By Sheryl Estrada
Black youth suffering from acute appendicitis who visit an emergency room in the U.S. will most likely remain in intense pain.
According to the study “Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments,” published on Monday in the Journal of the American Medical Association’s JAMA Pediatrics, racial differences do exist in the administration of analgesia or painkillers.
“There has been literature documenting racial disparities in the pain management of adults,” lead author Dr. Monika K. Goyal of the Children’s National Health System in Washington, D.C., told DiversityInc. “Our goal was to determine whether these racial disparities also existed in the care of children.”
Goyal said she and her team specifically chose appendicitis because “it is well regarded as a painful surgical condition, and management of pain, specifically with opioids, is one of the mainstays of treatment.”
Using data from the National Hospital Ambulatory Medical Care Survey from 2003 to 2010, the researchers analyzed data of almost one million patients age 21 or younger, including the variables of race, ethnicity, age, gender, insurance status, triage level and pain score.
Goyal and coauthors note that in the past there were persistent perceptions among clinicians that administering painkillers may mask symptoms, leading to diagnostic delays. However, several randomized trials have shown those concerns to be unfounded. And there are protocols to ensure children do not overdose or become dependent on the medication.
Yet only 56.8 percent of youth evaluated in emergency departments diagnosed with appendicitis received pain medication, and about 41.3 percent received at least one dose of an opioid, such as morphine and fentanyl.
Black patients in severe pain were 80 percent less likely than white patients to receive opioids for their pain. Approximately 21 percent of Black patients, compared to more than 40 percent of white patients, received opioids. Black patients with moderate pain were also less likely to receive any pain medication compared to white patients.
Goyal’s team wrote that while clinicians may recognize pain equally across racial groups, they may be reacting to the pain differently by treating Black patients with painkillers, such as ibuprofen and acetaminophen, while treating white patients with opioids for similar pain.
“This analysis by pain strata suggests that there may be a higher threshold of pain score for administering analgesia to Black patients with appendicitis,” the authors wrote.
Goyal said she was surprised the results of their research demonstrated such dramatic differences in opioid administration by race.
“We assess pain scores in the emergency department, meaning, we ask patients to rate the pain they are experiencing,” Goyal told DiversityInc. “We should be responding to the pain scores the patients provide us.”
The current study was not designed to understand why these disparities exist, so Goyal and her team are planning studies to further delve into the topic in order to “help inform the development of interventions to achieve health equity.”
“I believe that the causes of such racial disparities are multifactorial,” she explained, “which include both conscious and unconscious bias, institutional practices, parental preferences, and societal expectations.”
Dr. Imani Jackson Rosario is a clinical instructor at Rutgers New Jersey Medical School in Newark, N.J., who served as director of the Urology Residency Program. She agreed with Goyal’s perspective and said socioeconomic inequality and racial bias contribute to the disparity.
“Hospitals serving minority communities are often underfunded and understaffed,” Rosario told DiversityInc. “They serve a low-income population of patients who are uninsured or underinsured, which affects the hospital’s bottom line. These hospitals often operate under a deficit, which affects equipment purchasing and staffing, which ultimately affects quality of care.”
In regards to racial bias, she said, “There is data that shows medical professionals, including and often specifically doctors, carry personal biases related to culture and race that influence the way they care for patients. This phenomenon is well documented and this most recent study is further evidence of the problem. There has been a concerted effort, though more effort is needed in my opinion, to address this problem at the level of medical student education.”
The Institute of Medicine of the National Academy of Sciences has called for more studies looking at the role that the unconscious behavior of doctors plays in health care.
Goyal explained racial disparities in health care are also a societal issue.
“We are all accountable for these disparities,” she said. “I hope that our work makes us acknowledge that these disparities exist and motivates us to all work towards creating a more equitable health care system.”
She noted organizations participating in a movement in health care to eliminate disparities.
“The American Association of Medical Colleges has developed an initiative for health equity,” Goyal said. “The National Institutes of Health have an Institute on Minority Health and Health Disparities, the Institute of Medicine also has an initiative to reduce health disparities and the Center for Disease Control and Prevention’s Healthy People 2020 [agenda for improving the nation’s health] includes achievement of health equity as one of its goals.”