The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment
Cleveland G Shields, Jennifer J Griggs, Kevin Fiscella, Cezanne M Elias, Sharon L Christ, Joseph Colbert, Stephen G Henry, Beth G Hoh, Haslyn E R Hunte, Mary Marshall, Supriya Gupta Mohile, Sandy Plumb, Mohamedtaki A Tejani, Alison Venuti, Ronald M Epstein, Cleveland G Shields, Jennifer J Griggs, Kevin Fiscella, Cezanne M Elias, Sharon L Christ, Joseph Colbert, Stephen G Henry, Beth G Hoh, Haslyn E R Hunte, Mary Marshall, Supriya Gupta Mohile, Sandy Plumb, Mohamedtaki A Tejani, Alison Venuti, Ronald M Epstein
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.
Keywords: communication; doctor-patient relations; lung cancer; pain management; racial disparities.
Conflict of interest statement
The authors declare that they do not have a conflict of interest.
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Source: PubMed