Salimah H. Meghani

Patient-provider race-concordance: does it matter in improving minority patients' health outcomes?

Objective. To understand if patient–provider race-concordance is associated with improved health outcomes for minorities. Design. A comprehensive review of published research literature (1980–2008) using MEDLINE, HealthSTAR, and CINAHL databases were conducted. Studies were included if they had at least one research question examining the effect of patient–provider race-concordance on minority patients’ health outcomes and pertained to minorities in the USA. The database search and data analysis were each independently conducted by two authors. The review was limited to data analysis in tabular and text format. A meta-analysis was not possible due to the discrepancy in methods and outcomes across studies. Results. Twenty-seven studies met the inclusion criteria. Combined, the studies were based on data from 56,276 patients and only 1,756 providers. Whites/Caucasians (37.6%) and Blacks/African Americans (31.5%), followed by Hispanics/Latinos (13.3%), and Asians/Pacific Islanders (4.3%) comprised the majority of the patient sample. The median sample of providers was only 16 for African Americans, 10 for Asians and two for Hispanics. The review presented mixed results. Of the 27 studies, patient–provider race-concordance was associated with positive health outcomes for minorities in only nine studies (33%), while eight studies (30%) found no association of race-concordance with the outcomes studied and 10 (37%) presented mixed findings. Analysis suggested that having a provider of same race did not improve ‘receipt of services’ for minorities. No clear pattern of findings emerged in the domains of healthcare utilization, patient–provider communication, preference, satisfaction, or perception of respect. Conclusions. There is inconclusive evidence to support that patient–provider race-concordance is associated with positive health outcomes for minorities. Studies were limited to four racial/ethnic groups and generally employed small samples of minorities. Further research is needed to understand what health outcomes may be more sensitive to cultural proximity between patients and providers, and what patient, provider and setting-level variables may moderate or mediate these outcomes.

Advancing a National Agenda to Eliminate Disparities in Pain Care: Directions for Health Policy, Education, Practice, and Research

BACKGROUND Pain is strongly associated with significant personal and societal costs. A crucial element of any initiative on pain must focus on eliminating pain care disparities that are pervasive throughout the United States health care settings. OBJECTIVES This report focuses on macro-level factors related to pain care disparities in the United States that may be amenable to policy interventions. METHODS We identify concrete opportunities for achieving equity in pain care, especially those occasioned by recent legislative changes in the United States health care system. An aggressive policy, advocacy, and research agenda is synthesized in five domains: 1) structural/system; 2) policy and advocacy; 3) workforce; 4) provider; and 5) research. RESULTS Inequities in pain care remain an important and neglected health policy concern. Many direct and indirect provisions within the Affordable Care Act (ACA) and other national initiatives that leverage on ACA offer opportunities to achieve equity in pain care. These include changes in insurance, in public, provider, and legislative education, in primary care and pain specialist training, improving workforce diversity, achieving uniformity in race/ethnicity data collection, emphasizing patient-centered outcomes research, and encouraging focus on pain care disparities within the comparative effectiveness research paradigm. CONCLUSIONS Recent national legislative initiatives within ACA are expected to generate multilevel efforts that will impact the flow of funding to address the pervasive issue of disparities. It is an opportune time for the pain community to take a lead in implementing a concerted agenda on pain care disparities in order to leverage these national initiatives.

Corporatization of Pain Medicine: Implications for Widening Pain Care Disparities

The current health care system in the United States is structured in a way that ensures that more opportunity and resources flow to the wealthy and socially advantaged. The values intrinsic to the current profit-oriented culture are directly antithetical to the idea of equitable access. A large body of literature points to disparities in pain treatment and pain outcomes among vulnerable groups. These disparities range from the presence of disproportionately higher numbers and magnitude of risk factors for developing disabling pain, lack of access to primary care providers, analgesics and interventions, lack of referral to pain specialists, longer wait times to receive care, receipt of poor quality of pain care, and lack of geographical access to pharmacies that carry opioids. This article examines the manner in which the profit-oriented culture in medicine has directly and indirectly structured access to pain care, thereby widening pain treatment disparities among vulnerable groups. Specifically, the author argues that the corporatization of pain medicine amplifies disparities in pain outcomes in two ways: 1) directly through driving up the cost of pain care, rendering it inaccessible to the financially vulnerable; and 2) indirectly through an interface with corporate loss-aversion/risk management culture that draws upon irrelevant social characteristics, thus worsening disparities for certain populations. Thus, while financial vulnerability is the core reason for lack of access, it does not fully explain the implications of corporate microculture regarding access. The effect of corporatization on pain medicine must be conceptualized in terms of overt access to facilities, providers, pharmaceuticals, specialty services, and interventions, but also in terms of the indirect or covert effect of corporate culture in shaping clinical interactions and outcomes.

Challenges and Opportunities in Pain Management Disparities Research: Implications for Clinical Practice, Advocacy, and Policy

UNLABELLED Due to high profile initiatives at the national level, awareness of inadequate pain care affecting many groups in our society has never been greater. Nevertheless, increased awareness of pain disparities and the initiatives to address these disparities have yielded only modest progress, most notably in the form of growing appreciation that pain disparities likely result from multiple factors, including biological, psychological, environmental, health system, and cultural factors. Much less progress has been made in developing interventions that target these multiple determinants to reduce pain management disparities. In this paper we discuss key ethical and methodological challenges that undermine our capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Key challenges in the areas of research engagement, recruitment, design, and measurement are discussed from both scientific and normative standpoints. Specific opportunities within emerging research paradigms to improve designs and measures are also discussed. Finally, we conclude with identifying potential synergies between the pain management disparities research agenda and the broader areas of clinical practice, advocacy, and policy that could help to move the field forward. PERSPECTIVE Researchers studying disparities in pain care face a number of ethical and methodological challenges that must be addressed to advance the field towards eliminating disparities. We discuss these ethical and methodological challenges and propose opportunities for paradigmatic revisions in areas of research engagement, design, measurement, advocacy, and policy.

Policy brief: The Institute of Medicine report Dying in America: Improving quality and honoring individual preferences near the end of life

The Institute of Medicines 2014 report Dying in America: Improving quality and honoring individual preferences near the end of life provides recommendations for creating transformational change in the models of end-of-life care delivery, clinician-patient communication, and advance care planning; improving professional education, reforming policies, and payment systems; and engaging and educating the public toward high-quality, coordinated, and comprehensive care that is person centered and family oriented. This article provides a policy brief of this recently released report. The role of nursing in advancing these recommendations is discussed.

African Americans With Cancer Pain Are More Likely to Receive an Analgesic With Toxic Metabolite Despite Clinical Risks: A Mediation Analysis Study

PURPOSE Renal impairment is highly prevalent among patients with cancer, and many patients have undiagnosed chronic kidney disease (CKD) from underlying disease, treatment, or both. African American individuals have disproportionate risk factors (diabetes, hypertension) predisposing them to CKD. We investigated whether African American patients are more likely than white patients to receive morphine with 3- and 6-glucuronide metabolites, which are known to be neurotoxic and accumulate in CKD; whether insurance type mediates the relationship between race and the prescribers opioid selection; and whether the chosen opioid has a resultant negative effect according to race. PATIENTS AND METHODS Patients (N = 182) were recruited from oncology clinics within the University of Pennsylvania Health System. Inclusion was based on self-identified African American or white race, age older than 18 years, and the presence of cancer-related pain plus a prescription for morphine or oxycodone. Kidney function was estimated using the abbreviated Modification of Diet in Renal Disease formula. RESULTS Patients with CKD who received morphine reported a greater severity of analgesic-related adverse effects than patients with CKD who received oxycodone (P = .010). Controlling for health insurance type, African American patients had 71% lower odds of receiving a prescription of oxycodone than white patients (P < .001). Limiting analysis to those with CKD, the effect of private insurance became insignificant. However, race still remained a significant predictor of the prescribed opioid selection. Race was a strong predictor of adverse effect severity in the presence of CKD, and the type of opioid selection partially mediated this relationship. CONCLUSION Reducing racial disparities in the type of opioid prescription and understanding mechanisms of disproportionate opioid-related adverse effects in African American patients might decrease the clinical disparities in cancer pain outcomes.

Attitudes and barriers towards participation in an acupuncture trial among breast cancer patients: a survey study

BackgroundAs breast cancer patients increasingly use complementary and alternative medicine (CAM), clinical trials are needed to guide appropriate clinical use. We sought to identify socio-demographic, clinical and psychological factors related to willingness to participate (WTP) and to determine barriers to participation in an acupuncture clinical trial among breast cancer patients.MethodsWe conducted a cross-sectional survey study among post-menopausal women with stage I-III breast cancer on aromatase inhibitors at an urban academic cancer center.ResultsOf the 300 participants (92% response rate), 148 (49.8%) reported WTP in an acupuncture clinical trial. Higher education (p = 0.001), increased acupuncture expectancy (p < 0.001), and previous radiation therapy (p = 0.004) were significantly associated with WTP. Travel difficulty (p = 0.002), concern with experimentation (p = 0.013), and lack of interest in acupuncture (p < 0.001) were significant barriers to WTP. Barriers differed significantly by socio-demographic factors with white people more likely to endorse travel difficulty (p = 0.018) and non-white people more likely to report concern with experimentation (p = 0.024). Older patients and those with lower education were more likely to report concern with experimentation and lack of interest in acupuncture (p < 0.05).ConclusionsAlthough nearly half of the respondents reported WTP, significant barriers to participation exist and differ among subgroups. Research addressing these barriers is needed to ensure effective accrual and improve the representation of individuals from diverse backgrounds.

Spiritual expressions of African Americans and Whites in cancer pain.

Background: Spiritual practices are one way that individuals cope with cancer pain. Purpose: Describe and contrast expressions and values about the use of spirituality for pain in African American (AA) and White (WH) oncology patients. Methods: Six groups (3 AA; 3 WH; n=42; mean age 58) were conducted. Focus group and qualitative methodology with a cultural interpretive lens was utilized. The Model of Integrated Spirituality provided the conceptual framework for understanding the narratives. Findings: AAs and WHs did not differ on demographics, pain status, or integrative therapies. Three spirituality themes emerged: 1) pain and distress as antecedents to the use of spirituality; 2) active and existential attributes of the use of spirituality; and 3) mobilization of internal and external resources as outcomes. There were commonalities between AAs and WHs but greater frequency of certain subthemes and keywords in AAs. Conclusions: Future studies should examine whether differences in overt expressions translate into different types and levels of spiritual usage. Implications for Practice: Clinicians should recognizing similar as well as different uses and descriptions of spirituality between African Americans and Whites.

Characteristics and Outcomes of Patients Discharged from the Opioid Renewal Clinic at the Philadelphia VA Medical Center

The Opioid Renewal Clinic (ORC) is a pharmacist-run program that assists primary care providers in the management of chronic pain patients with aberrant behavior or high risk of prescription opioid abuse. In this study, charts of all discharged patients over a 22-month span (n = 86) were reviewed for outcomes for two years after discharge. The most frequent reason for discharge from the program was recurrent positive urine drug screens for illicit substances (n = 40; 47%). Only 15 (17%) were seen for addiction treatment in the two-year follow-up period. Forty-one percent of patients (n = 35) were prescribed opioids within two years of discharge. There was a positive correlation between length of time in the ORC and receipt of opioids post discharge. These outcomes reveal areas of need in the management of this complex population.

The use of comorbidities among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature

Objective: To systematically review how comorbidities are employed in the empirical literature for adults coping with multiple chronic conditions during common episodes of acute illness that resulted in transition across health care setting. Methods: Evolutionary concept analysis inductively identifies current consensus regarding the usage of a concept and results in exploring attributes and clarification of the concept. Sixty studies from 1965 to 2009 identified from MEDLINE, CINAHL, PsychINFO, and ISI Web of Science databases were analysed. Results: Comorbidities were used heterogeneously among reviewed studies with most controlling for their presence (n=33) and lacking robust measurement (n=37). The designation of index or principal condition was equally heterogeneous with approximately half (n=26) representing the main disease or diagnosis of interest to the researcher. In this study comorbidities were associated with personal, disease or system level antecedents and consequences. A conceptual framework is proposed. Discussion: The impact of comorbidities on the care and outcomes of adults coping with multiple chronic conditions is limited by heterogeneous and ambiguous usage. While analytic techniques have become more sophisticated, continued lack of meaningful conceptualization and instrument use has limited maturation of this important concept for research, practice and policy purposes.