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2023 HSR&D/QUERI National Conference Abstract

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4118 — A Cohort Study Examining Social Determinants of Health and Disruptions to Chronic Pain Care During the COVID-19 Pandemic

Lead/Presenter: Jessica Chen,  COIN - Seattle/Denver
All Authors: Chen JA (Seattle-Denver COIN, University of Washington), Chen HYP (Seattle-Denver COIN, Denver, CO) Williams EC (Seattle-Denver COIN, University of Washington, Seattle, WA) Zeliadt SB (Seattle-Denver COIN, University of Washington, Seattle, WA) Carey EP (Seattle-Denver COIN, University of Colorado, Denver, CO)

Objectives:
Manifestations of social disadvantage, including economic hardship, housing instability, and neighborhood deprivation, are disproportionately experienced by persons with minoritized racial and ethnic identities due to historical and present structural racism and discrimination. One of three Veterans receiving primary care in the Veterans Health Administration have disabling chronic pain, a condition requiring continuity of care that is differentially treated across racialized groups. The COVID-19 pandemic disrupted care for all chronic conditions, but some patient populations may be more vulnerable to disrupted care than others. Social determinants of health influenced access to care in the U.S. during the pandemic, but it is unknown whether pain care was differentially interrupted across patient subgroups. We examine whether receipt of outpatient pain care varied by race and ethnicity and measures of social disadvantage.

Methods:
In this retrospective national cohort study, we used the VA Corporate Data Warehouse to identify patients with chronic pain (via ICD diagnoses) who were seen in primary care pre-COVID (3/1/18–2/28-19) and in the year prior to COVID (3/1/19–2/29/20). We used unadjusted bivariate quasi-Poisson regressions to test associations between patient characteristics (race/ethnicity and three facets of social disadvantage based on health record documentation) and receipt of pain care (in-person, telephone, or video telehealth) during a 6-month follow-up (5/1/19-11/1/19 for pre-COVID, 5/1/20-11/1/20 for COVID-era). We report unadjusted models to report true prevalence and group differences.

Results:
While nationally there was a 23% decrease in VA outpatient pain care during the early months of the pandemic, not all patients were impacted equally. Pre-COVID, Black veterans were less likely to receive pain care relative to White veterans (RR = 0.95 [0.93, 0.97]), and this gap only increased during the pandemic (RR = 0.85 [0.83, 0.88]). Asian veterans, who did not differ from White veterans in pain care utilization pre-COVID (RR = 1.05 [0.95, 1.16]), were less likely than White veterans to receive pain care during the pandemic (RR = 0.87 [0.79, 0.96]). In both time periods, veterans with greater social disadvantage were more likely to receive pain care than those without these social stressors (documented economic hardship, RR = 1.52 [1.44, 1.59] pre-COVID, RR = 1.49 [1.41, 1.56] COVID-era; housing instability, RR = 1.32 [1.27, 1.37] pre-COVID, RR = 1.30 [1.26, 1.35] COVID-era; greater neighborhood disadvantage, least vs. most advantaged group, RR = 1.29 [1.25, 1.34] pre-COVID, RR = 1.27 [1.23, 1.31]).

Implications:
There was a concerning and widening Black-White racial disparity consistent with an extensive literature documenting under-receipt of pain care for Black patients, as well as evidence of an emergent Asian-White racial disparity during the pandemic. Additional work must be done to improve pain care outcomes for Black veterans. Surprisingly, measures of social disadvantage were positively associated with receipt of pain care, both before and during the pandemic. One possibility is that those with the greatest disadvantage rely most heavily on VA for their healthcare needs.

Impacts:
The study findings are reassuring that VA patients with chronic pain who experience economic hardship, housing instability, and neighborhood deprivation are not receiving VA pain care at lower rates than their more advantaged counterparts.