Examining pain among non‐Hispanic Black and non‐Hispanic White patients with cancer visiting emergency departments: CONCERN (Comprehensive Oncologic Emergencies Research Network)
Year: 2021
Type: article
Abstract: Pain is common in patients with cancer1 seeking emergency department (ED) care.2 Fifty percent of ED patients with cancer present with pain and 39% report pain at final ED pain assessment.3 Thus, ED practitioners seemingly remain challenged to manage pain in this population. Such findings support calls encouraging safe, effective, and timely pain management in EDs.4 Brown and colleagues5 encourage research into any racial or socioeconomic gaps in the treatment of pain in ED cancer patients. The purpose of this prospective cohort study was to assess the presence of pain management disparities in this cohort of ED cancer patients stratified by race. This is a secondary analysis of prospectively collected data from The Comprehensive Oncologic Emergencies Research Network (CONCERN), a National Cancer Institute (NCI)-sponsored multicenter research consortium. CONCERN conducted a multicenter prospective cohort study of 18 EDs from March 1, 2016, through January 30, 2017. The parent study methods and population have been previously described.6 Briefly, study participants were adults aged ≥18 years with active cancer who presented to the ED. Active cancer was defined as (1) ongoing (or within 12 months) antineoplastic therapy (radiotherapy, chemotherapy, cancer-related surgery, or other); (2) previously identified or ED physician-identified cancer recurrence or metastasis; or (3) cancer-related symptoms. Participants were excluded for the following reasons: pregnancy, incarceration, a psychiatric chief complaint, primary evaluation as a trauma response, non-English speaking, previous enrollment, or too ill or otherwise unable to participate in survey administration. Due to limited numbers of Hispanic participants, this study does not provide specific analyses of ethnicity. The study's null hypothesis was that there is no difference between non-Hispanic Black (NHB) and non-Hispanic White (NHW) in pain reports or treatment. Each site received institutional review board approval. All participants provided written informed consent; no incentive was provided. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. Trained research staff administered a patient questionnaire while the patient was in the ED and abstracted data from all available medical records 30 days after patient enrollment using standardized electronic forms and a data dictionary. Patient questionnaire items included demographics, cancer type, and cancer therapy within the preceding 30 days of ED visit. Medical record abstraction included Emergency Severity Index,7 ED vital signs, comorbid conditions, primary cancer type, recent cancer-related therapies, outpatient and ED–administered pain medications, ED diagnoses and disposition, inpatient diagnoses, additional ED visits and/or hospitalizations within 30 days, 30-day mortality, ED laboratory and imaging results, hospital length of stay, and presence of advance directives. Patients were asked to report the presence and intensity of pain at ED presentation and at ED disposition on a 10-point numeric rating scale. Report of any pain in the ED was categorized as none (0), mild (1–4), moderate (5–6), or severe (7–10). For home pain medication use, patients were queried on pain medication use and type in the 14 days prior to ED visit study. Demographic characteristics were determined by patient self-report and compared using Pearson chi-square with assessed cell residuals (with residuals deemed statistical significant at value greater than two) to measure the difference between observed and expected cell frequencies. Analyses included t-tests for differences in means and Wilcoxon for differences in medians. Analyses included univariate followed by multivariable logistic regression models with the reported dependent variables being presence of severe pain on initial ED pain score, receipt of any home pain medication and home opioids, and receipt of any ED pain medication and ED opioids. The independent variable of interest was race with other independent variables chosen from those likely to affect prescribing of pain medication: age, sex, marital status, education, presence of advanced cancer, cancer type, and initial ED pain score. The model also included study site to control for any region or site of care effect embedded in patient race estimates. Analysis was conducted using SAS software (version 9.4, SAS Institute, Inc.). A p-value < 0.05 was considered statistically significant. Table 1 presents clinical and demographic characteristics of study participants (n = 924) who self-identified as NHW (n = 804, 87%) or NHB (n = 120, 13%). At ED presentation. NHBs reported a higher median pain score (7.0 vs. 2.5) compared to NHWs. A greater proportion of NHWs reported no pain (40.9%) compared to NHBs (22.5%; p < 0.05). In contrast, a significantly greater proportion of NHBs reported severe pain (48.3% vs. 27.6%; p < 0.01). In multivariable analyses, NHBs remained more than twice as likely (odds ratio [OR] = 2.81, 95% confidence interval [CI] = 1.40 to 3.72, p < 0.01) than NHWs to report severe pain. Supplemental analyses revealed there was no difference between NHB and NHWs in home pain medication use (OR = 1.28, 95% CI = 0.77 to 2.13, p = 0.34) or home opioid use (OR = 1.32, 95% CI = –0.81 to 2.17, p = 0.26). Further, supplemental analyses indicated NHBs and NHWs did not experience differential ED pain medication administration (O= R 0.97, 95% CI = 0.58 to 1.62) or ED opioid administration (OR = 1.43, 95% CI = 0.85 to 2.42). In this study, NHB patients with cancer presenting to the ED were more likely to report severe pain compared to their NHW counterparts. This racial difference persisted when controlling for multiple sociodemographic factors, primary cancer type, and site of care. Future research may consider clinical practice and self-care tendencies, particularly for NHBs, in nonemergent practice settings. Our data do not include patient zip code, ED transportation method, and/or information regarding prior visits and settings. Hanchate et al.8 reported that NHBs and Hispanics were more likely to be transported to a safety net ED than NHWs residing in the same zip code. Cleeland et al.9 observed that minority patients received better pain management in community-based treatment settings than in settings predominantly serving minorities or university settings. It is possible the NHB ED users in this sample received prior care at predominantly minority-serving facilities or university settings. It is also possible NHB ED users experiencing less pain were differentially transported to EDs unaffiliated with the CONCERN and affiliated with the institution providing their cancer care. Since these data do not include information on participants' prior facilities or care received, investigators cannot tenably consider this possibility. Analyses did not detect any racial differences in home over-the-counter medication or opioid use after controlling for relevant characteristics, including pain. Analyses revealed that approximately 45% of NHWs and 58% of NHBs reported opioid use at home (results not shown). These findings may merely reflect an axiomatic relationship between pain and opioid use reports (i.e., pain portends opioid use). It is also possible that insufficient prescription amount or duration or suboptimal prescription adherence tendencies explain pain report differences. Since these data lack explicit prescribing information (e.g., prescription length and dose), investigators cannot infer providers prescribed for NHBs and NHWs at the same rate or in the same manner. Regarding adherence tendencies, medication-taking behavior can vary among patients and within the same patient over time. Future research may explicitly assess NHB prescription content and patient adherence to more precisely consider pain reports. Finally, analyses revealed no racial difference in receiving nonopioid pain medication or opioid-specific management in the ED, after controlling for relevant characteristics This finding does not necessarily conflict with the meta-analysis of Lee et al. indicating that Black and Hispanic patients are less likely to receive the equivalent analgesia medication in the ED compared to NHWs.10 Here, unlike those in Lee et al., these analyses exclusively consider a cancer patient population. It is possible that disease characteristics or unmeasured confounders distinguish our report from those such as Lee et al. These analyses also forwent an opportunity to clarify pain and opioid use in the Hispanic population—one at risk of underprescribing. However, the original study was not designed to examine racial and ethnic variation a priori and included only 76 Hispanic individuals.6 These data were derived from large urban academic health centers mostly affiliated with NCI-designated comprehensive cancer centers. Facilities and service may fundamentally differ from those serving NHBs and other disadvantaged populations elsewhere. This quantitative study encourages subsequent qualitative solicitation of ED care–seeking motivators. In this sample of NHB and NHW patients with cancer-seeking ED care at academic health center–affiliated facilities, NHB patients were more likely to report severe pain (and less likely to report no pain or moderate pain) compared to NHWs. Controlling for pain severity and additional patient characteristics, analyses revealed no difference between NHB and NHWs in home pain medication use or in ED-administered pain medication or opioids. These results encourage health equity–based research on precipitators of ED care seeking among cancer patients experiencing pain and particularly encourage research on social determinants of ED use among minority and disadvantaged populations. Dr. Caterino reported grants from AstraZeneca and personal fees from Wellstat Therapeutics outside this submitted work. Dr. Yeung was a member of an expert panel for Celgene, Inc. Dr. Yeung had funding support from Bristol-Myer Squibb, Inc. and DepoMed, Inc. Dr. Bernstein reported nonfinancial support from the National Cancer Institute during the conduct of the study. Dr. Henning reported grants from Roche Diagnostics and Baxter outside the submitted work. Dr. Ryan reported personal fees from EMCREG International outside the submitted work. Dr. Wilson reported grants from Gilead and grants and personal fees from Janssen and Pfizer outside the submitted work. The other authors have no potential conflicts to disclose. Dr. Coyne received grants from Gileand and personal fees from Genentech that are outside of the submitted work. Dr. Lyman reports research grant funding from Amgen (inst) and speaking or consulting fees from Partners Healthcare, Sandoz, ER Squibb, Merck, Jazz Pharm, TEVA, and Seattle Genetics outside the submitted work. Dr. Baugh is a consultant and paid speaker for Roche Diagnostics, advisory board member of Salix Pharmaceuticals, Nabriva Pharmaceuticals and AcelRx Pharmaceuticals and advisor for Lucia Health Guidelines. Dr. Grudzen reports support from NIA, NICCH, NCATS, PCORI and the Samuels Foundation outside the submitted work. Dr. Venkat reports consulting fees from the Western Pennsylvania Autism Service, Education, Resources, and Training Collaborative outside the submitted work. Dr. Strassels reports support from Trevena outside the submitted work. Study concept and design: Matthew F. Hudson, JMC, SAS. Acquisition of the data: JMC, David Adler, Sai-Ching J. Yeung, Steven L. Bernstein, Christopher W. Baugh, Christopher J. Coyne, Corita R. Grudzen, Daniel J. Henning, Adam Klotz, Troy E. Madsen, Daniel J. Pallin, Juan F. Rico, Richard J. Ryan, Nathan I. Shapiro, Robert Swor, Arvind Venkat, Jason Wilson, Charles R. Thomas, Jason J. Bischof, Gary H. Lyman. Analysis and Interpretation of the data: MFH, SAS, DDD, SS, JMC. Drafting of the manuscript: MFH, SAS, DDD, SS, JMC. Critical revision of the manuscript for important intellectual content: All Authors. Statistical expertise: DDD, SS. Acquisition of Funding: JMC, CRG.
Source: Academic Emergency Medicine
DOI: 10.1111/acem.14395
Authors: Matthew F. Hudson, Scott A. Strassels, Danielle D. Durham, Sunny Siddique, David Adler, Sai‐Ching J. Yeung, Steven L. Bernstein, Christopher W. Baugh, Christopher J. Coyne, Corita R. Grudzen, Daniel J. Henning, Adam Klotz, Troy E. Madsen, Daniel J. Pallin, Juan F. Rico, Richard J. Ryan, Nathan I. Shapiro, Robert Swor, Arvind Venkat, Jason Wilson, Charles R. Thomas, Jason J. Bischof, Gary H. Lyman, Jeffrey M. Caterino
Institutions: Prisma Health, The Ohio State University, University of North Carolina at Chapel Hill, National Cancer Institute, University of Rochester Medicine, University of Rochester, The University of Texas MD Anderson Cancer Center, Dartmouth–Hitchcock Medical Center, Dartmouth Health, Brigham and Women's Hospital, University of California San Diego, New York University, University of Washington, Memorial Sloan Kettering Cancer Center, University of Utah, University of South Florida, University of Cincinnati, University of Cincinnati Medical Center, Beth Israel Deaconess Medical Center, Beaumont Health, Corewell Health William Beaumont University Hospital, Allegheny Health Network, Oregon Health & Science University, OHSU Knight Cancer Institute, The Ohio State University Wexner Medical Center, Fred Hutch Cancer Center
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
Funders: Amgen, Pfizer, AstraZeneca, Gilead Sciences, Patient-Centered Outcomes Research Institute, Teva Pharmaceutical Industries, Celgene, Depomed, AcelRx Pharmaceuticals, Nabriva Therapeutics, Genentech, National Institute on Aging, National Cancer Institute, National Center for Advancing Translational Sciences
OpenAlex ID: W3201933354