Evaluating for Racial Differences in Pain Management of Long-Bone Fractures in a Pediatric Rural Population

Abstract

Objectives The aim of this study was to determine if a racial disparity exists in the administration of an analgesic, time to receiving analgesic, and type of analgesic administered to children with long-bone fractures. Prior studies have reported the existence of racial disparity but were mostly in adult and urban populations. Methods This is a retrospective chart review of 727 pediatric patients (aged 2–17 years) with International Classification of Diseases, Ninth Revision (or 10th revision) codes for long-one fractures in an emergency department that cares for a suburban and rural population between January 2013 and January 2016. Logistic regression was used to estimate the odds ratio of receiving no analgesic versus receiving an analgesic and receiving a nonopioid versus opioid drug. Linear regression analysis was performed to study the relationship between race and time to receive the analgesic, after adjusting for sex, age, insurance type, and mechanism of injury. Results Of the 727 children, 27% of them did not receive analgesics regardless of race. 27% (164/605) of white children, 25% (8/31) of African American children, and 24% (12/49) of Hispanic children did not receive analgesics. African Americans are 12% more likely (odds ratio [OR], 1.12; 95% confidence interval [CI], 0.48–2.61) to receive an analgesic compared with whites, and Hispanics are 22% more likely (OR, 1.22; 95% CI, 0.60–2.45) to receive an analgesic than whites. African Americans are 26% less likely (OR, 0.74; 95% CI, 0.31–1.75) to receive an opioid versus a nonopioid compared with whites, and Hispanics are 92% more likely (OR, 1.92; 95% CI, 0.91–4.17). Mean wait time across all races was 69 minutes, with no statistical difference between groups. Conclusions This study showed no statistical significance in the receipt or type of analgesic or wait time for pediatric long-bone fractures between race in a major academic level 1 trauma children's hospital, despite previous literature citing otherwise. This study augments to the few studies conducted in a rural setting. It is also one of the few studies that analyzed pain management in a large pediatric population as well as used waiting time to receive analgesic as an outcome measure. Overall, we found a mean wait time of 69 minutes for analgesic administration regardless of race, suggesting the need for more prompt pain management across all races for the management of long-bone fracture in the pediatric population.

Racial and Ethnic Disparities in Pain Management of Children With Limb Fractures or Suspected Appendicitis: A Retrospective Cross-Sectional Study

“…There are fewer studies investigating analgesic racial/ethnic disparities in children visiting the ED than for adults. Most of these studies either used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), an annual nationwide survey designed to collect ED service data (4-8), or involved single center studies with small sample size (10)(11)(12)(13). Prior work looking at disparities in pain management of a Each visit for an suspected appendicitis was considered independently; if a given patient had more than one visit for suspected appendicitis in the time period the receipt of medications would be considered separately.…”

“…Prior work looking at disparities in pain management of patients with long bone fractures shows heterogeneous results. Whereas one study using NHAMCS data from 1992 to 1998 ( 8 ) and two single center studies ( 11 , 12 ) found no differences in opioid administration between White NH and children of color, one recent multicenter study found that children of color were less likely to receive an opioid treatment when visiting the PED with a long bone fracture ( 9 ). The same heterogeneous results are observed regarding disparities in pain management of abdominal pain and appendicitis.…”

“…The covariates used in both cohorts included sex, age, median income by zip code, insurance type (public, private, self-pay), initial pain score and triage acuity level. We chose these covariates because they were a priori considered to have a potential relationship with analgesic and opioid administration based on prior literature ( 6 , 9 , 12 ). Specific covariates for the limb fracture cohort included location of the fracture (upper or lower limb) as well as receipt of sedation in the ED.…”

“…Studies using data from national surveys or multicentric studies have consistently shown racial and ethnic differences in pain management in the ED overall (4,5) but heterogeneous results for appendicitis (6,7) and limb fractures (8,9). Other studies, mainly retrospective and monocentric, find no racial differences in analgesic management of bone fractures or appendicitis (10)(11)(12)(13).…”

“…Opioid management in the ED is used in about 15% of abdominal pain cases and in about 40% of PED visits for fracture pain (4). Thus, abdominal pain/appendicitis and limb fractures have provided a convenient paradigm to evaluate racial/ethnic differences in analgesia management in PED (6)(7)(8)(9)(10)(11)(12)15). However, the majority of these pediatric studies look either at the use of analgesia in single conditions or the use or prescription of opioids across "potentially painful conditions" without data about the presence or severity of pain (5), and therefore miss an opportunity to look at the pervasiveness of potential pain management disparities across multiple specific painful conditions in a given setting.…”