Pain outcomes of inpatient pain and palliative care consultations: differences by race and diagnosis

Sociodemographic and Clinical Characteristics Associated With Worst Pain Intensity Among Cancer Patients

AIMS

Patients with cancer have pain due to their cancer, the cancer treatment and other causes, and the pain intensity varies considerably between individuals. Additional research is needed to understand the factors associated with worst pain intensity. Our study aim was to determine the association between worst pain intensity and sociodemographics and cancerspecific factors among patients with cancer.

DESIGN

A total of 1,280 patients with cancer recruited from multiple cancer centers over 25 years in the United States were asked to complete a questionnaire that collected respondents' demographic, chronic pain, and cancer-specific information.

SETTINGS

Worst, least, and current pain intensities were captured using a modified McGill Pain Questionnaire (pain intensity measured on 0-10 scale). A generalized linear regression analysis was utilized to assess the associations between significant bivariate predictors and worst pain intensity scores.Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain.

CONCLUSIONS

Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain. Findings identified being Hispanic and having previous severe toothache, stomachache, and headache pain as significant predictors of worst pain intensity among patients with cancer. After controlling for selected covariates, we did not note statistical differences in worst pain during a 25-year period. Therefore,studies focused on improving the management of pain among patients with cancer should target interventions for those with Hispanic heritage and those with past history of severe common pain.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries

BACKGROUND

Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups.

METHODS

Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed.

RESULTS

Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping.

CONCLUSIONS

There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns.

TRIAL REGISTRATION

PROSPERO- CRD42020167890 .

Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives

Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations.

PURPOSE

To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer.

METHODS

Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists.

RESULTS

Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues.

CONCLUSION

Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.

Identifying Opportunities to Improve Pain Among Patients With Serious Illness

CONTEXT

Pain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams.

OBJECTIVE

Identify characteristics associated with pain and pain improvement among inpatients referred to PC.

METHODS

Thirty-eight inpatient PC teams in the Palliative Care Quality Network entered data about patients seen between December 12, 2012 and March 15, 2016. We examined patient and care characteristics associated with pain and pain improvement.

RESULTS

Of patients who could self-report symptoms, 30.7% (4959 of 16,158) reported moderate-to-severe pain at first assessment. Over 40% of these patients had not been referred to PC for pain. Younger patients (P < 0.0001), women (P < 0.0001), patients with cancer (P < 0.0001), and patients in medical/surgical units (P < 0.0001) were more likely to report pain. Patients with pain had higher rates of anxiety (P < 0.0001), nausea (P < 0.0001), and dyspnea (P < 0.0001). Sixty-eight percent of patients with moderate-to-severe pain improved by the PC team's second assessment within 72 hours; 74.7% improved by final assessment. There was a significant variation in the rate of pain improvement between PC teams (P < 0.0001). Improvement in pain was associated with improvement in anxiety (OR = 2.9, P < 0.0001) and dyspnea (OR = 1.4, P = 0.03). Patients who reported an improvement in pain had shorter hospital length-of-stay by two days (P = 0.003).

CONCLUSION

Pain is common among inpatients referred to PC. Three-quarters of patients with pain improve and improvement in pain is associated with other symptom improvement. Standardized, multisite data collection can identify PC patients likely to have marked and refractory pain, create benchmarks for the field, and identify best practices to inform quality improvement.

Impact of Race/Ethnicity on Pain Management Outcomes in a Community-Based Teaching Hospital Following Inpatient Palliative Care Consultation

Objective

To examine race/ethnicity differences in pain management outcomes following inpatient palliative care consultation.

Methods

We conducted a retrospective study based on data from a community-based teaching hospital in Fresno, CA, USA, from April 2014 to July 2015. One hundred sixty-one patients with life-limiting diagnoses and palliative care pain-related consultations were included. The patients were categorized into four racial groups: Caucasians, African-Americans, Hispanics, and Asians/Others. Demographics and baseline pain scores using the Visual Analogue Scale (VAS) were obtained. The outcome measures included the length of stay, time to consult, and pain scores at admission, 24 hours before the consultation, 24–48 hours after consultation, and at discharge.

Results

The initial median pain scores were not significantly different between the groups, however, the Asians had slightly higher pain scores compared to the other groups. African-Americans, Caucasians, and Hispanics had significant differences in pain outcomes after consultation compared to 24 hours prior to consultation (p = 0.01, p < 0.01 and p = 0.02, respectively). Caucasians and Hispanics had significant differences in pain outcomes after palliative consultation compared to initial admission assessment (p < 0.01). The differences between discharge and admission pain scores were significant only for Asians, Caucasians, and Hispanics (p = 0.04, p < 0.01, p < 0.01, respectively) but not African-Americans. There were no significant pain score differences across the racial groups following consultations.

Conclusion

There were no significant differences in pain reduction amongst the racial groups, suggesting that pain can adequately be managed in individual racial groups after inpatient palliative care consultations.

What's the Plan? Needing Assistance with Plan of Care Is Associated with In-Hospital Death for ICU Patients Referred for Palliative Care Consultation

To inform earlier identification of intensive care unit (ICU) patients needing palliative care, we examined factors associated with in-hospital death among ICU patients (N=260) receiving palliative care consultations at a 542-bed tertiary care hospital (2005-2009). High pre-consultation length of stay (LOS, ≥7 days) (adjusted odds ratio (aOR)=5.0, 95% confidence interval (95% CI)=2.5-9.9, P<.01) and consultations for assistance with plan of care (aOR=11.6, 95% CI=5.6-23.9, P<.01) were independently associated with in-hospital death. Patients with both consultation for plan of care and high pre-consult LOS had the highest odds of in-hospital death (aOR=36.3, 95% CI=14.9-88.5, P<.001), followed by patients with consultation for plan of care and shorter pre-consult LOS (aOR=9.8, 95% CI=4.3-22.1, P<.001), and patients with long pre-consult LOS but no consultation for plan of care (aOR=4.7, 95% CI=1.8-12.4, P=.002). Our findings suggest that ICU patients who require assistance with plan of care need to be identified early to optimize end-of-life care and avoid in-hospital death.

Web-based collaborative care intervention to manage cancer-related symptoms in the palliative care setting

BACKGROUND

The aim of this study was to examine the efficacy of a collaborative care intervention in reducing depression, pain, and fatigue and improve quality of life.

METHODS

A total of 261 patients with advanced cancer and 179 family caregivers were randomized to a web-based collaborative care intervention or enhanced usual care. The intervention included the following: 1) a web site with written and audiovisual self-management strategies, a bulletin board, and other resources; 2) visits with a care coordinator during a physician's appointment every 2 months; and 3) telephone follow-up every 2 weeks. Primary patient outcomes included measures of depression, pain, fatigue, and health-related quality of life. Secondary outcomes included Interleukin (IL)-1α, IL-1β, IL-6, and IL-8 levels, Natural Killer (NK) cell numbers, and caregiver stress and depression.

RESULTS

At the baseline, 51% of the patients reported 1 or more symptoms in the clinical range. For patients who presented with clinical levels of symptoms and were randomized to the intervention, reductions in depression (Cohen's d = 0.71), pain (Cohen's d = 0.62), and fatigue (Cohen's d = 0.26) and improvements in quality of life (Cohen's d = 0.99) were observed when compared to those in the enhanced usual car arm at 6 months. Reductions in IL-6 (φ = 0.18), IL-1β (φ = 0.35), IL-1α (φ = 0.19), and IL-8 (φ = 0.15) and increases in NK cell numbers (φ = 0.23) were observed in comparison with enhanced usual care arm at 6 months. Reductions in caregiver stress (Cohen's d = 0.75) and depression (Cohen's d = 0.37) were observed at 6 months for caregivers whose loved ones were randomized to the intervention arm.

CONCLUSIONS

The integration of screening and symptom management into cancer care is recommended.

Non-pharmacological cancer pain interventions in populations with social disparities: a systematic review and meta-analysis

INTRODUCTION

Global advances in pain relief have improved the quality of life of cancer populations. Yet, variation in cancer pain outcomes has been found in populations with social disparities compared to mainstream groups. Populations with social disparities bear an inequitable distribution of resources such as ethnic minorities, low income individuals, and women in vulnerable circumstances.

RESEARCH PURPOSE

A systematic review and meta-analysis of the effect of non-pharmacological cancer pain interventions in cancer populations with social disparities of income, ethnicity, or gender.

METHODS

Randomized controlled trials, controlled trials, and before and after studies were targeted through comprehensive multidatabase searches. Two reviewers independently screened titles/abstracts for potentially relevant studies and reviewed the full text of relevant articles for inclusion. Data were extracted from included studies by one reviewer and verified by another reviewer. Four reviewers independently completed quality assessment. Studies were grouped by intervention. Effects were evaluated for heterogeneity and pooled.

RESULTS

The search found 5219 potential records. Full text of 26 reports was evaluated. Three randomized controlled trials (RCTs) met inclusion criteria, targeting ethnic minorities and underserved populations and/or women. Interventions included education, coaching, and online support groups. Studies found no significant differences in pain reduction between intervention and control groups or between ethnic minorities and their counterparts. A high risk of bias was found in all studies. Meta-analysis found no statistically significant difference on pain intensity among underserved groups, ethnic minorities, or between ethnic minorities and white counterparts.

CONCLUSION

Results show the need to examine supportive care interventions particularly in populations with social disparities.

Non-pharmacological cancer pain interventions in populations with social disparities: a systematic review and meta-analysis

INTRODUCTION

Global advances in pain relief have improved the quality of life of cancer populations. Yet, variation in cancer pain outcomes has been found in populations with social disparities compared to mainstream groups. Populations with social disparities bear an inequitable distribution of resources such as ethnic minorities, low income individuals, and women in vulnerable circumstances.

RESEARCH PURPOSE

A systematic review and meta-analysis of the effect of non-pharmacological cancer pain interventions in cancer populations with social disparities of income, ethnicity, or gender.

METHODS

Randomized controlled trials, controlled trials, and before and after studies were targeted through comprehensive multidatabase searches. Two reviewers independently screened titles/abstracts for potentially relevant studies and reviewed the full text of relevant articles for inclusion. Data were extracted from included studies by one reviewer and verified by another reviewer. Four reviewers independently completed quality assessment. Studies were grouped by intervention. Effects were evaluated for heterogeneity and pooled.

RESULTS

The search found 5219 potential records. Full text of 26 reports was evaluated. Three randomized controlled trials (RCTs) met inclusion criteria, targeting ethnic minorities and underserved populations and/or women. Interventions included education, coaching, and online support groups. Studies found no significant differences in pain reduction between intervention and control groups or between ethnic minorities and their counterparts. A high risk of bias was found in all studies. Meta-analysis found no statistically significant difference on pain intensity among underserved groups, ethnic minorities, or between ethnic minorities and white counterparts.

CONCLUSION

Results show the need to examine supportive care interventions particularly in populations with social disparities.

Just ask: hospice familiarity in Asian and Hispanic adults

CONTEXT

Previous research documents the under-utilization of hospice services by minority ethnic groups, but less data exist for Asian and Hispanic Americans. It is unclear whether these low utilization rates are a result of attitudinal or information barriers, or both.

OBJECTIVES

To examine self-reported familiarity and attitudes toward hospice among Asian and Hispanic groups in ethnically diverse Queens County, NY.

METHODS

We surveyed diverse adults during health fairs, at senior centers, and church programs directed at ethnic populations. Respondents completed surveys in their preferred language: Spanish, Chinese (Mandarin), and Korean. Analysis of variance was used to compare continuous variables among language groups; Fisher's exact test compared categorical variables.

RESULTS

A total of 604 community adults were surveyed: 99 Chinese, 349 Korean, 156 Spanish. Respondents were mostly female, average age 53 years. Familiarity with hospice varied significantly among the groups (P < 0.001) and was lower in the Hispanic (16%) and higher in the Chinese (45%) and Korean (56%) groups. Personal experiences with hospice were low (8-16%) in all groups. A majority (75-94%) responded they would share hospice information with loved ones, but the Hispanic group was significantly less likely to do so compared with Chinese and Korean Americans. Between 74 and 95% reported willingness to receive future information about hospice, but the Korean group was significantly less likely to want information.

CONCLUSION

When surveyed in their preferred language, Asian and Hispanic adults reported variable levels of familiarity with hospice services. Most responded positively to receiving future information and would tell friends and family members about hospice.

Factors associated with in-hospital death by site of consultation among elderly inpatients receiving pain and palliative care consultations

BACKGROUND

Despite palliative care implementation, most deaths still occur in hospitals.

OBJECTIVES

To identify factors associated with in-hospital death among elderly patients receiving palliative care, by site of consultation.

DESIGN

Prospective observational study.

SETTING/SUBJECTS

All inpatients aged 65 years and older receiving pain and palliative care consultations in a 533-bed acute tertiary care hospital in Honolulu, Hawaii, from January 2005 through December 2009.

MEASUREMENTS

During consultation, demographics, diagnoses, consultation site (intensive care unit [ICU], non-ICU medical, non-ICU surgical, and rehabilitation floors), consultation indication (assistance with establishing goals of care versus pain and/or symptom management), Karnofsky scores, length of stay (LOS), discharge disposition, and in-hospital death were collected. Multiple logistic regression analyses examined factors associated with in-hospital death.

RESULTS

Of 1630 elderly inpatients receiving palliative care, 305 (19%) died in-hospital. In-hospital death among non-ICU medical patients was associated with needing consultation to assist with plan of care (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.27-2.80). Likelihood of in-hospital death increased 2% for each additional hospital day before consultation (OR=1.02, 95% CI=1.01-1.03). Among elderly ICU patients, likelihood of in-hospital death increased 8% for each additional hospital day before consultation (OR=1.08, 95% CI=1.01-1.16).

CONCLUSION

Among elderly non-ICU medical patients receiving palliative care consultations, the need for a consultation to assist with plan of care was associated with in-hospital death, while length of stay prior to consultation was important among both elderly ICU and non-ICU medical patients. Elderly hospitalized patients may benefit from earlier identification and palliative care consultation for assistance with plan of care to avoid in-hospital death.

Racial and ethnic variation in pain following inpatient palliative care consultations

Studies have documented high levels of pain in hospitalized individuals at the end of life, with minorities reporting higher levels of pain than whites. In response, inpatient palliative care (IPC) teams have grown rapidly to improve care of seriously ill individuals. Although research indicates that IPC teams effectively reduce and maintain control of pain, racial and ethnic differences in pain following IPC consultation remain unclear. This study investigated racial and ethnic pain differences after an IPC intervention in 385 seriously ill white, black, and Latino individuals aged 65 and older. Using the 11-point Numeric Rating Scale for pain, individuals were asked to rate their pain intensity at four points during hospitalization (before IPC consultation, 2 and 24 hours after the consultation, and at hospital discharge). Results indicate that whites (F1.657, 173.998 = 16.528, P < .001), blacks (F1.800, 95.410 = 7.103, P = .002), and Latinos (F1.388, 73.584 = 10.902, P < .001) all experienced significant reductions in pain after the intervention. Adjusted multivariate models testing between-group racial and ethnic differences revealed that Latinos were 62% more likely than whites to report experiencing pain at hospital discharge (relative risk = 0.38, 95% confidence interval = 0.15-0.97). Regardless of race or ethnicity, IPC effectively reduces and controls pain after consultation. Despite pain decreases, Latinos remain more likely than whites to report pain at follow-up. Further research is needed to determine the mechanisms in operation and to better understand and address the needs of this population.