Cancer Pain in Relation to Metropolitan Area Segregation and Nursing Home Racial and Ethnic Composition

J Am Med Dir Assoc. 2020 Sep;21(9):1302-1308.e7. doi: 10.1016/j.jamda.2020.02.001. Epub 2020 Mar 26.


Objectives: To estimate pain reporting among residents with cancer in relation to metropolitan area segregation and NH racial and ethnic composition.

Design: Cross-sectional study.

Setting and participants: 383,757 newly admitted black (B), Hispanic (H), or white (W) residents with cancer in 12,096 US NHs (2011-2013).

Methods: Using the Minimum Data Set 3.0, pain in past 5 days was determined by self-report or use of pain management. The Theil entropy index, a measure of metropolitan area segregation, was categorized [high (up to 0.20), very high (0.20-0.30), or extreme (0.30-0.53)].

Results: Pain prevalence decreased across segregation level (black: high = 77%, very high = 75%, extreme = 72%; Hispanic: high = 79%, very high = 77%, extreme = 70%; white: high = 80%, very high = 77%, extreme = 74%). In extremely segregated areas, all residents were less likely to have recorded pain [adjusted prevalence ratios: blacks, 4.6% less likely, 95% confidence interval (CI) 3.1%-6.1%; Hispanics, 6.9% less likely, 95% CI 4.2%-9.6%; whites, 7.4% less likely, 95% CI 6.5%-8.2%] than in the least segregated areas. At all segregation levels, pain was recorded more frequently for residents (black or white) in predominantly white (>80%) NHs than in mostly black (>50%) NHs or residents (Hispanic or white) in predominantly white NHs than mostly Hispanic (>50%) NHs.

Conclusions and implications: We observed decreased pain recording in metropolitan areas with greater racial and ethnic segregation. This may occur through the inequitable distribution of resources between NHs, resident-provider empathy, provider implicit bias, resident trust, and other factors.

Keywords: Cancer; nursing homes; pain; racial and ethnic segregation.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Cancer Pain*
  • Cross-Sectional Studies
  • Hispanic or Latino
  • Humans
  • Neoplasms*
  • Nursing Homes
  • United States
  • White People