BACKGROUND/RATIONALE:
Prior research has identified racial disparities in pain management across a variety of disease types and treatment settings. These studies have consistently shown that Whites receive better pain management than other races. A pilot study we conducted in VA provided preliminary evidence of similar disparities, pointing to a need to further study and understand how racial disparities in pain management in VA can be eliminated. Recent evidence suggests that racial disparities may be less likely or smaller in magnitude in facilities with greater QI initiatives and resources that support high quality pain management.

OBJECTIVE(S):
The objectives of this study were to assess the extent to which racial disparities in pain management (screening, treatment, and outcomes) exist across VHA facilities and whether racial disparities are reduced in facilities with greater QI initiatives and resources that support high quality pain management.

METHODS:
To obtain a representative sample of the VA primary care population for which we could well identify race, we used the sampling frame for the 2007 Survey of Healthcare Experiences of Patients (SHEP) ambulatory care module. A) To examine racial disparities in pain screening (whether a pain score was recorded at the SHEP sampling visit), we utilized a base cohort of 27,683 Black and 233,765 White veterans from the SHEP. B) To examine disparities in pain treatment (type and duration of pain medication prescribed), we restricted attention to patients diagnosed with chronic pain (chronic low back, neck, or joint pain, or rheumatism) in the year prior to the SHEP sampling visit. C) To examine whether racial disparities exist in pain outcomes (perceived treatment effectiveness and functional interference due to pain reported on the SHEP), we restricted our sample to patients diagnosed with chronic pain in the prior year who reported they were treated for chronic pain in the VA in the past year. Data on pain management QI initiatives and resources were obtained from the 2007 VHA Clinical Practice Organizational Survey Primary Care Directors Module (CPOS). Key variables included: 1) tools promoting adherence to chronic pain management (e.g., computerized reminders; performance profiling and provider feedback, provider education); 2) chronic pain management resources in primary care; and 3) average wait for chronic pain patients to access specialty assessment and medication management, specialty interventional pain management, and physical therapy. In all analyses, we accounted for clustering by site and whether the patient was a new or established primary care patient as the SHEP sample is selected by facility and type of patient encounter.

FINDINGS/RESULTS:
A) Black patients were less likely than their White counterparts to be screened for pain (OR: 0.79 p < .0001) with estimated screening rates of 78% and 82% for Black and White established primary care patients at a typical VA facility, respectively. Further adjustment for demographic, medical and psychological comorbidity, active prescription of pain medication, outpatient utilization, and facility characteristics yielded an odds ratio of 0.86, (85% versus 87%, p < .05). Additional analyses revealed this reduction was explained by higher rates of outpatient visits in the two years prior to the index visit among Black patients, which was associated with lower rates of screening at the index visit.
B) Among chronic pain patients treated for pain in the past year, Blacks were more likely to be prescribed an opioid (OR=1.28, p<.0001; whites 19.96%, blacks 24.18%). However, when controlling for all covariates, Whites were more likely to be prescribed an opioid (OR=.87, p<.0001; whites: 15.20%, blacks: 13.47%). This reversal in the relationship between race and opioid prescriptions was primarily due to higher average pain scores and younger age among African Americans, both of which were associated with greater opioid prescription rates.
C) Among VA chronic pain patients treated for pain in the VA in the past year, who responded to the SHEP, Blacks were significantly less likely than their White counterparts to perceive their pain treatment as good, very good, or excellent (55% versus 60%, OR: 0.83, p = .0002). Adjusting for demographic, medical and psychological comorbidity, healthcare utilization, and facility characteristics reduced the estimated odds ratio to .91(p=.00). Additional analyses revealed that this reduction was explained primarily by the fact that Black patients were younger and were more likely to get non-opioids as opposed to opioids, both of which were associated with lower satisfaction with pain treatment. Similarly, among this sample of VA chronic patient patients who responded to the SHEP, Blacks were significantly more likely than their Whites to report experiencing functional interference due to pain moderately, quite a bit, or extremely over the past 4 weeks (69% versus 63%, OR: = 1.34 p < . 0001.) Adjusting for demographic, medical and psychological comorbidity, healthcare utilization, and facility characteristics reduced the estimated odds ratio to 1.06 (p =.16). This reduction in odds ratio was explained by the fact that Black patients were younger and were more likely to be treated with non-opioids as opposed to opioids, both of which were associated with greater functional interference.
D) We did not find support for our hypothesis that racial disparities in pain management would be reduced in facilities with greater QI initiatives and resources that support high quality pain management. Indeed, there was no consistent association between organizational factors that were expected to be related to high quality pain management and racial disparities in pain screening, treatment, perceived effectiveness of treatment, and functional interference due to pain. Moreover, we found little evidence that broader facility characteristics (such as size, region, whether facility was a VAMC or CBOC) moderated the association between race and pain management.

IMPACT:
This project identified racial disparities in pain management in VA. These disparities were not associated with the facility-level processes and structures that support high quality pain management measured as part of CPOS. Future research, potentially looking at other facility-level measures, is needed to understand how to reduce these disparities, particularly given the higher level of pain reported by Black Veterans with chronic pain.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Burgess DJ, Gravely AA, Nelson DB, van Ryn M, Bair MJ, Kerns RD, Higgins DM, Partin MR. A national study of racial differences in pain screening rates in the VA health care system. The Clinical Journal of Pain. 2013 Feb 1; 29(2):118-23. [view]
2. Burgess DJ, Gravely AA, Nelson DB, Bair MJ, Kerns RD, Higgins DM, Farmer MM, Partin MR. Association between pain outcomes and race and opioid treatment: Retrospective cohort study of Veterans. Journal of rehabilitation research and development. 2016 Feb 1; 53(1):13-24. [view]
3. Burgess DJ, Nelson DB, Gravely AA, Bair MJ, Kerns RD, Higgins DM, van Ryn M, Farmer M, Partin MR. Racial differences in prescription of opioid analgesics for chronic noncancer pain in a national sample of veterans. The journal of pain. 2014 Apr 1; 15(4):447-55. [view]

VA Cyberseminars

1. Burgess DJ. Understanding and Reducing Racial Disparities in Pain. [Cyberseminar]. 2014 Feb 4. [view]

Conference Presentations

1. Burgess DJ, Hirsch A, Sankar CA. A Socioecological Framework to Examine Disparities in Pain Care. Presented at: American Pain Society Annual Meeting; 2016 May 12; Austin, TX. [view]
2. Burgess DJ, Nelson DB, Gravely AA, Bair MJ, Kerns RD, Higgins D, Van Ryn M, Farmer Coste MM. Healthcare system level factors: Racial differences in prescription of opioid analgesics for chronic non-cancer pain. Paper presented at: American Pain Society Annual Meeting; 2016 May 12; Austin, TX. [view]
3. Burgess DJ, Nelson DB, Gravely AA, Bair MJ, kerns RD, Higgins D. Healthcare system level factors: Racial differences in prescription of opioid analgesics for chronic non-cancer pain. Presented at: American Academy of Pain Medicine Annual Meeting; 2016 May 12; Austin, TX. [view]

DRA: Health Systems Science, Other Conditions
DRE: Etiology
Keywords: Disparities, Organizational issues, Pain
MeSH Terms: none