Study Examines Whether African Americans are as Likely as Whites to Be Screened for Pain in VA Healthcare System

BACKGROUND:
In 2003, a VA directive mandated systematic screening for the presence and intensity of pain, known as "Pain as the 5th Vital Sign." In addition, an important part of improving the quality of pain management is addressing problems of racial equity. African Americans, in particular, are less likely than Whites to receive adequate pain treatment for all types of pain (e.g., acute, chronic, cancer-related). This cross-sectional study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts — and to determine the factors associated with differences in screening rates. Investigators identified 25,382 African American Veterans and 220,122 non-Hispanic White Veterans who had been randomly selected to receive the 2007 Survey of Healthcare Experiences of Patients (SHEP). [Survey responders and non-responders were included in this study]. The SHEP survey is administered quarterly by VA's Office of Quality and Performance to solicit patient-reported information regarding recent specific episodes of VA outpatient care. Using SHEP data and administrative records, investigators then measured rates of pain screening, demographics, medical and psychological comorbidity, outpatient prescription of pain medication (opioid and non-opioid), and healthcare utilization (number of outpatient visits, and inpatient visits two years prior to the patient's SHEP index visit).

FINDINGS:

• Results suggest that VA's mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit.
• Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years.

LIMITATIONS:

• This study used survey data from 2007, as well as administrative data that have limitations associated with obtaining information about patient race.
• Secondary data did not capture many of the variables that might contribute to racial differences in screening rates, i.e., racial sterotypes that might be held by some providers.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 07-071). Drs. Burgess, Nelson, and Partin, and Ms. Gravely are part of HSR&D's Center for Chronic Disease Outcomes Research, Minneapolis, MN. Dr. Bair is part of HSR&D's Center of Excellence on Implementing Evidence-Based Practice, Indianapolis, IN.

Burgess D, Gravely A, Nelson D, van Ryn M, Bair M, Kerns R, Higgins D, and Partin M. A National Study of Racial Differences in Pain Screening Rates in the VA Healthcare System. Clinical Journal of Pain November 21, 2012;e-pub ahead of print.