When it comes to disparities research, I sometimes get angry at researchers that we’re still spending so much time with studies pointing out disparities in medicine and so little time doing anything about them. I mean, is there anyone out there who denies that there are racial disparities in how we treat patients, that would change their mind if they just saw one more study? I think not.
But every once in a while, a study gets published that gets past my eye roll and makes me angry all over again. “Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments“:
IMPORTANCE: Racial disparities in use of analgesia in emergency departments have been previously documented. Further work to understand the causes of these disparities must be undertaken, which can then help inform the development of interventions to reduce and eradicate racial disparities in health care provision.
OBJECTIVE: To evaluate racial differences in analgesia administration, and particularly opioid administration, among children diagnosed as having appendicitis.
DESIGN, SETTING, AND PARTICIPANTS: Repeated cross-sectional study of patients aged 21 years or younger evaluated in the emergency department who had an International Classification of Diseases, Ninth Revision diagnosis of appendicitis, using the National Hospital Ambulatory Medical Care Survey from 2003 to 2010. We calculated the frequency of both opioid and nonopioid analgesia administration using complex survey weighting. We then performed multivariable logistic regression to examine racial differences in overall administration of analgesia, and specifically opioid analgesia, after adjusting for important demographic and visit covariates, including ethnicity and pain score.
MAIN OUTCOMES AND MEASURES: Receipt of analgesia administration (any and opioid) by race.
All of the participants are children with appendicitis, so this is an acute problem with pain. The researchers got data from the National Hospital Ambulatory Medical Care Survey, from 2003 to 2010. They looked at both opioid and nonopioid analgesia. They then looked at racial differences at their use after controlling for other factors, including pain score.
Over this time period, almost a million kids had appendicitis. About 57% of them got analgesia of any type; 41% got opioids. Unadjusted, there were big differences in the types of pain medicines received, though. White children got opioids 43% of the time and non-opioids 14% of the time. Black kids, on the other hand, got opioids 21% of the time and non-opioids 34% of the time
In adjusted analyses, white children were predicted to get analgesia 48% of the time versus 42% for black children; this difference wasn’t statistically significant, though. The differences in opioid use, however, were statistically significant. White children were predicted to get opioids 34% of the time versus 12% for black children, The adjusted odds ratio for black children to get opioids versus white children was 0.2.
Interestingly, there were also differences by the level of pain. If kids had severe pain, black kids were less likely to get opioids than white kids, but they were still as likely to get any analgesia at all. However, for those kids with moderate pain, not only were black kids less likely to get opioids, they were less likely to get any pain medications at all (adjusted odds ratio 0.1).
Let’s get some things out of the way immediately. These were children who all had been diagnosed with appendicitis, so any concerns about racial differences in ED use in general being involved go out the window. Black children only comprised 9% of the study population. This is an acute condition, and there’s no reason I can think of that you would treat black and white kids differently. These are also kids, so no talk about drug seeking behavior, please. They’re only going to get acute administration of pain meds in the ED, for their acute appendicitis. Let’s also acknowledge that opioids are falling out of favor, but that’s mostly for chronic pain. Not the acute pain of appendicitis.
It’s disturbing that kids in severe pain are much less likely to get opioid pain meds for their appendicitis. It’s even more disturbing that they’re less likely to get any meds at all for their moderate pain.
It amazes me that I can still be stunned by disparities research. We should fix this yesterday.
P.S. The pediatrician in me is also horrified by the fact that about 25% of all kids with severe pain from acute appendicitis were given no pain meds at all. What’s wrong with us?