Racial Gap in Management of Pediatric Appendicitis Pain

Nicola M. Parry, DVM

September 16, 2015

Appendicitis pain is undertreated in children in US emergency departments (EDs), and black children are less likely than white children to receive pain medication, particularly opioids, according to a new study.

Monika K. Goyal, MD, MSCE, principal investigator at the Children's National Health System's Children's Research Institute and assistant professor of emergency medicine and pediatrics at George Washington University, Washington, DC, and colleagues published the results of their study online September 14 in JAMA Pediatrics.

"In this nationally representative cross-sectional analysis of ED visits of children diagnosed as having appendicitis, we found low rates of analgesia and opioid administration overall and marked racial differences in opioid administration. Black children had one-fifth the odds of receiving opioid analgesia than white children, even after adjustment for potential confounders," the authors write.

Racial and ethnic disparities in healthcare have been widely documented across a range of medical conditions and healthcare services in adults and children. In the ED, these discrepancies are reflected in wait times, hospital admission rates, management of closed head trauma, and pain management, with lower rates of opioid prescription for black and Hispanic patients than for white patients. However, although studies have identified racial and ethnic differences in abdominal pain management in both adults and children in the ED, pediatric-specific data are relatively lacking. In addition, the disparities may reflect differences in ED use rather than ED management, because minority patients are more likely than white patients to use the ED as a usual source of healthcare.

Therefore, to reduce the possible effect of this spectrum bias, Dr Goyal and colleagues aimed to identify racial disparities in analgesia administration, specifically opioids, to children diagnosed with appendicitis in the ED. The researchers used National Hospital Ambulatory Medical Care Survey data from 2003 to 2010 to evaluate the administration of opioid and nonopioid analgesia in patients aged 21 years or younger who had an International Classification of Diseases, Ninth Revision, diagnosis of appendicitis in the ED.

Study results showed that of almost 1 million children diagnosed with appendicitis, only 56.8% (95% confidence interval [CI], 49.8% - 63.9%) received some form of analgesia, and only 41.3% (95% CI, 33.7% - 48.9%) received at least one dose of opioid analgesia. In addition, black children were less likely than white children to receive opioids (20.7% [95% CI, 5.3% - 36.0%] vs 43.1% [95% CI, 34.6% - 51.4%]; odds ratio [OR], 0.3; 95% CI, 0.1 - 0.9).

When analyzed by pain score and adjusted for ethnicity, among patients with moderate pain, black children were less likely than white children to receive any analgesia (adjusted OR [AOR], 0.1; 95% CI, 0.02 - 0.8), and among those with severe pain, black children were less likely than white children to receive opioids (AOR, 0.2; 95% CI, 0.06 - 0.9).

After adjustment for variables such as age, ethnicity, sex, insurance status, triage levels, and pain score, the results demonstrated no significant difference in the overall rate of analgesia administration by race (black, 42.0% [95% CI, 2.9% - 81.0%] vs white, 48.3% [95% CI, 12.2% - 84.4%]; AOR, 0.7; 95% CI, 0.3 - 1.8); however, opioid analgesia was administered significantly less frequently to black children than to white children (black, 12.2% [95% CI, 0.1% - 35.2%] vs white, 33.9% [95% CI, 0.6% - 74.9%]; AOR, 0.2; 95% CI, 0.06 - 0.8).

"Our findings suggest that there are racial disparities in opioid administration to children with appendicitis, even after adjustment for potential confounders," the authors write. "More research is needed to understand why such disparities exist," they conclude.

In an accompanying editorial, Eric W. Fleegler, MD, MPH, and Neil L. Schechter, MD, both from Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, emphasize that this study further highlights the pattern of extensive racial and ethnic healthcare disparities, including in pain management, that has emerged in recent decades. However, they point out that although previous research has identified a genetic contribution to ethnic differences in pain perception, physiological differences are unlikely to explain these disparities. "If there is no physiological explanation for differing treatment of the same phenomena, we are left with the notion that subtle biases, implicit and explicit, conscious and unconscious, influence the clinician's judgment," they write.

They also note that clinicians frequently underestimate patients' experience of pain, and that this is further exacerbated when clinicians and patients come from different racial backgrounds. However, Dr Fleegler and Dr Schechter advise that increased awareness of the potential for subtle bias in the assessment and treatment of pain would enable clinicians to reduce such disparities in healthcare.

"Although each medical decision should be individualized for the specific child and based on the available evidence, it is certainly possible to develop protocols for a number of clinical scenarios to reduce the possibility of bias," they write. "For example, unless there is a documented contraindication, analgesia should be administered to all children with appendicitis." They stress that such a policy would eliminate the probability that lack of clinical expertise or other nonpatient factors would contribute to inequity in healthcare.

"It is clear that despite the broad recognition that controlling pain is a cornerstone of compassionate care, significant disparities remain in our approach to pain management among different populations. Strategies and available knowledge exist to remedy this unfortunate situation; we can and should do better," they conclude.

This study was supported by the National Institutes of Health. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Pediatr. Published online September 14, 2015. Article full text, Editorial full text

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