will experience moderate to severe pain (Wiffen, Wee, Derry, Bell, & Moore, 2017). Initial and ongoing pain assessments are essential to determine the pathophysiology of pain and ensure proper pain management. According to the National Comprehensive Cancer Network (NCCN, 2022), undertreatment of pain remains a problem among a significant subset of cancer patients, survival is linked with symptom control and pain management, and pain management contributes to broad quality of life improvement. Furthermore, NCCN notes that formal pain reevaluation is required at each contact to ensure fulfilment of patient goals around comfort, function, and safety. Cancer patients have reported that pain interferes with their mood, work, relationships with other people, sleep and overall enjoyment of life (Moryl et al., 2018). To maximize patient outcomes, pain management is an essential part of oncologic management (NCCN, 2022).  

A recent analysis of registry data for chronic pain cancer patients found average pain intensity reported as mild (24.6% of patients), moderate (41.5%), and severe (33.9%). The study also indicated that patient report of pain relief is inversely related to the average pain intensity reported (Moryl et al., 2018). These data suggest that assessing and managing a cancer patient’s pain is critical and there remains significant room for improvement in assessing and mitigating cancer-related pain. A prospective study of changes in pain severity of cancer patients found that, at initial assessment, 47% of patients reported pain. At follow-up, the patients with pain at initial assessment reported reduced pain (32.2%), stable pain (48.2%) and worse pain (19.6%). Of the 53% of patients reporting no pain at initial assessment, 82.6% reported stable pain and 17.4% reported worse pain at follow-up assessment (Zhao et al., 2014). This study highlights the importance of initial and ongoing assessments of pain to identify gaps and ensure proper pain management.

-Screen all patients for pain at each contact. 

-Routinely quantify and document pain intensity and quality as characterized by the patient (whenever possible). Include patient reporting of breakthrough pain, treatments used and their impact on pain, satisfaction with pain relief, pain interference, provider assessment of impact on function, and any special issues for the patient relevant to pain treatment. If necessary, get additional information from caregiver regarding pain and impact on function. 

-Perform comprehensive pain assessment if new or worsening pain is present and regularly for persisting pain.

Various methods and tools exist to assess pain severity. Intensity of pain should be quantified using a numerical rating scale (i.e., 0-10), visual analog scale, categorical scale, or pictorial scale (e.g., The Faces Pain Rating Scale) (Category 2A) (National Comprehensive Cancer Network, 2022).

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'Moryl, N., Dave, V., Glare, P., Bokhari, A., Malhotra, V. T., Gulati, A., … Inturrisi, C. E. (2018). Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients. The Journal of Pain: official journal of the American Pain Society, 19(3), 278–290. doi:10.1016/j.jpain.2017.11.001'

Reference Type: CITATION

Reference Text: 'National Comprehensive Cancer Network (NCCN). (2022). NCCN Clinical Practice Guidelines in Oncology. Adult Cancer Pain Version 2.2022. Retrieved from http://www.nccn.org'

Reference Type: CITATION

Reference Text: 'National Institutes of Health - National Cancer Institute. (2020). Cancer Statistics. Retrieved from https://www.cancer.gov/about-cancer/understanding/statistics'

Reference Type: CITATION

Reference Text: 'Wiffen, P. J., Wee, B., Derry, S., Bell, R. F., & Moore, R. A. (2017). Opioids for cancer pain - an overview of Cochrane reviews. The Cochrane database of systematic reviews, 7(7), CD012592. doi:10.1002/14651858.CD012592.pub2'

Reference Type: CITATION

Reference Text: 'Zhao, F., Chang, V. T., Cleeland, C., Cleary, J. F., Mitchell, E. P., Wagner, L. I., & Fisch, M. J. (2014). Determinants of pain severity changes in ambulatory patients with cancer: an analysis from Eastern Cooperative Oncology Group trial E2Z02. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 32(4), 312–319. doi:10.1200/JCO.2013.50.6071'

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This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients with a diagnosis of cancer who are also currently receiving chemotherapy or radiation therapy during the measurement period. 

For patients receiving radiation therapy, pain intensity should be quantified at each radiation treatment management encounter where the patient and physician have a face-to-face or telehealth interaction. Due to the nature of some applicable coding related to radiation therapy (e.g., delivered in multiple fractions), the billing date for certain codes may or may not be the same as the face-to-face or telehealth encounter date. In this instance, for the reporting purposes of this measure, the billing date should be used to pull the appropriate patients into the initial population. It is expected, though, that the numerator criteria would be performed at the time of the actual face-to-face or telehealth encounter during the series of treatments. A lookback (retrospective) period of 7 days, including the billing date, may be used to identify the actual face-to-face or telehealth encounter, which is required to assess the numerator. Therefore, pain intensity should be quantified during the face-to-face or telehealth encounter occurring on the actual billing date or within the 6 days prior to the billing date.

For patients receiving chemotherapy, pain intensity should be quantified at each face-to-face or telehealth encounter with the physician while the patient is currently receiving chemotherapy. For purposes of identifying eligible encounters, patients "currently receiving chemotherapy" refers to patients administered chemotherapy on the same day as the encounter or during the 30 days before the date of the encounter AND during the 30 days after the date of the encounter. 

Pain intensity should be quantified using a standard instrument, such as a 0-10 numerical rating scale, visual analog scale, a categorical scale, or pictorial scale. Examples include the Faces Pain Rating Scale and the Brief Pain Inventory (BPI).

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy

Equals Initial Population

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Patient visits in which pain intensity is quantified

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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