Preparation and use of maps for highway purposes

The Illinois highway system consists of about 10,000 miles of primary (state) roads, and 20,000 miles of secondary (county) roads. The preparation of plans for a primary and secondary highway system of such size is an obvious step prior to construction and maintenance. In order to coordinate administration, location, surveys, right of way, construction, maintenance, traffic, legal and political activity, maps of various scales and types are required. This treatise will consider the types and classes of maps used by the state of Illinois for the purposes mentioned --Part I

Preparation and use of maps for highway purposes

The Illinois highway system consists of about 10,000 miles of primary (state) roads, and 20,000 miles of secondary (county) roads. The preparation of plans for a primary and secondary highway system of such size is an obvious step prior to construction and maintenance. In order to coordinate administration, location, surveys, right of way, construction, maintenance, traffic, legal and political activity, maps of various scales and types are required. This treatise will consider the types and classes of maps used by the state of Illinois for the purposes mentioned --Part I

Factors that Influence Providers’ Pain Treatment Decisions

poster abstractMedical and non-medical factors influence providers’ pain treatment decisions. Among these, patient demographic characteristics and substance use have received particular attention. However, few empirical studies have examined the specific factors providers rely on for their pain treatment decisions. This study employed lens model methodology to examine the factors that providers reportedly used, actually used, and would have used (if available) to make pain treatment decisions. We hypothesized that: (1) providers would rate patients’ pain history and description of pain as the most influential factors provided in the clinical vignettes, and (2) providers would rate patients’ substance use history as the most important factor not provided in the vignettes. 100 providers viewed 16 computer-simulated patients; each included a picture with accompanying text describing the patient’s medical condition. After making multi-modal treatment ratings for each patient, providers indicated the factors they used to make treatment decisions and the factors they would have used (if available) to make decisions. Results indicated that most providers reported being influenced by patients’ pain histories (98%) and descriptions (96%), whereas fewer reported using patients' movement (75%) or demographic characteristics (62%). Providers reported that they wanted additional information on patients’ treatment histories (98%), current/average pain (96%), and drug use (94%) to guide their decisions. Exploratory analyses indicated that, compared to providers who were not statistically influenced by patient demographics, a slightly greater proportion of providers who were statistically influenced by patient demographics wanted additional information about patients’ alcohol use to inform their decisions, χ2 (1) = 3.09, p = .08. These results suggest that providers prioritize both objective and subjective information about patients’ pain conditions, as well as patients’ substance use behaviors, when making treatment decisions. These findings have important implications for pain management and may lead to improved patient safety and care

Examining the influence of Hispanic ethnicity and ethnic bias on medical students’ pain decisions

Indiana University-Purdue University Indianapolis (IUPUI)Hispanic patients receive disparate pain care compared to non-Hispanic White (NHW) patients. Healthcare providers’ ethnic bias may be one reason for pain disparities. This investigation sought to determine the influence of Hispanic ethnicity and ethnic bias on chronic pain management decisions. During an online experiment, 97 medical students made pain assessment and opioid treatment decisions for Hispanic and NHW virtual human patients with chronic pain. They also completed explicit and implicit measures of ethnic bias. Individual-level analyses found that 31% and 36% of participants demonstrated large effect sizes (dz>.50), indicating that patient ethnicity strongly influenced their pain assessment and opioid treatment decisions, respectively. At the group level of analysis, participants’ decisions did not differ significantly between NHW and Hispanic patients (all p values >.05). Participants did not report significant explicit ethnic bias (t[96]=1.88, p=.06; dz=.19; Hispanic mean rating=77.6[SD=18.7]; NHW mean rating=75.2[SD=19.4]) but demonstrated a small-to-moderate implicit preference for NHWs relative to Hispanics (Mean=.31[SD=.41]). Patient ethnicity and implicit ethnic bias had an interactive effect on opioid treatment decisions (F[1, 95]=5.15, p<.05, generalized eta squared =.02); however, the direction of the effect was not as hypothesized. Participants with higher implicit ethnic bias gave significantly higher opioid ratings to Hispanics relative to NHWs (p=.05), whereas participants with lower bias gave marginally higher opioid ratings to NHWs relative to Hispanics (p=.20). Participants with higher vs. lower implicit ethnic bias differed only in their treatment ratings for NHW patients, such that participants with lower bias gave significantly higher opioid ratings to NHW patients than did participants with higher bias (p<.05). This investigation found that approximately one-third of participants made significantly different chronic pain management decisions for Hispanic vs. NHW patients. Participants’ implicit ethnic bias interacted with their opioid treatment decisions but not as expected. Future investigations should measure healthcare providers’ stereotypes about Hispanic patients with pain as this may better predict their pain decisions

Differences in Mexican Americans’ Prevalence of Chronic Pain and Co-Occurring Analgesic Medication and Substance Use Relative to Non-Hispanic White and Black Americans: Results from NHANES 1999–2004

Objective. Little is known about the burgeoning Mexican American (MA) population’s pain experience. Methods. Using 1999–2004 National Health and Nutrition Examination Survey (NHANES) data, prevalence of chronic pain, analgesic medication use, and substance use were examined among MA, non-Hispanic White (NHW), and non-Hispanic Black (NHB) respondents. Logistic and linear regression models examined racial/ethnic differences in: 1) chronic pain prevalence among all respondents, 2) location and number of pain sites among respondents with chronic pain, and 3) analgesic medication and substance use among respondents with chronic pain. Results. Compared to NHWs and NHBs, MAs were less likely to report any chronic pain. Among respondents with chronic pain, MAs had higher odds of reporting headache, abdominal pain, and a greater number of pain sites than NHWs. Compared to NHWs, MAs with chronic pain had lower odds of reporting past-month analgesic medication and COX-2 inhibitor use. MAs with chronic pain had lower odds of being a current cigarette smoker and heavy alcohol drinker but had similar street drug/cocaine use relative to NHWs. Conclusions. Results suggest that: 1) MAs are less likely to develop chronic pain than NHWs, 2) MAs with chronic pain report greater headache and abdominal pain than NHWs, and 3) MAs with chronic pain are less likely to use analgesic medications and other substances compared to NHWs. These results suggest that providers should consider taking extra time to discuss analgesic medications with MAs. Future investigations should examine reasons underlying these racial/ethnic differences in chronic pain, as well as differences in the use of other substances, such as marijuana

An investigation of medical trainees' self-insight into their chronic pain management decisions

Indiana University-Purdue University Indianapolis (IUPUI)While the majority of chronic pain patients report receiving inadequate care, there is evidence that female and Black patients receive less analgesic medications and treatment for their chronic pain compared to male and White patients, respectively. While treatment disparities have been evidenced in the literature, there is little understanding of provider-factors, such as their decision-making awareness and attitudes, which may contribute to the differences in treatment. This investigation employed quantitative and qualitative procedures to examine the relationship between patient demographics and chronic pain treatment variability, providers’ awareness of these non-medical influences on their decisions, and the extent to which providers’ gender and racial attitudes associate with their treatment decisions. Twenty healthcare trainees made pain treatment decisions (opioid, antidepressant, physical therapy, pain specialty referral) for 16 computer-simulated patients presenting with chronic low back pain; patient sex and race were manipulated across vignettes. Participants then selected among 9 factors, including patient demographics, to indicate which factors influenced their treatment decisions for the simulated patients and completed gender and racial attitude measures. After online study completion, follow-up semi-structured interviews were conducted to discuss the medical/non-medical factors that influence trainees’ clinical treatment decisions. Quantitative analysis indicated that 5%-25% of trainees were actually influenced (p<0.10) by patient sex and race in their treatments, and on the whole, trainees gave higher antidepressant ratings to White than Black patients (p<.05). Fifty-five percent demonstrated concordance, or awareness, between their actual and reported use of patient demographics. Follow-up McNemar’s test indicated trainees were generally aware of the influence of demographics on their decisions. Overall, gender and racial attitudes did not associate with trainees’ treatment decisions, except trainees’ complementary stereotypes about Black individuals were positively associated with their opioid decisions for White patients. During qualitative interviews, aware and unaware trainees discussed similar themes related to sex and racial/ethnic differences in pain presentation and tailoring treatments. We found that (1) a subset of trainees were influenced by patient sex and race when making chronic pain treatment decisions, (2) trainees were generally aware of the influence of patient demographics, and (3) trainees discussed differences in pain presentation based on patients’ sex and ethnic origin. These findings suggest trainees’ are influenced by patient demographics and hold stereotypes about patient populations, which may play a role in their decision-making

The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions

Although racial disparities in pain care are widely reported, much remains to be known about the role of provider and contextual factors. We used computer-simulated patients to examine the influence of patient race, provider racial bias, and clinical ambiguity on pain decisions. One hundred twenty-nine medical residents/fellows made assessment (pain intensity) and treatment (opioid and nonopioid analgesics) decisions for 12 virtual patients with acute pain. Race (black/white) and clinical ambiguity (high/low) were manipulated across vignettes. Participants completed the Implicit Association Test and feeling thermometers, which assess implicit and explicit racial biases, respectively. Individual- and group-level analyses indicated that race and ambiguity had an interactive effect on providers' decisions, such that decisions varied as a function of ambiguity for white but not for black patients. Individual differences across providers were observed for the effect of race and ambiguity on decisions; however, providers' implicit and explicit biases did not account for this variability. These data highlight the complexity of racial disparities and suggest that differences in care between white and black patients are, in part, attributable to the nature (ie, ambiguity) of the clinical scenario. The current study suggests that interventions to reduce disparities should differentially target patient, provider, and contextual factors. PERSPECTIVE: This study examined the unique and collective influence of patient race, provider racial bias, and clinical ambiguity on providers' pain management decisions. These results could inform the development of interventions aimed at reducing disparities and improving pain care

Healthcare providers’ perceptions of socioeconomically disadvantaged patients with chronic pain: A qualitative investigation

Socioeconomically disadvantaged individuals are at-risk for chronic pain and disparate care. In this qualitative study, we explored providers’ experiences with socioeconomically disadvantaged patients, with a particular focus on providers’: (1) perceptions of socioeconomically disadvantaged patients’ barriers to pain care, (2) attitudes towards this patient population, and (3) chronic pain decisions for these patients. Individual interviews were conducted with twenty-four healthcare providers. Providers discussed several patient-level access barriers, such as not having health insurance, financial constraints, and scheduling difficulties. Providers believed socioeconomically disadvantaged patients were at-risk to misuse prescription opioids and were less comfortable prescribing opioids to these patients. This investigation found that providers perceived numerous patient-level barriers to pain care, expressed suspicion towards these patients, and considered patients’ socioeconomic status when making pain management decisions. Future investigations should examine the extent to which providers’ attitudes influence their actual pain management decisions and lead to treatment disparities for this patient population

AN INVESTIGATION OF PROVIDER SELF-INSIGHT INTO THEIR CHRON-IC PAIN MANAGEMENT

poster abstractResearch indicates pain management varies across patient sex, race, and mental health status; however, little is known about the ex-tent to which providers are aware of these influences on their clinical decisions. This preliminary study examines the correspondence be-tween providers’ actual and self-reported use of these variables when making pain-related treatment decisions. We also examined the rela-tionship between providers’ self-awareness and their attitudes about sex, race, and depression. Forty-four participants (24 providers, 20 trainees) made pain treatment decisions for sixteen computer-simulated patients presenting with chronic back pain. Patient sex, race, and depression status were manipulated across vignettes. At study conclusion, participants rated the extent to which nine factors influenced their treatment decisions and completed measures as-sessing their attitudes about sex, race, and depression. Approximately 68% and 91% of participants reported using patient demographic characteristics and mental health symptoms, respectively, to make pain treatment decisions. Participants demonstrated some self-awareness for the influence of patient sex, but not race or depression, on their treatment decisions. Participants’ attitudes about sex and race were not significantly associated with their self-reported or actual use of patient demographic information when making treatment decisions. Of the participants who reportedly used mental health symptoms, higher negative attitudes about depression were significantly associat-ed with greater self-reported influence of mental health symptoms on pain treatment decisions (r=-0.42, p<0.01). However, there was no significant association between depression attitudes and actual use of depression symptoms. These findings suggest that (1) providers’ have some awareness of the influence of patient sex, but not race or de-pression, on their treatment decisions, and (2) providers’ attitudes about sex, race, and depression do not sufficiently explain this general lack of awareness. These findings have important clinical implications and may inform interventions to improve pain management and re-duce pain disparities

Impact of Race and Sex on Pain Management by Medical Trainees: A Mixed Methods Pilot Study of Decision Making and Awareness of Influence

Objective Previous research suggests female and black patients receive less optimal treatment for their chronic pain compared with male and white patients. Provider-related factors are hypothesized to contribute to unequal treatment, but these factors have not been examined extensively. This mixed methods investigation examined the influence of patients' demographic characteristics on providers' treatment decisions and providers' awareness of these influences on their treatment decisions. Methods Twenty medical trainees made treatment decisions (opioid, antidepressant, physical therapy) for 16 virtual patients with chronic low back pain; patient sex and race were manipulated across patients. Participants then indicated from a provided list the factors that influenced their treatment decisions, including patient demographics. Finally, individual interviews were conducted to discuss the role of patient demographics on providers' clinical decisions. Results Individual regression analyses indicated that 30% of participants were reliably influenced by patient sex and 15% by patient race when making their decisions (P < 0.05 or P < 0.10). Group analyses indicated that white patients received higher antidepressant recommendations, on average, than black patients (P < 0.05). Half of the medical trainees demonstrated awareness of the influence of demographic characteristics on their decision making. Participants, regardless of whether they were influenced by patients' demographics, discussed themes related to patient sex and race; however, participants' discussion of patient demographics in the interviews did not always align with their online study results. Conclusions These findings suggest there is a considerable variability in the extent to which medical trainees are influenced by patient demographics and their awareness of these decision making influences