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

UMMS Affiliation

Department of Population and Quantitative Health Sciences; Graduate School of Biomedical Sciences

Publication Date


Document Type



Epidemiology | Geriatrics | Health Services Administration | Health Services Research | Neoplasms | Pain Management | Race and Ethnicity


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.


Cancer, nursing homes, pain, racial and ethnic segregation

DOI of Published Version



Jesdale BM, Mack DS, Forrester SN, Lapane KL. Cancer Pain in Relation to Metropolitan Area Segregation and Nursing Home Racial and Ethnic Composition. J Am Med Dir Assoc. 2020 Mar 26:S1525-8610(20)30184-5. doi: 10.1016/j.jamda.2020.02.001. Epub ahead of print. PMID: 32224259. Link to article on publisher's site

Journal/Book/Conference Title

Journal of the American Medical Directors Association

PubMed ID


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Link to Article in PubMed