The medical management of menopause: a four-country comparison care in urban areas.

OBJECTIVE: To compare the medical management of menopause across urban areas in four countries which differ by level of income and degree of medicalization. METHODS: Surveys of health providers who advise women on the menopausal transition were carried out in Beirut, Lebanon (n=100), Madrid, Spain (n=60), Worcester, MA, U.S. (n=59), and Rabat, Morocco (n=50) between 2002 and 2004. Physician characteristics, hormone therapy (HT) prescribing practices, and concerns about the management of menopause were compared across countries using chi(2) and logistic regression analyses. RESULTS: Across sites, physicians were generally well informed about HT and thought that symptom alleviation and disease prevention were equally important. They had concerns about risks associated with HT, particularly breast cancer, and in 3 sites where the survey was conducted after the WHI (Beirut, Rabat, and Madrid) physicians changed their practices to prescribe HT less frequently, for shorter durations, or shifted to other medications. There were significant differences across sites in the recommended duration of HT, time spent talking with patients, perceived benefits of HT, tests recommended before prescribing HT, and concern about the risks associated with HT. Physicians in Madrid and Massachusetts were more likely to report that decisions about the management of menopause were difficult, but in all sites the main reason for difficulties was concerns about risks. The results also suggest discrepancies between physicians' perceptions and women's reports about the reasons why women consult at menopause. CONCLUSIONS: Prescription patterns and perceived benefits of HT appear to reflect local medical culture rather than simply physician characteristics. The impact of the WHI study was seen in prescribing patterns and concerns about HT. Physicians in all four countries were generally well informed. Financial support: NIH 5 900 000196.

Probing the paradox of patients' satisfaction with inadequate pain management.

The paradox of patients who are in pain, yet satisfied with their pain management, has been previously reported. To probe this paradox, we used cross-sectional data collected in the primary care setting on cancer patients' patterns of pain and pain treatment, beliefs and expectations about pain and pain relief, willingness to report pain and take pain medication, care from the provider, and satisfaction with their pain management (n = 316). Descriptive findings were similar to other studies: more than 75% of patients were satisfied or very satisfied with their overall pain management, despite almost half of all patients reporting recent moderate to severe pain. Univariate and bivariate analyses were consistent with the hypothesis that patients may expect and are therefore satisfied with the "peak and trough" pattern of pain severity that occurs with "as-needed" administration of analgesics. However, multivariate analyses failed to directly support this hypothesis. Instead, regression analyses identified factors related to characteristics of patients' pain experiences, patients' beliefs about pain and its inevitability, the frequency that patients reported their pain, and aspects of the patient--provider relationship. Predictors of patients' satisfaction with how their primary care doctor managed their pain included: whether or not the patient was told that treating pain was an important goal, whether or not the patient reported sustained long-term pain relief, and the degree to which the patient was willing to take opioids if prescribed by the doctor or nurse (adjusted R(2) = 0.22). Qualitative data collected from patients who were in severe pain during the past three days but satisfied with their pain management (n = 88) further suggest the importance of the patient--provider relationship in shaping patient expectations. Based on these findings, we recommend that future research on outcomes in pain management place greater emphasis on the potential impact of the patient-provider relationship.

Do patients' beliefs act as barriers to effective pain management behaviors and outcomes in patients with cancer-related or noncancer-related pain?

PURPOSE/OBJECTIVES: To understand the role of patients' beliefs in pain management in a cancer population treated in a primary care setting. DESIGN: Secondary analyses of data from the baseline phase of a randomized study. SETTING: Eight of the largest primary care clinics in a managed care system. SAMPLE: 342 patients with cancer who reported pain that would not dissipate on its own or when treated by over-the-counter medication; approximately half had pain that was not cancer related. METHODS: Telephone interviews. MAIN RESEARCH VARIABLES: Patients' demographic characteristics, self-reported history and beliefs about pain and pain treatment, willingness to report pain and take pain medication, recent pain intensity, and administrative data on opioid prescriptions. FINDINGS: Patients' beliefs were not associated strongly with reporting pain or taking medication. Regression analyses revealed that patients' beliefs played a limited role in predicting recent pain intensity, whereas the providers' pain management practices seemed to have a far greater predictive role. Additionally, among patients with recent moderate to severe pain, the relationship between patients' beliefs and their history of pain and pain treatment further suggests that beliefs are likely to be formed, in part, as a consequence of the care they receive. Results did not depend on whether the cause of pain was related to cancer. CONCLUSION: Patients' beliefs were important barriers to effective pain management, either as direct or indirect determinants of pain. Providers' pain management practices were more likely to determine the level of pain relief achieved and the beliefs their patients came to hold based on their personal experiences. IMPLICATIONS FOR NURSING: Nursing interventions should examine the impact of evaluating patients' beliefs in conjunction with pain assessment on pain-related behaviors and pain relief, as well as the ability of patient educational efforts to strengthen accurate beliefs and enable patients to assert themselves when interacting with less knowledgeable providers.