This recent study regarding pain control received a lot of press, covered by both Reuters and NBC News. The general gist of the breathless coverage seems to indict physicians for latent biases against treating African American children with opiates.
I’m not so certain.
This is a retrospective evaluation of a national Emergency Department database of seven years of ED visits for appendicitis, looking at pain control disparity between white children and minorities. Pain management was documented in only 57% of children, 41% of which was opiates. Children of African American descent received opiate medication only 12% of the time, leading to the authors’ observations of an apparent reluctance to treat this population with opiates.
But, I think the foundation of their analysis may be misleading. The authors state: “The following covariates were included in our analyses to adjust for potential confounding: ethnicity, age, sex, insurance status, triage acuity level, pain score, geographic region, ED type, and survey year.” However, I think these data need to be addressed at a within-hospital level, not as a pooled cohort. African Americans have been previously shown to be over-represented at low-quality, safety-net hospitals – the sort of hospitals almost assuredly do a poor job of addressing and managing pain across all their patients. Indeed, when other researchers have looked at racial disparities in care for acute myocardial infarction, performing within-hospital analyses dramatically altered their findings, with individual hospital inadequacies accounting for a greater effect than ethnicity.
The foundational issues in race-related difference in care may yet be present, but I do not believe to the magnitude these data reflect. Rather than suggesting “there may be a higher threshold of pain score for administering analgesia to black patients with appendicitis,” these data probably reflect the underlying under-resourced care available to this population. A tremendous and embarrassing problem, to be sure, but with a different approach needed for a solution.
“Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments”
http://archpedi.jamanetwork.com/article.aspx?articleid=2441797