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01-03-2019 | Lung Cancer | Original Research

The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment

Authors: Cleveland G. Shields, PhD, Jennifer J. Griggs, MD, MPH, Kevin Fiscella, MD, MPH, Cezanne M. Elias, PhD, Sharon L. Christ, PhD, Joseph Colbert, BA, Stephen G. Henry, MD, MSc, Beth G. Hoh, MSW, Haslyn E. R. Hunte, PhD, Mary Marshall, MS, Supriya Gupta Mohile, MD, MS, Sandy Plumb, BS, Mohamedtaki A. Tejani, MD, MS, Alison Venuti, BS, Ronald M. Epstein, MD

Published in: Journal of General Internal Medicine | Issue 3/2019

Abstract

Background

Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer.

Objective

To examine the effect of race on physicians’ pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation.

Design

Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles—a 62-year-old man with advanced lung cancer and uncontrolled pain—differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions.

Participants

Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians’ mean age was 52 years (SD = 27.17), 59% male, and 64% white.

Main Measures

Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment.

Key Results

SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81).

Conclusions

Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain.

Trial Registration

NCT01501006

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Title: The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment
Authors: Cleveland G. Shields, PhD
Jennifer J. Griggs, MD, MPH
Kevin Fiscella, MD, MPH
Cezanne M. Elias, PhD
Sharon L. Christ, PhD
Joseph Colbert, BA
Stephen G. Henry, MD, MSc
Beth G. Hoh, MSW
Haslyn E. R. Hunte, PhD
Mary Marshall, MS
Supriya Gupta Mohile, MD, MS
Sandy Plumb, BS
Mohamedtaki A. Tejani, MD, MS
Alison Venuti, BS
Ronald M. Epstein, MD
Publication date: 01-03-2019
Publisher: Springer International Publishing
Keywords: Lung Cancer
Lung Cancer
Opioids
Opioids
Morphine
Lung Cancer
Published in: Journal of General Internal Medicine / Issue 3/2019
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-018-4785-z

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The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment

Abstract

Background

Objective

Design

Participants

Main Measures

Key Results

Conclusions

Trial Registration

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Abstract

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Design

Participants

Main Measures

Key Results

Conclusions

Trial Registration

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