PATIENT ATTITUDES REGARDING HEALTHCARE UTILIZATION AND REFERRAL: DISCUSSION

10 Dec
2009

Pain is the major reason for healthcare utilization, significantly affecting health and well-being.

Yet, stark differences in the healthcare experiences (e.g., healthcare access, referral, and utilization) based upon gender, race, ethnicity, and social stratification are well described. In their studies on physician pain management, Green et al. demonstrated physician variability in pain management decision-making based upon patient demographic factors and type of pain. Most studies that have focused on healthcare access and utilization have not examined a racially and ethnically diverse chronic pain population. In this study, we report on the experiences and perceptions of African- and Caucasian Americans who received chronic pain treatment in a tertiary-care academic pain center. Potential factors that affect healthcare access and utilization in general, as well as access and utilization to a tertiary-pain care center in particular, were evaluated. This study provides new insights into the attitudes and perceptions regarding pain and healthcare services in a diverse patient population that is experiencing chronic pain.

Social stratification, ethnicity, and race influence insurance coverage as well as the ability to pay for healthcare services. Health insurance and prescription coverage were evenly distributed among both groups (i.e., African- and Caucasian Americans) in this study. However, African Americans were less likely to afford medical care and experienced more difficulty paying for healthcare, suggesting that copays may constitute a major financial barrier to healthcare among African Americans who have chronic pain—although other yet-to-be-determined factors may also contribute to these differences in attitude. These results confirm Crystal’s work, where the out-of-pocket cost burden was higher among individuals with chronic health conditions and who had Medicaid insurance. Kiefe also found that increases in copay over time was higher amongst African Americans when compared to Caucasian Americans. Copays are not the only factor limiting access to care. Keife found that despite the use of vouchers in low-income inner-city women, their access to mammography was further limited by transportation difficulties. buy viagra professional

For the poorest Americans, Medicaid provides a safety net which allows access to medical care. However, Medicaid often limits the healthcare choices and services available to the patient. Our results in a chronic-pain population revealed that African Americans were more likely to have Medicaid and, thus, may be more likely to be underin-sured than Caucasian Americans. Miller and Seib’s observed that African Americans experienced difficulties in receiving quality care, even when they are covered by insurance. Since many pain-management modalities are often not covered or covered less by Medicaid, it follows that the quality of chronic-pain treatment may be affected. This may also reflect differences in access as well as differences in outcomes that may be gender- or race based. In a study of screening services used among women, Krakauer showed that the patient-provider relationship and satisfaction with the healthcare provider was a determinant in continuity of care. In this study, we identified significant differences that affect chronic-pain management access and utilization, which may differentially affect racial and ethnic minorities. How these differences affect pain management outcomes is unclear and deserves further study.

Pain is the chief complaint for 35 million new physician office visits and accounts for over 70 million total physician visits annually. The literature suggests that racial and ethnic minorities were at risk for the undertreatment of all types of pain. Cleeland showed that physicians tended to underestimate the pain severity of minority patients. Consistent with previous research on healthcare utilization patterns, we found significant differences in the source of healthcare for African Americans when compared to Caucasian Americans. Although all subjects in this study had access to pain care, African Americans were less likely to have a primary care physician and were also more likely to use the emergency room for pain care than Caucasian Americans. This is an important finding, since others have shown that African Americans as well as other racial and ethnic minorities receive lesser pain care in the emergency room than Caucasian Americans. Husaini showed that older men covered by Medicaid and who had a psychiatric diagnosis tend to use less outpatient services and more emergency room services than women. African Americans with Medicaid insurance had different healthcare service utilization patterns as demonstrated by more emergency room visits. A particularly important finding is that African Americans waited longer to be seen in the pain center but believed that they should have been referred sooner for specialty pain care. Our results also revealed that African Americans used the emergency room more frequently for pain care. Once referred to the pain center, African Americans were more likely to be referred by a female physician. Overall, these findings,which deserve further study, suggest variability prior to treatment and referral to a pain center. cheap levitra professional

Depression, anxiety, post-traumatic-stress disorder, and other psychological morbidities commonly are present as comorbidities in chronic pain. These comorbidities may directly impact healthcare services use in chronic-pain patients. However, some racial and ethnic minority groups may not readily accept services provided through formal agencies. This is consistent with previous research that suggests that African Americans may use alternative resources and informal sources for mental healthcare. Ruiz provided information to suggest higher mental health morbidity in African Americans as well as the complexities in providing high-quality mental healthcare to this population. The studies suggesting that African Americans with chronic pain have increased psychological and physical morbidity make these findings particularly important. Yet, contrary to the findings of others regarding the reluctance of African Americans to seek mental healthcare, our results did not reveal differences in utilization. Further studies directed at cultural differences and insurance issues that may affect access to mental healthcare in a racially and ethnically diverse chronic pain population are necessary.

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