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J Gen Intern Med. 2019 Mar;34(3):435-442. doi: 10.1007/s11606-018-4785-z. Epub 2019 Jan 10.

The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment.

Author information

1
Center for Cancer Research, Purdue University, West Lafayette, IN, USA.
2
Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA.
3
Human Development & Family Studies, Purdue University, West Lafayette, IN, USA.
4
Department of Internal Medicine, Hematology/ Oncology Division, and Health Management and Policy, University of Michigan School of Medicine, Ann Arbor, MI, USA.
5
Department of Health Management & Policy, University of Michigan School of Medicine, Ann Arbor, MI, USA.
6
Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA.
7
Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
8
Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY, USA.
9
Department of Statistics, Purdue University, West Lafayette, IN, USA.
10
Department of Biostatistics, University of Michigan School of Medicine, Ann Arbor, MI, USA.
11
Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA.
12
Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA.
13
School of Public Health, Department of Social and Behavioral Sciences, West Virginia University, Morgantown, WV, USA.
14
James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA.
15
Center for Communication and Disparities Research, University of Rochester School of Medicine, Rochester, NY, USA. ronald_epstein@urmc.rochester.edu.
16
Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA. ronald_epstein@urmc.rochester.edu.
17
Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA. ronald_epstein@urmc.rochester.edu.
18
James P Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, NY, USA. ronald_epstein@urmc.rochester.edu.
19
Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA. ronald_epstein@urmc.rochester.edu.
20
Family Medicine Research Programs, University of Rochester, Rochester, NY, USA. ronald_epstein@urmc.rochester.edu.

Abstract

BACKGROUND:

Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer.

OBJECTIVE:

To examine the effect of race on physicians' pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation.

DESIGN:

Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles-a 62-year-old man with advanced lung cancer and uncontrolled pain-differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions.

PARTICIPANTS:

Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians' mean age was 52 years (SD = 27.17), 59% male, and 64% white.

MAIN MEASURES:

Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment.

KEY RESULTS:

SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81).

CONCLUSIONS:

Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain.

TRIAL REGISTRATION:

NCT01501006.

KEYWORDS:

communication; doctor-patient relations; lung cancer; pain management; racial disparities

PMID:
30632104
PMCID:
PMC6420510
[Available on 2020-03-01]
DOI:
10.1007/s11606-018-4785-z

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