Racial disparities in pain treatment of children with appendicitis in EDs

Black children were less likely to receive any pain medication for moderate pain and less likely to receive opioids for severe pain than white children in a study of racial disparities in the pain management of children with appendicitis in emergency departments, according to an article published online by JAMA Pediatrics.

Racial and ethnic differences in the emergency department (ED) management of pain have been described, with lower rates of opioid prescription for black and Hispanic patients than for white patients. However, there are fewer studies in children. Appendicitis is the most common surgical cause of abdominal pain in the ED and the use of analgesia to patients with appendicitis is encouraged.

Monika K. Goyal, M.D., M.S.C.E., of the Children's National Health System, Washington, and coauthors suggest that examining pain management among children diagnosed with appendicitis provides a more appropriate example in which to evaluate racial differences in the administration of analgesia.

The authors used data from the National Hospital Ambulatory Medical Care Survey from 2003 to 2010 to analyze both the administration of opioid and nonopioid analgesia.

Of an estimated almost 1 million children evaluated in EDs who were diagnosed with appendicitis, 56.8 percent of patients received any analgesia and 41.3 percent received any opioid analgesia, according to the results.

When analyzed by pain score and adjusted for ethnicity, black patients with moderate pain were less likely to receive any analgesia than white patients. Among those patients with severe pain, black patients were less likely to receive opioids than white patients.

While there was no significant difference in overall analgesia administration by race when multiple variables were accounted for, there was a difference in opioid administration by race: black children with appendicitis were less likely to receive opioid analgesia than white children (12.2 percent vs. 33.9 percent.)

Study limitations noted by the authors include patients possibly declining analgesia despite pain and the authors not being able to account for any analgesia patients may have received prior to arriving at the ED.

"Our findings suggest that there are racial disparities in opioid administration to children with appendicitis, even after adjustment for potential confounders. More research is needed to understand why such disparities exist. This could help inform the design of interventions to address and eliminate these disparities and to improve pain management for all youths," the study concludes.

In a related editorial, Eric W. Fleegler, M.D., M.P.H., and Neil L. Schechter, M.D., of Boston Children's Hospital and Harvard Medical School, Boston, write: "How do we explain the persistence of these disparities in treatment? ... 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. ... It is clear that despite 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."