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Halim A, Zhang D, FitzPatrick S, Fishman F. Professionalism in Hand Surgery: Treating the Noncompliant Patient. J Hand Surg Am 2024; 49:702-705. [PMID: 38713111 DOI: 10.1016/j.jhsa.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/09/2024] [Accepted: 03/09/2024] [Indexed: 05/08/2024]
Abstract
Every practicing hand surgeon has had the challenging experience of treating a patient who demonstrates difficulty with, or inability to comply with medical advice. Patient noncompliance can lead to not only poor patient outcomes but also deterioration in the therapeutic relationship, physician burnout, high cost of care, and medical-legal risk. The guiding principles in the ethical practice of medicine render it important to consider noncompliance as a potentially modifiable risk factor, and every attempt should be made to work with these noncompliant patients to achieve the best possible outcomes. Data suggest that noncompliance may be affected by socioeconomic status and race; many of these patients are among the vulnerable. However, in some instances, treatment options may warrant alteration or adjustment to reflect the noncompliance of the patient. Rarely, it may be reasonable for a physician to discharge a patient from care once any urgent problems have been managed. Ethical and responsible management of a noncompliant patient requires a thoughtful and measured approach.
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Affiliation(s)
- Andrea Halim
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT.
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | | | - Felicity Fishman
- Stritch School of Medicine, Loyola University, Maywood, Chicago, IL
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Anastas T, Wu W, Burgess DJ, Stewart JC, Salyers MP, Kroenke K, Hirsh AT. The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions. THE JOURNAL OF PAIN 2024; 25:104480. [PMID: 38246252 PMCID: PMC11180591 DOI: 10.1016/j.jpain.2024.01.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 01/12/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
Social stereotypes are more likely to influence decision-making under conditions of high cognitive load (ie, mental workload), such as in medical settings. We examined how patient race, patient socioeconomic status (SES), physician cognitive load, and physician implicit beliefs about race and SES differences in pain tolerance impacted physicians' pain treatment decisions. Physician residents and fellows (N = 120) made treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the physicians were randomized to be interrupted during the decision task to make hypertension medication conversion calculations (high cognitive load group), while the other half completed the task without interruptions (low cognitive load group). Both groups were given equal time to make pain care decisions (2.5 minutes/patient). Results of multilevel ordinal logistic regression analyses indicated that physicians prescribed weaker analgesics to patients with high vs. low SES (odds ratio = .68, 95% confidence interval [.48, .97], P = .03). There was also a patient SES-by-cognitive load interaction (odds ratio = .56, 95% confidence interval [.31, 1.01], P = .05) that is theoretically and potentially practically meaningful but was not statistically significant at P < .05. These findings shed light on physician cognitive load as a clinically-relevant factor in the context of pain care quality and equity. PERSPECTIVE: These findings highlight the clinical relevance of physician cognitive load (eg, mental workload) when providing pain care for diverse patients. This line of work can support the development of interventions to manage physician cognitive load and its impact on pain care, which may ultimately help reduce pain disparities.
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Affiliation(s)
- Tracy Anastas
- Department of Psychology, Indiana University Indianapolis
- Department of Psychiatry and Behavioral Sciences, University of Washington
- Department of Family Medicine, University of Washington
| | - Wei Wu
- Department of Psychology, Indiana University Indianapolis
| | - Diana J. Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center
- University of Minnesota Medical School
| | | | | | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine
- Regenstrief Institute, Inc
| | - Adam T. Hirsh
- Department of Psychology, Indiana University Indianapolis
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Flores MW, Sharp A, Lu F, Cook BL. Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System. J Racial Ethn Health Disparities 2024; 11:719-729. [PMID: 36892815 PMCID: PMC9997438 DOI: 10.1007/s40615-023-01555-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.
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Affiliation(s)
- Michael William Flores
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Amanda Sharp
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Center for Mindfulness and Compassion, Cambridge Health Alliance, Cambridge, MA, USA
| | - Frederick Lu
- Boston University School of Medicine, Boston, MA, USA
| | - Benjamin Lê Cook
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Thirukumaran CP, Fiscella KA, Rosenthal MB, Doshi JA, Schloemann DT, Ricciardi BF. Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements. J Am Geriatr Soc 2024; 72:102-112. [PMID: 37772461 PMCID: PMC10841259 DOI: 10.1111/jgs.18605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics – University of Rochester, NY
- Department of Public Health Sciences – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Kevin A. Fiscella
- Department of Public Health Sciences – University of Rochester, NY
- Department of Family Medicine – University of Rochester, NY
| | - Meredith B. Rosenthal
- Department of Health Policy and Management – Harvard T. H. Chan School of Public Health, MA
| | - Jalpa A. Doshi
- Division of General Internal Medicine – University of Pennsylvania Perelman School of Medicine, PA
| | - Derek T. Schloemann
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Benjamin F. Ricciardi
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
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Dore S, Weleff J, Anand A, Thompson NR, Barnett BS. Race, economic status, and disparities in the receipt of benzodiazepine prescriptions in a large primary care sample. Gen Hosp Psychiatry 2023; 85:28-34. [PMID: 37729721 DOI: 10.1016/j.genhosppsych.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE To evaluate the relationship between race, economic status, and patient characteristics with benzodiazepine prescribing in an urban and suburban primary care context. METHOD This retrospective study used data from a previously described cohort of patients seen in a large Ohio healthcare system's primary care clinics from 2019 to 2020. Associations and interactions between race, economic status (using median income of patient ZIP code as a proxy), patient characteristics, and prescription of benzodiazepines were assessed using multivariable logistic regression. RESULTS 455,537 patients had 1,643,473 primary care visits, and 5.8% of patients were prescribed a benzodiazepine. White patients were prescribed benzodiazepines more often than Multiracial/Multicultural, African American and Asian American patients (6.5%, 3.8%, 2.7% and 2.0% respectively). Patients from lower income ZIP codes were less likely to receive a prescription. Interaction effects were observed between race, patient economic status, gender, insurance status, and diagnoses (general anxiety disorder, insomnia, and panic disorder). The largest prescribing disparities by race were among patients with these three diagnoses. The largest disparity in prescription by income was seen in African American patients. CONCLUSION African American, Multicultural/Multiracial and Asian American patients were less likely than White patients to receive benzodiazepine prescriptions. Middle and lower-income patients are particularly susceptible to this prescribing disparity.
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Affiliation(s)
- Samyukta Dore
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland Clinic, Cleveland, OH, USA.
| | - Jeremy Weleff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Akhil Anand
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland Clinic, Cleveland, OH, USA; Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicolas R Thompson
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA; Neurological Institute, Center for Outcomes Research & Evaluation, Cleveland Clinic, Cleveland, OH, USA
| | - Brian S Barnett
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland Clinic, Cleveland, OH, USA; Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Umer A, Garrow J, Nesbitt M, Lilly C, Lefeber C, Breyel J, John C. Prenatal substance use in the rural and Appalachian state: Project WATCH study 2020-2022. J Rural Health 2023; 39:804-815. [PMID: 36823403 DOI: 10.1111/jrh.12752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
PURPOSE To examine the prevalence, patterns, and correlates of prenatal substance use in the rural Appalachian state of West Virginia (WV). METHODS Population-based cohort (Project WATCH) of all women (N = 34,309) who gave birth between February 2020 and June 2022. A composite substance use variable included 9 categories: "no substance use," "opioids," "cannabis," "sedatives/hypnotics," "stimulants," "opioids and cannabis," "opioids and stimulants," "cannabis and stimulants," and "opioids, cannabis, and stimulants." These data were gathered through self-report, medical records, and/or positive drug screen at labor and delivery. FINDINGS 12.4% of women used one or more substances (opioids, cannabis, stimulants, and sedatives/hypnotics) during their current pregnancy. The mean age of women using cannabis was 25.34 (SD = 5.31), stimulants was 28.88 (SD = 5.62), and opioid was 30.19 (SD = 4.78). White women were more likely to use opioids (aOR = 2.19, 95% CI 1.46, 3.28) and less likely to use cannabis (aOR = 0.39, 95% CI 0.34, 0.44) compared to minority racial groups. Women with cannabis use were more likely to live in urban versus rural regions (aOR = 1.47, 95% CI 1.33, 1.62). The odds of using any type of substance(s) were significantly higher in women who smoked (aOR range 4.17-30.85), had Medicaid (aOR range 1.52-7.65), and those receiving inadequate prenatal care (aOR range 1.96-16.83). CONCLUSIONS In this rural Appalachian state, 1 in 8 women used 1 or more substances (opioids, cannabis, stimulants, and/or sedatives/hypnotics) during pregnancy and the type of substance used varied by sociodemographic and health-related factors. These factors should inform state-level strategies and initiatives to address the substance use crisis for this population.
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Affiliation(s)
- Amna Umer
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Jana Garrow
- School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Makena Nesbitt
- Department of Biochemistry and Molecular Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Christa Lilly
- Department of Biostatistics, School of Public Health, West Virginia University, Morgantown, West Virginia, USA
| | - Candice Lefeber
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Janine Breyel
- West Virginia Perinatal Partnership, Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Collin John
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
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Kalmar CL, Zapatero ZD, Kosyk MS, Swanson JW, Taylor JA. Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter? Cleft Palate Craniofac J 2023; 60:1157-1165. [PMID: 35437063 DOI: 10.1177/10556656221093945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To analyze whether the choice of intraoperative local anesthetic for cleft lip repair is associated with the amount of perioperative narcotic utilization. Retrospective cohort study. Hospitals participating in the Pediatric Health Information System. Primary cleft lip repairs performed in the United States from 2010 to 2020. Local anesthesia injected-treatment with lidocaine alone, bupivacaine alone, or treatment with both agents. Perioperative narcotic administration. During the study interval, 8954 patients underwent primary cleft lip repair. Narcotic utilization for unilateral (P < .001) and bilateral (P = .004) cleft lip repair has decreased over the last 5 years. Overall, 21.8% (n = 1950) of infants were administered perioperative narcotics for cleft lip repair, such that 14.3% (n = 1282) required narcotics on POD 0, and 7.2% (n = 647) required narcotics on POD 1.In this study, 36.5% (n = 3269) patients received lidocaine, 22.0% (n = 1966) patients received bupivacaine, and 19.7% (n = 1762) patients received both local anesthetics. Administration of any perioperative narcotic was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P = .001, 17.5% vs 21.7%) or only bupivacaine (P < .001, 17.5% vs 22.9%). Narcotic utilization on the day of surgery was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P < .001, 11.5% vs 15.1%) or only bupivacaine (P = .004, 11.5% vs 14.6%). Narcotic utilization on the first postoperative day was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only bupivacaine (P = .009, 5.9% vs 8.1%). CONCLUSIONS In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.
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Affiliation(s)
- Christopher L Kalmar
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary D Zapatero
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mychajlo S Kosyk
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Essien-Aleksi IE, Zhang Y, Koren A, Palacios N, Falcon LM, Tucker KL. Sociocultural factors associated with persistent prescription opioid use (PPOU) among Puerto Rican adults in Massachusetts. PLoS One 2023; 18:e0290104. [PMID: 37607191 PMCID: PMC10443880 DOI: 10.1371/journal.pone.0290104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 08/01/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Increasing numbers of opioid-overdose deaths have been witnessed among Hispanics and other underserved populations in Massachusetts. Puerto Rican adults (PRs) have a disproportionately higher prevalence of chronic diseases than non-Hispanic White adults-conditions linked to increased prescription opioid use and misuse. Stress indicators, including low acculturation, low social support, and perceived discrimination, have been recognized as correlates of chronic diseases. However, little research has been undertaken on how these socio-cultural factors relate to persistent prescription opioid use among PRs. This study evaluated the prevalence of prescription opioid use and socio-cultural factors associated with persistent prescription opioid use among PRs. METHODS Data from the prospective population-based Boston Puerto Rican Health Study, at baseline, ~2-year, and ~ 6-year follow-up, were used to estimate prescription opioid use prevalence and its associations with acculturation, social support, and perceived discrimination. Analyses were conducted using multivariable binary logistic regression modeling. RESULTS The study sample was comprised of 798 PRs (age 56.5 ± 7.5y) with data at all three-time points. A high prevalence of prescription opioid use was observed and was associated with lower household income. PRs with experiences of perceived discrimination had higher odds of persistent prescription opioid use (y/n; OR = 2.85, 95% CI: 1.46-5.58). No significant associations were found between acculturation, social support, and persistent prescription opioid use. CONCLUSION Our study reported a high prevalence of prescription opioid use in PRs, with persistent prescription opioid use significantly associated with perceived discrimination. Future programs to limit discrimination practices may reduce persistent prescription opioid use and opioid-related complications among PRs.
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Affiliation(s)
- Inyene E. Essien-Aleksi
- School of Nursing and Health Sciences, Merrimack College, North Andover, Massachusetts, United States of America
| | - Yuan Zhang
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts, United States of America
| | - Ainat Koren
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts, United States of America
| | - Natalia Palacios
- Department of Public Health, University of Massachusetts Lowell, Lowell, Massachusetts, United States of America
| | - Luis M. Falcon
- College of Fine Arts, Humanities & Social Sciences, University of Massachusetts Lowell, Lowell, Massachusetts, United States of America
| | - Katherine L. Tucker
- Department of Biomedical & Nutritional Sciences, University of Massachusetts Lowell, Lowell, Massachusetts, United States of America
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Meidert U, Dönnges G, Bucher T, Wieber F, Gerber-Grote A. Unconscious Bias among Health Professionals: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6569. [PMID: 37623155 PMCID: PMC10454622 DOI: 10.3390/ijerph20166569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist. METHODS We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021. RESULTS A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies. CONCLUSIONS Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.
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Affiliation(s)
- Ursula Meidert
- School of Health Sciences, Zurich University of Applied Sciences, Katharina-Sulzer-Platz 9, 8400 Winterthur, Switzerland; (G.D.); (T.B.); (F.W.); (A.G.-G.)
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Ahmed A, McHenry N, Gulati S, Shah I, Sheth SG. Racial and Ethnic Disparities in Opioid Prescriptions for Patients with Abdominal Pain: Analysis of the National Ambulatory Medical Care Survey. J Clin Med 2023; 12:5030. [PMID: 37568432 PMCID: PMC10419480 DOI: 10.3390/jcm12155030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Disparities in pain control have been extensively studied in the hospital setting, but less is known regarding the racial/ethnic disparities in opioid prescriptions for patients with abdominal pain in ambulatory clinics. METHODS We examined opioid prescriptions during visits by patients presenting with abdominal pain between the years of 2006 and 2015, respectively, in the National Ambulatory Medical Care Survey database. Data weights for national-level estimates were applied. RESULTS We identified 4006 outpatient visits, equivalent to 114 million weighted visits. Rates of opioid use was highest among non-Hispanic White patients (12%), and then non-Hispanic Black patients (11%), and was the lowest in Hispanic patients (6%). Hispanic patients had lower odds of receiving opioid prescriptions compared to non-Hispanic White patients (OR = 0.49; 95% CI, 0.31-0.77, p = 0.002) and all non-Hispanic patients (OR 0.48; 95% CI 0.30-0.75; p = 0.002). No significant differences were noted in non-opioid analgesia prescriptions (p = 0.507). A higher frequency of anti-depressants/anti-psychotic prescriptions and alcohol use was recorded amongst the non-Hispanic patients (p = 0.027 and p = 0.001, respectively). CONCLUSIONS Rates of opioid prescriptions for abdominal pain patients were substantially lower for the Hispanic patients compared with the non-Hispanic patients, despite having a decreased rate of high-risk features, such as alcohol use and depression. The root cause of this disparity needs further research to ensure equitable access to pain management.
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Affiliation(s)
- Awais Ahmed
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
| | - Nicole McHenry
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
| | - Shivani Gulati
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
| | - Ishani Shah
- Department of Internal Medicine, Division of Gastroenterology, University of Utah Hospital, 50 N Medical Drive, Salt Lake City, UT 84132, USA
| | - Sunil G. Sheth
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA; (A.A.); (N.M.)
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Liou KT, Ashare R, Worster B, Jones KF, Yeager KA, Acevedo AM, Ferrer R, Meghani SH. SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities. JNCI Cancer Spectr 2023; 7:pkad042. [PMID: 37307074 PMCID: PMC10336300 DOI: 10.1093/jncics/pkad042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023] Open
Abstract
Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine.
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Affiliation(s)
- Kevin T Liou
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rebecca Ashare
- Department of Psychology, State University of New York at Buffalo, Buffalo, NY, USA
| | - Brooke Worster
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Katie F Jones
- Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Amanda M Acevedo
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Rebecca Ferrer
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Science, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Liao D, Kelpinski LF, Guntzviller LM. Using Normative Rhetorical Theory to Identify Dilemmas and Responses in Internal Medicine Patient-Provider Communication. HEALTH COMMUNICATION 2023; 38:1581-1590. [PMID: 34979831 DOI: 10.1080/10410236.2021.2021691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Drawing on normative rhetorical theory (NRT), we examined communication dilemmas that internal medicine residents (IMRs) experience when interacting with patients and responses they adopt to manage these dilemmas. We conducted semi-structured, intensive interviews with 15 IMRs and analyzed the data using the phronetic iterative approach. Findings suggested that IMRs experienced two interpersonal dilemmas: (a) asserting expertise while respecting patients and (b) discussing patient behaviors without indicating deviance. The two dilemmas were more salient for international IMRs who were less familiar with the local culture and embraced a different perspective of the IMR-patient relationship. The two interpersonal dilemmas were connected to a supra-level dilemma of practicing tasks required by evidence-based medicine while being patient-centered. IMRs reported engaging in an interpretive lens to view patients as "people" and communicative responses to manage the dilemmas. By applying NRT to a novel context, our findings demonstrate the impact of macro-level paradigms on IMRs' conflicting purposes in medical encounters and offer practical implications for communication interventions for IMRs.
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Affiliation(s)
- Danni Liao
- Department of Communication, University of Illinois at Urbana-Champaign
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Witkiewitz K, Vowles KE. Everybody Hurts: Intersecting and Colliding Epidemics and the Need for Integrated Behavioral Treatment of Chronic Pain and Substance Use. CURRENT DIRECTIONS IN PSYCHOLOGICAL SCIENCE 2023; 32:228-235. [PMID: 37645017 PMCID: PMC10465109 DOI: 10.1177/09637214231162366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Chronic pain and substance use disorders are both common, debilitating, and often persist over the longer term. On their own, each represents a significant health problem, with estimates indicating a substantial proportion of the adult population has chronic pain or a substance use disorder (SUD), and their co-occurrence is increasing. Chronic pain and SUD are also both often invisible, stigmatized disorders and persons with both regularly have difficulty accessing evidence-based treatments, particularly those that offer coordinated and integrated treatment for both conditions. But there is hope. Research is unraveling the mechanisms of chronic pain and substance use, as well as their co-occurrence, integrated behavioral treatment options based on acceptance- and mindfulness-based approaches are increasingly being developed and tested, government agencies are devoting more funds and resources to increase research on chronic pain and SUD, and there have been growing efforts in training, dissemination, and implementation of evidence-based treatments. At the very heart of the matter, though, is to recognize that everybody hurts sometimes, and treatments must empower people to life effectively with these experiences of being human.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology and Center on Alcohol, Substance use, And Addictions University of New Mexico
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Lichtl A, Casaw C, Edwards J, Popkin K, Yu J, Li QS, Cadwell M, Mao JJ, Liou KT. Music Therapy for Pain in Black and White Cancer Patients: A Retrospective Study. J Pain Symptom Manage 2022; 64:478-485. [PMID: 35870654 PMCID: PMC9588734 DOI: 10.1016/j.jpainsymman.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Racial pain disparities present challenges to cancer symptom management. Music therapy has demonstrated benefits for pain and is a promising treatment option for diverse populations due to music's multicultural presence. However, Black cancer patients are under-represented in music therapy trials. OBJECTIVES This study compared pain severity, treatment approaches, and responses to music therapy between Black and white cancer patients. The findings will be used to generate hypotheses for future music therapy research to address racial disparities in pain management. METHODS We conducted a retrospective program evaluation of Black and white patients who received music therapy at an NCI-Designated Comprehensive Cancer Center. We used the Edmonton Symptom Assessment Scale (ESAS) to assess pain. We abstracted opioid use, music therapy referral reasons, and treatment approaches from the electronic health record. RESULTS Among 358 patients, 18% were Black, 42% reported moderate-to-severe pain, and 47% received opioids. Black patients reported higher baseline pain than white patients, but similar proportions of Black and white patients received opioids. Greater proportions of Black patients received music therapy referrals for pain (73% vs. 56%, P = 0.04) and engaged in active techniques (92% vs. 82%, P = 0.04). Black and white patients reported clinically meaningful pain reduction of similar magnitude after music therapy. Black patients discussed spirituality more commonly during music therapy, whereas white patients focused on family bonds. CONCLUSION Black and white patients reported clinically meaningful pain reduction through varying music therapy approaches. Our findings may help inform cultural adaptations of music therapy to address racial pain disparities in oncology.
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Affiliation(s)
- Alexandria Lichtl
- New York University Grossman School of Medicine (A.L.), New York, NY, USA
| | - Camila Casaw
- Integrative Medicine Service, Department of Medicine (C.C., K.P., J.Y., Q.S.L., M.C., J.J.M., K.T.L.), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jasmine Edwards
- Steinhardt School of Culture, Education, and Human Development (J.E.), New York University, New York, NY, USA
| | - Karen Popkin
- Integrative Medicine Service, Department of Medicine (C.C., K.P., J.Y., Q.S.L., M.C., J.J.M., K.T.L.), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jennifer Yu
- Integrative Medicine Service, Department of Medicine (C.C., K.P., J.Y., Q.S.L., M.C., J.J.M., K.T.L.), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Qing S Li
- Integrative Medicine Service, Department of Medicine (C.C., K.P., J.Y., Q.S.L., M.C., J.J.M., K.T.L.), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Malik Cadwell
- Integrative Medicine Service, Department of Medicine (C.C., K.P., J.Y., Q.S.L., M.C., J.J.M., K.T.L.), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jun J Mao
- Integrative Medicine Service, Department of Medicine (C.C., K.P., J.Y., Q.S.L., M.C., J.J.M., K.T.L.), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin T Liou
- Integrative Medicine Service, Department of Medicine (C.C., K.P., J.Y., Q.S.L., M.C., J.J.M., K.T.L.), Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Murosko D, Paul K, Barfield WD, Montoya-Williams D, Parga-Belinkie J. Equity in Policies Regarding Urine Drug Testing in Infants. Neoreviews 2022; 23:788-795. [PMID: 36316251 PMCID: PMC10044569 DOI: 10.1542/neo.23-10-e788] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We are thrilled to introduce a new series, “EDI case series,” focused on examining and eliminating inequities in the neonatal health care setting. Disparities in birth outcomes for non-white infants have been recognized for decades, but solutions to close this gap remain elusive. We, at NeoReviews , believe that discussions about disparities and inequities in health care, lack of representation, and unconscious bias are an essential first step toward enacting actionable change at the institution level and the health care system level. We want to use our platform to disseminate educational content and ignite discussion and change. This innovative series was envisioned by Drs Kathryn Paul, Daria Murosko, Joanna Parga-Belinkie, and Diana Montoya-Williams, who have used this series in a conference-based format within their own institution. In collaboration with this inspiring team, we have adapted this to a written format in an effort to reach a wider multidisciplinary audience caring for neonates. In this case-based series, authors aim to:Review key literature Invite expert opinions Define terminology related to health inequities Provide tools and methods for readers to translate this new knowledge to foster change in their care practices and own institutions
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Nikpour J, Broome M, Silva S, Allen KD. Patient demographics and clinical characteristics influence opioid and nonopioid pain management prescriptions of primary care NPs, PAs, and physicians. J Am Assoc Nurse Pract 2022; 34:883-890. [PMID: 35544348 PMCID: PMC10201565 DOI: 10.1097/jxx.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evidence exists on racial and gender disparities in chronic pain management among veterans. Most literature has described physicians' disparate opioid prescribing patterns, although it is unknown if prescribing disparities exist among nurse practitioners (NPs) and physician assistants (PAs) or among prescription of nonopioid analgesic strategies. PURPOSE To identify patient characteristics associated with opioid and nonopioid prescriptions among Veterans Affairs (VA) chronic pain patients by primary care physicians, NPs, and PAs. METHODOLOGY We used data from the VA's Survey of Health care Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Outcomes included opioid and nonopioid analgesic prescriptions. Patient characteristics included race/ethnicity, gender, education level, age, and clinical characteristics (comorbidities, self-reported health, and self-reported mental health). Logistic regression was performed to test for associations of patient characteristics with outcomes. RESULTS Patients who were White, male, age 41-64 years, and with no postsecondary education had higher odds of receiving an opioid prescription (all p -values ≤ .01), whereas patients who were Black, female, and <65 years old had higher odds of a nonopioid prescription (all p -values < .01). Having 5+ comorbidities and fair/poor self-reported health increased the odds of opioid and nonopioid prescriptions (all p -values < .01). CONCLUSIONS Disparities in race, gender, and educational level significantly affect how primary care NPs, PAs, and physicians manage chronic pain. IMPLICATIONS NPs and other primary care providers should pursue training opportunities to identify and mitigate potential biases that may affect their practice. Future research should take an intersectional lens in examining the source of chronic pain disparities.
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Affiliation(s)
- Jacqueline Nikpour
- University of Pennsylvania School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Marion Broome
- Duke University School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Susan Silva
- Duke University School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Kelli D. Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
- School of Medicine, University of North Carolina-Chapel Hill
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Kim K, Xu W, Hong SJ, Starkweather A, Brown RF, Walsh S. Perceived discrimination and physical activity mediate the associations between receiving a survivorship care plan and cancer pain. Cancer Epidemiol 2022; 78:102155. [DOI: 10.1016/j.canep.2022.102155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022]
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Grant AD, Miller MM, Anastas TM, Quinn P, Lok B, Hirsh AT. Opioid-related risk perceptions in chronic pain: influence of patient gender and previous misuse behaviors. Pain 2022; 163:711-718. [PMID: 34285152 PMCID: PMC8761212 DOI: 10.1097/j.pain.0000000000002412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
ABSTRACT Little is known about the factors that influence providers' perceptions of patient risk for aberrant opioid use. Patient gender may interact with previous opioid misuse to influence these perceptions. We asked 131 physicians to view videos and vignettes for 8 virtual patients with chronic pain. Gender (male/female) and previous prescription opioid misuse (present/absent) varied across patients; the vignettes were otherwise balanced on demographic and clinical characteristics. For each patient, providers assessed 4 risk domains: opioid-related adverse events, opioid misuse or abuse, opioid addiction, and opioid diversion. Results indicated a significant gender-by-misuse interaction for risk of opioid misuse orabuse. When previous misuse behaviors were absent, providers rated men at higher risk; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid-related adverse events. Providers perceived men to be at higher risk when previous misuse behaviors were absent; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid addiction. Providers rated women at higher risk when previous misuse behaviors were present and men at higher risk when previous misuse behaviors were absent. There were significant main effects of gender and misuse for risk of opioid diversion. Providers rated men and those with previous misuse behaviors at higher risk. These results demonstrate that patient gender and previous opioid misuse have unique and interactive effects on provider perceptions of prescription opioid-related risks. Studies are needed to identify the mechanisms underlying these effects, such as gender-based stereotypes about risk-taking and drug abuse.
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Affiliation(s)
- Alexis D. Grant
- Department of Psychology, Indiana University-Purdue University Indianapolis
| | - Megan M. Miller
- Department of Psychology, Indiana University-Purdue University Indianapolis
| | - Tracy M. Anastas
- Department of Psychology, Indiana University-Purdue University Indianapolis
| | - Patrick Quinn
- School of Public Health, Indiana University Bloomington
| | - Benjamin Lok
- Department of Computer and Information Science and Engineering, University of Florida
| | - Adam T. Hirsh
- Department of Psychology, Indiana University-Purdue University Indianapolis
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Evaluating disparities in prescribing of naloxone after emergency department treatment of opioid overdose. J Subst Abuse Treat 2022; 139:108785. [PMID: 35537918 PMCID: PMC9187615 DOI: 10.1016/j.jsat.2022.108785] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/26/2022] [Accepted: 04/24/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Patients who initially survive opioid-related overdose are at high risk for subsequent mortality. Our health system aimed to evaluate the presence of disparities in prescribing naloxone following opioid overdose. METHODS This was a retrospective cohort study of patients seen in our health system, which comprises two academic centers and eight community hospitals. Eligible patients had at least one visit to any of our hospital's emergency departments (EDs) with a diagnosis code indicating opioid-related overdose between May 1, 2018, and April 30, 2021. The primary outcome measure was prescription of nasal naloxone after at least one visit for opioid-related overdose during the study period. RESULTS The health system had 1348 unique patients who presented 1593 times to at least one of the EDs with opioid overdose. Of included patients, 580 (43.2%) received one or more prescriptions for naloxone. The majority (68.9%, n = 925) were male. For race/ethnicity, 74.5% (1000) were Non-Hispanic White, 8.0% (n = 108) were Non-Hispanic Black, and 13.0% (n = 175) were Hispanic/Latinx. Compared with the reference age group of 16-24 years, only those 65+ were less likely to receive naloxone (adjusted odds ratio [aOR] 0.41, 95% confidence interval [CI] 0.20-0.84). The study found no difference for gender (male aOR 1.23, 95% CI 0.97-1.57 compared to female). Hispanic/Latinx patients were more likely to receive a prescription when compared to Non-Hispanic White patients (aOR 1.72, 95% CI 1.22-2.44), while no difference occurred between Non-Hispanic Black compared to Non-Hispanic White patients (aOR 1.31, 95% CI 0.87-1.98). CONCLUSIONS Naloxone prescribing after overdose in our system was suboptimal, with fewer than half of patients with an overdose diagnosis code receiving this lifesaving and evidence-based intervention. Patients who were Hispanic/Latinx were more likely to receive naloxone than other race and ethnicity groups, and patients who were older were less likely to receive it. Health systems need ongoing equity-informed implementation of programs to expand access to naloxone to all patients at risk.
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Jones KF, Laury E, Sanders JJ, Starr LT, Rosa WE, Booker SQ, Wachterman M, Jones CA, Hickman S, Merlin JS, Meghani SH. Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans. J Palliat Med 2022; 25:479-487. [PMID: 34788577 PMCID: PMC9022452 DOI: 10.1089/jpm.2021.0502] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Racial disparities, including decreased hospice utilization, lower quality symptom management, and poor-quality end-of-life care have been well documented in Black Americans. Improving health equity and access to high-quality serious illness care is a national palliative care (PC) priority. Accomplishing these goals requires clinician reflection, engagement, and large-scale change in clinical practice and health-related policies. In this article, we provide an overview of key concepts that underpin racism in health care, discuss common serious illness disparities in Black Americans, and propose steps to promote the delivery of antiracist PC.
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Affiliation(s)
| | - Esther Laury
- Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA.,Address correspondence to: Esther Laury, PhD, RN, Merck Sharp & Dohme Corp., US Outcomes Research, 351 N. Sumneytown Pike, North Wales, PA 19454, USA
| | - Justin J. Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren T. Starr
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Staja Q. Booker
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | - Melissa Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Christopher A. Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Eze B, Kumar S, Yang Y, Kilcoyne J, Starkweather A, Perry MA. Bias in Musculoskeletal Pain Management and Bias-Targeted Interventions to Improve Pain Outcomes: A Scoping Review. Orthop Nurs 2022; 41:137-145. [PMID: 35358134 PMCID: PMC9154307 DOI: 10.1097/nor.0000000000000833] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Bias in healthcare negatively impacts disparities in care, treatment, and outcomes, especially among minority populations. A scoping review of the literature was performed to provide a deeper understanding of how bias influences musculoskeletal pain and potential effects of bias-targeted interventions on reducing pain disparities, as well as identify gaps and make suggestions for further research in this area. Publications from peer-reviewed journals were searched using the databases PubMed/MEDLINE, PsycINFO, CINAHL, and Scopus, with 18 studies identified. The literature review revealed that clinician-based bias and discrimination worsen pain and disability by reducing access to treatment and increasing patient pain-related injustice, catastrophizing, depression, and perceived stress. In contrast, clinician education and perspective-taking, patient decision tools, and community outreach interventions can help reduce bias and disparities in musculoskeletal pain outcomes. Increasing the diversity of the healthcare workforce should also be a priority. Models of care focused on health equity may provide an ideal framework to reduce bias and provide sustainable improvement in musculoskeletal pain management.
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Affiliation(s)
- Bright Eze
- Bright Eze, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Sumanya Kumar, BS, Research Assistant, University of Connecticut School of Medicine, Storrs, CT
- Yuxuan Yang, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Jason Kilcoyne, BS, Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Angela Starkweather, PhD, ACNP-BC, CCRN, FAANP, FAAN, Professor, Associate Dean for Academic Affairs, University of Connecticut School of Nursing, Storrs, CT
- Mallory A. Perry, PhD, RN, CCRN, Postdoctoral Fellow, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Sumanya Kumar
- Bright Eze, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Sumanya Kumar, BS, Research Assistant, University of Connecticut School of Medicine, Storrs, CT
- Yuxuan Yang, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Jason Kilcoyne, BS, Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Angela Starkweather, PhD, ACNP-BC, CCRN, FAANP, FAAN, Professor, Associate Dean for Academic Affairs, University of Connecticut School of Nursing, Storrs, CT
- Mallory A. Perry, PhD, RN, CCRN, Postdoctoral Fellow, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Yuxuan Yang
- Bright Eze, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Sumanya Kumar, BS, Research Assistant, University of Connecticut School of Medicine, Storrs, CT
- Yuxuan Yang, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Jason Kilcoyne, BS, Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Angela Starkweather, PhD, ACNP-BC, CCRN, FAANP, FAAN, Professor, Associate Dean for Academic Affairs, University of Connecticut School of Nursing, Storrs, CT
- Mallory A. Perry, PhD, RN, CCRN, Postdoctoral Fellow, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Jason Kilcoyne
- Bright Eze, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Sumanya Kumar, BS, Research Assistant, University of Connecticut School of Medicine, Storrs, CT
- Yuxuan Yang, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Jason Kilcoyne, BS, Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Angela Starkweather, PhD, ACNP-BC, CCRN, FAANP, FAAN, Professor, Associate Dean for Academic Affairs, University of Connecticut School of Nursing, Storrs, CT
- Mallory A. Perry, PhD, RN, CCRN, Postdoctoral Fellow, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Angela Starkweather
- Bright Eze, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Sumanya Kumar, BS, Research Assistant, University of Connecticut School of Medicine, Storrs, CT
- Yuxuan Yang, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Jason Kilcoyne, BS, Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Angela Starkweather, PhD, ACNP-BC, CCRN, FAANP, FAAN, Professor, Associate Dean for Academic Affairs, University of Connecticut School of Nursing, Storrs, CT
- Mallory A. Perry, PhD, RN, CCRN, Postdoctoral Fellow, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Mallory A Perry
- Bright Eze, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Sumanya Kumar, BS, Research Assistant, University of Connecticut School of Medicine, Storrs, CT
- Yuxuan Yang, BS, RN, Graduate Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Jason Kilcoyne, BS, Research Assistant, University of Connecticut School of Nursing, Storrs, CT
- Angela Starkweather, PhD, ACNP-BC, CCRN, FAANP, FAAN, Professor, Associate Dean for Academic Affairs, University of Connecticut School of Nursing, Storrs, CT
- Mallory A. Perry, PhD, RN, CCRN, Postdoctoral Fellow, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
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Penn JA, Newman-Griffis D. Half the picture: Word frequencies reveal racial differences in clinical documentation, but not their causes. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2022:386-395. [PMID: 35854748 PMCID: PMC9285139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Clinical notes are the best record of a provider's perceptions of their patients, but their use in studying racial bias in clinical documentation has typically been limited to manual evaluation of small datasets. We investigated the use of computational methods to scale these insights to large, heterogeneous clinical text data. We found significant differences in negative emotional tone and language implying social dominance in clinical notes between Black and White patients, but identified multiple contributing factors in addition to potential provider bias, including mis-categorization of some healthcare vocabulary as emotion-related. We further found that notes for Black patients were significantly less likely to mention opioids than for White patients, potentially reflecting both inequitable access to medication and provider bias. Our analysis showed that computational tools have significant potential for studying racial bias in large clinical corpora, and identified key challenges to providing a nuanced analysis of bias in clinical documentation.
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When treatment algorithms fail: A response to the development of a nomogram to determine the frequency of elevated risk for non-medical opioid use in cancer patients. Palliat Support Care 2021; 19:636-637. [PMID: 34676813 DOI: 10.1017/s1478951521001255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Dalton MK, Manful A, Jarman MP, Pisano AJ, Learn PA, Koehlmoos TP, Weissman JS, Cooper Z, Schoenfeld AJ. Long-term prescription opioid use among US military service members injured in combat. J Trauma Acute Care Surg 2021; 91:S213-S220. [PMID: 34324474 DOI: 10.1097/ta.0000000000003133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION During the Global War on Terrorism, many US Military service members sustained injuries with potentially long-lasting functional limitations and chronic pain. We sought to understand the patterns of prescription opioid use among service members injured in combat. METHODS We queried the Military Health System Data Repository to identify service members injured in combat between 2007 and 2011. Sociodemographics, injury characteristics, treatment information, and costs of care were abstracted for all eligible patients. We surveyed for prescription opioid utilization subsequent to hospital discharge and through 2018. Negative binomial regression was used to identify factors associated with cumulative prescription opioid use. RESULTS We identified 3,981 service members with combat-related injuries presenting during the study period. The median age was 24 years (interquartile range [IQR], 22-29 years), 98.5% were male, and the median follow-up was 3.3 years. During the study period, 98% (n = 3,910) of patients were prescribed opioids at least once and were prescribed opioids for a median of 29 days (IQR, 9-85 days) per patient-year of follow-up. While nearly all patients (96%; n = 3,157) discontinued use within 6 months, 91% (n = 2,882) were prescribed opioids again after initially discontinuing opioids. Following regression analysis, patients with preinjury opioid exposure, more severe injuries, blast injuries, and enlisted rank had higher cumulative opioid use. Patients who discontinued opioids within 6 months had an unadjusted median total health care cost of US $97,800 (IQR, US $42,364-237,135) compared with US $230,524 (IQR, US $134,387-370,102) among those who did not discontinue opioids within 6 months (p < 0.001). CONCLUSION Nearly all service members injured in combat were prescribed opioids during treatment, and the vast majority experienced multiple episodes of prescription opioid use. Only 4% of the population met the criteria for sustained prescription opioid use at 6 months following discharge. Early discontinuation may not translate to long-term opioid cessation in this population. LEVEL OF EVIDENCE Epidemiology study, level III.
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Affiliation(s)
- Michael K Dalton
- From the Center for Surgery and Public Health, Department of Surgery (M.K.D., A.M., M.P.J., J.S.W., Z.C., A.J.S.) and Department of Orthopedic Surgery (A.J.P., A.J.S.), Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (P.A.L.) and Department of Preventive Medicine and Biostatistics (T.P.K.), F. Edward Hébert School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
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Engel-Rebitzer E, Dolan AR, Aronowitz SV, Shofer FS, Nguemeni Tiako MJ, Schapira MM, Perrone J, Hess EP, Rhodes KV, Bellamkonda VR, Cannuscio CC, Goldberg E, Bell J, Rodgers MA, Zyla M, Becker LB, McCollum S, Meisel ZF. Patient Preference and Risk Assessment in Opioid Prescribing Disparities: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2118801. [PMID: 34323984 PMCID: PMC8322998 DOI: 10.1001/jamanetworkopen.2021.18801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. OBJECTIVE To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. DESIGN, SETTING, AND PARTICIPANTS This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. INTERVENTIONS The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. MAIN OUTCOMES AND MEASURES Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. RESULTS Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. CONCLUSIONS AND RELEVANCE In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03134092.
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Affiliation(s)
- Eden Engel-Rebitzer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Abby R. Dolan
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Frances S. Shofer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Max Jordan Nguemeni Tiako
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Yale School of Medicine, New Haven, Connecticut
| | - Marilyn M. Schapira
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of General and Internal Medicine, University of Pennsylvania, Philadelphia
| | - Jeanmarie Perrone
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Penn Center for Addiction Medicine and Policy, Philadelphia, Pennsylvania
| | - Erik P. Hess
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karin V. Rhodes
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Venkatesh R. Bellamkonda
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Carolyn C. Cannuscio
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia
| | - Erica Goldberg
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Jeffrey Bell
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Melissa A. Rodgers
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- College of Education, University of Texas at Austin, Austin
| | - Michael Zyla
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Lance B. Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Sharon McCollum
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Zachary F. Meisel
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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