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Development of a set of indicators for the quality of chronic pain management in Chinese community-dwelling older adults: a Delphi study

BMC Geriatrics volume 24, Article number: 1041 (2024) Cite this article

Abstract

Background

Standardized and systematic quality assessments of chronic pain management, particularly among older adult populations, are lacking in resource-limited community settings. A specific set of indicators to evaluate the quality of chronic pain management in this population has yet to be developed. Therefore, the present study constructed a set of indicators to assess the quality of chronic pain management in Chinese community-dwelling older adults, providing a standardized reference and guidance for community health centers to manage chronic pain in this population.

Methods

The indicator set was developed in three steps. Step 1 involved preparation by forming a research team and establishing the guiding theory. Step 2 included developing an expert inquiry questionnaire based on a literature review and semi-structured interviews. Step 3 completed the construction of the indicator set through the Delphi method and hierarchical analysis to quantify the relative importance of each indicator and ensure the development of a scientifically validated and practically applicable evaluation model.

Results

The final set of indicators for evaluating the quality of chronic pain management among community-dwelling older adults in China comprised three primary indicators: structural quality indicator, process quality indicator, and outcome quality indicator. Structural quality indicators included 3 secondary and 11 tertiary indicators; process quality indicators included 4 secondary and 21 tertiary indicators; and outcome quality indicators included 2 secondary and 4 tertiary indicators. Across two rounds of questionnaires, the response rate was 100%, with expert authority coefficients of 0.924 and 0.938, coefficients of variation ranging from 0 to 0.32 and 0 to 0.20, and Kendall’s concordance coefficients of 0.302 and 0.220, respectively. Hierarchical analysis showed that the consistency ratios of all indicators were < 0.1000, indicating a balanced distribution of indicator weights.

Conclusions

This study introduces a preliminary framework, based on the “Structure-Process-Outcome” theory, to evaluate chronic pain management in Chinese community-dwelling older adults. Its reliance on expert opinions without empirical validation, exclusion of patient perspectives, and focus on Chinese communities limit its applicability and generalizability. Future research should address these limitations by incorporating patient feedback, empirically validating indicators, and evaluating their applicability across diverse populations.

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Background

The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage [1]. Chronic pain is described as pain lasting for more than 3 months [1]. With the global trend of population aging and the rising prevalence of chronic and degenerative diseases, the incidence of chronic pain is increasing among older adults [2, 3], defined by the United Nations and the World Health Organization as individuals aged 60 years and older [4, 5]. The prevalence of chronic pain among older adults worldwide varies significantly, ranging from 27 to 86% [6,7,8,9]. To improve bed turnover rates and alleviate economic burdens, most older patients with chronic pain opt for community treatment and home care after their condition is controlled. The estimated prevalence of chronic pain among community-dwelling older adults in China ranges from 41.5 to 50% [10, 11]. Due to its high incidence and prolonged duration, chronic pain in older adults leads to reduced mobility, long-term sleep disturbances, and poor self-care [12, 13]. Prolonged pain may cause catastrophic perceptions of pain in this population, leading to psychological and social issues such as anxiety and depression [14, 15]. Chronic pain also disrupts immune system balance and triggers various complications. These negative outcomes significantly impact the physical and mental health and reduce the quality of life of older adults; additionally, they consume substantial healthcare resources and impose economic burdens on healthcare systems, families, and society [16,17,18]. Chronic pain management in older adults is particularly challenging, primarily due to age-related physiological changes and the impact of multiple comorbidities [19]. The decline in physiological function, reduced renal metabolism and excretory capacity, presence of multiple comorbidities, and frequent polypharmacy among older adults pose substantial challenges to effective pain management [20]. These factors can alter medication pharmacokinetics and pharmacodynamics, elevate the risk of adverse drug reactions, and significantly impact both treatment adherence and effectiveness [21, 22]. Additionally, older adults may be reluctant to discuss health concerns openly [23], healthcare professionals may have limited expertise in managing chronic pain in this population [24], and the increased potential for adverse medication effects [25] further complicates their pain management. However, effective pain relief in older adults is achievable through comprehensive assessment, individualized treatment plans, multidisciplinary collaboration, and close monitoring [26,27,28]. Quality indicators, defined as quantitative measures, can be used to monitor and evaluate the quality of healthcare and support services. The application of quality indicators can improve patient outcomes, enhance care quality, and promote continuous quality improvement [29]. China’s dual economic structure in urban and rural areas has led to an uneven distribution of healthcare resources, resulting in significant disparities between these regions and among healthcare organizations [30]. Community medical resources are limited, the service system is underdeveloped, and service accessibility and management are significantly lower than those in tertiary care institutions. Previous studies have primarily focused on orthopedic and postoperative pain management in tertiary hospitals [31, 32], leaving a gap in the development of indicators for evaluating the quality of community-based chronic pain management in older adults. Therefore, constructing a set of quality indicators for community-based chronic pain management in older adults is particularly urgent.

Methods

A rigorous, multi-step methodology was followed to develop a comprehensive set of indicators for assessing the quality of chronic pain management among community-dwelling older adults. Step 1 involved preparation by forming a research team and establishing the guiding theory. Step 2 included the development of an expert inquiry questionnaire based on a literature review and semi-structured interviews. Step 3 completed the construction of the indicator set through the Delphi method and hierarchical analysis to quantify the relative importance of each indicator, thus ensuring a scientifically validated and practically applicable evaluation model.

Step 1: research team formation and establishment of the guiding theory

Step 1.1 research team

This project involved six researchers, including a professor specializing in pain management, an associate professor focusing on pain care education, a pain specialist nurse with an associate senior title from a tertiary A-level hospital specializing in pain care, and three lecturers specializing in chronic pain management for community-dwelling older adults, pain management skills training for patients and their caregivers, and research on evaluating care quality and pain management indicators. The research group was mainly responsible for the literature review; conducting semi-structured interviews; drafting of the initial indicator set; compiling expert inquiry questionnaires; selecting experts for inquiry; conducting expert inquiries; organizing, analyzing, and summarizing expert opinions; revising the indicator set based on expert feedback; and analyzing the data.

Step 1.2 establishing the guiding theory

This study employed Donabedian’s “Structure-Process-Outcome” framework as the guiding theory [33]. This model categorizes healthcare quality into three dimensions: structure, process, and outcome [34]. “Structure” includes attributes of the healthcare environment, such as organizational structure and physical and human resources. “Process” refers to the use of these resources in delivering medical care and services. Finally, “Outcome” assesses the results of these processes, reflecting the effectiveness of healthcare delivery [35, 36].

Step 2: development of the expert questionnaire

Step 2.1 comprehensive literature review

The literature review aimed to identify existing research findings and evidence in chronic pain management for community-dwelling older adults. This provided scientific references and theoretical guidance for the study’s framework, methodological design, and the development of the indicator set. This study employed a comprehensive literature search strategy using both Chinese and English keywords related to chronic pain management in older adult populations. The Chinese keywords were “community health centers,” “community clinics,” “primary health care,” “chronic pain management,” and “quality of chronic pain management,” combined with terms including “older people,” “older person*,” “older adult*,” “geriatric,” “age ≧ 60 years,” “elderly*,” “indicators,” “indicator set,” “evaluation indicators,” and “Delphi method” in the titles or abstracts. Studies that did not consider community health centers, indicators, or older adults were still considered eligible, as excluding them would have been too restrictive. This approach was chosen to ensure a thorough literature review. The selected sources provided crucial theoretical and practical insights, enabling us to identify universally relevant elements of pain management across different populations and adapt them to the context of older adults. These terms were also used to search major Chinese databases, including the China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese Science and Technology Periodical Databases (VIP) databases. In parallel, relevant literature was searched in the PubMed, Elton B. Stephens Company (EBSCO), Springer, and ScienceDirect databases applying the same keywords in English. The search included a variety of study types, such as cross-sectional, longitudinal, and intervention studies, along with systematic reviews, meta-analyses, qualitative research, and guidelines or consensus documents. This diverse range of study designs enhances the review’s comprehensiveness, rigor, and diversity, offering valuable insights into the quality of chronic pain management from multiple perspectives. Such an approach fosters a broader and deeper understanding necessary for constructing the study’s indicator set, ensuring thoroughness and scientific rigor. The selected studies were published between 2013 and 2023, and the inclusion criteria were: (1) studies focused on chronic pain management, including assessments of chronic pain, pharmacological and non-pharmacological interventions, and patient education; and (2) publications available in either Chinese or English. The exclusion criteria were: (1) duplicate or incomplete/updated literature; (2) documents with inaccessible full text; (3) studies unrelated to chronic pain management; and (4) findings associated with cognitive impairment in older adults. The process flow for the literature search is illustrated in Fig. 1. To ensure the quality of the included literature, two researchers independently evaluated each one using appropriate assessment tools tailored to specific study types: AXIS for cross-sectional studies [37], the Newcastle-Ottawa Scale (NOS) for cohort studies [38], AMSTAR 2 for systematic reviews and meta-analyses [39], CASP for qualitative studies [40], and AGREE II for guidelines and consensus statements [41]. The quality of each study was assessed according to the evaluation criteria specified by the corresponding assessment tools. After completing their assessments, the researchers compared their results and resolved any discrepancies through discussion with a third researcher to ensure consistency.

Fig. 1
figure 1

Flowchart of the literature search and retrieval process

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EndNote software was used to manage the references, with retrieved literature imported and duplicates removed through a combination of automatic detection and manual verification to ensure uniqueness. The accuracy of duplicate removal was independently verified by two researchers. As a result, 27 out of 109 studies met the predefined high-quality criteria and were selected for further analysis. A descriptive analysis of these 27 studies on chronic pain management in older adults was conducted to systematically extract and classify a set of determinants or indicators of chronic pain management. Three researchers independently coded and classified themes, followed by group discussions to refine and finalize the classification framework. This process yielded a set of determinants or indicators of chronic pain management, organized into structural quality, process quality, and outcome quality, as shown in Table 1.

Table 1 Indicators derived from a comprehensive literature analysis
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Based on existing research findings (Table 1), the research team systematically developed and categorized a set of quality evaluation indicators for chronic pain management within the Donabedian quality evaluation framework. Guided by Donabedian’s theory [33], the quality evaluation is divided into three dimensions: Structure, Process, and Outcome. This organization establishes a clear hierarchical framework for the overall quality set. In this context, “primary indicators” align with the three quality dimensions defined in Donabedian’s theory—structure, process, and outcome—emphasizing the evaluation framework’s comprehensiveness and systematic nature. Following Donabedian’s model [33], this study identifies three primary indicators: “structure quality,” “process quality,” and “outcome quality.” During the indicator development process, the team adhered to principles that ensured logical relationships among indicators, content independence, and feasibility [69]. Each primary dimension was further categorized into secondary indicators based on relevance, which were then refined into specific tertiary indicators. Independent extraction and classification of indicators were conducted by two researchers, with regular team meetings held to resolve discrepancies and achieve consensus. Ultimately, this approach resulted in a structured indicator set for chronic pain management in community-dwelling older adults, comprising 3 primary indicators, 8 secondary indicators, and 38 tertiary indicators.

Step 2.2 semi-structured interviews

Interview purpose

The interviews aimed to obtain in-depth insights from healthcare professionals regarding the quality of chronic pain management for community-dwelling older adults. The interviews also aimed to identify key indicators and practices that contribute to effective pain management in this population and to explore potential areas for improvement in community health settings.

Sample selection

A purposive sampling method was utilized based on available resources. In-person interviews were conducted by healthcare professionals specializing in chronic pain management from five community health centers in the research area, including internal medicine physicians, internal medicine nurses, pharmacists, rehabilitation therapists, and community health center administrative staff. The inclusion criteria for healthcare professionals participating in the interviews included current employment in relevant fields; at least an undergraduate degree; mid-level or higher professional title; >5 years of experience in pain medicine, management, or nursing services; and a willingness to provide informed consent and cooperate fully.

Procedures

The researchers arranged interview locations and times with the interviewees before the sessions and conducted one-on-one, semi-structured interviews in quiet and undisturbed settings. The interviews were recorded with the interviewees’ consent, and the interview content was adjusted according to the interviewees’ fields. The interview outline was as follows: (1) Describe your daily practice of managing chronic pain in older patients at a community health center. (2) What measures does your community health center currently implement to manage chronic pain among older patients? (3) Can you discuss your understanding of the quality of chronic pain management in community-dwelling older adults? (4) How do you assess the quality of chronic pain management in older patients in your community health center? (5) Regarding chronic pain management in older patients, what do you perceive as the future direction for community health centers? Each interview lasted approximately 1 h, with each interviewee participating in 1–2 sessions.

Analysis

A total of three internal medicine physicians, three internal medicine nurses, one pharmacist, one rehabilitation therapist, and one administrative staff member from five community health centers participated in the interviews. The sample size was determined based on the principle of data saturation [70]. Data saturation was assessed through continuous comparative analysis, where data were reviewed systematically after every three interviews. No new themes emerged after the 7th, 8th, and 9th interviews, indicating that data saturation had been reached. Consequently, it was concluded that nine participants were sufficient for this study. Despite the small sample size, the dynamic evaluation approach ensured the richness of the data and supported the reliability of the findings. The interviews were digitally recorded and transcribed verbatim, with detailed field notes taken during each session to ensure data accuracy and richness. The analysis, following Sundler et al.‘s qualitative thematic approach [71], comprised four steps: (1) an open-minded reading of the text to become thoroughly familiar with the material; (2) re-reading the text to identify specific details that revealed new insights and meaning units related to the experiences of chronic pain management among older adults; (3) highlighting the identified meaning units in the text and briefly noting them in the margins for systematic comparison for similarities and differences and grouping to identify emerging patterns; and (4) condensing the meaning units into a descriptive narrative, which was further refined and organized into themes through an iterative process of writing and rewriting to explore and clarify meanings. In the final step, these themes were synthesized to develop a comprehensive understanding of the experiences of community health center healthcare providers in managing chronic pain among older adults. The first author led the analysis in close collaboration with the second author, with all authors contributing to the refinement of themes through discussions to reach a consensus. Additionally, the results were discussed with experienced researchers in the same field to incorporate their expert insights and further enhance the analysis, leading to further refinements and ultimately identifying one additional secondary and five additional tertiary indicators.

Step 2.3 development of an expert inquiry questionnaire based on the literature review and semi-structured interviews

Based on literature analysis and semi-structured interviews, a preliminary evaluation indicator set consisting of three primary indicators, nine secondary indicators, and 43 tertiary indicators was formulated. This formed a first-round expert inquiry questionnaire comprising three parts: (1) the introduction, which provided the background, purpose, significance, and evaluation methods of the questionnaire. (2) The main body, which included specific content for each indicator and suggestions for modification. The experts rated the importance of each indicator using a Likert five-point scale ranging from “not important at all” to “very important,” which were assigned scores from 1 to 5, respectively. In the modification suggestions section, the experts could provide personal opinions or suggestions and explain the reasons for adding or removing indicators. (3) The general information survey of the experts, which included their basic information, their judgment criteria for indicators, and their familiarity with the general information survey of the experts, which included their basic information, their judgment criteria for indicators, and their familiarity with the field (The content of the first-round expert consultation questionnaire is provided in Additional File 3, whereas background information on the indicator set can be found in Additional File 2. The content for the second-round expert consultation questionnaire is included in Additional File 4).

Step 3 completing the construction of the indicator set through the Delphi method and hierarchical analysis

Step 3.1 expert inquiry through the Delphi method

Purpose

The Delphi method was originally developed in a study sponsored by the Air Force-sponsored Rand Corporation to achieve the most reliable consensus from a group of experts [72]. The present study employed this method to construct a comprehensive set of indicators to evaluate the quality of chronic pain management among community-dwelling older adults in China. This method was chosen for its systematic approach to achieving expert consensus on complex issues, particularly in cases where direct empirical evidence is limited or where expert judgment is required to interpret and integrate existing data.

Criteria for expert selection        

Considering the scope of the questions, available resources, and the multidisciplinary nature of chronic pain management in older adults [73,74,75], the study employed purposive sampling to form a Delphi expert panel, adhering to rigorous selection criteria. Experts were chosen based on their academic qualifications, research and practical experience, and regional representation, ensuring the panel’s authority and representativeness. To determine the appropriate size of the panel, the research team reviewed literature on Delphi expert consultation panels. Although most sources suggest panel sizes ranging from 10 to 50 members [76, 77], Okoli and Pawlowski recommend an optimal size of 10 to 18 [78]. Given the early stage of research on chronic pain management in community-dwelling older adult populations, the pool of qualified senior experts was limited. Consequently, the study invited 16 experts with extensive experience in managing chronic pain among older adults in community health centers. All 16 confirmed their participation, forming the final expert sample. To ensure comprehensive and broadly applicable results, the panel included experts from across China’s three major economic belts—East, Central, and West—spanning provinces such as Zhejiang, Jiangsu, Shanghai, Anhui, Jiangxi, Hubei, Yunnan, Sichuan, and the Ningxia Hui Autonomous Region. This diverse composition facilitated the integration of unique regional perspectives, providing the study with comprehensive, in-depth, and targeted recommendations. A total of 16 experts were selected based on the following criteria: (1) engagement in fields such as anesthesia, geriatrics, pain medicine, pain nursing, internal medicine, and medical quality control management, with at least an undergraduate degree and a minimum of an associate senior title; (2) over 15 years of work experience, including more than 5 years of research or practical experience in managing chronic pain among community-dwelling older adults; and (3) a willingness to participate in the inquiry.

Process

The expert inquiry questionnaire, based on a literature review and semi-structured interviews, was distributed to 16 experts. According to their preferences, 11 experts received the inquiry questionnaire via email, and five received it via WeChat, with a request for a response within 2–3 weeks. Two rounds of inquiries were performed. In the first round, the experts evaluated the preliminary set of indicators. The experts rated the importance of each indicator using a Likert five-point scale, ranging from “not important at all” (scored as 1) to “very important” (scored as 5). Additionally, the experts were encouraged to provide suggestions for modifications, additions, or deletions of indicators and to justify their recommendations. The responses from the first round were analyzed to identify indicators with an average importance score of > 3.5 and a coefficient of variation (CV) of < 0.25, which were retained for further consideration.

Indicators with a score > 3.5 are generally considered to have moderate to high importance, whereas a CV < 0.25 reflects a relatively low level of disagreement among experts [79]. Indicators that did not meet these criteria were revised based on expert feedback or removed. In the second round, the revised set of indicators was redistributed to the same experts, who were again asked to rate the importance of each indicator and provide additional feedback. This round aimed to further refine the indicator set, ensuring that a strong consensus was reached.

Step 3.2 hierarchical analysis

After completing the Delphi method consultation, the analytic hierarchy process (AHP) was employed to systematically clarify and quantify the relative importance of each indicator. The AHP, a multi-criteria decision support tool, systematically breaks down complex problems into multiple levels, constructing a hierarchical model to assess the relative importance of factors at each level [80, 81]. AHP was particularly advantageous in this study, as it effectively handles multi-level and multi-criteria decision-making, rendering it well-suited for constructing complex indicator sets. By employing pairwise comparisons, AHP quantifies expert judgments, transforming subjective opinions into quantitative data, thus ensuring a more objective determination of indicator weights. The consistency test within AHP further ensures the reliability of expert opinions, providing a robust foundation for the final indicator sets [80,81,82]. The Saaty scale was applied to the second round of the Delphi method to determine the mean differences in importance assignment, and a consistency ratio (CR) was obtained by constructing a judgment matrix, performing hierarchical single sorting and a consistency test, and determining the weights of each indicator and their combinations [83]. Yaahp 11.0 software was used to calculate the relative weights of each indicator, representing their contributions to the overall evaluation system. Additionally, the CRs were calculated, with values < 0.1 indicating a high level of consistency and credibility of expert opinions [84]. Finally, the calculated weights were integrated into a comprehensive evaluation model using a weighted average method, reflecting the relative importance of the indicators at each level [84]. Consistency testing further optimized the model’s structure, ensuring both its scientific validity and practical applicability.

Ethical considerations

The study was approved by the Medical Ethics Committee of the first, second, fifth, and sixth authors’ universities (No. 2023YR0040). The medical staff with roles related to pain management in community health hospitals who participated in the qualitative interviews and the experts in the field of chronic pain management who participated in the Delphi expert consultation provided written and verbal informed consent.

Results

Literature analysis and semi-structured interviews

A total of 109 articles were initially retrieved during the search. The indicators were primarily derived from the studies listed in Table 1 [42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68]. Based on this literature analysis, we identified and included three primary indicators, eight secondary indicators, and thirty-eight tertiary indicators, one additional secondary and five additional tertiary indicators were identified, as listed in Table 2.

Table 2 Additional quality indicators for chronic pain management in community-dwelling older adults identified through semi-structured interviews
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Characteristics of the experts included in the Delphi method

Two rounds of inquiries were conducted, with 16 experts participating in each round of correspondence. The experts ranged in age from 38 to 62 years (mean: 51.59 ± 7.27 years) and had work experience ranging from 15 to 42 years (mean: 30.06 ± 9.52 years). Their experience in this specific field varied from 8 to 23 years (mean: 16.88 ± 4.92 years). The characteristics of the experts are presented in Table 3.

Table 3 Expert characteristics (n = 16)
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Expert enthusiasm and degree of authority

In each of the two rounds of inquiries, 16 identical questionnaires were distributed to the 16 experts in each round. Sixteen valid questionnaires were retrieved in both rounds, yielding an effective response rate of 100%. Among the experts in the two rounds, 10 (62.5%) and four (25.0%) provided constructive opinions, respectively. The experts’ authority coefficient (Cr) was determined by their familiarity with the problem (Cs) and the basis of their judgment (Ca), calculated as Cr = (Cs + Ca)/2 [85]. The expert authority coefficients for the two rounds were 0.924 and 0.938, respectively, indicating a high level of authority that ensured the credibility of the results.

Consistency of the expert opinions

The CV and Kendall’s coefficient of concordance (W) were used to assess the degree of coordination among the expert opinions consulted in this study. A smaller CV and a larger W indicate a higher degree of coordination [72]. In the present study, the CV values for the indicators in the first and second rounds of inquiry ranged from 0 to 0.32 and 0–0.20, respectively. The W values for the two rounds of expert inquiries were 0.302 and 0.220, respectively. The W values for the primary, secondary, and tertiary indicators in the first round were 0.232, 0.360, and 0.276, respectively, and 0.332, 0.351, and 0.211 in the second round. According to the chi-square test, the W value in the second round was statistically significant (P < 0.001), indicating fair consistency among the expert opinions.

Indicator modification and deletion

Following the two rounds of expert inquiries, the indicators were revised based on the inclusion criteria, expert opinions, and discussions within the research group. The specific revisions are shown in Table 4. The flow of the indicator selection is shown in Fig. 2. After two rounds of inquiry, all experts reached a consensus. The final indicator set contained three primary indicators, nine secondary indicators, and 36 tertiary indicators (Table 5).

Table 4 Indicator modifications and deletions
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Fig. 2
figure 2

Flowchart of the indicator selection process

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Table 5 Set of indicators to assess the quality of chronic pain management in Chinese community-dwelling older adults (three primary indicators, nine secondary indicators, and 36 tertiary indicators)
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Weight distributions of the quality of chronic pain management indicators

In the context of the quality of chronic pain management in Chinese community-dwelling older adults, the evaluation of the quality of chronic pain management was structured into a four-tier hierarchy using the AHP. In this hierarchy, ‘A’ represented the quality of chronic pain management, whereas ‘B–D’ denoted the primary, secondary, and tertiary indicators, respectively. The present study constructed a total of 13 judgment matrices and presented the results of the consistency tests and the weight coefficients for each. The consistency test results for the B-A level yielded a consistency index (CI) < 0.1 and a CR < 0.1, indicating that the weight distribution among the primary indicators was free of logical inconsistencies. The consistency results for the C-B and D-C levels are shown in Table 6. Concurrently, the weight coefficients were derived for each indicator, as shown in Additional File 1.

Table 6 Consistency test results for each judgment matrix
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Discussion

Significance of constructing evaluation indicators for chronic pain management in community-dwelling older adults

China’s aging population has led to a rising prevalence of chronic and degenerative diseases [2, 3], alongside an increasing incidence of chronic pain among older adults [86]. The complexity and high prevalence of chronic pain in this population make it essential to address the challenges of effective pain management, evaluate management quality, and improve the quality of life for community-dwelling older adults. Although China’s health authorities have issued documents such as the Guidelines for Cancer Pain Diagnosis and Treatment (2001) [87] and the Detailed Rules for the Implementation of Tertiary General Hospital Review Standards [88], these guidelines are inadequate for chronic pain management in community settings. The cancer pain guidelines are unsuitable due to differences in pathological mechanisms, disease progression, and treatment approaches, whereas the tertiary hospital standards lack the specificity required for community-based pain management. Consequently, specific accreditation standards or quality indicators for chronic pain management in older adults within community settings are lacking. In the US, Arnstein’s Evidence-based Practice Guideline: Persistent Pain Management in Older Adults highlights the importance of comprehensive patient assessment, multimodal pain therapy, multidisciplinary teams, continuous education for pain management personnel, and ongoing monitoring of outcomes [47]. Similarly, in the UK, Abdulla’s Guidance on the Management of Pain in Older People emphasizes the need for pain assessment and both pharmacological and non-pharmacological interventions, including tailored opioid therapy and regular monitoring for adverse drug reactions [54]. However, these approaches may not fully translate to the Chinese context due to cultural and healthcare differences. Recognizing these differences, the present study, guided by Donabedian’s “structure-process-outcome” framework [35], developed an indicator set specifically tailored to China’s needs. This study developed culturally relevant and practical indicators for chronic pain management in Chinese community health centers. This development process began with a comprehensive literature review, followed by interviews of nine professionals across five regions and a Delphi consultation with 16 experts from three economic belts. The indicators reflect the unique needs of Chinese older adults, including assessments of the psychological and social impacts of pain, and are tailored to the resources of community health centers and China’s economy. The present study also proposed localized criteria for multidisciplinary teams and integrated a continuous quality improvement mechanism aligned with China’s healthcare system. These adaptations ensure the indicators’ relevance and effectiveness, providing a framework for standardizing care, supporting ongoing improvement, and enhancing health outcomes for older adults. This set of indicators also lays the foundation for future research and policy development.

Scientific rationality and comprehensiveness of quality indicators for the management of chronic pain in community-dwelling older adults

This study used the “Structure-Process-Outcome” theoretical framework to construct an indicator set for evaluating chronic pain management quality in community-dwelling older adults. A diverse expert panel, selected for their complementary expertise and geographical diversity, provided high-quality insights throughout the research process. The selection ensured comprehensive and universally applicable outcomes. The study achieved a 100% effective response rate in both rounds of questionnaires, with significant expert engagement and authority coefficients of 0.924 and 0.938, respectively. Fair concordance among expert opinions (Kendall’s coefficients of 0.302 and 0.220, respectively) and consistent CR values < 0.1000 confirmed the rationality and reliability of the proposed indicators.

This structural indicator ensures the stability of community-based chronic pain management for older adults. It comprises three secondary indicators (basic conditions, human resources, and systems) and 11 tertiary indicators. Human resources have a significant weight (0.6479), underscoring their critical role in sustaining effective medical team operations. Among the tertiary indicators, the “multidisciplinary pain management team” has the highest weight (0.6902), reflecting consensus among experts and alignment with both domestic and international perspectives [73,74,75, 89]. Due to the interdisciplinary nature of chronic pain management, these teams integrate various professional disciplines to deliver comprehensive and efficient care, enhancing patient outcomes and satisfaction. The “guidelines for managing chronic pain in the elderly” ranked second (0.6333) because they provide a structured framework that standardizes practices, reduces variation, and improves the quality and cost-effectiveness of services [90, 91].

The process indicator addresses procedural management and professional content related to chronic pain, ensuring continuity of care. It includes four secondary indicators (pain assessment, pharmacological interventions for pain, non-pharmacological interventions for pain, and pain health education) and 21 tertiary indicators. Among these, “individualized pain relief based on the organ’s functional status and reserve capacity of patients with pain” had the highest weight (0.0621), reflecting the impact of aging-related physiological changes on pain control. Older patients often have multiple comorbidities, increasing the risk of adverse drug effects and complicating pain management [20, 92].

The outcome indicators include two secondary (pain relief effects and analgesic assessment) and four tertiary indicators. The “treatment rate of moderate to severe pain” (0.8) and “analgesic adequacy rate” (0.8333) are particularly significant as they assess treatment coverage and quality, providing a basis for optimizing resource allocation and developing individualized pain management strategies.

Comparisons of quality indicators for chronic pain management in community-dwelling older adults with indicators from similar studies

The study by Etzioni et al. shares methodological similarities with the present study, as both employed a systematic approach based on expert consensus and literature analysis to develop quality indicators for chronic pain management, thus ensuring the scientific validity, rigor, and broad applicability of the findings [93]. The indicators in the study by Etzioni et al., which focused on persistent pain screening, prevention of opioid-induced constipation, and persistent pain education [93], are similar to the present study’s emphasis on pain screening, assessment, observation of adverse effects during medication interventions, and health education on pain management. However, the studies differ in focus and application. Etzioni et al. targeted a vulnerable older adult population in the US to develop metrics suitable for various healthcare settings, including outpatient, inpatient, and long-term care, with an emphasis on optimizing multidisciplinary teamwork in well-resourced environments and systematically documenting pain assessments, particularly for cognitively impaired patients. In contrast, the present study considered the limitations of healthcare resources and addressed the realities of community-based healthcare in China, which apply broadly to all types of chronic pain management except for patients with cognitive impairment, and adding indicators for non-pharmacological interventions. Additionally, the present study applied AHP to quantify the weight of each indicator in resource-limited settings, thus ensuring that standardized processes and resource allocation accurately reflect the needs of China’s community healthcare system, whereas the study by Etzioni et al. is better suited for resource-rich settings.

Study limitation

This study offers a reference framework for evaluating the quality of chronic pain management in community-dwelling older adults in China. However, some limitations should be acknowledged. The study primarily focused on expert opinions without incorporating the perspectives of older patients, which are essential for ensuring the relevance of the indicators. Additionally, the indicator set has not yet been empirically validated, leaving its applicability and impact untested. The focus on Chinese communities may also limit the generalizability of the findings to other regions. Furthermore, excluding cognitively impaired older adults may reduce the specificity and comprehensiveness of the chronic pain management indicator set, potentially restricting its applicability to this unique population. These limitations underscore the need for ongoing research to refine and validate the framework for chronic pain management in older populations.

Conclusions

This study offers a reference framework for evaluating the quality of chronic pain management in community-dwelling older adults in China, based on the three-dimensional quality evaluation theory of “Structure-Process-Outcome.” The indicator set, which includes three primary, nine secondary, and 36 tertiary indicators, offers a valuable reference for standardizing pain management practices in community settings. Future research should focus on developing and validating a questionnaire based on this indicator set to ensure its practical effectiveness in real-world settings. This validation is essential for confirming the reliability and utility of the indicator set for objectively assessing and improving the quality of chronic pain management in older adults.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

AHP:

Analytic hierarchy process

CI:

Consistency index

CNKI:

China National Knowledge Infrastructure

CR:

Consistency ratio

CV:

Coefficient of variation

IASP:

International Association for the Study of Pain

NOS:

Newcastle-Ottawa Scale

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Acknowledgements

We would like to thank Editage (www.editage.cn) for English language editing.

Funding

This study was supported by a General Research Project of Zhejiang Provincial Department of Education (Y202148302), a Zhejiang Provincial Health Science and Technology Plan Project (2022KY1454), a Zhejiang Provincial Soft Science Research Program Project (2023C35069), and a Zhejiang Provincial Health Science and Technology Plan Project (2024KY591). The funders had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. Medicine College, Lishui University, Lishui, Zhejiang, China

    Xiaoyan Li, Jihua Zou, Jingquan Gao & Linyan Xu

  2. Medical Education Department, Qingyuan County Hospital of Traditional Chinese Medicine, Lishui, Zhejiang Province, China

    Qiying Hu

  3. Research Institute of Xi’an Jiaotong University, Zhejiang, Hangzhou, Zhejiang Province, China

    Rui Li

  4. The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China

    Jiajia Chen

  5. Hangzhou Normal University, Hangzhou, Zhejiang Province, China

    Yingge Tong

  6. Harbin Medical University, Daqing, Heilongjiang Province, China

    Yubin Chen

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Contributions

Research design: LXY, ZJH, GJQ, XLY, TYG, and LR; preparation of questionnaires for expert correspondence: LXY, ZJH, HQY, and CJJ; data acquisition: LXY, ZJH, and CYB; data analysis: LXY and CYB; manuscript drafting: LXY and ZJH; manuscript revision: LXY, ZJH, HQY, LR, GJQ, XLY, CJJ, TYG, and CYB. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Jihua Zou.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the Medical Ethics Committee of the first, second, fifth, and sixth authors’ universities (No. 2023YR0040). Medical staff related to pain management in community health hospitals who participated in qualitative interviews and experts in the field of chronic pain management who participated in the Delphi expert consultation provided written and verbal informed consent.

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Supplementary Information

12877_2024_5638_MOESM1_ESM.docx

Additional file 1. Evaluation indicator system for assessing the quality of chronic pain management in Chinese community-dwelling older adults. 2nd round of correspondence, good concentration of expert opinion, no modifications, finalized evaluation indicator system for the quality of chronic pain management in Chinese community-dwelling older adults. Including three primary, nine secondary, and 36 tertiary indicators. The results of the correspondence were combined with the hierarchical analysis method to calculate the weights of the indicators, and the CR of all the level indicators was<0.100.

12877_2024_5638_MOESM2_ESM.docx

Additional file 2. Operational definition of indicators. The research team conducted a comprehensive literature review, applied scientific operational definitions, and referenced the Guidance Standard for the Establishment of Urban Community Health Service Centers and the Measures for Medical Quality Management. Additionally, field investigations were carried out in community health service centers. As a result, the indicators have been further refined and clarified, leading to the development of a preliminary set of tertiary indicator rules for managing chronic pain quality among older individuals in community health service centers. These details aim to provide a clearer understanding of the background and context of these indicator sets; for more information, please refer to Additional File 2. It is important to note that Additional File 2 is for reference only and is not included in the consultation content.

12877_2024_5638_MOESM3_ESM.docx

Additional file 3. Correspondence questionnaire on evaluation indicator set for the quality of chronic pain management in Chinese community-dwelling older adults (First round). This file presents the indicators and content of the Delphi expert consultation in the first round.

12877_2024_5638_MOESM4_ESM.docx

Additional file 4. Correspondence questionnaire on evaluation indicator set for the quality of chronic pain management in Chinese community-dwelling older adults (Second round). This file presents the indicators and content of the Delphi expert consultation in the second round.

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Li, X., Zou, J., Hu, Q. et al. Development of a set of indicators for the quality of chronic pain management in Chinese community-dwelling older adults: a Delphi study. BMC Geriatr 24, 1041 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-024-05638-2

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BMC Geriatrics

ISSN: 1471-2318

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