Racial Gap in Management of Pediatric Appendicitis Pain

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
http://www.medscape.com/viewarticle/851072