Oncology: Medical and Radiation – Plan of Care for Pain

Measure Specification

Pain is one of the most common and debilitating symptoms reported amongst cancer patients and in fact ICD-11 contains a new classification for chronic cancer-related pain, defining it as chronic pain caused by the primary cancer itself, or metastases, or its treatment. A systematic review found that 55 percent of patients undergoing anticancer treatment reported pain and chemotherapy and radiation specifically are associated with several distinct pain syndromes.

Each year, over a million cancer patients in the US receive chemotherapy or radiation. Severe pain increases the risk of anxiety and depression and a recent study showed that cancer patients who reported pain had worse employment and financial outcomes; the greater the pain, the worse the outcomes. Cancer patients have also reported that pain interferes with their mood, work, relationships with other people, sleep, and overall enjoyment of life.

Assessing pain and developing a plan of care (i.e., pain management) are critical for symptom control, pain management, and the cancer patient’s overall quality of life; it is an essential part of the oncologic management of a cancer patient (National Comprehensive Cancer Network® (NCCN), 2024). However, many oncology patients report insufficient pain control.

A retrospective chart review analysis found an 84 percent adherence to the documentation of pain intensity and 43 percent adherence to pain re-assessment within an hour of medication administration. An observational study found that over half of its cancer patients had a negative pain management index score, indicating that the prescribed pain treatments were not commensurate with the pain intensity reported by the patient.

Disparities exist as well, for example, a recent study evaluated opioid prescription fills and potency among cancer patients near end of life between 2007-2019. The study found that while all patients had a steady decline in opioid access, Black and Hispanic patients were less likely to receive opioids than White patients (Black, -4.3 percentage points, 95% CI; Hispanic, -3.

6 percentage points, 95% CI) and received lower daily doses (Black, -10.5 MMED, 95% CI; Hispanic, -9.1 MMED, 95% CI). The intent of the paired measures 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 and Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain is to improve pain management, thereby improving the function and quality of life of the cancer patient.

Specific clinical practice guideline recommendations that support this measure are: (NCCN, 2024) 1. Perform pain reassessment at specified intervals to ensure that analgesic therapy is providing maximum benefit with minimal adverse effects, and that the treatment plan is followed. 2. General principles of cancer pain management a. Optimize pain management therapies to improve function and meet patient's goals of care.

b. Select the most appropriate analgesic regimen based on the pain diagnosis, comorbid conditions, safety, potential drug interactions, estimated trajectory of pain, medication availability, and expense/financial toxicity. c. Analgesic regimen may include an opioid, acetaminophen, nonsteroidal anti-inflammatory drugs, and/or adjuvant analgesics. d.

Provide psychosocial support. e. Provide patient and family/caregiver education. f. Optimize integrative interventions and multidisciplinary care. 3. Ongoing care & goals of treatment a. Have regular follow-up schedule to monitor pain therapy outcomes. b. Monitor for the use of analgesics as prescribed, especially in patients with risk factors for or history of substance misuse/diversion or cognitive dysfunction.

c. Provide written follow-up pain plan, including prescribed medications. d. Routinely reevaluate pain at each contact and as needed to meet patient-specific goals for comfort, function, and safety. e. Instruct the patient on the importance of i. Following documented pain plan. ii. Scheduling and keeping outpatient appointments. iii. Contacting clinician if pain worsens or adverse effects are inadequately controlled, including availability of after-hours assistance to facilitate titration of analgesic.

4. Pain intensity rating a. Pain intensity rating scales can be used as part of universal screening and comprehensive pain assessment. At minimum, patients should be asked about “current” pain, as well as "worst" pain, “average” pain, and "least" pain in the past 24 hours. b. For comprehensive assessment, also include "worst pain in past week," "pain at rest," and "pain with movement.

" 5. Comprehensive Pain Assessment a. The goal of comprehensive pain assessment is to find the cause of the pain and identify optimal therapies. Individualized pain treatment is based on the etiology and characteristics of pain, pain trajectory, the patient's clinical condition, and patient-centered goals of care. 6. Psychosocial Support a. Describe the mutually agreed upon plan of care to be taken and when results can be expected.

This measure contains two strata defined by two submission criteria. This measure produces a single performance rate using a weighted average. There are 2 Submission Criteria for this measure: 1) All visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy who report having pain OR 2) All visits for patients, regardless of age, with a diagnosis of cancer currently receiving radiation therapy who report having pain For the purposes of MIPS implementation, this visit measure is submitted each time a patient has a denominator eligible encounter during the performance period.