A Multicenter Evaluation of the Impact of Sex on Abdominal and Fracture Pain Care

Analgesia Administration by Sex Among Pediatric Emergency Department Patients with Abdominal Pain

Background

There is conflicting data about sex-based differences in the treatment of acute pain in the ED. Little is known about sex-based disparities in analgesia in pediatric ED patients.

Objectives

Our objective was to determine whether analgesic administration rates differ between female and male pediatric patients presenting to the ED with abdominal pain.

Methods

We conducted a retrospective cohort study of ED patients 5-21 years old with abdominal pain between 6/1/19 and 6/30/21. The primary outcome was receipt of any analgesia, and secondary outcomes were receipt of opioid analgesia and time to receipt of analgesia. Multivariable regression models were fitted for each outcome.

Results

We studied 1,087 patients; 681 (63%) were female with a median age of 17 years (IQR 13, 19) and 406 (37%) were male with a median age of 14 years (IQR 9, 18). 371 female patients (55%) and 180 male patients (44%) received any analgesia. 132 female patients (19%) and 83 male patients (20%) received opioid analgesia. In multivariate analyses, female patients were equally likely to receive any analgesia (OR 1.30, 95% CI 0.97 - 1.74, p = 0.07), but time to analgesia was 14% longer (GMR 1.14, 95% CI 1.00 - 1.29, p = 0.04). Non-White patients were 32% less likely to receive opioids (OR 0.68, 95% CI 0.47 - 0.97, p = 0.04).

Conclusions

Female pediatric ED patients were equally likely to receive any analgesia as male patients, but their time to analgesia was longer. Non-White patients were less likely to receive opioid analgesia than White patients.

Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group

Introduction

Health equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex‐based differences, including metrics such as door‐to‐room (DTR) and door‐to‐healthcare practitioner (DTP) times to look for potential signs of systemic bias.

Methods

We conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min.

Results

A total of 106,011 adult visits to the ED were investigated. Female patients had 8‐min longer median length‐of‐stay (LOS) than males (P < 0.01). Females had longer DTR (2‐min median difference, P < 0.01), and longer DTP (5‐min median difference, P < 0.01). Females had longer median door‐to‐over‐the‐counter analgesia time (84 vs. 80, P = 0.58), door‐to‐advanced analgesia (95 vs. 84, P < 0.01), door‐to‐PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door‐to‐intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males.

Conclusion

Numerous statistically significant differences were identified in throughput and care measures—mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department

This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending

There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008-19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.

Race/Ethnicity and Sex and Opioid Administration in the Emergency Room

BACKGROUND

Although racial/ethnic and sex disparities have been examined in health care generally and pain management more specifically, the combined influence of these sociodemographic factors together has not been well documented. The aim of this study was to examine the association between administration of opioid analgesics in the emergency department (ED) and interaction of race/ethnicity and sex.

METHODS

We conducted a retrospective cohort study using 2010-2014 Center for Disease Control-National Hospital Ambulatory Medical Care Survey data for patients 12-55 years of age presenting to EDs with a primary diagnosis of appendicitis or gallbladder disease as defined by International Classification of Diseases, Ninth Revision codes. The primary outcome was the receipt of opioid analgesic medications. Secondary outcomes included: receipt of nonopioids, receipt of antiemetic medications, wait time to see a provider, and length of visit in the ED. The association between sex and analgesic receipt within Caucasian non-Hispanic and non-Caucasian groups was evaluated adjusting for pain score on presentation, patient age, emergent status, number of comorbidities, time of visit (month, day of the week, standard versus nonstandard working hours, year), and US region.

RESULTS

After exclusions, a weighted sample of 553 ED visits was identified, representing 2,622,926 unique visits. The sample population was comprised of 1,858,035 (70.8%) females and 1,535,794 (58.6%) Caucasian non-Hispanics. No interaction was found in adjusted sampling-weighted model between sex and race/ethnicity on the odds of receiving opioids (P = .74). There was no difference in opioid administration to males as compared to females (odds ratio [OR] = 0.96, 95% CI, 0.87-1.06; P = .42) or to non-Caucasians as compared to Caucasians (OR = 0.99, 95% CI, 0.89-1.10; P = .84). In adjusted weighted models, non-Caucasian males, 123,121/239,457 (51.4%) did not differ from Caucasian non-Hispanic males, 317,427/525,434 (60.4%), on odds of receiving opioids, aOR = 0.88, 95% CI, 0.39-1.99; P = .75. Non-Caucasian females, 547,709/847,675 (64.6%) also did not differ from Caucasian females, 621,638/1,010,360 (61.5%), on odds of receiving opioids, aOR = 1.01, 95% CI, 0.53-1.90; P = .98. Across both sexes, non-Caucasians did not differ from Caucasians on receipt of nonopioid analgesics or antiemetics. Neither wait time to see a provider nor the length of the hospital visit was significantly different between sexes or race/ethnicities.

CONCLUSIONS

Based on National Hospital Ambulatory Medical Care Survey data from 2010 to 2014, there is no statistically significant interaction between race/ethnicity and sex for administration of opioid analgesia to people presenting to the ED with appendicitis or gallbladder disease. These results suggest that the joint effect of patient race/ethnicity and sex may not manifest in disparities in opioid management.

Cancer costs and gender: a snapshot of issues, trends, and opportunities to reduce inequities using Australia as an example

As the cancer burden increases, so too does the cost, to health systems, economies, and individuals. There is increasing interest in productivity and out-of-pocket costs for individuals and their carers, but these remain poorly understood. The costs of cancer in women, often carers themselves, are less understood. This summary analysis explored data on the cancer burden in Australia (and health costs in comparable countries), including expenditure reports and literature on macroeconomic outcomes and out-of-pocket costs, to highlight the cost impacts of a cancer diagnosis in women, at a societal and an individual level. Data on productivity costs were skewed toward men, as men are over-represented in paid work compared with women. Data on societal and individual costs of cancer in women were scant, yet the predominance of women in unpaid work suggests the cost is significant. Evidence for the benefits of cancer prevention and early detection suggests that improved targeting of interventions to women would reduce costs at a societal and an individual level. More research is needed on the specific impacts of cancer on women and those they care for, to better target public health and support services to need.

Is There Gender Discrimination in Acute Renal Colic Pain Management? A Retrospective Analysis in an Emergency Department Setting

BACKGROUND

Pain is a widespread problem, affecting both men and women; studies have found that women in the emergency department receive analgesic medication and opioids less often compared with men.

AIMS

The aim of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender, and thereby to examine the extent of gender discrimination in treating pain.

DESIGN

This is a single-center retrospective cohort study that included 824 patients.

SETTINGS

Emergency department of tertiary hospital in Israel.

PARTICIPANTS/SUBJECTS

The patients stratified by gender to compare pain treatments and waiting times between men and women in renal colic complaint.

METHODS

As an acute pain model, we used renal colic with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by Visual Analog Scale (VAS) scores and number of VAS examinations. Time intervals were calculated between admissions to different stations in the emergency department. We recorded the number of analgesic drugs administered, type of drugs prescribed, and drug class (opioids or others).

RESULTS

A total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity, and laboratory findings. VAS assessments were higher in men than in women (6.43 versus 5.90, p = .001, respectively). More men than women received analgesics (68.8% versus 62.1%, p = .04, respectively) and opioids were prescribed more often for men than for women (48.3 versus 35.7%, p = .001). The number of drugs prescribed per patient was also higher in men compared with women (1.06 versus 0.93, p = .03). A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women.

CONCLUSIONS

We found differences in pain management between genders, which could be interpreted as gender discrimination. Yet these differences could also be attributed to other factors not based on gender discrimination but rather on gender differences.

The roles of gender and profession on gender role expectations of pain in health care professionals

Introduction

Gender-related stereotypes of pain may account for some assessment and treatment disparities among patients. Among health care providers, demographic factors including gender and profession may influence the use of gender cues in pain management decision-making. The Gender Role Expectations of Pain Questionnaire was developed to assess gender-related stereotypic attributions of pain regarding sensitivity, endurance, and willingness to report pain, and has not yet been used in a sample of health care providers. The purpose of this study was to examine the presence of gender role expectation of pain among health care providers. It was hypothesized that health care providers of both genders would endorse gender stereotypic views of pain and physicians would be more likely than dentists to endorse these views.

Methods

One-hundred and sixty-nine providers (89 dentists, 80 physicians; 40% women) were recruited as part of a larger study examining providers’ use of demographic cues in making pain management decisions. Participants completed the Gender Role Expectations of Pain Questionnaire to assess the participant’s views of gender differences in pain sensitivity, pain endurance, and willingness to report pain.

Results

Results of repeated measures analysis of variance revealed that health care providers of both genders endorsed stereotypic views of pain regarding willingness to report pain (F_(1,165)=34.241, P<0.001; d=0.479). Furthermore, female dentists rated men as having less endurance than women (F_(1,165)=4.654, P=0.032; d=0.333).

Conclusion

These findings affirm the presence of some gender-related stereotypic views among health care providers and suggest the presence of a view among health care providers that men are underreporting their pain in comparison to women. Future work can refine the effects of social learning history and other psychosocial factors that contribute to gender and provider differences in pain management decisions.