Pain care disparities: A comprehensive integration of patient‐ and provider‐level mechanisms with dyadic communication processes using a mixed‐methods research design

Despite decades of efforts to reduce gaps in pain care, the pain of some patients—especially those in vulnerable populations—is still undertreated. As persistent pain experience robustly predicts poorer quality of life overall, pain care disparities represent a central factor fueling larger social problems. While previous work has identified a host of patient and provider factors that contribute to disparities in healthcare in general and thus also likely contribute to disparities in pain care, there has been limited clinically-meaningful progress in closing these gaps. Thus, there is an urgent need to address this decades-old issue 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 suboptimal 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 undertreatment of pain stems, in part, from disruptions in behavioral coordination that occur during interactions between patients and their providers. These hypotheses will be tested within the context of preoperative consultations because 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) characterize the levels, duration, patterns, and context of behavioral coordination in preoperative consultations (both overall and during pain discussion specifically); 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 both disrupt and enhance 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).