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dcyphr | Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain

Abstract

Oligoanalgesia, or the undertreatment of acute pain, was previously thought to be because of physician’s fears of covering up serious underlying causes of acute pain. In this study, the researchers assessed whether gender disparities exist in the administration of analgesics (pain relievers) by physicians. The researchers studied nonpregnant adults with acute stomach pain who went to urban emergency departments from April 2004 to January 2005. The main outcomes studied were analgesia administration and the time it took for patients to receive analgesia. The researchers found that of 981 patients, 62% received any analgesia. Men and women had similar pain scores, but women were less likely to receive opioid analgesia, even after controlling for diagnosis, age, race, triage class, and pain score. There was no gender difference in administration of nonopioid analgesia. Women also waited longer to receive analgesia. In conclusion, gender bias may be an explanation for the undertreatment of acute pain for stomach pain in emergency departments (ED). Standardization of protocols for analgesic administration may reduce the discrepancies found in this study.

Aims

The researchers wanted to understand if there were gender disparities in the administration of analgesia in EDs for acute stomach pain.

Introduction

Oligoanalgesia in emergency departments (EDs) is well-documented. Discrepancies in pain management have previously been associated with patient demographics, physician characteristics, triage acuity, diagnosis, and ED crowding. 

Abdominal pain is the most frequent reason for ED visits. Oligoanalgesia of stomach pain is influenced by physicians’ fear of masking peritonitis, an inflammation of the inner abdominal wall, and hesitancy to base treatment off of patients’ self-assessment of pain. However, studies investigating these issues have debunked these factors as determinants of oligoanalgesia. 

In this study, the researchers assessed the management of ED patients with acute abdominal pain to determine whether gender disparities existed and could be a reason for oligoanalgesia.

Results

Of 1,000 patients, 981 were included in the study. 65% were women, and gender differences in patient demographics are shown in Table 1.

Analgesia was administered to 62% of patients. Women had a similar pain score to men (6.7 vs 6.5), but were less likely to receive any analgesia (60% vs 67%) and opiates (45% vs 56%). Women were as likely as men to receive non-opioid analgesia. 80 patients underwent surgical treatment for their abdominal pain, 50% of whom were women. 62% of these women received opioid analgesia compared to 78% of men who underwent surgery. These disparities persisted even after adjusting for diagnoses and other demographic factors.


The researchers also analyzed age, race, pain score, and triage class to see how these factors affected gender disparities. This analysis showed that men, older patients, non-black patients, and patients with higher triage/pain acuity scores were more likely to receive opioid analgesia. Only higher triage/pain acuity scores were associated with an increased probability of receiving any analgesia at all. Even after adjusting for these factors, women were still 13%-25% less likely to receive opioid analgesia.

Finally, women waited longer for their pain medications than men (65 minutes v. 49 minutes). This difference was particularly prominent for opiates, for which women waited 15 minutes longer for.

Discussion

Previous studies on abdominal pain management suggested that clinicians withheld analgesia out of concern that it would decrease the accuracy of their diagnosis. There is little research that explores other factors such as gender that could influence oligoanalgesia. This study was conducted to understand if there are gender disparities in oligoanalgesia for abdominal pain by evaluating the probability of receiving analgesia and the time it took for patients to receive analgesia.


Gender disparities have been observed in other studies about pain management for musculoskeletal and abdominal pain, which were influenced by providers’ perception of their patients’ pain. In this study, however, men were more likely to receive analgesia even if their self-reported pain levels were the same. This difference was also observed regardless of the provider’s gender, suggesting that implicit bias may exist.


Other factors that could influence gender disparities are race, triage classification, and final diagnosis. Even after adjusting for these factors, however, women were still less likely to receive opioid analgesia than men. This difference only persisted in patients less than 50 years old, which could be explained by provider bias when treating gynecologic diseases more common in younger women. Even after controlling gender-specific diagnoses like gynecologic disease, women were still 9% less likely to receive opioid analgesia. 


Women who received analgesia waited 16 minutes longer for their medication than men. The need for pregnancy testing and pelvic examination may explain delayed analgesia, although in theory they should not. In previous studies, increased testing has been associated with longer wait times. In addition, women received lower triage acuity scores, but there was no analysis made about what caused this phenomenon. Further studies are necessary to explain how longer wait times and severity of disease may influence analgesia administration.

A final factor that could influence gender disparities in pain management is ED crowding. One study found that patients received analgesia more quickly during times of less crowding. Crowding may delay women’s pelvic and abdominal exams, further exacerbating delays in analgesia administration.

Methods

Study Design

The researchers conducted a secondary analysis on a previous study that sought to identify new biomarkers for abdominal pain.


Study Setting and Population

The study was conducted in an urban academic ED with approximately 55,000 annual patient visits. Patients 18 years and older with abdominal pain of 72 hours or less were enrolled from April 2004 to January 2005. Exclusion criteria included pregnancy, abdominal trauma, or abdominal surgery.


Study Protocol

Patients were identified and enrolled in the study from 8am to midnight, 7 days a week. Triage score (1-10), patient demographics, their health provider’s gender, and whether they were admitted/denied to the ED were recorded. The type and time of analgesic administration were collected from patients’ electronic medical records. Medical history, physical exam results, and final diagnoses were reported by treating physicians. Final diagnoses were categorized by organ system to adjust results later on.


Measurements

Initial pain was documented on a scale of 1-10, with 1 being “no pain” and 10 being “worst pain of my life.” Time to analgesia was defined as time from admitting the patient into the hospital to when analgesia administration was documented by a nurse or physician. Analgesia were separated based on whether they were opioid or nonopioid. Triage class was determined by a triage nurse on a scale of 1-4, with 1 being the most emergent. The main outcomes were analgesic administration and time to analgesia.


Data Analysis

All data was analyzed in SAS.