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

尽管几十年来努力减少种族疼痛差异，但黑人患者的疼痛仍然得不到充分治疗。AS 持续的疼痛经历有力地预测了总体生活质量较差，种族疼痛护理差异代表着 加剧社会不平等的核心因素。虽然之前的工作已经确定了大量的患者和提供者 造成一般医疗保健方面种族差异的因素，因此也可能造成差异 在疼痛护理方面，在消除这些差异方面取得了有限的临床意义的进展。因此，有 迫切需要采取创新的方法来解决这一长达数十年的不平等问题。我们认为，这种缺乏 进步的原因是先前的研究已经调查了患者和提供者因素对 孤立，而不是检查他们的互动。成功的疼痛护理需要建设性的患者提供者 建设性的沟通既是二元的，也是动态的。这项拟议的研究将 建立以患者与提供者沟通为基础的二元性和动态过程为关键 患者和提供者因素导致两种患者的种族差异的机制- 以疼痛为中心和临床结果。这类二元过程的一种广为接受的操作方式是 行为协调(即行为节奏或行为模式的空间/时间匹配 参与互动的个人，如同步性、领导者和追随者动态以及话轮转换)。我们 假设黑人患者的疼痛继续得不到充分治疗，因为黑人(与白人)患者 更有可能参与种族不和谐的医疗互动(即，看到其他种族的提供者)，并作为 结果是，他们更有可能在行为协调方面遇到障碍。这些假说将得到检验。 在术前咨询的背景下，因为手术疼痛结果的种族差异很好- 所有程序都有记录，而且，术前会诊的质量与术后的质量有关 疼痛管理。我们将使用一种融合的混合方法研究设计来评估行为协调 在数量上(例如，水平、持续时间、模式)和质量上(例如，价数、讨论主题)。这项工作将： 目的1)比较术前行为协调的水平、持续时间、模式和背景 黑人和白人患者之间的会诊(包括全面的和具体的疼痛讨论)；目标2) 阐明患者/提供者因素与术前会诊中的协调之间的联系；以及目标3) 在术前会诊中确定有助于种族的行为协调的具体方面 手术后以患者为中心的结果(例如，疼痛管理自我效能、生活质量)和 临床结果(例如，疼痛程度、处方)。由于本研究关注的是疼痛管理的自我效能 和生活质量作为主要结果，这些发现将在手术疼痛之外得到推广。拟议中的工作 将为开发针对可修改因素(潜在的二元过程)的干预措施奠定基础 可通过利用现有基础设施(医疗培训)来解决。

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).