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dcyphr | Racial Disparities in Pain Management of Children with Appendicitis in Emergency Departments

Abstract

Racial disparities in pain management have been previously documented. Further understanding of the causes of these disparities is needed to make healthcare provision equitable.

In this study, the researchers wanted to understand racial differences in how analgesia is administered in children with appendicitis. Analgesia are drugs that relieve pain. They paid special attention to the administration of opioids.

This study was a repeated, observational study of patients less than 21 years old. The researchers calculated the frequency of opioid and non-opioid analgesia administration. They performed statistical analysis to examine racial differences in opioid and non-opioid analgesia.

0.94 million children were diagnosed with appendicitis. 56.8% of children received analgesia of any type. Black patients with moderate pain were less likely to receive any analgesia compared to white patients. Rate of analgesia administration was not significantly different by race. However, black patients received opioid analgesia significantly less than white patients.

Appendicitis pain is undertreated, and racial disparities in analgesia administration exist. Black children are less likely to receive any pain medication and to receive opioids.

Aims

The researchers wanted to understand whether there were racial differences in analgesia administration in the emergency department.

Introduction

There are racial disparities in many aspects of healthcare. Racial disparities have been demonstrated in the emergency department (ED), such as differences in wait time and hospital admission. Previous research has also described differences in pain management in the ED, with black and Hispanic patients having opioids prescribed less frequently than white patients. There are few studies of this nature in children.

Previous studies have shown racial disparities in ED management of abdominal pain. Appendicitis is the most common surgical cause of abdominal pain in the ED. Administering analgesia for appendicitis is encouraged. The investigation of pain management in children with appendicitis may provide a good understanding of racial differences in analgesia administration.

Methods

Study Design

The researchers conducted an observational study. They used the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2003 to 2010.


Data Source and Study Population

The NHAMCS is a survey of visits to the EDs of hospitals in all 50 states. It is conducted by the CDC for a 4-week period each year. The population used in the study was all NHAMCS-sampled ED visits by patients 21 years or younger with a diagnosis of appendicitis.


Variables

The researchers collected data about analgesic administration (overall, nonopioid, and opioid) in each visit from the NHAMCS. Each visit was categorized as no analgesia prescribed or analgesia prescribed. They further categorized the group with analgesia prescribed as opioid or non-opioid analgesia.


Independent Variables

Races captured by the NHAMCS include white, black/African American, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or more than 1 race reported. These races are recategorized as white, black, or other. The researchers used the latter to categorize analgesia prescription.

The researchers adjusted the results using variables of ethnicity, age, sex, insurance status, triage acuity level, pain score, geographic region, ED type, and survey year.


Statistical Analysis

The researchers used Stata for data analysis. They performed 2-variable regression to understand the association between race and both overall and opioid analgesia administration. They performed multivariable regression to adjust for other variables.

Results

There were 0.94 million ED visits for appendicitis in children. 

Overall, 56.8% of patients received some form of analgesia. 41.3% received opioid analgesia. In 2-variable analysis, there was no association between race and analgesia administration. However, black patients were less likely to receive opioid analgesia than white patients, at 20.7% and 43.1% respectively.

Older age and higher pain score were associated with higher rates of analgesia administration. Opioid administration was associated with higher pain score. There were no significant differences in analgesia administration by ethnicity, sex, insurance status, triage level, geographic region, or ED type.

When the results were categorized by pain score and adjusted for ethnicity, black patients with moderate pain were less likely to receive analgesia compared to white patients, at 15.7% and 58.5% respectively. Black patients with severe pain were also less likely to receive opioids than white patients, at 24.5% and 58.3% respectively.

Discussion

The results of this study show low rates of analgesia and opioid administration overall and racial differences in opioid administration. Overall, only 56.8% of children received any analgesia, and 41.3% received opioid analgesia. These results are consistent with previous studies, demonstrating a low rate of analgesia administration for patients with appendicitis. This may result from clinicians believing that analgesia leads to diagnostic delays. But this would not explain racial disparities in analgesia administration. This failure to administer analgesia may be more present in children due to fear of adverse outcomes with opioids. Previous studies have shown that children are much less likely to receive analgesia than adults.

Eliminating racial health disparities is important for healthcare. There is growing evidence that patients of color receive a lesser quality of care compared to white patients. Stereotyping and biases by healthcare providers can contribute to these health disparities. This study exposes racial disparities in analgesia administration and allows for future efforts to minimize these disparities.

Opioid administration is a major component of pain management for appendicitis. Although there was no difference in overall analgesia administration between white and black patients, the racial disparities found opioid administration in the study are concerning. This suggests that although clinicians recognize pain equally in white and black patients, they react to the pain differently and administer different medications. These disparities in opioid analgesia found in this study are similar to other studies.

As pain scores increased, so did analgesia administration. However, it seemed as though there was a threshold effect with analgesia administration by race. Black patients with moderate pain were less likely to receive any analgesia. Black patients with severe pain were less likely to receive opioid analgesia. This suggests there may be a higher threshold for pain score for administering analgesia to black patients.

Other studies have suggested ethnic differences in opioid administration, but this study did not find any. This may be explained by observations that Hispanic children more frequently present with appendiceal perforation rather than appendicitis. There were no differences in triage or pain score by race or ethnicity.

In conclusion, these findings show racial disparities in opioid administration to children with appendicitis. More research is necessary to understand why these disparities exist. This research could help with designing interventions to improve pain management for all.