New initiative addresses health disparities in rates of poorly controlled pain

Recent data and studies, especially during the pandemic, have shed light on racial disparities that exist within health care. These trends prompted a closer look at our own data related to inpatient pain management, revealing apparent disparities at Michigan Medicine.

The Rewrite the Script (RWTS) team, originally established in response to the growing opioid crisis, has been studying opioid prescribing and utilization, and making significant recommendations in practice to reduce opioid addiction. The team studied data to discover if there were disparities in the experience of pain for different groups of hospitalized patients.

They found that despite equal access to pain management care — such as consult from a service with expertise in managing pain, opioid therapy and time to first pain score taken — Black patients were 40% more likely than White patients to report uncontrolled pain scores.

“We are looking closely at many possible contributing factors within the inpatient setting, but also need to acknowledge that much of the disparity may be occurring before patients enter the hospital,” said Paul Hilliard, RWTS lead and associate professor of anesthesiology at the U-M Medical School. “Patients with chronic pain already suffer from stigma. Pain is both a sensory and emotional experience, and this can become an even deeper challenge for those who may experience societal racism or other issues such as food insecurity or a lack of transportation.”

To meet the challenge, the leadership team from University Hospital and Frankel Cardiovascular Center (UH/CVC), in partnership with RWTS, launched an initiative to build a more equitable pain management program across the adult hospitals. Falling under the Belonging and Inclusion priority of the BASE (Belonging and Inclusion, Access, Safety and Quality, Experience) strategic priorities, the Pain Management Initiative is an important focus within the UH/CVC FY22 priorities.

Beginning in January 2022, the team will focus on reducing disparities in pain for Black patients. Two pilot programs within the adult hospitals during the first half of 2022 will use enhanced pain management tools or modalities for all patients in an effort to reduce those disparities. The tools include a personalized pain profile and a functional pain assessment.

The team is also exploring ways to leverage enhanced interventions — including non-pharmacological therapies and specialized conversations about pain — by our Acute Pain Service (APS) nurses.

“Our goals within this initiative are to increase awareness about the disparities in the data and gain a better understanding of what we can do to address them,” said Linda Larin, FACHE, M.B.A., chief operating officer for the adult hospitals. “The care teams involved in the pilot programs will provide valuable insights for changes needed to ensure effective pain management for all patients.”

“It’s hard to say what tools will have the biggest impact, because we are still trying to understand what factors are contributing to this disparity,” Hilliard said. “At the end of the day, one of the most impactful interventions will likely be communication — sharing the data with our clinical teams and enabling an open dialogue about the disparity and what might be contributing to it.

“All patients have unique life experiences and cultural backgrounds which can impact how they relate to health care providers and how we, as providers, relate to them — particularly when working with very personal, and often invisible, chronic pain,” Hilliard added. “Some patients may carry the added burden of psychosocial stressors that can amplify a painful experience while others minimize their pain. Attempting to better understand these individual factors will inform our approach to pain management and result in a better experience for patients who are at risk of poorly controlled pain.”

Searching for systemwide solutions

While the pilot programs will be very localized, with an emphasis on personalized care, the objective of the program is to find organizationwide, system solutions.

Once the program results are analyzed and improvements are implemented at the adult hospitals, next steps for the team will be to consider how tools and methods can be shared across more units and patient populations. The team is also considering how expanded non-pharmacologic options, such as massage and acupuncture, could assist in the future.

“As we gather insights from the pilot programs in the coming months, we will align our efforts across the adult hospitals and do everything we can to support all patients in their pain management needs,” said Larin.

“Our ultimate goal is to ensure we are providing equal and individualized pain management, and to optimize pain control for all patients during their hospitalization,” said Hilliard. “A first step is understanding that disparity exists and educating all of us about the systemic issues at play. We need to recognize that we serve patients who are vulnerable to uncontrolled pain for a variety of reasons, and how our own biases can impact their experience.”

In addition to this initiative, the RWTS team continues to develop and introduce a variety of resources to support patient pain management and substance abuse treatment across the organization. Watch for future Headlines articles on this work.