The University of Michigan Health System Institutional Review Board (IRB) provided human subjects approval for this study. A prospective cross-sectional design with survey methodology was used to compare the healthcare experiences of African- and Caucasian Americans with chronic pain presenting to the Multidisciplinary Pain Center (MPC) at the University of Michigan.
A four-page, 50-item questionnaire was developed to evaluate healthcare access and utilization patterns in patients receiving treatment for chronic pain. The multi-item questionnaire consisted of items addressing: 1) demographic variables (e.g., age, race, ethnicity, gender), 2) healthcare services utilization, 3) healthcare sources, 4) physical and financial access to pain treatment, 5) attitudes and perceptions regarding pain management, and 6) attitudes and perceptions regarding healthcare access. The 13 items directed at healthcare utilization included questions, such as the total number of days spent in an inpatient unit, number of emergency room visits, and number of specialty healthcare provider visits. Response choices were coded as the total number of days/visits at each facility. Potential healthcare sources included emergency room and healthcare clinics. Response choices and questions were treated as a dichotomous variable (“yes” versus “no”). Financial access was determined using a five-item subscale and focused on the participant’s medical insurance and difficulties paying for healthcare. Physical access questions focused on the participant’s means of transportation to their appointments. Subjects also rated their agreement level for 13 items regarding the importance of sociodemographic factors on pain management and healthcare using a five-point Likert scale (0=completely disagree, 4=completely agree).
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The investigators and faculty members from the University of Michigan’s Department of Anesthesiology were enlisted to critique an early draft of the survey to improve its internal validity. Questions that were ambiguous or lacked clarity were revised, and content areas that were overlooked were added.
Participant Recruitment and Survey Distribution
A database was queried to identify people who attended the pain center for a two-year period. black/African Americans (n=324) and white/Caucasian Americans (n=300) who were currently seen at the MPC were selected. Potential study participants were recruited via two mechanisms: 1) at their MPC visit or 2) via U.S. mail. Participants recruited at the MPC were given the study materials during their clinic visit. A package which contained the survey instrument and an accompanying cover letter describing the study was provided to potential subjects. The cover letter encouraged participation but informed subjects that their participation was entirely voluntary and their responses confidential. Attached to the survey was a postcard that was used to document the subject’s willingness to participate and informed consent. Subjects who wished to par ticipate separated the postcard from the survey and returned the completed questionnaire via U.S. mail in the enclosed postage-paid envelopes or to a locked box inside the MPC. The postcard and survey (which had no identifying marks) were returned separately to prevent any linking of participants to their confidential survey responses.
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Subjects who were recruited during their clinic visit were sent the same information packet by U.S. mail. Consent was obtained when a subject returned their informed-consent document and survey using the previously described methodology. To obtain an optimal response, follow-up of nonresponders used the Total Design Method (i.e., three follow-up mailings of the survey with reminder postcards and letters within a two-month period). No incentives were offered to encourage study participation. An abbreviated nonresponse questionnaire was sent to those persons who did not respond to the mailings to elicit their reasons for nonparticipation.
Descriptive statistics (e.g., frequency distribution) were calculated to establish sample sociodemographic characteristics and performance on the measures included in the study (i.e., healthcare utilization, healthcare source, financial and physical access to healthcare, and attitudes regarding healthcare). T-tests or Mann-Whitney U tests were performed for continuous data when applicable. For categorical data, a Chi-square test was used to compare the two groups. Measures of association (odds ratios) were calculated to compare patterns of healthcare accessibility and utilization, healthcare source, financial access, physical access, and attitudes regarding pain management and treatment between African- and Caucasian Americans. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) version 10.0. Statistical significance for all analyses were determined using two-tailed tests, with the probability of Type 1 error, p<0.05.