Do White Children Receive Better Pain Management Than Black Children Do?

Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial disparities in pain management of children with appendicitis in emergency departments [published online September 14, 2015]. JAMA Pediatr. 2015;169(11):996-1002.

Racial disparities have been documented in many areas of health care, from emergency department (ED) wait times to hospital admission rates. Pain management is one particular area in which racial and ethnic differences are evident, with lower rates of opioid prescriptions being written for black and Hispanic patients in the ED.

To further examine these disparities among a pediatric population, Monica K. Goyal, MD, MSCE, and colleagues looked at pain management in the setting of appendicitis. They chose this condition specifically with the thought of minimizing spectrum bias, since all patients with appendicitis, regardless of race, would require inpatient treatment. Moreover, previous research has shown that minorities may be more likely to present to the ED for nonsurgical causes of abdominal pain, and that the undertreatment of acute pain is a known concern among all children regardless of race treated in the outpatient setting.

Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2003 to 2010, the researchers conducted a repeated cross-sectional analysis of patients aged 21 years or younger who had been evaluated in the ED and who had received a diagnosis of appendicitis based on the International Classification of Diseases, Ninth Revision. NHAMCS is a multistage national probability sample survey of visits to EDs and outpatient departments of hospitals in all 50 states and the District of Columbia. The outcome measure studied was the receipt of analgesic medication (overall, nonopioid, and opioid) by race. Visits were categorized as those in which analgesia was prescribed and those in which it was not prescribed. When analgesia was administered, it was classified as opioid or nonopioid. Other factors examined included ethnicity, age, sex, insurance status, pain score, geographic region, and ED type. Logistic regression analyses were performed to determine the strength of association of race on administration of pain medication, and also to adjust for confounding specific covariates.

Just under 1 million ED visits for appendicitis occurred during the study period. Only 56.8% (95% confidence interval [CI], 49.8%-63.9%) of patients received analgesia, despite growing acceptance of the need for pain treatment in the setting of appendicitis. A total of 41.3% of patients received at least one opioid. Black patients were significantly less likely to receive opioid analgesia than were white patients (20.7% [95% CI, 5.3%-36.0%] vs 43.1% [95% CI, 34.6%-51.4%], respectively; odds ratio [OR], 0.3 [95% CI, 0.1-0.9]). No differences were found in overall analgesia administration or opioid administration by sex, insurance status, geographic region, or ED type.

On further review, black patients with moderate pain were less likely to receive any analgesia at all compared with white patients with moderate pain (15.7% [95% CI, 0.1%-39.5%] vs 58.5% [95% CI, 45.8%-71.1%], respectively; adjusted OR, 0.1 [95% CI, 0.02-0.8]). When their pain score was listed as “severe,” black patients were less likely to receive opioids (24.5% [95% CI, 1.1%-48.0%] vs 58.3% [95% CI, 46.1%-70.4%], respectively; adjusted OR, 0.2 [95% CI, 0.06-0.9]) than were their white counterparts.

These data have several implications. First, it is worth noting that only 56.8% of this pediatric study population received any analgesia at all, despite studies demonstrating the safety of opioid administration in the setting of appendicitis. The results also suggest that racial disparities exist in the administration of opioids to children with appendicitis. Many complex factors account for these racial health disparities, but research must continue and interventions must be designed to improve the quality of medical care that minority patients receive.

Jessica Tomaszewski, MD, is an assistant clinical professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD—Series Editor, is a professor of pediatrics, senior associate dean of student affairs and career counseling, and associate provost for student affairs at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.