Pain Assessment Disparities by Race, Ethnicity, and Language in Adult Hospitalized Patients

Racial and Ethnic Underserved Populations Prescription Analgesic Use Before and After Lower Extremity Amputation in US Medicare

BACKGROUND

Racial disparities exist in access to health care and management of multiple health conditions including chronic pain; however, racial disparities in pre- and postoperative pain management in lower extremity amputation are not well-studied. Our objective was to examine the association between different racial and ethnic groups and prescription opioid and other analgesics use before and after lower extremity amputation. We hypothesize prescription opioid and other analgesic use among Black, Hispanic, and Native American US Medicare beneficiaries undergoing lower extremity amputations will be lower compared to White US Medicare beneficiaries.

METHODS

This retrospective cohort study included a 5% national sample of all Medicare beneficiaries from 2011 to 2015 and 15% national sample of fee-for-service Medicare beneficiaries from 2016 to 2018 undergoing nontraumatic, lower extremity amputations. The exposure of interest was racial and ethnic group membership (ie, Black, Hispanic, Native American, White, and others-with others being the combination of the categories Asian and other) as provided in Medicare claims data. Using multivariable generalized estimating equations with a logistic link to account for repeated measurements over time, we estimated the odds of prescription opioid use within 6 months before and after lower extremity amputation across different racial and ethnic groups separately, adjusting for sociodemographic and health status factors (eg, Elixhauser index). Adjusted odds ratios (aORs) and 95% confidence intervals (95% CI) were reported.

RESULTS

Among 16,068 eligible beneficiaries who underwent major and minor amputations (mean age = 65.1 ± 12.7 years; female = 36.1%), 10,107 (62.9%) were White, 3462 (21.5%) were Black, 1959 (12.2%) were Hispanic, 247 (1.5%) were Native American, and 151 (2.9%) were beneficiaries of other races. During the 6 months before lower extremity amputation, Hispanic beneficiaries (aOR, 0.71, 95% CI, 0.65-0.78) and beneficiaries of other races (aOR, 0.60, 95% CI, 0.47-0.76) had significantly lower odds of using prescription opioids compared to White beneficiaries. Similarly, Hispanic beneficiaries (aOR, 0.78, 95% CI, 0.71-0.84) and beneficiaries of other races (aOR, 0.63, 95% CI, 0.51-0.78) were associated with lower odds of opioid use in the 6 months after amputation compared to White beneficiaries.

CONCLUSIONS

Among fee-for-service Medicare beneficiaries, Hispanic and other (eg, Asian) fee-for-service Medicare beneficiaries had lower odds of prescription opioid use than their White counterparts before and after nontraumatic, lower extremity amputations. Efforts to determine the underlying reasons are needed to ensure equitable health care access.

Inequities in Opioid Administration by Race and Ethnicity for Hospitalized Patients With and Without Substance Use Disorders

BACKGROUND

Adequate pain management is challenging in patients with substance use disorders, particularly those from racial/ethnic minority groups who face intersecting biases.

OBJECTIVE

To investigate inequities in pain management for racial/ethnic minority groups with and without concurrent substance use disorders.

DESIGN

Retrospective cohort study from 2021 to 2022 on an acute care general medicine service at UCSF Medical Center.

PARTICIPANTS

All adults ≥ 18 years old.

EXPOSURES

Primary exposure was the patient's self-identified race/ethnicity (Asian, Black or African American, Latino, Multi-Race/Ethnicity, Native American or Alaska Native, Native Hawaiian or Pacific Islander, Southwest Asian or North African, White, Other, and Unknown/Declined).

MAIN OUTCOME AND MEASURES

The primary outcome was average daily inpatient opioids received (morphine milligram equivalents, MME). Multivariable negative binomial regression assessed the relationship between self-reported race/ethnicity and opioid administration, adjusting for demographics, clinical factors, substance use disorders, and pain characteristics. The subgroup analyses focused on patients with substance use disorders and on patients without any buprenorphine or methadone prescriptions.

KEY RESULTS

In the overall cohort of 13,058 hospitalizations (mean age 62.7 years, 51.2% male, 31.3% with substance use disorder), patients from racial/ethnic minority groups received significantly fewer opioids than White patients in adjusted analyses: Asian (- 61.3 MME/day), Black (- 44.9 MME/day), Latino (- 48.8 MME/day), Native American/Alaska Native (- 80.4 MME/day), and Native Hawaiian/Pacific Islander (- 72.9 MME/day). Similar, significant disparities were present in both subgroups. Notably, in the substance use disorder-only subgroup (n = 4446), larger disparities persisted for Asian (- 124.4 MME/day), Black (- 68.7 MME/day), and Latino (- 110.8 MME/day) patients compared to White patients.

CONCLUSIONS

Substantial racial/ethnic inequities in inpatient opioid prescribing for pain control were observed, particularly among patients with concurrent substance use disorders. These findings highlight the need for interventions promoting equitable, culturally competent pain management for marginalized populations facing intersecting biases and stigma.

The Status and Challenges of Pain Assessment in Hospitalized Patients: A Cross-Sectional Study

BACKGROUND

Accurate pain assessment still faces many challenges, which impact the effectiveness of analgesic interventions. Understanding the current status of pain assessment implementation and its inhibiting and facilitating factors might help facilitate accurate pain assessment.

PURPOSE

To investigate the nurses' current pain assessment practices for hospitalized patients and analyze the factors that facilitate or inhibit the standardization of pain assessment implementation.

DESIGN

This study is a cross-sectional survey that includes a questionnaire survey and an on-site observation. The questionnaire survey was conducted in 78 public hospitals in 18 districts or counties of Sichuan Province, China, with 1,050 clinical registered nurses surveyed. The on-site observation was conducted in a university-affiliated tertiary hospital, separate from the public hospitals.

METHOD

In the questionnaire survey, a structured self-administered "Pain Nursing Practice Questionnaire" was used to assess nurses' pain practice behaviors in four aspects: pain assessment, recording, intervention, and education. Additionally, in third-party on-site observations, observers evaluated nurses' pain assessment practices in clinical settings.

RESULTS

Results for the questionnaire survey showed that pain assessments were most frequently conducted once per day (53.4%), primarily triggered by patient reports of pain (93.0%) and following pain management interventions (93.0%). The Numerical Rating Scale was the most commonly used tool for patients who could report pain (86.7%), while the Checklist of Nonverbal Pain Indicators was most used for nonverbal patients (63.2%). Factors affecting accurate pain assessment included poor compliance with protocols (79.71%) and insufficient knowledge of pain assessment (65.43%). The average assessment time reported by nurses for speaking patients was 198 seconds. However, the average time nurses took to assess the pain of speaking patients was 98 seconds in on-site observations. The on-site observations showed an average assessment time of 124.9 seconds upon patient admission and 77.3 seconds for patients during hospitalization, with the difference being statistically significant (t = 2.123, p = .038). Additionally, 10.2% of nurses did not inquire about specific pain complaints, and 18.4% did not use pain assessment tools.

CONCLUSIONS

The study reveals significant discrepancies in pain assessment practices among nurses. In the process of pain assessment practice, the assessment time is shorter, and the process is less standardized compared to self-reported results. The factors impeding standardized pain assessment included nurses' insufficient knowledge and poor protocol adherence. Therefore, enhanced training, more explicit guidelines, and robust institutional support are needed to standardize pain assessments and improve patient outcomes.

Navigating the light and shadow of scientific publishing faced with machine learning and generative AI

BACKGROUND

The public release of ChatGPT in November 2022 sparked a boom and public interest in generative artificial intelligence (AI) that has led to journals and journal families hastily releasing generative AI policies, ranging from asking authors for acknowledgement or declaration to the outright banning of use.

RESULTS

Here, we briefly discuss the basics of machine learning, generative AI, and how it will affect scientific publishing. We focus especially on potential risks and benefits to the scientific community as a whole and journals specifically.

CONCLUSION

While the concerns of editors, for example about manufactured studies, are valid, some recently implemented or suggested policies will not be sustainable in the long run. The quality of generated text and code is quickly becoming so high that it will not only be impossible to detect the use of generative AI but would also mean taking a powerful tool away from researchers that can make their life easier every day.

SIGNIFICANCE

We discuss the history and current state of AI and highlight its relevance for medical publishing and pain research. We provide guidance on how to act now to increase good scientific practice in the world of ChatGPT and call for a task force focusing on improving publishing pain research with use of generative AI.

Health Policy Advocacy: From the Front Line to Capitol Hill

Empowering staff nurses.

Dysmenorrhea Among Women Living in Saudi Arabia: Prevalence, Determinants, and Impact

Dysmenorrhea, or painful menstruation, is one of the most prevalent conditions among adolescents and young females globally, significantly affecting academic performance, quality of life, and social interactions. Despite its high prevalence, dysmenorrhea has been rarely investigated in Saudi Arabia, resulting in a scarcity of national data. This study aimed to evaluate the prevalence, severity, and determinants of dysmenorrhea among females in Saudi Arabia. This cross-sectional, questionnaire-based study included 1026 participants recruited from various regions of Saudi Arabia using a convenience sampling technique. Data collection was conducted using a validated, self-administered online questionnaire. Descriptive and inferential statistics were utilized to evaluate the prevalence, severity, and associated symptoms of dysmenorrhea. Additionally, multiple logistic regression was employed to identify the determinants of dysmenorrhea within the sample. The analysis was performed using R software. The prevalence of dysmenorrhea among the sample was 87%, with a mean pain score of 6 ± 2.2. Common menstrual cycle-associated symptoms included mood swings (79%), abdominal bloating (60%), diarrhea (32%), and constipation (26%). Factors associated with an increased risk of dysmenorrhea included Saudi nationality (OR = 1.96, p = 0.032), employment (OR = 1.75, p = 0.034), and a history of gynecological surgeries (OR = 1.81, p = 0.045). Conversely, multiparity was associated with a reduced risk of dysmenorrhea (OR = 0.36, p = 0.046). Dysmenorrhea is highly prevalent among Saudi women and is accompanied by significant menstrual symptoms that adversely affect quality of life. Understanding its determinants and associated symptoms is essential for improving management strategies and mitigating its impact on women's lives.

Differences in Acute Postoperative Opioid Use by English Proficiency, Race, and Ethnicity After Total Knee and Hip Arthroplasty

BACKGROUND

There is increasing interest in documenting disparities in pain management for racial and ethnic minorities and patients with language barriers. Previous studies have found differential prescription patterns of opioids for racial and ethnic minority group and patients having limited English proficiency (LEP) after arthroplasty. However, there is a knowledge gap regarding how the intersection of these sociodemographic factors is associated with immediate postoperative pain management. This study aimed to explore language and racial-ethnic disparities in short-term opioid utilization after total hip and knee arthroplasty.

METHODS

We conducted a retrospective cohort study of adult patients who underwent total hip and knee arthroplasty from 2015 to 2019 at an urban medical center. The primary predictor variables included LEP status and racial-ethnic category, and the primary outcome variables were oral morphine equivalents (OMEs) during 2 distinct postoperative periods: the first 12 hours after surgery and from the end of surgery to the end of postoperative day (POD) 1. Patient characteristics and perioperative metrics were described by language status, race, and ethnicity using nonparametric tests, as appropriate. We performed an adjusted generalized estimating equation to assess the total effect of the intersection of LEP and racial-ethnic categories on short-term postoperative opioid use in mean ratios (MRs).

RESULTS

This study included a total of 4090 observations, in which 7.9% (323) patients had LEP. Patients reported various racial-ethnic categories, with 72.7% (2975) non-Hispanic White, and minority groups including non-Hispanic Asian and Pacific Islander (AAPI), Hispanic/Latinx, non-Hispanic Black/African American, and Others. Patients self-identifying as non-Hispanic AAPI received fewer OME regardless of LEP status during the first 12 hours postoperatively (MR for English proficient [EP], 0.12 [95% confidence interval, CI, 0.08-0.18]; MR for LEP, 0.22 [95% CI, 0.13-0.37]) and from end of surgery to the end of POD 1 (MR for EP, 0.24 [95% CI, 0.16-0.37]; MR for LEP, 0.42, [95% CI, 0.24-0.73]) than EP non-Hispanic White. Hispanic/Latinx patients with LEP received lower amounts of OME during the first postoperative 12 hours (MR, 0.29; 95% CI, 0.17-0.53) and from end of surgery to the end of POD 1 (MR, 0.42; 95% CI 0.23-0.79) than EP non-Hispanic White. Furthermore, within the non-Hispanic White group, those with LEP received fewer OME within the first 12 hours (MR, 0.33; 95% CI, 0.13-0.83).

CONCLUSIONS

We identified an association between LEP, racial-ethnic identity, and short-term postoperative OME utilization after total knee and hip arthroplasty. The observed differences in opioid utilization imply there may be language and racial-ethnic disparities in acute pain management and perioperative care.

Regarding the Pain of Others? Contradictions Between Public Discourse and the Lived Experience of Pain

BACKGROUND/OBJECTIVES

Pain is a complex and subjective experience influenced by psychological, cultural, and social factors. This study aims to investigate how social perceptions of pain affect the lived experiences and coping mechanisms of individuals suffering from pain. By comparing public discourse with the experiences of sufferers, we explore whether the social legitimacy of pain influences how it is managed.

METHODS

A multi-phase qualitative study was conducted, comprising eight focus groups with members of the Spanish general population and 19 in-depth interviews with individuals suffering from various types of pain. The focus groups explored social perceptions of pain's legitimacy, while the interviews delved into the sufferers' personal experiences. The data were analyzed using thematic analysis to identify patterns and disparities between public discourse and individual narratives.

RESULTS

The focus groups revealed widespread social empathy towards all types of pain. However, interviewees reported significant social pressure to normalize their behavior and downplay their pain. Many felt misunderstood, unsupported, and stigmatized, especially in environments where they held subordinate roles, such as the workplace or healthcare settings. Sufferers often resorted to silence or isolation to avoid judgment.

CONCLUSIONS

While Spanish society outwardly legitimizes all forms of pain, sufferers experience significant discrepancies between public empathy and actual social support. The findings suggest that raising awareness alone is insufficient, and that structural changes are needed to address the daily burdens that individuals face when coping with pain, particularly in workplace and healthcare environments.

Assessing for differences in opioid administration during inpatient end-of-life care for patients with limited English proficiency

BACKGROUND

Patients with limited English proficiency (LEP) may have worse health outcomes and differences in processes of care. Language status may particularly affect situations that depend on communication, such as symptom management or end-of-life (EOL) care.

OBJECTIVE

The objective of this study was to assess whether opioid prescribing and administration differs by English proficiency (EP) status among hospitalized patients receiving EOL care.

METHODS

This single-center retrospective study identified all adult patients receiving "comfort care" on the general medicine service from January 2013 to September 2021. We assessed for differences in the quantity of opioids administered (measured by oral morphine equivalents [OME]) by patient LEP status using multivariable linear regression, controlling for other patient and medical factors.

RESULTS

We identified 2652 patients receiving comfort care at our institution during the time period, of whom 1813 (68%) died during the hospitalization. There were no significant differences by LEP status in terms of mean OME per day (LEP received 30.8 fewer OME compared to EP, p = .91) or in the final 24 h before discharge (LEP received 61.7 more OME compared to EP, p = .80).

CONCLUSION

LEP was not associated with differences in the amount of opioids received for patients whose EOL management involved standardized order sets for symptom management at our hospital.