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Slopen N, Chang AR, Johnson TJ, Anderson AT, Bate AM, Clark S, Cohen A, Jindal M, Karbeah J, Pachter LM, Priest N, Suglia SF, Bryce N, Fawcett A, Heard-Garris N. Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:147-158. [PMID: 38242597 DOI: 10.1016/s2352-4642(23)00251-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 08/02/2023] [Accepted: 09/08/2023] [Indexed: 01/21/2024]
Abstract
Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.
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Affiliation(s)
- Natalie Slopen
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Center on the Developing Child, Harvard University, Boston, MA, USA.
| | - Andrew R Chang
- Harvard Medical School, Harvard University, Boston, MA, USA
| | | | - Ashaunta T Anderson
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Aleha M Bate
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA
| | - Shawnese Clark
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alyssa Cohen
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Monique Jindal
- Department of Clinical Medicine, University of Illinois, Chicago, IL, USA
| | - J'Mag Karbeah
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Lee M Pachter
- Institute for Research on Equity and Community Health, ChristianaCare, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; School of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Naomi Priest
- Centre for Social Research and Methods, Australian National University, Canberra, ACT, Australia; Population Health, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nessa Bryce
- Department of Psychology, Harvard University, Boston, MA, USA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Chicago, IL, USA
| | - Nia Heard-Garris
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Department of Pediatrics, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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2
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Pekas D, Telken W, Sahmoun AE, Beal JR. Association Between Race and Usage of Pain Medications in Children With Long Bone Fractures in US Emergency Departments, 2011-2019. Pediatr Emerg Care 2023; 39:393-396. [PMID: 37159330 DOI: 10.1097/pec.0000000000002958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the association between race and analgesic administration for children with long bone fracture (LBF) in US emergency departments. Previous studies have shown conflicting results regarding association between race and analgesic administration for pediatric LBFs. METHODS We conducted a retrospective analysis of pediatric emergency department visits for LBF using the 2011-2019 National Hospital Ambulatory Medical Care Survey-Emergency Department. We investigated the diagnostic workup and analgesic prescription rate among White, Black, and other pediatric emergency department visits for LBF. RESULTS Of the estimated 292 million pediatric visits to US emergency departments from 2011 to 2019, 3.1% were LBFs. Black children were less likely to be seen for a LBF than White or other children (1.8% vs 3.6% and 3.1%, P < 0.001). There was no association between race and subjective pain scale ( P = 0.998), triage severity ( P = 0.980), imaging (x-ray, P = 0.612; computed tomography scan, P = 0.291), or analgesic administration (opioids, P = 0.068; nonsteroidal antiinflammatory drugs/acetaminophen, P = 0.750). Trend analysis showed a significant decrease in opioid administration for pediatric LBF from 2011 to 2019 ( P < 0.001), with 33.0% receiving opioids. CONCLUSIONS There was no association between race and analgesic administration, including opioids, or diagnostic workup in pediatric LBF. In addition, there was a significant downtrend in opioid administration for pediatric LBF from 2011 to 2019.
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Affiliation(s)
- Devon Pekas
- From the University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Wyatt Telken
- From the University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Abe E Sahmoun
- Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, ND
| | - James R Beal
- Department of Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
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Jernigan RE, Keil LG, Dadoo S, Jackson CL, Vergun AD. Do kids with forearm fractures need opioids at discharge from the emergency department? Analgesic prescribing and pain control following closed reduction of pediatric forearm fractures. J Am Coll Emerg Physicians Open 2023; 4:e12884. [PMID: 36852187 PMCID: PMC9958247 DOI: 10.1002/emp2.12884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 12/08/2022] [Accepted: 12/21/2022] [Indexed: 02/27/2023] Open
Abstract
Objective The purpose of this 2-part study is to determine opioid prescribing patterns and opioid use and pain control after discharge following closed reduction of pediatric forearm fractures. Methods A retrospective study was conducted from December 2016 to January 2018 at a level 1 trauma center to determine opioid prescribing habits for patients 1-17 years old with forearm fractures treated with closed reduction. A prospective study was then conducted from August 2019 to October 2020 to determine pain control and opioid use after discharge. Data were collected through chart review and with telephone surveys on post-discharge days 1, 3, and 5 to collect pain scores and opioid use. Results Fifty patients with a median age of 8 (interquartile range [IQR], 5-11) years old and 51 patients with a mean age of 9 (IQR, 6-11) years old were included in the retrospective and prospective cohorts, respectively. From the retrospective study, 21 patients (42%) were prescribed a median of 10 opioid doses (IQR, 8-12) at discharge. From the prospective study, 12 patients (24%) were discharged with a median of 8 opioid doses (IQR, 5.5-10), for a total of 98 total doses. Of those, only 7 doses (7%) were used by 3 patients. Higher weight and initial pain score were associated with increased rates of opioid prescription. Conclusions Pediatric patients who undergo closed reduction of a forearm fracture under procedural sedation in the emergency department are prescribed approximately 14 times the amount of opioid that is used. We propose that prescribing only non-opioid analgesics to these patients would afford equivalent pain control without the side-effects and abuse potential of opioid use at an early age.
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Affiliation(s)
- Richard E. Jernigan
- Medical Doctorate ProgramUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Lukas G. Keil
- Department of OrthopaedicsUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Sahil Dadoo
- Department of OrthopaedicsUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Cheryl L. Jackson
- Departments of Pediatrics and Emergency MedicineUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Anna D. Vergun
- Department of OrthopaedicsUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
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Abstract
Purpose of Review The goal of this review is to describe how socioeconomic status (SES) is evaluated in the pediatric trauma literature and further consider how differences in SES can lead to inequities in pediatric injury. Recent Findings Insurance status, area-level income, and indices of socioeconomic deprivation are the most common assessments of socioeconomic status. Children from socioeconomically disadvantaged backgrounds experience higher rates of firearm-related injuries, motor vehicle-related injuries, and violence-related injuries, contributing to inequities in morbidity and mortality after pediatric injury. Differences in SES may also lead to inequities in post-injury care and recovery, with higher rates of readmission, recidivism, and PTSD for children from socioeconomically disadvantaged backgrounds. Summary Additional research looking at family-level measures of SES and more granular measures of neighborhood deprivation are needed. SES can serve as an upstream target for interventions to reduce pediatric injury and narrow the equity gap.
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Affiliation(s)
- Stephen Trinidad
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH MLC 2023 USA
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH MLC 2023 USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH USA
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Trinidad S, Kotagal M. Social determinants of health as drivers of inequities in pediatric injury. Semin Pediatr Surg 2022; 31:151221. [PMID: 36347129 DOI: 10.1016/j.sempedsurg.2022.151221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A child's social determinants of health (SDH), including their neighborhood environment, insurance status, race and ethnicity, English language proficiency and geographic location, all significantly impact their risk of injury and outcomes after injury. Children from socioeconomically disadvantaged neighborhoods experience overall higher rates of injury and different types of injuries, including higher rates of motor vehicle-, firearm-, and violence-related injuries. Similarly, children with public insurance or no insurance, as a proxy for lower socioeconomic status, experience higher rates of injuries including firearm-related injuries and non-accidental trauma, with overall worse outcomes. Race and associated racism also impact a child's risk of injury and care received after injury. Black children, Hispanic children, and those from other minority groups disproportionately experience socioeconomic disadvantage with sequelae of injury risk as described above. Even after controlling for socioeconomic status, there are still notable disparities with further evidence of racial inequities and bias in pediatric trauma care after injury. Finally, where a child lives geographically also significantly impacts their risk of injury and available care after injury, with differences based on whether a child lives in a rural or urban area and the degree of state laws regarding injury prevention. There are clear inequities based on a child's SDH, most predominantly in a child's risk of injury and the types of injuries they experience. These injuries are preventable and the SDH provide potential upstream targets in injury prevention efforts.
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Affiliation(s)
- Stephen Trinidad
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children...s Hospital Medical Center, Cincinnati, Ohio.
| | - Meera Kotagal
- Assistant Professor, Division of General and Thoracic Surgery, Director, Trauma Services, Director, Pediatric Surgery Global Health Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, United States.
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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Dispensed Opioid Prescription Patterns, by Racial/Ethnic Groups, Among South Carolina Medicaid-Funded Children Experiencing Limb Fracture Injuries. Acad Pediatr 2022; 22:631-639. [PMID: 35257927 DOI: 10.1016/j.acap.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 02/13/2022] [Accepted: 02/26/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine dispensed opioid prescription patterns for limb fractures across racial/ethnic groups in a pediatric population. METHODS We used South Carolina's Medicaid claims data 2000 to 2018 for pediatric limb fracture cases (under age 19) discharged from the emergency department. The key independent variable was the child's race/ethnicity. The outcomes were: 1) whether the patient had a dispensed opioid prescription; and 2) whether dispensed opioid supply was longer than 5 days among cases with any dispensed opioid prescriptions. Logistic regression models were used to test the association between race/ethnicity and the outcomes. Covariates included age-at-service, gender, service year, and having multiple fracture injuries. RESULTS Compared with non-Hispanic White cases (NHW), the odds of receiving dispensed opioid prescriptions were lower for cases of non-Hispanic Black (NHB) (OR = 0.73; 95% confidence interval [CI]: 0.71, 0.75), Asian (OR = 0.69; CI: 0.53, 0.90), Other/Unknown (OR = 0.86; CI: 0.80, 0.92), and Hispanic (OR = 0.84; CI: 0.79, 0.90) race/ethnicity. The odds of receiving >5 days of dispensed opioid prescription supply did not differ significantly among race/ethnic categories. CONCLUSIONS Our study confirms previous findings that as compared to NHW, the NHB children were less likely to receive dispensed opioid prescriptions. Also, it reveals that the different minority race/ethnic groups are not homogenous in their likelihoods of receiving dispensed opioid prescriptions after a limb fracture compared to NHW, findings underreported in previous studies. Children in the Other/Unknown race/ethnicity category have prescribing patterns different from those of other minority race/ethnic groups and should be analyzed separately.
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8
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Gutman CK, Holmes S, Balhara KS. Low-value care in pediatric populations: There is no silver lining. Acad Emerg Med 2022; 29:804-807. [PMID: 35212441 DOI: 10.1111/acem.14470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Colleen K. Gutman
- Department of Emergency Medicine University of Florida College of Medicine Gainesville Florida USA
| | - Sherita Holmes
- Department of Pediatrics Emory University School of Medicine Atlanta Georgia USA
- Division of Emergency Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Kamna S. Balhara
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
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Kopp TM, Frey TM, Zakrajsek M, Nystrom J, Koutsounadis GN, Falcone KS, Zhang Y, Wall E, Byczkowski T, Mittiga MR. Poorly Controlled Pediatric Fracture Pain Requiring Unplanned Medical Assistance or Advice. Pediatr Emerg Care 2022; 38:e410-e416. [PMID: 34986594 DOI: 10.1097/pec.0000000000002304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to define the proportion of children who seek assistance for poorly controlled fracture pain, identify factors associated with requesting help, and explore caregivers' opioid preferences. METHODS We enrolled 251 children and their caregivers in the orthopedic surgery clinic of a tertiary care children's hospital. Children 5 to 17 years old presenting within 10 days of injury for follow-up for a single-extremity, nonoperative long bone fracture(s) were eligible. The primary outcome was seeking unscheduled evaluation or advice for poorly controlled pain before the first routine follow-up appointment by telephone call, medical visit, or rescheduling to an earlier appointment. Factors associated with the outcome were assessed using bivariable analysis. RESULTS Overall, 7.3% (95% confidence interval, 4.1%-10.6%) of participants sought unscheduled evaluation or advice for poorly controlled pain. The 2 most common reasons were to obtain over-the-counter analgesic dosage information (64.7%) and a stronger analgesic (29.4%). These children were more likely to have a leg fracture, have an overriding or translated fracture, or require manual reduction under procedural sedation. These children had higher Patient-Reported Outcomes Measurement Information System Pain Behavior and Pain Interference scores and more anxious caregivers. One-third of caregivers expressed hesitancy or refusal to use opioids to treat severe pain, and 45.7% reported potential addiction or abuse as the rationale. CONCLUSIONS A notable proportion of children seek assistance for poorly controlled fracture-related pain. Medical providers should target discharge instructions to the identified risk factors and engage caregivers in shared decision making if opioids are recommended.
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Affiliation(s)
- Tara M Kopp
- From the Department of Pediatrics, Norton Children's and University of Louisville School of Medicine, Louisville, KY
| | | | | | - Jennifer Nystrom
- Section of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Gena N Koutsounadis
- New York Institute of Technology School of Osteopathic Medicine, Old Westbury, NY
| | | | - Yin Zhang
- Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center
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10
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Goyal MK, Drendel AL, Chamberlain JM, Wheeler J, Olsen C, Grundmeier RW, Cook L, Bajaj L, Babcock L, Zorc JJ, Johnson T, Alpern ER. Racial/Ethnic Differences in ED Opioid Prescriptions for Long Bone Fractures: Trends Over Time. Pediatrics 2021; 148:e2021052481. [PMID: 34645690 DOI: 10.1542/peds.2021-052481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Monika K Goyal
- Department of Pediatric Emergency Medicine, Children's National Hospital and The School of Medicine & Health Sciences, The George Washington University, Washington, District of Columbia
| | - Amy L Drendel
- Department of Pediatrics, Medical College of Wisconsin, University of Wisconsin, Madison, Wisconsin
| | - James M Chamberlain
- Department of Pediatric Emergency Medicine, Children's National Hospital and The School of Medicine & Health Sciences, The George Washington University, Washington, District of Columbia
| | - Justin Wheeler
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Cody Olsen
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Robert W Grundmeier
- Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Larry Cook
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Lalit Bajaj
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Lynn Babcock
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center
| | - Joeseph J Zorc
- Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tiffani Johnson
- Department of Emergency Medicine, University of California Davis, Sacramento, California
| | - Elizabeth R Alpern
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital
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11
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Engel-Rebitzer E, Dolan AR, Aronowitz SV, Shofer FS, Nguemeni Tiako MJ, Schapira MM, Perrone J, Hess EP, Rhodes KV, Bellamkonda VR, Cannuscio CC, Goldberg E, Bell J, Rodgers MA, Zyla M, Becker LB, McCollum S, Meisel ZF. Patient Preference and Risk Assessment in Opioid Prescribing Disparities: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2118801. [PMID: 34323984 PMCID: PMC8322998 DOI: 10.1001/jamanetworkopen.2021.18801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. OBJECTIVE To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. DESIGN, SETTING, AND PARTICIPANTS This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. INTERVENTIONS The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. MAIN OUTCOMES AND MEASURES Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. RESULTS Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. CONCLUSIONS AND RELEVANCE In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03134092.
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Affiliation(s)
- Eden Engel-Rebitzer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Abby R. Dolan
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Frances S. Shofer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Max Jordan Nguemeni Tiako
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Yale School of Medicine, New Haven, Connecticut
| | - Marilyn M. Schapira
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of General and Internal Medicine, University of Pennsylvania, Philadelphia
| | - Jeanmarie Perrone
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Penn Center for Addiction Medicine and Policy, Philadelphia, Pennsylvania
| | - Erik P. Hess
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karin V. Rhodes
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Venkatesh R. Bellamkonda
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Carolyn C. Cannuscio
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia
| | - Erica Goldberg
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Jeffrey Bell
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Melissa A. Rodgers
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- College of Education, University of Texas at Austin, Austin
| | - Michael Zyla
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Lance B. Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Sharon McCollum
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Zachary F. Meisel
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
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12
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Bryl AW, Demartinis N, Etkin M, Hollenbach KA, Huang J, Shah S. Reducing Opioid Doses Prescribed From a Pediatric Emergency Department. Pediatrics 2021; 147:peds.2020-1180. [PMID: 33674462 DOI: 10.1542/peds.2020-1180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Opioid overdose and abuse have reached epidemic rates in the United States. Medical prescriptions are a large source of opioid misuse. Our quality improvement initiative aimed to reduce opioid exposure from the pediatric emergency department (ED). Objective was to reduce opioid doses prescribed weekly from our ED by 50% within 4 months. METHODS Three categories of interventions were implemented in Plan-Do-Study-Act cycles: guidelines and education, electronic medical record optimization, and provider-specific feedback. Primary measures were opioid doses prescribed weekly from the ED and opioid doses per 100 ED visits. Process measures were opioid prescriptions, opioid doses per prescription, and opioid prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection. Balancing measures were phone calls and return visits for poor pain control in patients prescribed opioids and reports of poor pain control in call backs to orthopedic reduction patients. We used statistical process control to examine changes in measures over time. RESULTS Opioid doses decreased from 153 to 14 per week and from 8 to 0.7 doses per 100 ED visits in 10 months, sustained for 9 months. Opioid prescriptions, opioid doses per prescription, and prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection decreased. Phone calls and return visits in patients prescribed opioids did not increase. There were 2 reports of poor pain control among 152 orthopedic reduction patients called back. CONCLUSIONS We decreased opioid doses prescribed weekly from the pediatric ED by 91% while minimizing return visits and reports of poor pain control.
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Affiliation(s)
- Amy W Bryl
- Department of Pediatrics, School of Medicine and .,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Nicole Demartinis
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Marc Etkin
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Kathryn A Hollenbach
- Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California; and
| | | | - Seema Shah
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
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