Inequitable access to nonpharmacologic pain treatment providers among cancer-free U.S. adults.

OBJECTIVE: Using evidence-based nonpharmacologic pain treatments may prevent opioid overuse and associated adverse outcomes. There is limited data on the impact of access-promoting social determinants of health (SDoH: education, income, transportation) on use of nonpharmacologic pain treatments. Our objective was to examine the relationship between SDoH and use of nonpharmacologic pain treatment providers. Our goal was to understand policy-actionable factors contributing to inequity in pain treatment. METHODS: Based on Andersen's Health Utilization Model, this cross-sectional analysis of 2016-2019 Medical Expenditure Panel Survey data evaluated whether use of outpatient nonpharmacologic pain treatment providers is driven by enabling (i.e., advantageous socioeconomic resources) or need (i.e., perceived disability and diagnosed disease) factors. The study sample (unweighted n = 28,188) represented a weighted N = 81,912,730 noninstitutionalized, cancer-free, U.S. adults with pain interference. The primary outcome measured use of nonpharmacologic providers relative to exclusive prescription opioid use or no treatment (i.e., neither opioids nor nonpharmacologic). To quantify equitable access, we compared the variance-between access-promoting enabling factors versus medical need factors-that explained utilization. RESULTS: Compared to enabling factors, need factors explained twice the variance predicting pain treatment utilization. Still, the adjusted odds of using nonpharmacologic providers instead of opioids alone were 39% lower among respondents identifying as Black (95% Confidence Interval [CI], 0.49-0.76) and respondents residing in the U.S. South (95% CI, 0.51-0.74). Higher education (95% CI, 1.72-2.79) and income (95% CI, 1.68-2.42) both facilitated using nonpharmacologic providers instead of opioids. CONCLUSIONS: These findings highlight the substantial influence access-promoting SDoH have on pain treatment utilization.

Characteristics of Early Interventions for Pain and Function Following Lower Extremity Joint Replacement: Systematic Review.

Occupational therapy is beneficial among adults with chronic pain; however, occupational therapy interventions addressing earlier phases of pain have not been clearly explicated. This systematic review characterized acute and subacute interventions billable by occupational therapy after hip or knee replacement to improve pain and function. Seven articles met inclusion criteria. Six articles had a low risk of bias. Three intervention types were found: task-oriented exercise, water-based, and modalities. Only task-oriented interventions improved both pain and function one-year after surgery. There are long-term benefits to early task-oriented exercise. Further research is needed to contextualize occupational therapy's role in early pain interventions.

Bridging the humanities and health care with theatre: Theory and outcomes of a theatre-based model for enhancing psychiatric care via stigma reduction.

OBJECTIVE: This article describes the rational, methods, implementation, and effectiveness of Identity Development Evolution and Sharing (IDEAS), an evidence-supported, narrative theater-based training that reduces stigma among health care providers to increase health care equity in psychiatric rehabilitation. METHOD: The IDEAS model has been used to reduce provider bias toward patients. From May 2017 to January 2020, we interviewed people from three patient groups who have been harmed by stigma, including Black women, transgender, and gender-diverse people, and people with substance use disorders. These interviews informed the creation of three theatrical scripts that were performed by professional actors for audiences of health care providers from January 2020 to May 2022. The performances aimed to raise conscious awareness of implicit provider biases and to provide a reflective opportunity to ameliorate these biases. The purpose of IDEAS is to improve experiences in health care settings such as psychiatric rehabilitation of patients from groups who have been harmed by stigma. We used paired-samples t tests to compare pre/postprovider stigma, measured via the Acceptance and Action Questionnaire-Stigma (AAQ-S). RESULTS: Sociodemographic factors for providers who viewed IDEAS were similar across all three performances. IDEAS significantly decreased AAQ-S scores (t = 11.32, df = 50, M = 13.65, 95% confidence limit: [11.32, 15.97], p < .0001). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: IDEAS reduces provider stigma to support positive clinical encounters with diverse patient populations. These findings are relevant for psychiatric rehabilitation settings, which seek to establish positive rapport between providers and patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Trends in the Use of Opioids vs Nonpharmacologic Treatments in Adults With Pain, 2011-2019.

Importance: Chronic pain prevalence among US adults increased between 2010 and 2019. Yet little is known about trends in the use of prescription opioids and nonpharmacologic alternatives in treating pain. Objectives: To compare annual trends in the use of prescription opioids, nonpharmacologic alternatives, both treatments, and neither treatment; compare estimates for the annual use of acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy; and estimate the association between calendar year and pain treatment based on the severity of pain interference. Design, Setting, and Participants: A serial cross-sectional analysis was conducted using the nationally representative Medical Expenditure Panel Survey to estimate the use of outpatient services by cancer-free adults with chronic or surgical pain between calendar years 2011 and 2019. Data analysis was performed from December 29, 2021, to August 5, 2022. Exposures: Calendar year (2011-2019) was the primary exposure. Main Outcomes and Measures: The association between calendar year and mutually exclusive pain treatments (opioid vs nonpharmacologic vs both vs neither treatment) was examined. A secondary outcome was the prevalence of nonpharmacologic treatments (acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy). All analyses were stratified by pain type. Results: Among the unweighted 46 420 respondents, 9643 (20.4% weighted) received surgery and 36 777 (79.6% weighted) did not. Weighted percentages indicated that 41.7% of the respondents were aged 45 to 64 years and 55.0% were women. There were significant trends in the use of pain treatments after adjusting for demographic factors, socioeconomic status, health conditions, and pain severity. For example, exclusive use of nonpharmacologic treatments increased in 2019 for both cohorts (chronic pain: adjusted odds ratio [aOR], 2.72; 95% CI, 2.30-3.21; surgical pain: aOR, 1.53; 95% CI, 1.13-2.08) compared with 2011. The use of neither treatment decreased in 2019 for both cohorts (chronic pain: aOR, 0.43; 95% CI, 0.37-0.49; surgical pain: aOR, 0.59; 95% CI, 0.46-0.75) compared with 2011. Among nonpharmacologic treatments, chiropractors and physical therapists were the most common licensed healthcare professionals. Conclusions and Relevance: Among cancer-free adults with pain, the annual prevalence of nonpharmacologic pain treatments increased and the prevalent use of neither opioids nor nonpharmacologic therapy decreased for both chronic and surgical pain cohorts. These findings suggest that, although access to outpatient nonpharmacologic treatments is increasing, more severe pain interference may inhibit this access.

Incident Functional Limitations Among Community-Dwelling Adults Using Opioids: A Retrospective Cohort Study Using a Propensity Analysis with the Health and Retirement Study.

BACKGROUND: Opioid analgesics are commonly used to manage pain; however, it is unclear how they affect patient function. This study examines the association between opioid analgesics and incident limitations in activities of daily living (ADL), instrumental activities of daily living (IADL), and cognitive functioning among community-dwelling older adults. METHODS: Data included 10,003 participants of the 2016 and 2018 waves of the Health and Retirement Study, which sampled US adults aged 51-98 years. The primary exposure was self-reported opioid pain medication use in 2016. Outcomes included incident limitations in ADL, IADL, and cognitive functioning in 2018. Statistical methods adjusted for confounding using multivariable logistic regressions, inverse probability of treatment weighting, and propensity scores. RESULTS: Opioid use (adjusted odds ratio [aOR]: 1.34, 95% confidence interval [CI] 1.07-1.68) was associated with a statistically significant higher odds of incident ADL limitation in multivariable regression and in propensity score adjustment (aOR: 1.41, 95% CI 1.13-1.76). The association between opioid use and ADL and IADL limitations was modified by age. Adults aged < 65 years had a higher odds of incident ADL (aOR: 1.83, 95% CI 1.38-2.42) and IADL (aOR: 1.42, 95% CI 1.06-1.90) limitations compared with those aged ≥ 65 years. CONCLUSIONS: Community-dwelling adults using opioid analgesics to manage pain may be at risk for incident ADL limitations. Middle-aged adults, compared with those older than 65 years of age, experienced the greatest odds for incident ADL and IADL limitations following opioid use. According to sensitivity analyses, our findings were robust to unmeasured confounding.

Cross-National Comparisons of Cognitive and Physical Health in Older Adults Across China, Japan, and Korea: A Systematic Review.

BACKGROUND: Cross-national studies are an emerging research area in public health. Specifically, cross-national health comparisons are important for understanding the factors driving the success or failure of public health policies. Therefore, this study systematically analyzed studies that compared health status (physical health and cognition) of the older adults using national panel data for three East Asian countries-China, Japan, and Korea. METHODS: Google Scholar and PubMed were used for the literature search. The search strategy targeted papers published between 2005 and 2020, yielding a total of 2690 papers, of which seven were selected for the review. The Center for Evidence-Based Medicine (CEBM) criteria was used to assess study design quality. The risk of bias for non-randomized studies (RoBANS) tool, a quality assessment tool developed in Korea to evaluate non-randomized interventional studies, measured risk of bias. RESULTS: Of the seven included papers, two studies performed cognitive comparisons, four studies performed physical health comparisons, and one study compared both cognition and physical health. The studies selected for this study by CEBM criteria included four prospective cohort studies (Level 2B) and three expert opinions without explicit critical appraisal (Level 5). Risk of bias using the RoBANS tool found a risk of confounding variables in four out of seven papers. Finally, measurement items of cognitive and physical health differed across all three countries' panel surveys. CONCLUSION: These results suggest that in order to compare East Asian health policies according to the aging society, it is necessary to develop consistent cognitive and physical health evaluation tools in the future.

Functional Status Across Post-Acute Settings is Associated With 30-Day and 90-Day Hospital Readmissions.

OBJECTIVE: To examine the association between cocalibrated functional scores across post-acute care settings and the subsequent risk of hospital readmission. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We analyzed 781,021 fee-for-service Medicare beneficiaries discharged to either inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHA) after an acute hospital stay for stroke (N = 143,277), lower extremity joint replacements (512,577), and hip/femur fracture (125,167) between January 1, 2013, and August 31, 2014. MEASURES: Functional items from IRF-PAI, MDS, and OASIS were categorized into self-care and mobility domains. We cocalibrated admission functional scores across post-acute settings and divided scores into 4 functional levels using quartiles (Q1-Q4, with Q4 representing the most independent function). The primary outcomes were 30-day and 90-day hospital readmissions (yes/no) after an initial post-acute stay. RESULTS: Patients who were more dependent in self-care and mobility at the initial post-acute setting were significantly more likely to experience hospital readmission [eg, hazard ratios of 30-day readmission in stroke: 1.54 (95% confidence interval [CI] 1.47-1.61), 1.18 (95% CI 1.14-1.23), and 1.12 (95% CI 1.08-1.16) for Q1, Q2 and Q3, compared to Q4]. We found similar results for risk of 90-day hospital readmission across impairment conditions. CONCLUSIONS AND IMPLICATIONS: Patients who were more functionally dependent at the initial post-acute setting had a higher risk to readmit to the hospitals after discharging from the post-acute setting for 30 and 90 days, compared with patients who were more functionally independent. This finding is consistent across impairment conditions and post-acute settings. Future research should determine effective strategies of maintaining and facilitating functional performance across post-acute settings to optimize long-term patient outcomes.

Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees.

OBJECTIVE: To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty. DESIGN: This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015. SETTING: Home health or outpatient. PARTICIPANTS: Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068). INTERVENTIONS: We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use. MAIN OUTCOME MEASURES: Duration of prescription opioid use. RESULTS: Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative. CONCLUSIONS: Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.

Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement.

OBJECTIVES: Understand the association between social determinants of health and community discharge after elective total joint arthroplasty. DESIGN: Retrospective cohort design using Optum de-identified electronic health record dataset. SETTING AND PARTICIPANTS: A total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018. METHODS: Logistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics. RESULTS: Mean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.85; knee: OR 0.73, 95% CI 0.69-0.77], current smoking (hip: OR 0.82, 95% CI 0.77-0.88; knee: OR 0.90, 95% CI 0.85-0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50-0.60; knee: OR 0.57, 95% CI 0.53-0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively. CONCLUSIONS AND IMPLICATIONS: Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.

Dysphagia Associated with Risk of Depressive Symptoms among Stroke Survivors after Discharge from a Cluster of Inpatient Rehabilitation Facilities.

OBJECTIVES: To examine the association of stroke-induced dysphagia during an inpatient rehabilitation facility (IRF) stay and depressive symptoms at a 3-month follow-up. METHODS: A retrospective cross-sectional design using the Stroke Recovery in Underserved Populations 2005-2006 study database. Hierarchical logistic regression models were utilized to examine if stroke-induced dysphagia is a significant predictor for depressive symptoms at 3-month follow-up across the stepwise introduction of the demographics and clinical characteristics at the IRF discharge and 3-month follow-up. Multiple imputations with Markov-chain Monte Carlo method was used to address the covariates with missing observations. RESULTS: In a total of 1,045 stroke survivors, 335 (32.1%) stroke survivors had dysphagia and 710 (67.9%) stroke survivors did not have dysphagia during the IRF stay. The adjusted logistic regression model and multiple imputation method revealed that stroke survivors with dysphagia are more likely to have depressive symptoms at 3-month follow-up (Odds ratio [OR] 3.169, 95% confidence interval [CI] 1.379-7.283; OR 1.746, 95% CI 1.153-2.642, respectively). A high level of functional and cognitive status, functional support, and community participation at the 3-month follow-up was inversely associated with depressive symptoms (OR 0.973, 95% CI 0.951- 0.995; OR 0.884, 95% CI 0.829-0.942; OR 0.793, 95% CI 0.714-0.882). DISCUSSION: Stroke survivors experiencing dysphagia during the IRF stay had a higher risk of developing depressive symptoms compared to those without dysphagia at 3-month follow-up. Healthcare providers should pay attention to dysphagia care in IRFs which might prevent the development of depressive symptoms when the stroke survivors are discharged and back in their communities.

Policy and Payment Changes Create New Opportunities for Occupational Therapy in Acute Care.

IMPORTANCE: Changes in health care policy and payment over the past decade have resulted in a greater emphasis on cost effectiveness, quality outcomes, and the health care consumer's experience. Payers' response to the new policies and their expectations have created expanded opportunities for occupational therapy practitioners in health care overall but particularly in acute care hospitals. OBJECTIVE: The objective of this article is to empower occupational therapy directors, practitioners, educators, and students to be proactive in a rapidly changing acute care setting. EVIDENCE REVIEW: Research on policy and payment changes since the passage of the Patient Protection and Affordable Care Act (Pub. L. 111-148) was synthesized with evidence related to occupational therapy practice and education. FINDINGS: Occupational therapy practitioners in acute care environments are experiencing expanded roles in optimizing patient readiness for safe community discharge, decreasing lengths of stay, and protecting them from hospital-acquired conditions. CONCLUSIONS AND RELEVANCE: Policy and payment initiatives reward health care organizations for the added value occupational therapy practitioners bring to acute care teams. WHAT THIS ARTICLE ADDS: This article details how occupational therapy practitioners can advance consumer satisfaction, outcomes, and efficiency in acute care, which can lead to increased recognition of the vital role that occupational therapy can play, thus leading to expanded opportunities.