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When it comes to disparities research, I sometimes get angry at researchers that we're still spending so much time with studies pointing out disparities in medicine and so little time doing anything about them. I mean, is there anyone out there who denies that there are racial disparities in how we treat patients, that would change their mind if they just saw one more study? I think not. But every once in a while, a study gets published that gets past my eye roll and makes me angry all over again. This is Healthcare Triage News.

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Dr. Aaron Carroll: Is there anyone out there that denies that there are racial disparities in how we treat patients, but who would change their mind if they saw just one more study? I think not. And yet we keep on publishing them.

But every once in a while, I see a study that gets past my eye roll and makes me angry all over again. This is Healthcare Triage News.

(Intro)

JAMA Pediatrics: racial disparities of pain management in children with appendicitis in emergency departments. Let's wade in.

There are many many studies that document that there are racial disparities in how we use pain medications in the emergency department. No matter how many times it gets documented, it seems to continue, but some people try to rationalize that fact. They argue that it's because of a different racial makeup in emergency department care vs. primary care. Or they argue it's because of drug-seeking behavior, where someone fakes symptoms to get opioids, and it occurs at different rates in different people of different races.

All of the participants in this study were children with appendicitis, so this is an acute problem with pain. The researchers got data from the National Hospital Ambulatory Medical Care Survey, from 2003 to 2010. They looked at both opioid and non-opioid analgesia. And, they then looked at racial differences in their use after controlling for other factors, including this like pain score.

Over this time period almost a million kids had appendicitis. About 57% of them got analgesia of any type, 41% got opioids. Unadjusted, there were big differences in the types of pain medications received, though. White children got opioids 43% of the time and non-opioids 14% of the time. Black kids, on the other hand, got opioids 21% of the time and non-opioids 34% of the time.

In adjusted analyses, white children were predicted to get some form of analgesia 43% of the time versus 42% for black children. This difference wasn't statistically significant, though. The differences in opioid use, however, were statistically significant. White children were predicted to get opioids 34% of the time versus 12% for black children. The adjusted odds ratio for black children to get opioids versus white children was 0.2.

Interestingly, there were also differences by the level of pain. If kids had severe pain, black kids were less likely to get opioids than white kids, but they were still as likely to get some form of analgesia. However, for those kids with moderate pain, not only were black kids less likely to get opioids, they were less likely to get any pain medication at all, with an adjusted odds ratio of 0.1.

Let's get some things out of the way immediately. These were all children who had been diagnosed with appendicitis, so any concerns about racial differences in emergency department use in general being involved go out the window. Black children only comprised 90% of the study population, so they weren't going to the emergency department instead of their primary care doctor. This is an acute condition, and there's no reason I can think of that you would treat black and white kids differently. These are also kids, so no talk about drug seeking behavior please. They're only going to get acute administration of pain meds for their acute appendicitis. Let's also acknowledge that opioids are falling out of favor, but that's mostly for chronic pain, not the acute pain of appendicitis.

Now it's possible that this is because of differences in hospital practice instead of differences in patients. The researchers were only able to control for region (Northeast, Midwest, South, and West) and whether the patient was seen in a pediatric or general emergency department. They couldn't adjust for individual hospital.

But I'd argue that information would only be meaningful for interventional purposes. Even if these are hospital differences, and the fact that black kids' pain is being ignored is because they're seen at hospital that mainly care for minority populations, it's still horrific. It's disturbing that black kids in severe pain are much less likely to get opioid pain meds for their appendicitis. It's even more disturbing that they're less likely to get any meds at all for their moderate pain.

It amazes me that I can still be stunned by disparities research. We should fix this yesterday. Also, the pediatrician in me is horrified by the fact that about a quarter of all kids with severe pain from acute appendicitis get no pain medication at all. What is wrong with us?

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