Racial/Ethnic Disparities in Pain Management

1. Racial/Ethnic Disparities in Pain Management Raymond Tait, PhD Saint Louis University

2. Disclosures • Spouse is on the Speaker’s Bureau for Lilly • Center for World Health & Medicine (direct report) has a project jointly funded by Lilly and J&J • No discussion of unapproved uses

3. The study of error is not only in the highest degree prophylactic, but it serves as a stimulating introduction to the study of truth. --Walter Lippmann (1922)

4. Objectives • To (briefly) review of the literature on racial/ethnic disparities in pain-related healthcare. • To describe chronic pain characteristics that contribute to patient vulnerability to disparities in treatment and outcomes. • To review patient, provider, and environmental factors that occasion disparate care.

5. AHRQ National Healthcare Disparities Report:2012 Quality of Care Indicators

6. AHRQ National Healthcare Disparities Report:2000-02 vs. 2008-10 Quality of Care Indicators

7. Disparities in Pain Care: Multiple Conditions & Demographic Groups • Conditions • Low back pain (Tait et al., 2004) • Acute pain (Salmon & Manyande, 1996) • Recurrent pain (Elander et al., 2006) • Cancer pain (Cleeland et al., 1997) • Race/ethnicity • Todd et al., 1993; Green et al., 2003; IOM, 2003; Chibnall et al., 2005; Anderson et al., 2009; IOM, 2011; Meghani et al., 2012 • Gender • Martin & Lemos, 2002; Taylor et al., 2005 • Age • Old (Hadjistravropoulos et al., 2007; Weiner et al, 2002) • Young (Howard, 2003; Anthony & Schanberg, 2005) • Socioeconomic status • Morrison et al., 2000; Mayberry et al., 2000

8. Racial and Socioeconomic Factors in Disparate Care • Socioeconomic factors co-vary with minority status (Mayberry et al., 2000; Meghani et al., 2012) • Access • Analgesics (Morrison et al., 2000; Green et al., ) • Medical care (Meghani et al., 2012) • Insurance(Zuvekas and Taliaferro, 2003) • Resources(Tait & Chibnall, 2012)

9. Disparities in Occupational Lumbar Injury Outcomes Research (DOLOR)(Agency for Healthcare Research and Quality, R01 HS13087-01) • Missouri cases of LB injuries that were settled between 1/01 and 6/02 • St. Louis city, St. Louis county, Jackson county • 90% of African Americans in the state • 2,934 cases • 50.3% completed survey • 14.7% refused survey • 35.0% could not be traced • Data sources • WC database • Telephone survey instruments

10. Demographics(N = 1,475) • Age  43.6 years • Education = 13.07 years • Gender = 896 males, 533 females • Race (self-identified) = 889 Caucasian, 540 African Americans, 43 mixed, 3 refused • Working full-time at time of injury = 95.2% • Working full-time now = 62.8%

11. WC Management Database by Race

12. Predictors of WC Management:Demographics, SES, and Injury*(Tait et al., Pain, 2004) * Simultaneous entry multiple hierarchical regression: R2 change (all P’s < 0.001)

13. WC Database: Surgical vs. Non-Surgical Treatment(Chibnall et al., Spine, 2006) 2(1) = 106.1, P < 0.0001 OR = 4.0; 95% CI = 2.9 – 5.4

14. Claimants with HNP: Predictors of Surgery* • *No surgery vs surgery: 2(8) = 59.6, P < .001; R2 = 0.13 (N =640)

15. Clinical Outcomes: 2 Years Post-Settlement (Chibnall et al., Pain, 2005) * P < 0.0001

16. 6-Year Follow-Up: High Levels of Pain, Catastrophizing, and Disability(Chibnall & Tait, Pain Medicine, 2011) * 1 = high (pain ≥ 7; PCS ≥ 30; PDI ≥ 45) vs. 0 = less than high

17. 10 * 9.5 Caucasian 9 African American 8.5 8 7.5 7 6.5 6 5.5 Pct. Change from Baseline 5 * 4.5 * 4 * 3.5 * 3 2.5 * * 2 1.5 1 0.5 0 Baseline Year 1 Year 2 Year 3 Year 4 Year 5 Post-Settlement Years Race Effects on Financial Court Actions: 5 Years Post-Settlement(Tait & Chibnall, Spine, 2012)

18. Implications for Race & SES • Race/ethnicity and SES are associated with differences in patient/provider approach to treatment and intermediate-term outcomes • Race/ethnicity appears to account for greater effect during active clinical management • Race/ethnicity and SES are associated with differences in long-term outcomes • SES accounts for greater long-term effects • What accounts for disparate clinical management?

19. Judging Pain in Others: A Social Interaction

20. Judging Pain in Others: A Projective Test? One Patient Two Providers Opinion #1 Opinion #2

21. Acute Pain as symptom Biologic utility Anxiety Opioids OK Low addiction potential Pathology recognized Cure likely Chronic Pain as disease Little utility Depression Opioids problematic Poly-addiction potential Pathology unclear Cure often not possible Distinctions between Acute and Chronic Pain

23. Glasgow Illness Model(Adapted from Waddell et al., Pain, 1993) Sick Role Illness Behavior Psychological Distress Attitudes & Beliefs Pain/Illness

24. Internist Judgments of Chronic Low Back Pain(Chibnall, Dabney & Tait, Pain Medicine, 2000) • 48 internists from an academic school of medicine • 2 x 4 mixed between and within-subjects design • Vignettes describing hypothetical low back pain patients varied by pain severity (low vs. high) • Internists provided 4 waves of clinical information (history  physical exam findings  functional disability  diagnostic test results) • Measures = MD judgments regarding patient medical/psychological/disability status, treatment, diagnostic testing, and referral options

25. MD Judgments: Reliability Across 4 Waves of Information

26. RATES OF AGREEMENT IN PATIENT & CAREGIVER PAIN RATINGS(from Grossman et al., Correlation of patient and caregiver ratings of cancer pain, J. Pain Symp Manag, 1991; 6:53-57)

27. High Pain Severity: Implications for Clinical Judgment Pain Report Low (1-3) Moderate (4-6) High (7-10) Little likelihood of context effects Some likelihood of context effects without objective evidence High likelihood of context effects with/without objective evidence

28. The Patient (“The Target”): Characteristics that Influence Judgments

29. Patient Factors that Influence Judgments • Chronicity • Klein et al., 1982; Teske et al., 1983; Taylor et al., 1984; Leclere et al., 1990; Eccleston et al., 1997; Hahn, 2001 • Distribution • Ransford et al., 1976; Von Baeyer et al., 1983; Margolis et al., 1986; Tait et al., 1990 • Behavior • Prkachin et al., 1994; Krause et al., 1994;Solomon et al., 1997; Prkachin et al., 2001 • Demographic • Race/ethnicity • Age • Gender

30. Ethnicity as a risk factor for inadequate emergency department analgesia(Todd, Samaroo, Hoffman. JAMA, 1993) Sample: Hispanic and white emergency department patients with isolated long-bone fractures Hispanics more than twice as likely as whites to receive NO analgesic medication for pain.

31. The Context (“The Situation”):Characteristics that Influence Judgments

32. Factors that Influence Judgments: Situational Features • Compensation status • Hadler, 1994; Kennedy, 1997; Chibnall and Tait, 1999; Merskey and Teasell, 2000; Kappesser et al., 2006 • Medical evidence • Carey et al., 1988; Birdwell et al., 1993; Tait and Chibnall, 1994; Chibnall and Tait, 1995; Chibnall et al., 1997; Tait et al., 2006

33. Neurological exam Gait/posture Spinal mobility Muscle function (tone, mass, strength) Soft tissue exam Mobility of weight bearing joints Plain radiography Mobility of non-weight bearing joints CT scan Electromyography Contrast radiography Internal organ exam Nuclear medicine Laboratory tests Thermography Blood count EEG ECG Medical Procedures for Assessment of Chronic Pain(Rudy et al, Pain, 1988)

35. Incremental Certainty of Disability: Low Back Pain(Carey et al., J ClinEpidemiol 1988;41:691-697)

36. The Provider (“The Judge”):Characteristics that Influence Judgments

37. Cognition in Intuition and Reasoning(from Kahneman, American Psychologist, 2003)

38. Key Constructs of Cognitive Miser • Tends to attribute behavior to personal disposition, not situational factors • Behavior “engulfs the field” (Heider, 1958) • Makes common use of stereotypes • Cognitive structures that represent simplified knowledge about a concept or type of stimulus • Facilitates “top-down,” conceptually driven information processing • Shapes expectations

39. Features of Stereotypes • Usually cued by visually prominent physical features • Commonly applied to attributes such as gender, race, SES, age, mental health, attractiveness • Operates on perceptions at earliest moments (i.e., expectancies) • Creates less complex concepts • Stereotype consistent information more easily remembered than inconsistent information • Encoding inconsistent information requires effort

41. Judging Pain: Physician Specialty(Tait et al., 2010) * P < 0.05; ** P < 0.001

42. Pain Management: A Social Transaction • Pain management is an interactive phenomenon • Social transaction (Craig et al., 2010) • Participative decision-making (Frantsve & Kerns, 2006) • Social contract (Kappesser et al., 2008) • Contract influenced by assumed roles (patient and provider) • Implied contractual demands of patients with severe, chronic pain • Fix me • At least help me—analgesic medications (opioids?) • Handle any regulatory implications • Assume long-term management (not cure) • Embrace high (ongoing?) time demands • Recognize the likelihood of associated psychological distress • Tackle disability-related sequelae • Manage sick role, litigation and other system issues • Treat likely co-morbidities • Prepare for high costs of care

43. Conclusions I: Pain management as Social Judgment • Judgments regarding pain assessment and treatment fit a (complex) social cognition model • Racial/ethnic stereotypes appear to operate in clinical encounter • Social cognitive influences are greatest when pain is severe and supporting medical evidence is lacking • Patient factors (e.g., race/ethnicity) susceptible to symptom discountingunder conditions of high pain severity • Pain management best viewed as a social transaction

44. Situational Factors that Influence Judgments

45. Patient Factors that Influence Judgments

46. Provider Factors that Influence Judgments

47. Conclusions II: Strategies to Reduce Disparities in Care • Treatment guidelines/education may minimize errors in judgment • Evidence-based medicine? • Multidisciplinary approaches • Maximize sources of input • Distribute treatment burden • Lessen empathy influences • Multiple sources of information to reduce bias • Pain severity, pain distribution, pain behavior • Levels of pain-related disability • Psychological distress as modifying, not invalidating pain experience