Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures

Date reviewed 7/1/20

  • The most common reason for seeking emergency medicine treatment is pain yet it is poorly treated.
  • Children are still more likely to be undertreated for pain despite national efforts due to the Joint Commission to improve treatment of pain and as well as racial / ethnic differences.
  • Prior reports found racial differences in opioids in pediatric patients with appendicitis even after adjustment for pain score and severity9.
  • Long bone fracture most common presenting complaint among children in the emergency departments.
  • Adult literature showed disparities in ED management of pain with long bone fractures but previous data primarily in adults, single center data, over a decade ago, only assessed analgesic administration instead of clinical outcomes.
  • Todd et al, found that Hispanic adolescents and adults with long bone fractures were less than half as likely as non-Hispanic white to receive pain medications and less likely to receive opioids.
  • More recent studies found no racial or ethnic associations with difference in pain management but was in adults and older data.
Are minority children less likely to receive analgesia and achieve pain reduction? Study set out to answer process measures as well as clinical outcomes.
Design: Retrospective Cohort Study Population: Pediatric Emergency Care Applied Research Network Registry including 4 large tertiary care children’s hospital health systems involving a total of 7 total emergency departments (4 pediatric emergency departments and 3 affiliate satellite pediatric emergency departments) over the course of 3 years, July 1, 2014-June 30, 2017. Inclusion Criteria:
  • < 18 years of age Long bone fracture (clavicle, humerus, ulna, radius, femur,tibia/fibula)
  • Identified by ICD 10 code and radiology report indicating long bone fracture
  • Exclusion Criteria:
  • Incomplete data (I.E. missing race/ethnicity or pain scores)
  • Patients with mild or no pain
  • ESI category 1 or 5
  • Missing emergency department disposition – Left without being seen or Against Medical Advice as well
  • Exposure: Race / Ethnicity Confounding Variables:
  • Injury severity
  • Visit level characteristics
  • Patient level characteristics
  • Outcomes Evaluated:
  • Process Measures:
  • Receipt of any analgesia
  • Receipt of any opioid medication
  • Clinical Outcome Measure
  • Pain reduction of > or equal to 2 pts within 90 minutes of last recorded highest pain score. [ 1-3 = mild pain, 4-6 moderate pain, 7-10 severe pain]
  • Optimal pain reduction within 90 minutes of maximum pain defined as achieving mild or no pain.
Statistics: Used descriptive statistics to describe study populations and measure by race and ethnicity proportions of outcomes listed above. Bivariable and multivariable logistic regression was used to develop unadjusted and adjusted odds ratios to measure the strength of association of race and ethnicity with the outcome measures.
  • 34,544 patient visits – 1,289 patients with no or mild pain excluded = 21,069 patients
  • 8,533 had reassessment with pain score within 90 minutes
  • Median age of 10 and 47% of study population was non-Hispanic white.
Process Measures:
  1. 86% received one dose of analgesia from (18,129 of 21,069 patients). Minority children were more likely to receive any analgesia.
  2. 45.4% children with moderate to severe pain received opioid analgesia.
  3. Minority children less likely to receive opioid analgesia.
Clinical Outcome Measures:
  1. 89.2% achieved a > or equal to 2 pt reduction in pain (7,614/8,533)
  2. Minority children were more likely to achieve a 2pt or more reduction
  3. 62.2% patients had none/mild pain at 90 minutes from highest pain score

Minority children were less likely to achieve optimal pain reduction

Strengths:
  • Evaluates both process and clinical outcomes of pain management.
  • Adjusts for clinical severity by removing the ESI 1 and 5s.
  • Accounts for potential confounding variables.
  • < 5% of children did not have pain scores compared to other studies ~50% missing pain scores.
  • May be more reflective of current practice since most studies were in the 2000s.
Limitations:
  • Only looked at tertiary care pediatric emergency departments, which according to Petrack et al, previously reported pediatric emergency departments are more likely to administer analgesics when compared with general community emergency departments, which may limit external validity.
  • Cohort studies will have some bias.
  • It is unclear if patients refused analgesia since this was not a measure collected.
  • Only 47% of patients had follow up data which may affect strength of the results of the clinical outcome measures because of the missing data. Only 29% of total patients were included in the evaluation of optimal pain reduction.
  • Prehospital analgesia was not accounted for or obtained to evaluate if that affected patient results.
  • Observed racial/ethnic differences in both management and clinical outcomes of pain.
  • Minority children were more likely to receive some kind of analgesia and achieve > or equal to 2-point reduction in pain BUT even after injury severity adjustment were less likely to receive opioid medications and achieve optimal pain control.
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  2. Todd KH, Ducharme J, Choiniere M, et al; PEMI Study Group. Pain in the emergency department: results of the Pain and Emergency Medicine Initiative (PEMI) multicenter study. J Pain. 2007; 8(6):460–466
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