Association Between Patient-Prescriber Racial and Ethnic Concordance and Postpartum Pain and Opioid Prescribing

Racial and Ethnic Concordance Between the Patient and Anesthesia Team and Patients' Satisfaction With Pain Management During Cesarean Delivery

BACKGROUND

Racial and ethnic concordance between patients and health care providers increases patient satisfaction but has not been examined in obstetric anesthesia care. This study evaluated the association between racial and ethnic concordance and satisfaction with management of pain during cesarean delivery (PDCD).

METHODS

This was a secondary analysis on a cohort of patients undergoing cesarean deliveries under neuraxial anesthesia that examined PDCD. The outcome was satisfaction, recorded within 48 hours after delivery using the survey question, "Overall, how satisfied are you with the anesthesia care during the C-section as it relates to pain management?" Using a 5-point Likert scale, satisfaction was defined with the answer "very satisfied." Participants were also asked, "If you have another C-section, would you want the same anesthesia team?" The exposure was racial and ethnic concordance between the patient and anesthesia team members (attending with a resident, nurse anesthetist, or fellow) categorized into full concordance, partial concordance, discordance, and missing. Risk factors for satisfaction were identified using a multivariable analysis.

RESULTS

Among 403 participants, 305 (78.2%; 95% confidence interval [CI], 73.8-82.1) were "very satisfied," and 358 of 399 (89.7%; 95% CI, 86.3-92.5) "would want the same anesthesia team." Full concordance occurred in 18 (4.5%) cases, partial concordance in 117 (29.0%), discordance in 175 (43.4%), and missing in 93 (23.1%). Satisfaction rate was 88.9% for full concordance, 71.8% for partial concordance, 81.1% for discordance, and 78.5% for missing (P value = .202). In the multivariable analysis, there was insufficient evidence for an association of concordance with satisfaction. Compared to full concordance, partial concordance was associated with a nonsignificant 57% (95% CI, -113 to 91) decrease in the odds of being satisfied, discordance with a 29% (95% CI, -251 to 85) decrease, and missing with a 39% (95% CI, -210 to 88) decrease. Risk factors for not being "very satisfied" were PDCD, anxiety disorders, pregnancy resulting from in vitro fertilization, intravenous medication administration, intrapartum cesarean with extension of labor epidural, having 3 anesthesia team members (instead of 2), and a higher intraoperative blood loss.

CONCLUSIONS

Our inability to identify an association between concordance and satisfaction is likely due to the high satisfaction rate in our cohort (78.2%), combined with low proportion of full concordance (4.5%). Addressing elements such as PDCD, anxiety, intravenous medication administration, and use of epidural anesthesia for cesarean delivery, and a better understanding of the interplay between concordance and satisfaction are warranted.

The Association of Nonmodifiable Patient Factors on Antipsychotic Medication use in the Intensive Care Unit

PURPOSE

We investigated the association of age, sex, race, and insurance status on antipsychotic medication use among intensive care unit (ICU) patients.

MATERIALS AND METHODS

Retrospective study of adults admitted to ICUs at a tertiary academic center. Patient characteristics, hospital course, and medication (olanzapine, quetiapine, and haloperidol) data were collected. Logistic regression models evaluated the independent association of age, sex, race, and insurance status on the use of each antipsychotic, adjusting for prespecified covariates.

RESULTS

Of 27,137 encounters identified, 6191 (22.8%) received antipsychotics. Age was significantly associated with the odds of receiving olanzapine (P < .001), quetiapine (P = .001), and haloperidol (P = .0046). Male sex and public insurance status were associated with increased odds of receiving antipsychotics olanzapine, quetiapine, and haloperidol (Male vs Female: OR 1.13, 95% CI [1.04, 1.24], P = .0005; OR 1.22, 95% CI [1.10, 1.34], P = .0001; OR 1.28, 95% CI [1.17, 1.40], P < .0001, respectively; public insurance vs private insurance: OR 1.32, 95% CI [1.20, 1.46], P < .0001; OR 1.21, 95% CI [1.09, 1.34], P = .0004; OR 1.15, 95% CI [1.04, 1.27], P = .0058, respectively). Black race was also associated with a decreased odds of receiving all antipsychotics (olanzapine (P = .0177), quetiapine (P = .004), haloperidol (P = .0041)).

CONCLUSIONS

Age, sex, race, and insurance status were associated with the use of all antipsychotic medications investigated, highlighting the importance of investigating the potential impact of these prescribing decisions on patient outcomes across diverse populations. Recognizing how nonmodifiable patient factors have the potential to influence prescribing practices may be considered an important factor toward optimizing medication regimens.

Review of racial/ethnic disparities in obstetrics-related anesthesia administration and pain management

While racial/ethnic disparities in maternal outcomes including mortality and severe maternal morbidity are well documented, there is limited information on disparities in obstetric anesthesia practices. This paper reviews literature on racial/ethnic disparities in peripartum anesthesia administration and postpartum pain management. Current literature demonstrates racial/ethnic disparities in several aspects of obstetric anesthesia care including neuraxial administration for vaginal labor pain, neuraxial versus general anesthesia for cesarean delivery, post neuraxial anesthesia complications, postpartum pain management and postdural puncture headache treatment practices. However, many studies are dated or have limited data from single institutions or states. More research on nation-wide racial/ethnic disparities in obstetric anesthesia is needed to understand its broader practice and management in the USA.

Disparities in postoperative opioid prescribing by race and ethnicity: an electronic health records-based observational study from Northern California, 2015-2020

OBJECTIVES

To examine racial and ethnic disparities in postoperative opioid prescribing.

DATA SOURCES

Electronic health records (EHR) data across 24 hospitals from a healthcare delivery system in Northern California from January 1, 2015 to February 2, 2020 (study period).

STUDY DESIGN

Cross-sectional, secondary data analyses were conducted to examine differences by race and ethnicity in opioid prescribing, measured as morphine milligram equivalents (MME), among patients who underwent select, but commonly performed, surgical procedures. Linear regression models included adjustment for factors that would likely influence prescribing decisions and race and ethnicity-specific propensity weights. Opioid prescribing, overall and by race and ethnicity, was also compared to postoperative opioid guidelines.

DATA EXTRACTION

Data were extracted from the EHR on adult patients undergoing a procedure during the study period, discharged to home with an opioid prescription.

PRINCIPAL FINDINGS

Among 61,564 patients, on adjusted regression analysis, non-Hispanic Black (NHB) patients received prescriptions with higher mean MME than non-Hispanic white (NHW) patients (+ 6.4% [95% confidence interval: 4.4%, 8.3%]), whereas Hispanic and non-Hispanic Asian patients received lower mean MME (-4.2% [-5.1%, -3.2%] and - 3.6% [-4.8%, -2.3%], respectively). Nevertheless, 72.8% of all patients received prescriptions above guidelines, ranging from 71.0 to 80.3% by race and ethnicity. Disparities in prescribing were eliminated among Hispanic and NHB patients versus NHW patients when prescriptions were written within guideline recommendations.

CONCLUSIONS

Racial and ethnic disparities in opioid prescribing exist in the postoperative setting, yet all groups received prescriptions above guideline recommendations. Policies encouraging guideline-based prescribing may reduce disparities and overall excess prescribing.

Maternal psychosocial factors associated with postpartum pain

BACKGROUND

The experience of pain is shaped by a host of psychological, cultural, and social factors. Although pain is the most common postpartum complaint, data on its relationship with psychosocial factors and postpartum pain are limited.

OBJECTIVE

This study aimed to examine the relationship between self-reported postpartum pain scores and patient-level psychosocial factors, including relationship status, pregnancy intendedness, employment, education, and psychiatric diagnosis.

STUDY DESIGN

This was a secondary analysis of data from a prospective observational study of postpartum patients at 1 institution (May 2017 to July 2019) who used an oral opioid at least once during their postpartum hospitalization. Enrolled participants completed a survey, which included questions regarding their social situation (including relationship status), psychiatric diagnoses, and perceptions of their pain control during their postpartum hospitalization. The primary outcome was self-reported overall pain during the postpartum hospitalization (score of 0-100). Multivariable analyses accounted for age, body mass index, nulliparity, and mode of delivery.

RESULTS

In this cohort of 494 postpartum patients, most patients (84.0%) underwent cesarean delivery, and 41.3% of patients were nulliparous. In a pain score of 0 to 100, participants reported a median pain score of 47. On bivariable analyses, there was no significant difference in pain score between patients with and without an unplanned pregnancy or a psychiatric diagnosis. Patients who were unpartnered, those without a college education, and those who were unemployed reported significantly higher pain scores (57.5 vs 44.8 [P<.01], 52.6 vs 44.6 [P<.01], and 53.6 vs 44.6 [P<.01], respectively). In multivariable analyses, patients who were unpartnered and unemployed reported significantly higher adjusted pain scores than patients who were partnered and employed (adjusted beta coefficients: 7.93 [95% confidence interval, 2.29-13.57] vs 6.67 [95% confidence interval, 2.28-11.05]).

CONCLUSION

Psychosocial factors, such as relationship and employment statuses, which are indicators of social support, are associated with the experience of pain postpartum. These findings suggest that addressing social support, such as via enhanced support from the health care team, warrants exploration as a nonpharmacologic means of improving the postpartum pain experience.

Association Between Utilization of Digital Prenatal Services and Vaginal Birth After Cesarean

INTRODUCTION

Digital health services are a promising but understudied method for reducing common barriers to vaginal birth after cesarean (VBAC), including connection to facilities offering labor after cesarean and patient-centered counseling about mode of birth. This study assesses the relationship between use of digital prenatal services and VBAC.

METHODS

In this retrospective cohort study, we analyzed the use of digital prenatal services and mode of birth among users of an employer-sponsored digital women's and family digital health platform. All users had a prior cesarean birth. Users' self-reported data included demographics, medical history, and birth preferences. We used basic descriptive statistics and logistic regression models to assess the association between digital services utilization and VBAC, adjusting for key patient characteristics.

RESULTS

Of 271 included users, 44 (16.2%) had a VBAC and 227 (83.8%) had a cesarean birth. Users of both groups were similar in age, race, and ethnicity. Fewer users in the VBAC group (5/44, 11.4%) as compared with the cesarean birth group (62/227, 27.3%) had a prepregnancy body mass index greater than or equal to 30 (P = 0.02). Likewise, more users in the VBAC group preferred vaginal birth (34/44, 77.3% vs 55/227, 24.2%; P < 0.01). In adjusted models, the services associated with VBAC were care advocate appointments (adjusted odds ratio [aOR], 7.67; 95% CI, 1.99-54.4), health care provider appointments (aOR, 1.12; 95% CI, 1.02-1.25), and resource reads (aOR, 1.05, 95% CI, 1.00-1.09). VBAC rates were higher for users who reported the digital health platform influenced aspects of their pregnancy and birth.

DISCUSSION

Reducing cesarean birth rates is a national priority. Digital health services, particularly care coordination and education, are promising for accomplishing this goal through increasing rates of trial of labor after cesarean and subsequent VBAC rates.