Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents
Abstract Background Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypoth...
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| Format: | Article |
| Language: | English |
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BMC
2021-06-01
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| Series: | BMC Medical Research Methodology |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12874-021-01327-5 |
| _version_ | 1818662172334489600 |
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| author | Anthony P. Nunes Danni Zhao William M. Jesdale Kate L. Lapane |
| author_facet | Anthony P. Nunes Danni Zhao William M. Jesdale Kate L. Lapane |
| author_sort | Anthony P. Nunes |
| collection | DOAJ |
| description | Abstract Background Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypothesis that the inverse association may be partially attributable to differential misclassification due to recall and communication limitations, this study implemented a missing data approach to quantify the absolute magnitude of misclassification of pain, pain frequency, and pain intensity by level of cognitive impairment. Methods Using the 2016 Minimum Data Set 3.0, we conducted a cross-sectional study among newly admitted US nursing home residents. Pain presence, severity, and frequency is assessed via resident-reported measures. For residents unable to communicate their pain, nursing home staff document pain based on direct resident observation and record review. We estimate a counterfactual expected level of pain in the absence of cognitive impairment by multiply imputing modified pain indicators for which the values were retained for residents with no/mild cognitive impairment and set to missing for residents with moderate/severe cognitive impairment. Absolute differences (∆) in the presence and magnitude of pain were calculated as the difference between documented pain and the expected level of pain. Results The difference between observed and expected resident reported pain was greater in residents with severe cognitive impairment (∆ = -10.2%, 95% Confidence Interval (CI): -10.9% to -9.4%) than those with moderate cognitive impairment (∆ = -4.5%, 95% CI: -5.4% to -3.6%). For staff-assessed pain, the magnitude of apparent underreporting was similar between residents with moderate impairment (∆ = -7.2%, 95% CI: -8.3% to -6.0%) and residents with severe impairment (∆ = -7.2%, 95% CI: -8.0% to -6.3%). Pain characterized as “mild” had the highest magnitude of apparent underreporting. Conclusions In residents with moderate to severe cognitive impairment, documentation of any pain was lower than expected in the absence of cognitive impairment. This finding supports the hypothesis that an inverse association between pain and cognitive impairment may be explained by differential misclassification. This study highlights the need to develop analytic and/or procedural solutions to correct for recall/reporter bias resulting from cognitive impairment. |
| first_indexed | 2024-12-17T04:56:43Z |
| format | Article |
| id | doaj.art-dcc0e75bf168473b8914f207388ab300 |
| institution | Directory Open Access Journal |
| issn | 1471-2288 |
| language | English |
| last_indexed | 2024-12-17T04:56:43Z |
| publishDate | 2021-06-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Medical Research Methodology |
| spelling | doaj.art-dcc0e75bf168473b8914f207388ab3002022-12-21T22:02:41ZengBMCBMC Medical Research Methodology1471-22882021-06-0121111210.1186/s12874-021-01327-5Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residentsAnthony P. Nunes0Danni Zhao1William M. Jesdale2Kate L. Lapane3Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical SchoolDivision of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical SchoolDivision of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical SchoolDivision of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical SchoolAbstract Background Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypothesis that the inverse association may be partially attributable to differential misclassification due to recall and communication limitations, this study implemented a missing data approach to quantify the absolute magnitude of misclassification of pain, pain frequency, and pain intensity by level of cognitive impairment. Methods Using the 2016 Minimum Data Set 3.0, we conducted a cross-sectional study among newly admitted US nursing home residents. Pain presence, severity, and frequency is assessed via resident-reported measures. For residents unable to communicate their pain, nursing home staff document pain based on direct resident observation and record review. We estimate a counterfactual expected level of pain in the absence of cognitive impairment by multiply imputing modified pain indicators for which the values were retained for residents with no/mild cognitive impairment and set to missing for residents with moderate/severe cognitive impairment. Absolute differences (∆) in the presence and magnitude of pain were calculated as the difference between documented pain and the expected level of pain. Results The difference between observed and expected resident reported pain was greater in residents with severe cognitive impairment (∆ = -10.2%, 95% Confidence Interval (CI): -10.9% to -9.4%) than those with moderate cognitive impairment (∆ = -4.5%, 95% CI: -5.4% to -3.6%). For staff-assessed pain, the magnitude of apparent underreporting was similar between residents with moderate impairment (∆ = -7.2%, 95% CI: -8.3% to -6.0%) and residents with severe impairment (∆ = -7.2%, 95% CI: -8.0% to -6.3%). Pain characterized as “mild” had the highest magnitude of apparent underreporting. Conclusions In residents with moderate to severe cognitive impairment, documentation of any pain was lower than expected in the absence of cognitive impairment. This finding supports the hypothesis that an inverse association between pain and cognitive impairment may be explained by differential misclassification. This study highlights the need to develop analytic and/or procedural solutions to correct for recall/reporter bias resulting from cognitive impairment.https://doi.org/10.1186/s12874-021-01327-5MisclassificationMultiple imputationPainNursing homes |
| spellingShingle | Anthony P. Nunes Danni Zhao William M. Jesdale Kate L. Lapane Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents BMC Medical Research Methodology Misclassification Multiple imputation Pain Nursing homes |
| title | Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents |
| title_full | Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents |
| title_fullStr | Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents |
| title_full_unstemmed | Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents |
| title_short | Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents |
| title_sort | multiple imputation to quantify misclassification in observational studies of the cognitively impaired an application for pain assessment in nursing home residents |
| topic | Misclassification Multiple imputation Pain Nursing homes |
| url | https://doi.org/10.1186/s12874-021-01327-5 |
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