Racial Disparities in Pain Care: A Comprehensive Integration of Patient- and Provider-Level Mechanisms with Dyadic Communication Processes Using a Mixed-Methods Research Design

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Despite decades of efforts to reduce racial pain disparities, the pain of Black patients is still undertreated. As persistent pain experience robustly predicts poorer quality of life overall, racial pain care disparities represent a central factor fueling larger social inequalities. While previous work has identified a host of patient and provider factors that contribute to racial disparities in healthcare in general and thus also likely contributing to disparities in pain care, there has been limited clinically-meaningful progress in eliminating these disparities. Thus, there is an urgent need to address this decades-old inequity by taking an innovative approach. We argue that this lack of progress is due to the fact that prior research has investigated the influence of patient and provider factors in isolation, rather than examining their interaction. Successful pain care requires constructive patient-provider communication, and constructive communication is both dyadic and dynamic. This proposed research will establish the dyadic and dynamic processes underlying patient-provider communication as the key mechanism through which patient and provider factors contribute to racial disparities in both patient- centered and clinical pain outcomes. One well-accepted operationalization of such dyadic processes is behavioral coordination (i.e., spatial/temporal matching in the rhythms or patterns of behaviors between individuals engaged in an interaction, such as synchrony, leader-and-follower dynamics, and turn-taking). We hypothesize that the pain of Black patients continues to be undertreated because Black (vs. White) patients are more likely to participate in racially discordant medical interactions (i.e., seeing other-race providers) and as a result, are more likely to experience disruptions in behavioral coordination. These hypotheses will be tested within the context of preoperative consultations because racial disparities in surgical pain outcomes are well- documented across procedures, and further, the quality of preoperative consultations is linked to post-surgical pain management. We will use a convergent mixed methods research design to assess behavioral coordination quantitatively (e.g., levels, duration, patterns) and qualitatively (e.g., valence, discussion themes). This work will: Aim 1) compare the levels, duration, patterns, and context of behavioral coordination in preoperative consultations (both overall and during pain discussion specifically) between Black and White patients; Aim 2) elucidate links between patient/provider factors and coordination in preoperative consultations; and Aim 3) identify specific aspects of behavioral coordination in preoperative consultations that contribute to racial disparities in post-surgical patient-centered outcomes (e.g., pain management self-efficacy, quality of life) and clinical outcomes (e.g., pain level, prescriptions). Since this research focuses on pain management self-efficacy and quality of life as primary outcomes, findings will be generalizable beyond surgical pain. The proposed work will lay the foundation for developing interventions that target modifiable factors (the dyadic processes underlying patient-provider communication) that can be addressed by leveraging existing infrastructure (medical training).