title: Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial.
abstract: BACKGROUND
  Unrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making.
  
  
  OBJECTIVE
  The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents.
  
  
  METHODS
  The study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger's Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility.
  
  
  RESULTS
  The final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. LIMITATIONS/LESSONS: The investigators encountered several methodological challenges that were inherent to both the design and implementation of the study. The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment. It was difficult to identify valid, reliable, and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report. Another challenge was the inability to incorporate advances in implementation science into the ongoing study
  
  
  CONCLUSIONS
  Methodological challenges are inevitable in the conduct of an RCT. The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study.
authors.affiliation: Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104-6096, USA. ersekm@nursing.upenn.edu
authors.forename: Mary
authors.initials: M
authors.lastname: Ersek
authors.forename: Nayak
authors.initials: N
authors.lastname: Polissar
authors.forename: Anna Du
authors.initials: AD
authors.lastname: Pen
authors.forename: Anita
authors.initials: A
authors.lastname: Jablonski
authors.forename: Keela
authors.initials: K
authors.lastname: Herr
authors.forename: Moni B
authors.initials: MB
authors.lastname: Neradilek
mesh_terms: D000368:Aged; D000465:Algorithms; D002985:Clinical Protocols; D003657:Decision Making; D019983:Guideline Adherence; D006707:Homes for the Aged / Q000458:organization & administration*; D006801:Humans; D007318:Inservice Training; D009735:Nursing Homes / Q000458:organization & administration*; D059408:Pain Management / Q000379:methods*; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic / Q000379:methods*; D015203:Reproducibility of Results; D012107:Research Design