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Are racial disparities in ED analgesia improving? Evidence from a national database
American Journal of Emergency Medicine (2008) 26, 462–464
www.elsevier.com/locate/ajem
Brief Report
Are racial disparities in ED analgesia improving? Evidence from a national database Shaila Quazi DO, Mary Eberhart MD, Jeanne Jacoby MD, Michael Heller MD⁎ Emergency Medicine Residency, St Luke's Hospital, Bethlehem, PA 18015, USA Received 15 January 2007; revised 7 May 2007; accepted 11 May 2007
Abstract Objective: Ethnic disparities in emergency department (ED) analgesic use have been noted previously; the purpose of this study was to determine if current ED practice has been altered subsequent to the widespread recognition of these inequalities. Methods: Using data from the National Hospital Ambulatory Care Survey, we analyzed ED analgesic treatment with respect to race for the complaints of headache (HA) and long bone fractures (LBF) for 1995 to 1999 (period A) and compared that with data for 2000 to 2003 (period B). We compared the use of “any analgesics” and “opioids” among blacks, whites, and Hispanics. Results: For both HA and LBF, improvements over time were noted in all 3 ethnic subgroups. A statistically significant increase was documented in the treatment of HA among Hispanics using any analgesia (71.3% vs 80.8%, P = .011). Although individual differences between the 2 periods in the LBF cohort were not statistically significant for any of the 3 ethnic groups, there was an overall improvement noted when combining all ethnicities: among all patients treated for LBF, 66% received some analgesic and 42.8% received opioid analgesia during period A vs 75% and 51%, respectively, during period B (all P b .001). Furthermore, in the latest study period, there were no differences in the frequency of analgesic administration for LBF with respect to race (blacks, 43%; whites, 48%; Hispanics, 43.8%; P N .1). Conclusion: There is evidence that previously described racial inequalities in analgesic use have decreased over time. © 2008 Elsevier Inc. All rights reserved.
1. Introduction In the 1990s, several studies documented substantial differences in the medical management of common diseases among racial subgroups. Blacks and Hispanics were shown to be less likely to receive adequate treatment in complaints ranging from cardiovascular disease to end-of-life care [1-4].
This article was presented as a poster at the American College of Emergency Physicians Scientific Assembly, October 2006. ⁎ Corresponding author. 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2007.05.007
Widespread dissemination of these findings contributed to research, education, and changes in health care practices and protocols, which were designed to encourage more rational and equitable treatment [5]. The purpose of this study was to determine whether emergency department (ED) practice in the period subsequent to these efforts reflected any measurable improvements. Specifically, our focus was on the treatment of painful complaints in the ED among blacks, whites, and Hispanics. Using a nationally representative sample, we analyzed the use of opioids and any analgesics for both a subjective and an objective painful complaint among racial subgroups.
Racial disparities in ED analgesia — improving?
463
2. Methods Using data from the National Hospital Ambulatory Care Survey, we analyzed ED analgesic treatment with respect to race for the complaints of headache (HA) and long bone fractures (LBF) for 1995 to 1999 (period A) and compared that with data for 2000 to 2003 (period B). This database includes a nationally representative sample of all ED patients. We compared the use of “any analgesics” and opiates among blacks, whites, and Hispanics. A total of 5116 patient encounters were analyzed with the complaint of HA and 2388 patients with LBF. This represented a weighted national sample of 19.73 million ED visits for HA and 9.1 million visits for LBF, respectively. A logistic regression model was performed to adjust for insurance status, geographic region, and hospital type before statistical analysis. All comparisons were by χ2 with α set at .05.
3. Results The HA subgroup consisted of 19.8% black (B), 69.8% white (W), and 10.4% Hispanic (H) subjects. During period A, 76.3% of the total sample population received some analgesic and 37.9% received an opioid as compared to 79.3% and 44.1%, respectively, during period B (P = .012 and 0.001, respectively). However, subgroup analysis showed that only Hispanics had a statistically significant improvement in “any analgesia” from period A to B (71.3% vs 80.8% H P = .011) (Fig. 1). With respect to opiate analgesia, Hispanics did not show significant improvement, whereas their black and white counterparts showed significant improvement (40.3% vs 47.5% [whites], P = .001; 29.5% vs 35.5% [blacks], P = .047; 36.6% vs 38.5% [Hispanics], P = .655) (Fig. 2). In the multiple logistic regression model analysis for 1995 to 2003, there were no significant differences in analgesia for HA with respect to ethnicity while controlling for other variables. Among patients treated for LBF (10.8% [blacks], 78.8% [whites], 10.5% [Hispanics]), 66% received some analgesic and 42.8% received opioid during period A vs 75% and 51%,
Fig. 1
Opioid use in headache.
Fig. 2
Analgesia use in HA.
respectively, during period B (P = .001). In the multiple logistic regression model for 1995 to 2003, blacks (78.1%) were more likely to receive any analgesic compared to whites (70.1%) or Hispanics (67.7%, all P b .03). Although the percentages for all groups appear to be trending toward significance for any analgesic, only whites have a statistically significant improvement between time frames (65.4% vs 74.4% [whites], P = .001; 73.6% vs 82.4% [blacks], P = .087; 62.5% vs 72.5% [Hispanics], P = .09) (Fig. 3). With regard to opioid treatment of LBF, neither blacks nor Hispanics showed statistically significant interval improvement, although their white counterparts did (43.4% vs 52.3% [whites], P = .001; 37.6% vs 48.1% [blacks], P = .09; 43.3% vs 44.3% [Hispanics], P = .881) (Fig. 4). When these results are extrapolated to a weighted national sample, all P values become statistically significant.
4. Discussion Ethnic disparities in health care have been a widely discussed and researched topic. Discrepancies between whites and nonwhites in treatment of complaints ranging from chest pain to end-of-life care have been documented in studies for over a decade [5-10]. In the realm of analgesia, several studies by Todd et al [2,3] and other
Fig. 3
Long bone fracture—any analgesic.
464
S. Quazi et al.
Fig. 4
Opioid use in LBF.
groups [4,5,11-13] demonstrated that both Hispanics and blacks were substantially undertreated for pain, in the ED and in other settings. In 1999, the US Congress mandated that the Agency for Healthcare Research and Quality produce an annual National Healthcare Disparities Report, guided by the Institute of Medicine. Goals included identifying major areas where disparities exist and designing approaches to rectify those particular discrepancies; hospitals, insurance companies, and other organizations followed suit to identify and address these issues [6,14,15]. The purpose of this retrospective review was to see if change has occurred with the emergence of a better awareness of the social inequalities present in medical treatment, specifically in the use of analgesia in headache and LBF. This study evaluates data collected in 1995 to 2003, subsequent to the period studied by Todd et al. We evaluated the ED treatment of both a subjective (HA) and objective (LBF) complaint of pain with respect to race. We divided our data set into 2 time frames, 1995 to 1999 and 2000 to 2003, and compared treatment practices to determine whether a change was evident. The current study indicates a trend toward increased use of analgesics in general, and opiates in particular, across all subgroups, although most of these individual increases were not statistically significant. For headache, all racial subgroups received some form of analgesia equally; however, whites were more likely to receive an opiate for this complaint. In the treatment of LBF, the only significant difference noted was among white patients, although there was a trend for improvement among blacks and less so for Hispanics. This is a significant change compared to previously published data, suggesting that ED analgesia prescribing patterns have indeed been altered. Although the reason for this change is unclear, it is likely that the emerging awareness of the problem of inadequate analgesia has led to a change in practice and protocols for black patients but less so for Hispanic patients. Other factors, perhaps including a
change in the racial and demographic profiles of ED practitioners, may also be a factor. It is notable that the changes we report occurred over a relatively brief period; the 2 study periods were contiguous. Ongoing analysis of the National Hospital Ambulatory Care Survey and similar databases appear warranted to confirm the encouraging trends noted. Ethnic differences in analgesic use appear to have lessened in recent years. This trend is more apparent in the treatment of the objective diagnosis—LBF—than the subjective complaint of headache. Although blacks and Hispanics with the subjective complaint of headache remain less likely to receive opioid analgesics than their white counterparts, it seems that all ethnic groups with the more objective finding of LBF are treated similarly. It appears that irregularities in ED analgesic practice have decreased over the past decade. Future research is needed to determine more significant progress, especially with regards to trends in opiate prescription among Hispanic populations.
References [1] Cone DC, Richardson LD, Todd KH, et al. Health care disparities in emergency medicine. Acad Emerg Med 2003;10:1176-83. [2] Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate ED analgesia. JAMA 1993;269:1537-9. [3] Todd KH, Deaton CR, D'Adamo AP, et al. Ethnicity and analgesic practice. Ann Emerg Med 2000;35:11-6. [4] Morrison RS, Wallenstein S, Natale DK, et al. “We don't carry that”— failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342:1023-6. [5] Sullivan LW, Eagel BA. Leveling the playing field: recognizing and rectifying disparities in managementof pain. Pain Med 2005;6(1):5-10. [6] Green CR, Anderson K, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med 2003;4:277-94. [7] Chin MH, et al. Diabetes in the African-American medicare population. Diabetes Care 1998;21(7):1090-5. [8] Perez-Stable E, et al. The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Med Care 1997;35 (12):1212-9. [9] Velanovich V, et al. Racial differences in the presentation and surgical management of breast cancer. Surgery 1999:375-9. [10] Fiscella K, et al. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000:2579-84. [11] Sobel RM, Todd KH. Risk factors in oligoanalgesia. Am J Emerg Med 2002;20(2):126. [12] Todd KH. Pain assessment and ethnicity. Ann Emerg Med 1996;27(4): 421-3. [13] Todd KH. Influence of ethnicity on emergency department pain management. Emerg Med 2001;13(3):274-8. [14] Mitchell J, McCormack L. Time trends in late-stage diagnosis of cervical cancer: differences by race/ethnicity and income. Med Care 1997;35(12):1220-4. [15] Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington: National Academy Press; 2003. p. 29-85.
www.elsevier.com/locate/ajem
Brief Report
Are racial disparities in ED analgesia improving? Evidence from a national database Shaila Quazi DO, Mary Eberhart MD, Jeanne Jacoby MD, Michael Heller MD⁎ Emergency Medicine Residency, St Luke's Hospital, Bethlehem, PA 18015, USA Received 15 January 2007; revised 7 May 2007; accepted 11 May 2007
Abstract Objective: Ethnic disparities in emergency department (ED) analgesic use have been noted previously; the purpose of this study was to determine if current ED practice has been altered subsequent to the widespread recognition of these inequalities. Methods: Using data from the National Hospital Ambulatory Care Survey, we analyzed ED analgesic treatment with respect to race for the complaints of headache (HA) and long bone fractures (LBF) for 1995 to 1999 (period A) and compared that with data for 2000 to 2003 (period B). We compared the use of “any analgesics” and “opioids” among blacks, whites, and Hispanics. Results: For both HA and LBF, improvements over time were noted in all 3 ethnic subgroups. A statistically significant increase was documented in the treatment of HA among Hispanics using any analgesia (71.3% vs 80.8%, P = .011). Although individual differences between the 2 periods in the LBF cohort were not statistically significant for any of the 3 ethnic groups, there was an overall improvement noted when combining all ethnicities: among all patients treated for LBF, 66% received some analgesic and 42.8% received opioid analgesia during period A vs 75% and 51%, respectively, during period B (all P b .001). Furthermore, in the latest study period, there were no differences in the frequency of analgesic administration for LBF with respect to race (blacks, 43%; whites, 48%; Hispanics, 43.8%; P N .1). Conclusion: There is evidence that previously described racial inequalities in analgesic use have decreased over time. © 2008 Elsevier Inc. All rights reserved.
1. Introduction In the 1990s, several studies documented substantial differences in the medical management of common diseases among racial subgroups. Blacks and Hispanics were shown to be less likely to receive adequate treatment in complaints ranging from cardiovascular disease to end-of-life care [1-4].
This article was presented as a poster at the American College of Emergency Physicians Scientific Assembly, October 2006. ⁎ Corresponding author. 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2007.05.007
Widespread dissemination of these findings contributed to research, education, and changes in health care practices and protocols, which were designed to encourage more rational and equitable treatment [5]. The purpose of this study was to determine whether emergency department (ED) practice in the period subsequent to these efforts reflected any measurable improvements. Specifically, our focus was on the treatment of painful complaints in the ED among blacks, whites, and Hispanics. Using a nationally representative sample, we analyzed the use of opioids and any analgesics for both a subjective and an objective painful complaint among racial subgroups.
Racial disparities in ED analgesia — improving?
463
2. Methods Using data from the National Hospital Ambulatory Care Survey, we analyzed ED analgesic treatment with respect to race for the complaints of headache (HA) and long bone fractures (LBF) for 1995 to 1999 (period A) and compared that with data for 2000 to 2003 (period B). This database includes a nationally representative sample of all ED patients. We compared the use of “any analgesics” and opiates among blacks, whites, and Hispanics. A total of 5116 patient encounters were analyzed with the complaint of HA and 2388 patients with LBF. This represented a weighted national sample of 19.73 million ED visits for HA and 9.1 million visits for LBF, respectively. A logistic regression model was performed to adjust for insurance status, geographic region, and hospital type before statistical analysis. All comparisons were by χ2 with α set at .05.
3. Results The HA subgroup consisted of 19.8% black (B), 69.8% white (W), and 10.4% Hispanic (H) subjects. During period A, 76.3% of the total sample population received some analgesic and 37.9% received an opioid as compared to 79.3% and 44.1%, respectively, during period B (P = .012 and 0.001, respectively). However, subgroup analysis showed that only Hispanics had a statistically significant improvement in “any analgesia” from period A to B (71.3% vs 80.8% H P = .011) (Fig. 1). With respect to opiate analgesia, Hispanics did not show significant improvement, whereas their black and white counterparts showed significant improvement (40.3% vs 47.5% [whites], P = .001; 29.5% vs 35.5% [blacks], P = .047; 36.6% vs 38.5% [Hispanics], P = .655) (Fig. 2). In the multiple logistic regression model analysis for 1995 to 2003, there were no significant differences in analgesia for HA with respect to ethnicity while controlling for other variables. Among patients treated for LBF (10.8% [blacks], 78.8% [whites], 10.5% [Hispanics]), 66% received some analgesic and 42.8% received opioid during period A vs 75% and 51%,
Fig. 1
Opioid use in headache.
Fig. 2
Analgesia use in HA.
respectively, during period B (P = .001). In the multiple logistic regression model for 1995 to 2003, blacks (78.1%) were more likely to receive any analgesic compared to whites (70.1%) or Hispanics (67.7%, all P b .03). Although the percentages for all groups appear to be trending toward significance for any analgesic, only whites have a statistically significant improvement between time frames (65.4% vs 74.4% [whites], P = .001; 73.6% vs 82.4% [blacks], P = .087; 62.5% vs 72.5% [Hispanics], P = .09) (Fig. 3). With regard to opioid treatment of LBF, neither blacks nor Hispanics showed statistically significant interval improvement, although their white counterparts did (43.4% vs 52.3% [whites], P = .001; 37.6% vs 48.1% [blacks], P = .09; 43.3% vs 44.3% [Hispanics], P = .881) (Fig. 4). When these results are extrapolated to a weighted national sample, all P values become statistically significant.
4. Discussion Ethnic disparities in health care have been a widely discussed and researched topic. Discrepancies between whites and nonwhites in treatment of complaints ranging from chest pain to end-of-life care have been documented in studies for over a decade [5-10]. In the realm of analgesia, several studies by Todd et al [2,3] and other
Fig. 3
Long bone fracture—any analgesic.
464
S. Quazi et al.
Fig. 4
Opioid use in LBF.
groups [4,5,11-13] demonstrated that both Hispanics and blacks were substantially undertreated for pain, in the ED and in other settings. In 1999, the US Congress mandated that the Agency for Healthcare Research and Quality produce an annual National Healthcare Disparities Report, guided by the Institute of Medicine. Goals included identifying major areas where disparities exist and designing approaches to rectify those particular discrepancies; hospitals, insurance companies, and other organizations followed suit to identify and address these issues [6,14,15]. The purpose of this retrospective review was to see if change has occurred with the emergence of a better awareness of the social inequalities present in medical treatment, specifically in the use of analgesia in headache and LBF. This study evaluates data collected in 1995 to 2003, subsequent to the period studied by Todd et al. We evaluated the ED treatment of both a subjective (HA) and objective (LBF) complaint of pain with respect to race. We divided our data set into 2 time frames, 1995 to 1999 and 2000 to 2003, and compared treatment practices to determine whether a change was evident. The current study indicates a trend toward increased use of analgesics in general, and opiates in particular, across all subgroups, although most of these individual increases were not statistically significant. For headache, all racial subgroups received some form of analgesia equally; however, whites were more likely to receive an opiate for this complaint. In the treatment of LBF, the only significant difference noted was among white patients, although there was a trend for improvement among blacks and less so for Hispanics. This is a significant change compared to previously published data, suggesting that ED analgesia prescribing patterns have indeed been altered. Although the reason for this change is unclear, it is likely that the emerging awareness of the problem of inadequate analgesia has led to a change in practice and protocols for black patients but less so for Hispanic patients. Other factors, perhaps including a
change in the racial and demographic profiles of ED practitioners, may also be a factor. It is notable that the changes we report occurred over a relatively brief period; the 2 study periods were contiguous. Ongoing analysis of the National Hospital Ambulatory Care Survey and similar databases appear warranted to confirm the encouraging trends noted. Ethnic differences in analgesic use appear to have lessened in recent years. This trend is more apparent in the treatment of the objective diagnosis—LBF—than the subjective complaint of headache. Although blacks and Hispanics with the subjective complaint of headache remain less likely to receive opioid analgesics than their white counterparts, it seems that all ethnic groups with the more objective finding of LBF are treated similarly. It appears that irregularities in ED analgesic practice have decreased over the past decade. Future research is needed to determine more significant progress, especially with regards to trends in opiate prescription among Hispanic populations.
References [1] Cone DC, Richardson LD, Todd KH, et al. Health care disparities in emergency medicine. Acad Emerg Med 2003;10:1176-83. [2] Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate ED analgesia. JAMA 1993;269:1537-9. [3] Todd KH, Deaton CR, D'Adamo AP, et al. Ethnicity and analgesic practice. Ann Emerg Med 2000;35:11-6. [4] Morrison RS, Wallenstein S, Natale DK, et al. “We don't carry that”— failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342:1023-6. [5] Sullivan LW, Eagel BA. Leveling the playing field: recognizing and rectifying disparities in managementof pain. Pain Med 2005;6(1):5-10. [6] Green CR, Anderson K, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med 2003;4:277-94. [7] Chin MH, et al. Diabetes in the African-American medicare population. Diabetes Care 1998;21(7):1090-5. [8] Perez-Stable E, et al. The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Med Care 1997;35 (12):1212-9. [9] Velanovich V, et al. Racial differences in the presentation and surgical management of breast cancer. Surgery 1999:375-9. [10] Fiscella K, et al. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000:2579-84. [11] Sobel RM, Todd KH. Risk factors in oligoanalgesia. Am J Emerg Med 2002;20(2):126. [12] Todd KH. Pain assessment and ethnicity. Ann Emerg Med 1996;27(4): 421-3. [13] Todd KH. Influence of ethnicity on emergency department pain management. Emerg Med 2001;13(3):274-8. [14] Mitchell J, McCormack L. Time trends in late-stage diagnosis of cervical cancer: differences by race/ethnicity and income. Med Care 1997;35(12):1220-4. [15] Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington: National Academy Press; 2003. p. 29-85.