Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments

Abstract

IMPORTANCE: Racial disparities in use of analgesia in emergency departments have been previously documented. Further work to understand the causes of these disparities must be undertaken, which can then help inform the development of interventions to reduce and eradicate racial disparities in health care provision. OBJECTIVE: To evaluate racial differences in analgesia administration, and particularly opioid administration, among children diagnosed as having appendicitis. DESIGN, SETTING, AND PARTICIPANTS: Repeated cross-sectional study of patients aged 21 years or younger evaluated in the emergency department who had an International Classification of Diseases, Ninth Revision diagnosis of appendicitis, using the National Hospital Ambulatory Medical Care Survey from 2003 to 2010. We calculated the frequency of both opioid and nonopioid analgesia administration using complex survey weighting. We then performed multivariable logistic regression to examine racial differences in overall administration of analgesia, and specifically opioid analgesia, after adjusting for important demographic and visit covariates, including ethnicity and pain score. MAIN OUTCOMES AND MEASURES: Receipt of analgesia administration (any and opioid) by race. RESULTS: An estimated 0.94 (95% CI, 0.78-1.10) million children were diagnosed as having appendicitis. Of those, 56.8% (95% CI, 49.8%-63.9%) received analgesia of any type; 41.3% (95% CI, 33.7%-48.9%) received opioid analgesia (20.7% [95% CI, 5.3%-36.0%] of black patients vs 43.1% [95% CI, 34.6%-51.4%] of white patients). When stratified by pain score and adjusted for ethnicity, black patients with moderate pain were less likely to receive any analgesia than white patients (adjusted odds ratio = 0.1 [95% CI, 0.02-0.8]). Among those with severe pain, black patients were less likely to receive opioids than white patients (adjusted odds ratio = 0.2 [95% CI, 0.06-0.9]). In a multivariable model, there were no significant differences in the overall rate of analgesia administration by race. However, black patients received opioid analgesia significantly less frequently than white patients (12.2% [95% CI, 0.1%-35.2%] vs 33.9% [95% CI, 0.6%-74.9%], respectively; adjusted odds ratio = 0.2 [95% CI, 0.06-0.8]). CONCLUSIONS AND RELEVANCE: Appendicitis pain is undertreated in pediatrics, and racial disparities with respect to analgesia administration exist. Black children are less likely to receive any pain medication for moderate pain and less likely to receive opioids for severe pain, suggesting a different threshold for treatment.