Pain Impacting Quality of Life in Persons with Dementia Dying in the Nursing Home by Alternative Medicare Payment Model.

Abstract

<b><i>Background:</i></b> Medicare alternative payment models were created to improve health care value by controlling costs and improving care quality. <b><i>Objective:</i></b> To determine if prevalence of pain affecting quality of life (QoL) differs by Medicare payment model among nursing home (NH) decedents with dementia at the end of life. <b><i>Setting/Subjects:</i></b> NH decedents in 2017/2018 in the United States with dementia who self-reported pain on a Minimum Data Set assessment in the last 30 days of life. <b><i>Measurements:</i></b> Main outcome was pain impacting QoL (i.e., affecting day-to-day activities or sleep). Multivariable logistic analysis examined the association between payment model (traditional Medicare [TM], Medicare Advantage [MA], or accountable care organizations [ACOs]) and pain impacting QoL after controlling for potential confounders. <b><i>Results:</i></b> There were 115,757 NH residents with dementia who self-reported pain in the last 30 days of life. Of those, 17.8% (<i>n</i> = 20,585) reported having pain the last five days from assessment, which varied by Medicare payment model (17.7% in TM, 17.5% in MA, and 19.1% in ACOs; <i>p</i> < 0.001). Among decedents reporting pain, 23.6% of ACO decedents reported pain affecting QoL compared to 22.1% in MA and 21.6% in TM (<i>p</i> = 0.09). After adjustment, decedents in ACOs compared to TM had greater predicted probability of pain affecting QoL (absolute marginal difference 0.017, 95% CI 0.00-0.035, <i>p</i> = 0.05), and persons in MA did not differ from persons in TM (absolute marginal difference 0.005, 95% CI -0.008 to 0.019, <i>p</i> = 0.41). <b><i>Conclusions and Implications:</i></b> Among dementia decedents dying with pain, pain impacted QoL in more than one in five persons. All payment models can improve pain management.