Adopting otitis media practice guidelines increases adherence within a large primary care network.

AIM: Unnecessary antibiotic prescriptions to treat otitis media (OM) contribute to adverse drug reactions, increased cost and antibiotic resistance. Clinical care guidelines can help promote consistent treatment of conditions such as OM. This study evaluates adherence before and after implementation of an institutional guideline for the diagnosis and treatment of paediatric OM. METHODS: A retrospective chart review was performed to collect encounter information for paediatric patients seen within a primary care clinic network and diagnosed with OM before and after full implementation of a clinical care guideline. Patient cohorts from 2013 and 2016 were compared to determine which factors, including age, symptoms and diagnosis, were associated with treatment guideline adherence. RESULTS: Comparison of encounters from 2013 (n = 418) to 2016 (n = 635) revealed a significant difference in adherence to the 2013 Michigan Medicine Otitis Media Guideline. Overall adherence increased from 61.2% in 2013 to 70.6% in 2016 (χ2  = 9.85, P < 0.0017). Antibiotic use for acute OM decreased from 99.7% in 2013 to 96.7% in 2016 (χ2  = 10.04, P = 0.0015). Antibiotic prescriptions for OM with effusion decreased significantly from 42.9% in 2013 to 17.4% in 2016 (χ2  = 11.93, P < 0.0006). CONCLUSION: Implementation of an institutional OM clinical practice guideline contributed to a significant increase in overall treatment adherence of OM for paediatric patients between the 2013 and 2016 cohorts. The number of antibiotic prescriptions for paediatric patients diagnosed with acute OM or OM with effusion significantly decreased from 2013 to 2016.

Considerations for using race and ethnicity as quantitative variables in medical education research.

Throughout history, race and ethnicity have been used as key descriptors to categorize and label individuals. The use of these concepts as variables can impact resources, policy, and perceptions in medical education. Despite the pervasive use of race and ethnicity as quantitative variables, it is unclear whether researchers use them in their proper context. In this Eye Opener, we present the following seven considerations with corresponding recommendations, for using race and ethnicity as variables in medical education research: 1) Ensure race and ethnicity variables are used to address questions directly related to these concepts. 2) Use race and ethnicity to represent social experiences, not biological facts, to explain the phenomenon under study. 3) Allow study participants to define their preferred racial and ethnic identity. 4) Collect complete and accurate race and ethnicity data that maximizes data richness and minimizes opportunities for researchers' assumptions about participants' identity. 5) Follow evidence-based practices to describe and collapse individual-level race and ethnicity data into broader categories. 6) Align statistical analyses with the study's conceptualization and operationalization of race and ethnicity. 7) Provide thorough interpretation of results beyond simple reporting of statistical significance. By following these recommendations, medical education researchers can avoid major pitfalls associated with the use of race and ethnicity and make informed decisions around some of the most challenging race and ethnicity topics in medical education.

Sociodemographic Factors Associated With Adherence to Referrals From the Pediatric Emergency Department.

BACKGROUND: Outpatient referrals constitute a critical component of emergency medical care. However, barriers to care after emergency department (ED) visits have not been investigated thoroughly. OBJECTIVE: The purpose of this study was to determine the impact of sociodemographic variables on referral attendance after ED visits. METHODS: A retrospective cohort study was designed. Patients aged 0-17 years who visited the C.S. Mott Children's Hospital ED in 2016 and received a referral were included. Multiple referrals for 1 patient were counted as independent encounters for statistical analysis. RESULTS: Chart review was performed on 6120 pediatric ED encounters, producing a total of 822 referrals to University of Michigan Health System outpatient clinics. Referral attendance did not differ by race, ethnicity, language, or religion. Older age was associated with decreased attendance at referrals (p = 0.043). Patients who were black and female (p = 0.019), patients with public health insurance (p = 0.004), and patients residing in areas with either high rates of unemployment (p = 0.003), or lower high school education rates (p = 0.006) demonstrated decreased attendance. Patients referred to pediatric neurology had lower attendance rates (p < 0.001), and those referred to pediatric orthopedic surgery attended referrals more often (p = 0.006). CONCLUSIONS: This study provides an overview of the impact of sociodemographic and departmental factors on attendance at outpatient follow-up referrals. Significant disparities exist with respect to referral attendance after emergency medical care. Informed resource allocation may be utilized to improve care for these at-risk patient populations.

The impact of sexual or physical abuse history on pain-related outcomes among blacks and whites with chronic pain: gender influence.

OBJECTIVES: Physical and sexual abuses commonly co-occur with chronic pain. We hypothesized that: 1) abuse history questions would form distinct factors that relate differently to pain perceptions and pain outcomes; 2) abuse history consequences on physical and mental health differ by gender; and 3) different abuse types and age of occurrence (childhood vs adolescent/adulthood) predict different negative outcomes. METHODS: Chronic pain patients at a tertiary care pain center provided data (64% women, 50% black) through a confidential survey. Factors were formed for abuse type and age. Linear regression, controlling for socio-demographic information, was used to examine the relationship between abuse and abuse by sex interactions with pain-related outcomes. RESULTS: Six 3-item abuse factors (α = 0.77-0.91)-sexual molestation, sexual penetration, and physical abuse-were identified in both childhood and adulthood. Lifetime prevalence of abuse was 70% for men and 65% for women. Women experienced lower physical abuse (P = 0.01) in childhood, and higher penetration (P = 0.02) in adulthood. Decreased general health was associated with all abuse types (P < 0.05) in childhood. Affective pain was associated with all childhood abuse scales and adulthood molestation, though childhood molestation only for men (P = 0.04). Disability was associated with childhood (P = 0.02) and adulthood rape (P = 0.04). Men with childhood or adulthood molestation (P = 0.02; P = 0.02) reported higher post-traumatic stress disorder. CONCLUSIONS: Our study confirms physical and mental health, and pain-related outcomes are affected by abuse history for men and women. These results support screening all patients for abuse to improve the survivor's overall health and well-being.

The association between race and neighborhood socioeconomic status in younger Black and White adults with chronic pain.

UNLABELLED: Both race and socioeconomic status (SES) contribute to disparities. We assessed the relative roles of neighborhood socioeconomic status (nSES) and race in the chronic pain experience for young adults (<50 years old). Data from a tertiary care pain center was matched to 2000 US Census data to examine the role of race and nSES on chronic pain and its sequelae in 3,730 adults (9.7% black, 61% female) 18 to 49 years old (37 ± 8 years). Blacks had significantly more pain and disability and lived in lower SES neighborhoods. Living in a lower SES neighborhood was associated with increased sensory, affective, and "other" pain, pain-related disability, and mood disorders. Race was independently associated with affective and "other" pain on the McGill Pain Questionnaire scales, and both disability factors. Racial disparities in sensory pain and mood disorders were mediated by nSES. In every case, race and neighborhood SES played important roles in the outcomes for chronic pain. Age was related to both disability outcomes. Gender was associated with voluntary disability and mood disorders, with men displaying worse outcomes. PERSPECTIVE: Important racial- and SES-related variability in pain related outcomes in young adults with chronic pain were defined. Black race was associated with neighborhood SES, and black race plays an important role in pain outcomes beyond neighborhood SES.

Cancer-related chronic pain: examining quality of life in diverse cancer survivors.

BACKGROUND: Disparities in cancer survival and pain rates negatively impact quality of life (QOL). This study examines cancer-related chronic pain (CP) and its impact on QOL in diverse cancer survivors. METHODS: This survey study focused on current and past pain, health, and QOL in black and white cancer survivors. Participants with breast, colorectal, lung, and prostate cancer and multiple myeloma were recruited through the Michigan State Cancer Registry. Analysis of variance was used to examine outcome differences by pain status, race, and sex. Hierarchical regressions explored predictors for experiencing pain. RESULTS: The subjects (N = 199) were 31% black, 49% female, and 57 to 79 years old; 19.5% experienced current pain, and 42.6% reported pain since diagnosis. Women experience more pain (P < .001) and greater pain severity (P = .04) than men. Blacks experienced more pain interference and disability (P < .05). Experiencing pain is related to greater depressive symptoms, poorer functioning, and more symptoms. In hierarchical regressions, female sex predicted pain since diagnosis; pain severity for pain since diagnosis was predicted by black race and female sex. CONCLUSIONS: The authors extend the literature by showing that 20% of diverse cancer survivors had cancer-related CP, and 43% had experienced pain since diagnosis, revealing racial and sex disparities in cancer-related CP's incidence and impact on QOL. Having pain was related to poorer QOL in several domains and was more frequently experienced by women. Although black race was not related to pain prevalence, it was related to greater severity. This study reveals an unaddressed cancer survivorship research, clinical, and policy issue.

The impact of chronic pain on the health of black and white men.

Persistent pain, disability, and depression are hallmarks for chronic pain. While disparities based upon race, gender, and class are documented, little is known about pain disparities in minority men. This investigation examines black (6.2%) and white (93.8%) men (N = 1650) presenting for initial assessment at a tertiary care pain center. Racial comparisons utilized analysis of variance; all variables of interest were then placed in a theoretical model using path analysis. The model included race, age, education, neighborhood income, marital status, litigation, substance use, and high blood pressure as predictors and pain, depression, affective distress, posttraumatic stress disorder (PTSD), and disability as outcomes. Black race was associated with lower neighborhood income, education and marriage rates, and higher rates of litigation and high blood pressure. Black men also had higher pain (affective and miscellaneous), disability, and depression. Path analysis found black race was a direct predictor of greater pain, and through pain, was an indirect predictor of depression, affective distress, PTSD, and disability. Path analysis confirmed the complexity of relationships and supported using techniques to understand these relationships. Our data highlight disparities in the pain experience for black men. They also elucidate potential mechanisms through which disparities work in vulnerable and understudied populations.

The adequacy of chronic pain management prior to presenting at a tertiary care pain center: the role of patient socio-demographic characteristics.

UNLABELLED: The Pain Management Index (PMI) is used to assess pain medication adequacy in black and white chronic pain patients (18-50 years) at referral to tertiary pain care. Using WHO guidelines for pain treatment, PMI was calculated from pain severity and drug analgesic potency. From 183 patients recruited, 128 provided treatment information for analyses (53% white, 60% female). Most (51.6%) had adequate PMI. Blacks were prescribed fewer pain medications (P = .03); fewer women had adequate medication strength (P = .04). In hierarchical regression, PMI was predicted at entry by female gender, lower MPI, higher affective MPQ, and a gender X age interaction. Younger men experienced better pain management, reducing toward the PMI level of women by age 50. In the final block, black race, being married, affective pain, and gender X age were associated with higher PMI, female gender and being employed were associated with lower PMI. Women, particularly younger women, were at higher risk for inadequate pain management in a primary care environment. These results support variability in chronic pain care and the need for research focusing on whether these disparities persist with specialized pain care. PERSPECTIVE: Most people with pain receive initial care in a primary care setting. This study examining the adequacy of pain management prior to specialty pain care showed blacks and women had less adequate pain care at referral. These results suggest the need for interventions and education in the primary care arena to improve pain care.

Physical and psychosocial health in older women with chronic pain: comparing clusters of clinical and nonclinical samples.

BACKGROUND: This investigation examined why some elderly women with severe pain symptoms and impairment in health status were not seen in a tertiary care pain center. METHODS: Three groups of older (> or = 60 years) women were included in the study: women seeking chronic pain treatment at a multidisciplinary pain center (N = 49), and research volunteers from the same institution with (N = 28) and without (N = 27) chronic pain. A clustering classification technique was used to identify clusters of older women with similar physical and mental health status. RESULTS: We found three clusters: 1) a healthy cluster (cluster 1: mostly nonclinical women); 2) a cluster with very poor physical and mental health status (cluster 3); and 3) a cluster with low physical health but average mental health (cluster 2). Although only cluster 1 had significantly higher physical health (P < 0.001), all three clusters had different mental health (P < 0.001). Within cluster 2, clinical women had more pain than nonclinical women, but within cluster 3, this was not so, indicating that mental health issues may create an obstacle to women having their pain appropriately assessed and treated. CONCLUSIONS: Our findings support that while disability and pain severity contribute to specialized pain services usage among older women, there is a subgroup of people not receiving pain care for whom these pain symptoms are similar. Further studies are needed to assess the role of health-seeking behavior, coping preferences, referral patterns, and patient-physician communication on access to tertiary pain care for older women.

Cancer pain: an age-based analysis.

OBJECTIVE: Although cancer pain (consistent and breakthrough pain [BTP; pain flares interrupting well-controlled baseline pain]) is common among cancer patients, its characteristics, etiology, and impact on health-related quality of life (HRQOL) across the lifespan are poorly understood. DESIGN: This longitudinal study examines age-based differences and pain-related interference in young and old patients with cancer-related pain over 6 months. Patients in the community with stage III or IV breast, prostate, colorectal, or lung cancer, or stage II-IV multiple myeloma with BTP completed surveys (upon initial assessment, 3 and 6 months) assessing consistent pain, BTP, depressed affect, active coping ability, and HRQOL using previously validated measures. RESULTS: Respondents (N= 96) were 70% white and 66% female, with a mean age of 57±10 years. There were no significant differences in pain severity based upon age. However, the younger group experienced more pain flares with greater frequency (P=0.05). The oldest group had better emotional functioning at baseline but worse physical functioning at 6 months. Younger groups also had worse cognitive functioning at 6 months (P=0.03). Pain interference was independent of age. CONCLUSIONS: These data provide evidence for the significant toll of cancer pain on overall health and well-being of young and old adults alike but demonstrate an increased toll for younger adults (especially financially). Beyond race and gender disparities, further health care disparities in the cancer and cancer pain were identified by age, illustrating the need for additional research across the lifespan in diverse cancer survivors.

Sleep problems in a racially diverse chronic pain population.

OBJECTIVE: This study describes and compares sleep disturbances in chronic pain patients while assessing the role of age, race, gender, and psychological health on sleep. METHODS: Self-report data fitted from chronic pain patients (N=4269) presenting for initial assessment were fitted to regression models predicting difficulty falling asleep, difficulty staying asleep, and overall sleep quality. RESULTS: We found high prevalence of difficulty falling (71.1%) and staying asleep (78.3%), and relatively poor sleep quality (9.76+/-2.86; 3=best; 18=worse). Blacks, men, and younger people with chronic pain were at higher risk for poor sleep quality and difficulty falling asleep. Significant interactions between race, age, gender, and sleep were identified. Sleep improved with age, but the gender gap in difficulty falling asleep and poor sleep quality was greatest at younger age, with young men at greatest risk. Young black men had more difficulty staying asleep, with a significant improvement with age. Individuals with chronic pain most at risk for sleep disturbances differed from those identified in general populations. DISCUSSION: The ability of health professionals to identify individuals at risk for sleep disturbance and to understand the dynamics of sleep, pain, and psychological health could improve healthcare quality.

Body mass index and quality of life: examining blacks and whites with chronic pain.

UNLABELLED: Obesity contributes to several chronic pain conditions, negatively affecting quality of life (QOL). However, obesity's relationship with chronic pain is poorly understood. This prospective survey study examines obesity's role in chronic pain and subsequent impact on QOL. Black and white patients with chronic pain (N = 183, 18-50 years of age, 64% women, 50% black) were studied to determine predictors for the presence of body mass index (BMI) information in medical records, group BMI differences, and how BMI and pain contribute to mental/physical outcomes. BMI was calculated by using medical records nearest the enrollment date. Sociodemographic data, sleep, pain, functioning, disability, and depression were measured. BMI data were available for 143 subjects (78%), with blacks having a higher BMI (P = .002). Black (P = .08), people with higher pain (P < .01), affective distress (P < .01), and post-traumatic stress disorder scores (P = .07) were less likely to have their BMI recorded. Path analysis tested relationships between sociodemographics, BMI and pain with functioning, depression, and disability. BMI was positively associated with black race and age and predicted poorer physical functioning and greater disability. Pain was not predicted by race or age but was associated with all outcomes. These findings support assessing BMI when managing chronic pain and its negative impact on QOL, especially for minority patients. PERSPECTIVE: This study examines the relationships among sociodemographic factors, BMI, and QOL in chronic pain. Our results demonstrate significant racial disparity among chronic pain patients in assessing BMI and quality of pain care. These findings support obesity's negative impact on overall health and the importance of measuring BMI in patients with chronic pain, especially racial and ethnic minorities.

Consistent and breakthrough pain in diverse advanced cancer patients: a longitudinal examination.

Although cancer pain, both consistent and breakthrough pain ([BTP]; pain flares interrupting well-controlled baseline pain), is common among cancer patients, its prevalence, characteristics, etiology, and impact on health-related quality of life (HRQOL) are poorly understood. This longitudinal study examined the experience and treatment of cancer-related pain over six months, including an evaluation of ethnic differences. Patients with Stage III or IV breast, prostate, colorectal, or lung cancer, or Stage II-IV multiple myeloma with BTP completed surveys on initial assessment and at three and six months. Each survey assessed consistent pain, BTP, depressed affect, active coping ability, and HRQOL. Among the respondents (n=96), 70% were white, 66% were female, and had a mean age of 56+/-10 years. Nonwhites reported significantly greater severity for consistent pain at its worst (P = 0.009), least (P < or = 0.001), on average (P = 0.004), and upon initial assessment (P = 0.04), and greater severity for BTP at its worst (P = 0.03), least (P = 0.02), and at initial assessment (P = 0.008). Women also had higher levels of some BTP measures. Ethnic disparities persisted when data estimation techniques were used. Examined longitudinally, consistent pain on average and several BTP measures reduced over time, although not greatly, indicating the persistence of pain in the cancer experience. These data provide evidence for the significant toll of cancer pain, while demonstrating further health care disparities in the cancer pain experience.

The association among neighborhood socioeconomic status, race and chronic pain in black and white older adults.

The association among race, neighborhood socioeconomic status (SES), and chronic pain has not been well examined in older people. Clinical data was obtained from older adults (>50 years old) presenting to a tertiary care pain center. The relative roles of race and neighborhood SES on the chronic pain experienced in older black and white adults were assessed. Older blacks experienced more affective pain, pain-related disability and mood disorder symptoms than older whites. Confirmatory factor analysis confirmed previously hypothesized factors for the McGill Pain Questionnaire pain dimensions and the Pain Disability Index. Exploratory and confirmatory factor analyses also identified factors in the Brief Symptom Inventory and neighborhood SES. Structural equation modeling showed black race was associated with lower neighborhood SES and also with increased affective pain, obligatory disability and mood disorders mediationally through neighborhood SES. It was indirectly associated with increased sensory and miscellaneous pain, and voluntary disability through low neighborhood SES. Racial interaction examination showed that neighborhood SES had the same relationship to outcomes by race. We found increasing neighborhood SES is associated with decreasing negative chronic pain outcomes for older blacks and whites. Our data provide evidence that both race and neighborhood SES are important factors to consider when examining the chronic pain experience among older Americans.

When mothers have serious mental health problems: parenting as a proximal mediator.

Maternal mental health (MMH) problems are associated with lack of confidence in one's parenting, overly lax or too harsh discipline, and child academic underperformance. We asked if parenting mediates the effect of MMH problems on academic outcomes even among mothers with serious mental illness (n=164). Structural equation analyses show a significant association between MMH problems and permissive (lack of parenting confidence, lack of follow through) parenting and verbal hostility as well as worse academic outcomes (school recorded grades, teacher reported behaviour). Permissive parenting completely mediated the direct effect of MMH on academic outcomes. Further analyses showed that the mediation effect was attributed to a single component of permissive parenting-lack of parenting confidence.