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Lor M, Schaeffer NC, Brown R. Initial Psychometric Testing of a Pain Quality Pictogram Tool Among Hmong Limited English Proficient and Bilingual Community Members and Healthcare Practitioners. Pain Manag Nurs 2024; 25:e214-e222. [PMID: 38431504 DOI: 10.1016/j.pmn.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 01/19/2024] [Accepted: 01/28/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE To assess the matching and content validity of a pain quality pictogram tool with a Hmong community. DESIGN A Qualtrics survey was administered to two groups of participants. METHODS Sixty Hmong participants (n = 49 limited English proficiency and bilingual Hmong community members in group 1; n = 11 bilingual Hmong healthcare practitioners in group 2) participated in this study. Hmong community members in group 1 were asked to identify the pain pictogram that best matched a pre-recorded Hmong pain quality phrase. The practitioners in group 2 were asked to evaluate how well each pain pictogram represented the pre-recorded Hmong pain quality phrase it intended to measure. To assess the matching, we assessed agreement between the pain concept in the phrase and the pictogram intended to represent it, using group 1. A content validity index (CVI) was calculated to assess the content validity of the tool using group 2. RESULTS Among the community participants, 8 of the 15 pictograms were matched with the intended phrase almost perfectly, and 3 were matched by a substantial majority. There were no differences in matching by patient gender and language proficiency. Among practitioners, 11 of 15 pain pictograms met the CVI threshold of 0.70 for all three dimensions (i.e., representativeness, relevance, and comprehension). CONCLUSION Findings support including most of the pain pictograms in the tool but suggest specific areas for improvement. CLINICAL IMPLICATIONS Findings provide insights for redesigning the selected pain pictogram tool to be used in clinical settings with LEP Hmong patients.
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Affiliation(s)
- Maichou Lor
- University of Wisconsin-Madison, School of Nursing, Madison, Wisconsin.
| | - Nora Cate Schaeffer
- University of Wisconsin-Madison, Department of Sociology, Madison, Wisconsin
| | - Roger Brown
- University of Wisconsin-Madison, School of Nursing, Madison, Wisconsin
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Zhu T, Baker ZG, Trabold M, Kelley-Quon LI, Basin MF, Vazirani R, Chen J, Kokorowski PJ. Sociodemographic differences in opioid use and recovery following ambulatory pediatric urologic procedures. J Child Health Care 2024; 28:291-301. [PMID: 36062326 DOI: 10.1177/13674935221124738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our aim was to examine associations between sociodemographic factors and postoperative opioid use and recovery among pediatric patients undergoing outpatient urologic procedures. We retrospectively evaluated 831 patients undergoing ambulatory urologic procedures from 2013 to 2017 at an urban pediatric hospital. Patients were evaluated for days of opioid use and days until return to baseline behavior. Differences in outcomes by race/ethnicity, primary language, median neighborhood household income, and health insurance type were analyzed using negative binomial regression models. Overall, patients reported a median of 1.0 day (IQR: 2.0) of postoperative opioid use and 3.0 days (IQR: 6.0) of recovery time. After controlling for covariates, patients with non-English speaking parents took opioids for 26.5% (95% CI: 11.4-41.7%) longer and had 27.8% (95% CI: 8.1-51.0%) longer recovery time than patients with English-speaking parents. Hispanic patients took opioids for 27.5% (95% CI: 0.1-54.9%) longer than White patients. Patients with public insurance used opioids for 47.6% (95% CI: 5.0-107.4%) longer than privately insured patients. Non-English speaking, Hispanic, and publicly insured patients had a longer duration of postoperative opioid use than primarily English-speaking, White, and privately insured patients, respectively. Identifying these disparities is important for designing equitable postoperative care pathways.
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Affiliation(s)
- Terry Zhu
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Zoë G Baker
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Melissa Trabold
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael F Basin
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Ragini Vazirani
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Jiayao Chen
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Paul J Kokorowski
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Levy RA, Kay AH, Hills N, Chen LM, Chapman JS. Exploring the relationship between language, postoperative pain, and opioid use. AJOG GLOBAL REPORTS 2024; 4:100342. [PMID: 38681953 PMCID: PMC11046298 DOI: 10.1016/j.xagr.2024.100342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Racial and ethnic disparities in pain management are well documented. Differences in pain assessment and management by language have not been studied in the postoperative setting in gynecologic surgery. OBJECTIVE This study aimed to investigate the association between language and immediate postoperative pain management by comparing pain assessments and perioperative opioid use in non-English speakers and English speakers. STUDY DESIGN This was a retrospective cohort study comparing perioperative outcomes between non-English-speaking patients and English-speaking patients who had undergone a gynecologic oncology open surgery between July 2012 and December 2020. The primary language was extracted from the electronic medical record. Opioid use is expressed in oral morphine equivalents. Proportions are compared using chi-square tests, and mean values are compared using 2-sample t tests. Although interpreter services are widely available in our institution, the use of interpreters for any given inpatient-provider interaction is not documented. RESULTS Between 2012 and 2020, 1203 gynecologic oncology patients underwent open surgery, of whom 181 (15.1%) were non-English speakers and 1018 (84.9%) were English speakers. There was no difference between the 2 cohorts concerning body mass index, surgical risk score, or preoperative opioid use. Compared with the English-speaking group, the non-English-speaking group was younger (57 vs 54 years old, respectively; P<.01) and had lower rates of depression (26% vs 14%, respectively; P<.01) and chronic pain (13% vs 6%, respectively; P<.01). Although non-English-speaking patients had higher rates of hysterectomy than English-speaking patients (80% vs 72%, respectively; P=.03), there was no difference in the rates of bowel resections, adnexal surgeries, lengths of surgery, intraoperative oral morphine equivalents administered, blood loss, use of opioid-sparing modalities, lengths of hospital stay, or intensive care unit admissions. In the postoperative period, compared with English-speaking patients, non-English-speaking patients received fewer oral morphine equivalents per day (31.7 vs 43.9 oral morphine equivalents, respectively; P<.01) and had their pain assessed less frequently (7.7 vs 8.8 checks per day, respectively; P<.01) postoperatively. English-speaking patients received a median of 19.5 more units of oral morphine equivalents daily in the hospital and 205.1 more units of oral morphine equivalents at the time of discharge (P=.02 and P=.04, respectively) than non-English-speaking patients. When controlling for differences between groups and several factors that may influence oral morphine equivalent use, English-speaking patients received a median of 15.9 more units of oral morphine equivalents daily in the hospital cohort and similar oral morphine equivalents at the time of discharge compared with non-English-speaking patients. CONCLUSION Patients who do not speak English may be at risk of undertreated pain in the immediate postoperative setting. Language barrier, frequency of pain assessments, and provider bias may perpetuate disparity in pain management. Based on this study's findings, we advocate for the use of regular verbal pain assessments with language-concordant staff or medical interpreters for all postoperative patients.
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Affiliation(s)
- Rachel A. Levy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California (Dr Levy), San Francisco, CA
| | - Allison H. Kay
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California (Drs Kay, Chen, and Chapman), San Francisco, CA
| | - Nancy Hills
- Clinical and Translational Sciences Institute, University of California (Dr Hills), San Francisco, CA
| | - Lee-may Chen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California (Drs Kay, Chen, and Chapman), San Francisco, CA
| | - Jocelyn S. Chapman
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California (Drs Kay, Chen, and Chapman), San Francisco, CA
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Curatola N, Prasad P, Bell BK, Fang MC, Rambachan A. Assessing for differences in opioid administration during inpatient end-of-life care for patients with limited English proficiency. J Hosp Med 2024. [PMID: 38544317 DOI: 10.1002/jhm.13325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/09/2024] [Accepted: 02/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Patients with limited English proficiency (LEP) may have worse health outcomes and differences in processes of care. Language status may particularly affect situations that depend on communication, such as symptom management or end-of-life (EOL) care. OBJECTIVE The objective of this study was to assess whether opioid prescribing and administration differs by English proficiency (EP) status among hospitalized patients receiving EOL care. METHODS This single-center retrospective study identified all adult patients receiving "comfort care" on the general medicine service from January 2013 to September 2021. We assessed for differences in the quantity of opioids administered (measured by oral morphine equivalents [OME]) by patient LEP status using multivariable linear regression, controlling for other patient and medical factors. RESULTS We identified 2652 patients receiving comfort care at our institution during the time period, of whom 1813 (68%) died during the hospitalization. There were no significant differences by LEP status in terms of mean OME per day (LEP received 30.8 fewer OME compared to EP, p = .91) or in the final 24 h before discharge (LEP received 61.7 more OME compared to EP, p = .80). CONCLUSION LEP was not associated with differences in the amount of opioids received for patients whose EOL management involved standardized order sets for symptom management at our hospital.
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Affiliation(s)
- Nicole Curatola
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Priya Prasad
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brieze K Bell
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Palliative Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aksharananda Rambachan
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
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Emmanuel M, Margolis R, Badh R, Kachroo N, Teach SJ, Parikh K. Caregiver Language Preference and Health Care Utilization Among Children With Asthma. Pediatrics 2023; 152:e2023061869. [PMID: 37964708 DOI: 10.1542/peds.2023-061869] [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] [Accepted: 09/19/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Asthma is a leading cause of health care utilization in children and disproportionately affects historically marginalized populations. Yet, limited data exist on the role of caregiver language preference on asthma morbidity. The study aim was to determine whether caregiver non-English language preference (NELP) is associated with unscheduled asthma-related health care utilization in pediatric patients. METHODS This was a retrospective cohort study using data from a population-level, disease-specific registry of pediatric patients with asthma living in the District of Columbia (DC). Patients aged 2 to 17 years were included and the study period was 2019. The primary exposure variable was language preference: English preferred (EP) or NELP by self-identified language preference. The primary outcome was unscheduled asthma-related health care utilization including emergency department visits, hospitalizations (ICU and non-ICU), and ICU visits alone. Logistic regression was used to calculate adjusted odds ratios (aORs). RESULTS Of the 14 431 patients included, 8.1% had NELP (1172 patients). In analyses adjusted for age, sex, ethnicity, insurance status, diagnosis of persistent asthma, controller prescription, and encounter with a primary care provider, caregiver NELP was associated with an increased odds of having an asthma-related emergency department visit (aOR, 1.37; 95% CI, 1.08-1.74), hospitalization (aOR, 1.79; 95% CI, 1.18-2.72), and ICU visit (aOR, 4.37; 95% CI, 1.93-9.92). In the Hispanic subgroup (n = 1555), caregiver NELP was associated with an increased odds of having an asthma-related hospitalization (aOR, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS In the population of children in the District of Columbia with asthma, caregiver NELP was associated with increased odds of asthma-related health care utilization, suggesting that caregiver language preference is a significant determinant of asthma outcomes.
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Affiliation(s)
| | | | | | | | - Stephen J Teach
- Division of Emergency Medicine
- Center for Translational Research
| | - Kavita Parikh
- Center for Translational Research
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
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Segal KR, Gomez JA, Schulz JF, Alvandi LM, Fornari ED. The Impact of Standardized Recovery Pathways on Language Barriers and Inpatient Pain Management. Hosp Pediatr 2023; 13:1001-1009. [PMID: 37850258 DOI: 10.1542/hpeds.2023-007232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Inpatient postoperative care is reliant upon clear, open communication between providers and patient-families, and thus is particularly vulnerable to disparities when discordant languages exist. It is not yet understood how standardized postoperative protocols may mitigate disparities related to language discordance. METHODS This is a retrospective cohort study among adolescent idiopathic scoliosis patients who underwent posterior spinal fusion at a tertiary care children's hospital in Bronx, New York after implementation of a postoperative pathway in 2017. Outcomes reliant upon communication between patient-families and providers were measured, including measures of pain management (number and type of pain medications requested, daily pain assessments, total opioids consumed), as well as outpatient pain scores. RESULTS A total of 160 patients were included (39 language other than English [LOE]). Between patient cohorts, there were no significant differences in demographic or operative characteristics. On univariate analyses, LOE patients were more likely to be given a basal dosing of patient-controlled analgesia or additional boluses (26% vs 12%, P = .03), consumed 0.53 fewer benzodiazepine medications per day (P = .01), and were more likely to have pain at outpatient follow-up (67% vs 43%, P = .03). On multivariate analyses, LOE patients were more likely to be placed on basally dosed or receive additional boluses of patient-controlled analgesia (odds ratio 3.19, 95% confidence interval 1.15-8.85). CONCLUSIONS As standardized pathways become more common in health care, it is critical to monitor for components of these protocols that may be vulnerable to language-related disparities, such as therapies reliant on symptom description and outpatient follow-up.
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Keane OA, Ourshalimian S, Odegard M, Goldstein RY, Andras LM, Kim E, Kelley-Quon LI. Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study. J Surg Res 2023; 291:237-244. [PMID: 37478647 PMCID: PMC10578681 DOI: 10.1016/j.jss.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/17/2023] [Accepted: 06/12/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention. METHODS Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability. RESULTS Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730). CONCLUSIONS The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.
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Affiliation(s)
- Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rachel Y Goldstein
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Lindsay M Andras
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles, California
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Joshi M, Prasad PA, Hubbard CC, Iverson N, Manuel SP, Fang MC, Rambachan A. Racial, Ethnic, and Language-Based Inequities in Inpatient Opioid Prescribing by Diagnosis from Internal Medicine Services, a Retrospective Cohort Study. Pain Res Manag 2023; 2023:1658413. [PMID: 37780096 PMCID: PMC10539084 DOI: 10.1155/2023/1658413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023]
Abstract
Introduction Opioid administration is extremely common in the inpatient setting, yet we do not know how the administration of opioids varies across different medical conditions and patient characteristics on internal medicine services. Our goal was to assess racial, ethnic, and language-based inequities in opioid prescribing practices for patients admitted to internal medicine services. Methods We conducted a retrospective cohort study of all adult patients admitted to internal medicine services from 2013 to 2021 and identified subcohorts of patients treated for the six most frequent primary hospital conditions (pneumonia, sepsis, cellulitis, gastrointestinal bleed, pyelonephritis/urinary tract infection, and respiratory disease) and three select conditions typically associated with pain (abdominal pain, acute back pain, and pancreatitis). We conducted a negative binomial regression analysis to determine how average administered daily opioids, measured as morphine milligram equivalents (MMEs), were associated with race, ethnicity, and language, while adjusting for additional patient demographics, hospitalization characteristics, medical comorbidities, prior opioid therapy, and substance use disorders. Results The study cohort included 61,831 patient hospitalizations. In adjusted models, we found that patients with limited English proficiency received significantly fewer opioids (66 MMEs, 95% CI: 52, 80) compared to English-speaking patients (101 MMEs, 95% CI: 91, 111). Asian (59 MMEs, 95% CI: 51, 66), Latinx (89 MMEs, 95% CI: 79, 100), and multi-race/ethnicity patients (81 MMEs, 95% CI: 65, 97) received significantly fewer opioids compared to white patients (103 MMEs, 95% CI: 94, 112). American Indian/Alaska Native (227 MMEs, 95% CI: 110, 344) patients received significantly more opioids. Significant inequities were also identified across race, ethnicity, and language groups when analyses were conducted within the subcohorts. Most notably, Asian and Latinx patients received significantly fewer MMEs and American Indian/Alaska Native patients received significantly more MMEs compared to white patients for the top six most frequent conditions. Most patients from minority groups also received fewer MMEs compared to white patients for three select pain conditions. Discussion. There are notable inequities in opioid prescribing based on patient race, ethnicity, and language status for those admitted to inpatient internal medicine services across all conditions and in the subcohorts of the six most frequent hospital conditions and three pain-associated conditions. This represents an institutional and societal opportunity for quality improvement initiatives to promote equitable pain management.
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Affiliation(s)
- Mihir Joshi
- Santa Clara Valley Medical Center, San Jose, USA
| | - Priya A. Prasad
- University of California San Francisco, Department of Medicine, Division of Hospital Medicine, San Francisco, USA
| | - Colin C. Hubbard
- University of California San Francisco, Department of Medicine, Division of Hospital Medicine, San Francisco, USA
| | - Nicholas Iverson
- Division of Hospital Medicine, San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Solmaz P. Manuel
- University of California San Francisco, Department of Anesthesia and Perioperative Care, San Francisco, USA
| | - Margaret C. Fang
- University of California San Francisco, Department of Medicine, Division of Hospital Medicine, San Francisco, USA
| | - Aksharananda Rambachan
- University of California San Francisco, Department of Medicine, Division of Hospital Medicine, San Francisco, USA
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Kranjac AW, Kranjac D, Kain ZN, Ehwerhemuepha L, Donaldson C, Jenkins BN. Neighborhood disadvantage and pediatric inpatient opioid prescription patterns. J Pediatr Nurs 2023; 72:e145-e151. [PMID: 37344343 DOI: 10.1016/j.pedn.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/01/2023] [Accepted: 06/10/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND To explore the role of children's residential environment on opioid prescribing patterns in a predominantly Latinx sample. METHODS We connected geocoded data from electronic medical records in a diverse sample of pediatric patients to neighborhood environments constructed using latent profile modeling techniques. We then estimated a series of multilevel models to determine whether opioid prescribing patterns vary by residential context. RESULTS A stepwise pattern exists between neighborhood disadvantage and pediatric opioid prescription patterns, such that higher levels of disadvantage associate with a greater likelihood of opioid prescription, independent of the patient's individual profile. CONCLUSION In a largely Latinx sample of children, the neighborhood in which a child lives influences whether or not they will receive opioids. Considering the differences in patient residential environment may reduce variation in opioid dispensing rates among pediatric patients.
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Affiliation(s)
- Ashley W Kranjac
- Department of Sociology, Chapman University, Orange, CA, United States of America; Center for Stress & Health, University of California School of Medicine, Irvine, CA, United States of America
| | - Dinko Kranjac
- Psychology Program, Institute of Mental Health and Psychological Well-Being, University of La Verne, La Verne, CA, United States of America
| | - Zeev N Kain
- Center for Stress & Health, University of California School of Medicine, Irvine, CA, United States of America; Department of Anesthesiology and Perioperative Care, University of California, Irvine, CA, United States of America; Yale Child Study Center, Yale University, New Haven, CT, United States of America
| | - Louis Ehwerhemuepha
- Computational Research, Children's Health of Orange County, Orange, CA, United States of America
| | - Candice Donaldson
- Department of Psychology, Chapman University, Orange, CA, United States of America
| | - Brooke N Jenkins
- Center for Stress & Health, University of California School of Medicine, Irvine, CA, United States of America; Department of Anesthesiology and Perioperative Care, University of California, Irvine, CA, United States of America; Department of Psychology, Chapman University, Orange, CA, United States of America.
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Imanpour S, Park S. Disparities and inequalities in pain treatment among people with limited English proficiency. SSM Popul Health 2023; 23:101466. [PMID: 37520307 PMCID: PMC10374957 DOI: 10.1016/j.ssmph.2023.101466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 08/01/2023] Open
Abstract
•The role of patient language in pain management and treatment is understudied.•There are disparities in access to pain relievers among people with Limited English Proficiency (LEP).•We need to address the need of people with LEP to reach the objectives of Healthy People 2030.
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Affiliation(s)
- Sara Imanpour
- Corresponding author. School of Public Affairs, Penn State University, Harrisburg. 777 West Harrisburg Pike, W 160 Olmsted, USA.
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Harbell MW, Maloney J, Anderson MA, Attanti S, Kraus MB, Strand N. Addressing Bias in Acute Postoperative Pain Management. Curr Pain Headache Rep 2023; 27:407-415. [PMID: 37405551 DOI: 10.1007/s11916-023-01135-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE OF REVIEW This review evaluates disparities in acute postoperative pain management with regard to gender, race, socioeconomic status, age, and language. Strategies for addressing bias are also discussed. RECENT FINDINGS Inequities in acute postoperative pain management may lead to longer hospital stays and adverse health outcomes. Recent literature suggests that there are disparities in acute pain management related to patient gender, race, and age. Interventions to address these disparities are reviewed but require further investigation. Recent literature highlights inequities in postoperative pain management, particularly in relation to gender, race, and age. There is a need for continued research in this area. Strategies such as implicit bias training and using culturally competent pain measurement scales may help reduce these disparities. Continued efforts by both providers and institutions to address and eliminate biases in postoperative pain management are needed to ensure better health outcomes.
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Affiliation(s)
- Monica W Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Jillian Maloney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | | | | | - Molly B Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Natalie Strand
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
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Willer BL, Mpody C, Nafiu OO. Racial Inequity in Pediatric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2023; 13:108-116. [PMID: 37168831 PMCID: PMC10150147 DOI: 10.1007/s40140-023-00560-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 05/13/2023]
Abstract
Purpose of Review Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism. Recent Findings Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments. Summary Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.
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Affiliation(s)
- Brittany L. Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
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Lion KC, Zhou C, Fishman P, Senturia K, Cole A, Sherr K, Opel DJ, Stout J, Hazim CE, Warren L, Rains BH, Lewis CC. A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol. Implement Sci 2023; 18:8. [PMID: 36915138 PMCID: PMC10012737 DOI: 10.1186/s13012-023-01263-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/12/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices. METHODS We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data. DISCUSSION Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities. TRIAL REGISTRATION NCT05591586.
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Affiliation(s)
- K Casey Lion
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, 98145-5005, USA.
| | - Chuan Zhou
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, 98145-5005, USA
| | - Paul Fishman
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Kirsten Senturia
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Allison Cole
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - James Stout
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Carmen E Hazim
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
| | - Louise Warren
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Bonnie H Rains
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Cara C Lewis
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Begley BB, Cerniglia KS, Aboelatta MM, Begum L, Gilbert G, Mathew J, Meixner SR, Franklin CC, Ramirez RN. Race, Gender, and Primary Language Were Not Associated With Changes in Opioid Prescribing in Children: Results From a Single Institution, 2010 to 2020. Clin Orthop Relat Res 2023; 481:338-344. [PMID: 36125497 PMCID: PMC9831194 DOI: 10.1097/corr.0000000000002414] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients should be prescribed medication based on their medical condition, without prejudice because of their race, gender, or primary language. However, previous research has shown that men are prescribed more medication than women, patients who are White are prescribed more medications than patients who are non-White, and English-speaking people are prescribed more medications than non-English-speaking patients. However, it is unclear whether these differences also occur in pediatric orthopaedic populations. QUESTIONS/PURPOSES We asked: (1) Was the amount of opiates prescribed at discharge associated with patient age, gender, race, or primary language? (2) Did the amount of opiates prescribed to patients at discharge change from 2010 to 2020? METHODS In a single center, between January 2010 and December 2019, we treated 331 patients younger than 18 years surgically for upper and lower long-bone extremity fractures. Patients were considered eligible if they had a nonpathologic fracture. Femur fractures were not included. Based on these criteria, all patients were eligible. The mean age was 12 ± 4 years. The mean weight was 57 ± 33 kg. Among these patients, 76% (253 of 331) were boys and 24% (78 of 331) were girls. From the hospital discharge records, we recorded the amount of opiates prescribed at the time of discharge as measured by morphine milligram equivalents (MMEs). We examined the association of age, gender, race, primary language, weight, and year of treatment using this measurement. We determined a patient's race retrospectively by information given by their parents at time of admission. We did not attempt to contact patients to obtain more nuanced information about their racial background. These data were obtained from the electronic health record. The Wilcoxon rank sum test, t-test, or chi-square test was used to assess associations depending on the distribution of variables, as appropriate. Because opioids as measured in MMEs is zero-inflated, a two-part model analysis was used to adjust for confounding variables. One component of the model was for the probability of having any opiate prescription and another was for the mean number of opioids received. Findings were considered statistically significant if p values were < 0.05. RESULTS In total, 57% (189 of 331) of children were prescribed opiates at discharge after surgery for long-bone fractures. Opiate MMEs increased with patient age (r = 0.38; p < 0.01). Boys and girls showed no difference in the amounts of pain medication (adjusted odds ratio [OR] 1.38 [95% confidence interval (CI) 0.80 to 2.39]; p = 0.71; adjusted opioid difference: 0.35 MME [95% CI -51.7 to 52.4]; p = 0.99), nor were there differences between patients who were White and those who were non-White (adjusted OR 0.78 [95% CI 0.49 to 1.23]; p = 0.28; adjusted opioid difference: 21.5 MME [95% CI -19.3 to 62.4]; p = 0.30), or between patients for whom English was there primary language and those for whom English was not their primary language (adjusted OR 1.16 [95% CI 0.52 to 2.57]; p = 0.71; adjusted opioid difference: 22.7 MME [95% CI -55.7 to 101.3]; p = 0.57) when adjusted for age and weight. There was no change in opioid prescription amounts from 2010 to 2020 after adjusting for changes in patient age across years (Spearman r = -0.08; p = 0.16). CONCLUSION Fairness in opioid prescribing based on race, gender, or primary language is possible. Additional research is needed to determine what factors in our institution led to this result. We suggest that prescribers should apply consistent protocols based on factors such as weight or injury type rather than making individual decisions for each patient. This will lead to fairer opioid prescribing to patients from different race and gender groups. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | | | | | - Lubna Begum
- Cooper Medical School at Rowan University, Camden, NJ, USA
| | - Grace Gilbert
- Cooper Medical School at Rowan University, Camden, NJ, USA
| | - Justin Mathew
- Cooper Medical School at Rowan University, Camden, NJ, USA
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15
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Schwartz H, Menza R, Lindquist K, Mackersie R, Fernández A, Stein D, Bongiovanni T. Limited English Proficiency Associated With Suboptimal Pain Assessment in Hospitalized Trauma Patients. J Surg Res 2022; 278:169-178. [DOI: 10.1016/j.jss.2022.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 03/22/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
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16
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Clark RA, Garcia IC, Jacobson JC, Chung DH. Ethnic Disparities in the Management of Pediatric Subcutaneous Abscesses. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101428. [PMID: 36291364 PMCID: PMC9600215 DOI: 10.3390/children9101428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/16/2022]
Abstract
(1) Background: Significant racial and ethnic disparities affect access to pediatric Emergency Department (ED) and surgical care across the United States. The present study sought to assess the role of racial and ethnic disparities in the management of pediatric subcutaneous abscesses. (2) Methods: A retrospective chart review was performed including ED visits for subcutaneous abscesses in patients < 18 years of age, over a 12-month period. The effects of self-reported ethnicity (Hispanic versus non-Hispanic) and race (Hispanic, Black, Caucasian and Asian) on the diagnosis and management of subcutaneous abscesses were analyzed. (3) Results: 192 patients were identified with an average age of 4.7 ± 5.3 years and 43.8% identified as Hispanic. Non-Hispanic patients were significantly more likely to receive treatment of their SSTI prior to the ED and to be admitted, compared to Hispanic patients. There was no difference in bedside versus operating room incision and drainage (I&D); however, significantly more non-Hispanic patients received procedural sedation for bedside I&D compared to Hispanic patients. There were no differences in outcomes such as recurrence or re-admission based on ethnicity or race. (4) Conclusions: Ethnic and racial disparities exist in the management of subcutaneous abscesses in the United States. Further studies are needed to address the systemic causes of these disparities such as access to tertiary healthcare facilities and systems-based analyses of unconscious bias in healthcare.
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Luan-Erfe BM, Erfe JM, DeCaria B, Okocha O. Limited English Proficiency and Perioperative Patient-Centered Outcomes: A Systematic Review. Anesth Analg 2022; 136:1096-1106. [PMID: 36066429 DOI: 10.1213/ane.0000000000006159] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This systematic review assesses whether limited-English proficiency (LEP) increases risk of having poor perioperative care and outcomes. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 99 articles were identified in Embase and PubMed and screened by 2 independent reviewers. Ten studies, which included 3 prospective cohort studies, 6 retrospective cohort studies, and 1 cross-sectional study, met inclusion and exclusion criteria. All studies were of high-quality rating according to the Newcastle-Ottawa scale. Subsequently, the Levels of Evidence Rating Scale for Prognostic/Risk Studies and Grade Practice Recommendations from the American Society of Plastic Surgeons were used to assess the quality of evidence of each study and the strength of the body of evidence, respectively. There is strong evidence that professional medical interpreter (PMI) use or having a language-concordant provider for LEP patients improves understanding of the procedural consent. The evidence also highly suggests that LEP patients are at risk of poorer postoperative pain control and poorer understanding of discharge instructions compared with English-speaking patients. Further studies are needed to discern whether consistent PMI use can minimize the disparities in pain control and discharge planning between LEP and English-proficient (EP) patients. There is some evidence that LEP status is not associated with differences in having adequate access to and receiving surgical preoperative evaluation. However, the evidence is weak given the small number of studies available. There are currently no studies on whether LEP status impacts access to preoperative evaluation by an anesthesiology-led team to optimize the patient for surgery. There is some evidence to suggest that LEP patients, especially when PMI services are not used consistently, are at risk for increased length of stay, more complications, and worse clinical outcomes. The available outcomes research is limited by the relative infrequency of complications. Additionally, only 4 studies validated whether LEP patients utilized a PMI. Future studies should use larger sample sizes and ascertain whether LEP patients utilized a PMI, and the effect of PMI use on outcomes.
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Affiliation(s)
- Betty M Luan-Erfe
- From the Department of Anesthesiology, Northwestern Memorial Hospital, Northwestern University, Chicago, Illinois
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18
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Nguyen KH, Rambachan A, Ward DT, Manuel SP. Language barriers and postoperative opioid prescription use after total knee arthroplasty. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 7:100171. [PMID: 36082144 PMCID: PMC9445381 DOI: 10.1016/j.rcsop.2022.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/03/2022] [Accepted: 08/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background Patients with limited English proficiency (LEP) face difficulties in access to postoperative follow-up care, including post-discharge medication refills. However, prior studies have not examined how utilization of prescription pain medications after discharge from joint replacement surgeries differs between English proficient (EP) and LEP patients. Objective This study explored the relationship between English language proficiency and opioid prescription refill requests after hospital discharge for total knee arthroplasty (TKA). Methods This was an observational cohort study of patients ≥18 years of age who underwent TKA between January 2015 and December 2019 at a single academic center. LEP status was defined as not having English as the primary language and requesting an interpreter. Primary outcome variables included opioid pain medication refill requests between 0 and 90 days from discharge. Multivariable logistic regression modeling calculated the odds ratios of requesting an opioid refill. Results A total of 2148 patients underwent TKA, and 9.8% had LEP. Postoperative pain levels and rates of prior opioid use did not differ between LEP and EP patients. LEP patients were less likely to request an opioid prescription refill within 30 days (35.3% vs 52.4%, p < 0.001), 60 days (48.7% vs 61.0%, p = 0.004), and 90 days (54.0% vs 62.9%, p = 0.041) after discharge. In multivariable analysis, LEP patients had an odds ratio of 0.61 of requesting an opioid refill (95% CI, 0.41–0.92, p = 0.019) within 30 days of discharge. Having Medicare insurance and longer lengths of hospitalization were correlated with lower odds of 0–30 days opioid refills, while prior opioid use and being discharged home were associated with higher odds of opioid refill requests 0–30 days after discharge for TKA. Conclusions Language barriers may contribute to poorer access to postoperative care, including prescription medication refills. Barriers to postoperative care may exist at multiple levels for LEP patients undergoing surgical procedures.
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Schiefelbein AM, Krebsbach JK, Taylor AK, Zhang J, Haimson CE, Trentham-Dietz A, Skala MC, Eason JM, Weber SM, Varley PR, Zafar SN, LoConte NK. Treatment Inequity: Examining the Influence of Non-Hispanic Black Race and Ethnicity on Pancreatic Cancer Care and Survival in Wisconsin. WMJ : OFFICIAL PUBLICATION OF THE STATE MEDICAL SOCIETY OF WISCONSIN 2022; 121:77-93. [PMID: 35857681 PMCID: PMC9354557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION We investigated race and ethnicity-based disparities in first course treatment and overall survival among Wisconsin pancreatic cancer patients. METHODS We identified adults diagnosed with pancreatic adenocarcinoma in the Wisconsin Cancer Reporting System from 2004 through 2017. We assessed race and ethnicity-based disparities in first course of treatment via adjusted logistic regression and overall survival via 4 incremental Cox proportional hazards regression models. RESULTS The study included 8,490 patients: 91.3% (n = 7,755) non-Hispanic White; 5.1% (n = 437) non-Hispanic Black, 1.8% (n = 151) Hispanic, 0.6% Native American (n = 53), and 0.6% Asian (n = 51) race and ethnicities. Non-Hispanic Black patients had lower odds of treatment than non-Hispanic White patients for full patient (OR, 0.52; 95% CI, 0.41-0.65) and Medicare cohorts (OR, 0.40; 95% CI, 0.29-0.55). Non-Hispanic Black patients had lower odds of receiving surgery than non-Hispanic White patients (full cohort OR, 0.67 [95% CI, 0.48-0.92]; Medicare cohort OR, 0.57 [95% CI, 0.34-0.93]). Non-Hispanic Black patients experienced worse survival than non-Hispanic White patients in the first 2 incremental Cox proportional hazard regression models (model II HR, 1.18; 95% CI, 1.06-1.31). After adding insurance and treatment course, non-Hispanic Black and non-Hispanic White patients experienced similar survival (HR, 0.98; 95% CI, 0.88-1.09). CONCLUSION Non-Hispanic Black patients were almost 50% less likely to receive any treatment and 33% less likely to receive surgery than non-Hispanic White patients. After including treatment course, non-Hispanic Black and non-Hispanic White patient survival was similar. Increasing non-Hispanic Black patient treatment rates by addressing structural factors affecting treatment availability and employing culturally humble approaches to treatment discussions may mitigate these disparities.
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Affiliation(s)
| | - John K Krebsbach
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Amy K Taylor
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison Wisconsin
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Jienian Zhang
- Department of Sociology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Chloe E Haimson
- Department of Sociology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Amy Trentham-Dietz
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Melissa C Skala
- Morgridge Institute for Research, Madison, Wisconsin
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - John M Eason
- Department of Sociology, University of Wisconsin-Madison, Madison, Wisconsin
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Community and Environmental Sociology, University of Wisconsin-Madison, Madison, Wisconsin
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, Wisconsin
| | - Sharon M Weber
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Patrick R Varley
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Surgical Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Syed N Zafar
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Surgical Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Noelle K LoConte
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison Wisconsin,
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
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A Realist Evaluation Analysis of a Novel Multi-Faceted Inpatient Patient Navigation Program. Acad Pediatr 2022; 22:789-796. [PMID: 34551342 PMCID: PMC8934306 DOI: 10.1016/j.acap.2021.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/30/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Children of color and from low-income families experience disparities in hospital care and outcomes. This study examined the experiences of parents and providers who participated in a novel patient navigation program designed to address these disparities. METHODS Between April and October 2018, we conducted semistructured interviews with parents enrolled in the Family Bridge navigation pilot study, and inpatient care providers. Each set of interviews was thematically coded and analyzed according to the Realist Evaluation Framework of context, mechanism and outcomes; to identify how and when the program worked, for whom, and with what results. RESULTS Of 60 parents enrolled in the intervention, 50 (83%) completed an interview. All enrolled children had public insurance; 66% were Hispanic, 24% were non-Hispanic Black, and 36% of parents preferred Spanish for communication. Of 23 providers who completed an interview, 16 (70%) were attending physicians. Parents identified 4 contexts influencing intervention effectiveness: past clinical experience, barriers to communication, access to resources, and timing of intervention delivery. Four mechanisms were identified by both parents and providers: emotional support, information collection and sharing, facilitating communication, and addressing unmet social needs. Parent-level outcomes included improved communication, feeling supported, and increased parental knowledge surrounding the child's care and the health system. Provider-level outcomes included providing tailored communication and attending to family nonmedical needs. CONCLUSIONS This study provided insight into the mechanisms by which an inpatient navigation program may improve communication, support, and knowledge for parents of low-income children of color, both directly and by changing provider behavior.
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Uong A, Plancarte CA. Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia. Hosp Pediatr 2022; 12:e210-e212. [PMID: 35499380 DOI: 10.1542/hpeds.2022-006661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Audrey Uong
- Division of Pediatric Hospital Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Carlos A Plancarte
- Division of Pediatric Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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22
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Payson A, Pulido A, San Martin S, Garlesky C, Garcia E, Reyes C, Reyes M, Leyenaar J. Inequities in Pain Assessment and Care of Hospitalized Children With Limited English Proficiency. Hosp Pediatr 2022; 12:561-568. [PMID: 35499379 DOI: 10.1542/hpeds.2021-006445] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To examine inequities in pain assessment and management of hospitalized children with limited English proficiency (LEP) as assessed by (1) self-reported pain prevalence and intensity, and (2) nurse-documented pain assessments and analgesia. METHODS A cross-sectional survey of hospitalized children and parent proxies examined preferred language and pain prevalence, intensity, and etiology; subsequent electronic medical record chart review examined demographics, nurse-documented pain scores, and analgesia prescribed for children aged ≤21 years at a tertiary care children's hospital. The primary outcome was a difference of ≥3 points between self-reported and nurse-documented worst pain scores. Descriptive statistics, Fisher's exact tests, and multivariable logistic regression were used to identify differences in outcomes between children with and without LEP. RESULTS A total of 155 patients (50% children and 50% parental proxies) were interviewed (96% response rate). Of those, 60% (n = 93) reported pain in the previous 24 hours, most frequently because of acute illnesses. Of patients reporting pain, 65% (n = 60) reported a worst pain score of ≥3 points higher than nurse-documented scores; this discrepancy affected more patients with LEP (82%, n = 27) than English-proficient patients (55%, n = 33) (P = .01) with an adjusted odds ratio of 3.2 (95% confidence interval: 1.13-10.31). Patients with LEP were also less likely than English-proficient patients to receive medications at the time of their worst pain (60% vs 82%, P = .03), particularly opioid analgesia (9% vs 22%, P = .04). CONCLUSIONS Children with LEP were more likely to self-report pain scores that exceeded nurse-documented scores and received less medications, particularly opiates. This population may be particularly vulnerable to underassessment and inadequate management of pain.
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Affiliation(s)
- Alison Payson
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Anamaria Pulido
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | | | - Cindy Garlesky
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Erileen Garcia
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Clara Reyes
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Mario Reyes
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - JoAnna Leyenaar
- Department of Pediatrics and the Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Shaw RE, Staffa SJ, Nasr VG, Tung C. Impact of Parental Primary Spoken Language on Postoperative Pain Management in Children, a Retrospective Cohort Study. CHILDREN 2022; 9:children9050739. [PMID: 35626916 PMCID: PMC9139688 DOI: 10.3390/children9050739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 11/23/2022]
Abstract
Background: Healthcare providers encounter varying languages every day in patient care. The goal of this study was to examine whether a difference exists in pain scoring and treatment amongst pediatric patients whose families’ primary language was not English. We hypothesized that patients of both Arabic-speaking (AS) and Spanish-speaking (SS) backgrounds received higher pain scores and higher daily opioid equivalents (OEs) postoperatively compared to English-speaking (ES) patients. Methods: This was a retrospective cohort study of patients undergoing surgery for treatment of various esophageal and airway disorders from 2014 to 2019. Records were queried for patients undergoing thoracotomies for treatment of esophageal and airway disorders. Analysis was focused on the three most common languages in this selected population: English, Arabic, and Spanish. Propensity score matching was utilized for comparisons of pain scores between AS, SS, and ES patient groups. Primary outcomes were opioid equivalents (OEs) and pain scores postoperatively. Multivariable median regression analysis was used to perform an adjusted comparison of pain scores as well as OEs. Results: A total of 610 patient encounters were included in our analysis. In propensity matched analysis, there were no significant differences in OEs between all groups postoperatively. However, statistically significant higher pain scores were reported in the ES group matched AS groups. Conclusions: Language differences did not lead to difference in pain assessment and treatment.
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Affiliation(s)
- Robert E. Shaw
- Division of Pediatric Anesthesia, Department of Anesthesiology, University of Wisconsin, Madison, WI 53792, USA
- Correspondence:
| | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (V.G.N.); (C.T.)
| | - Viviane G. Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (V.G.N.); (C.T.)
| | - Cynthia Tung
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (V.G.N.); (C.T.)
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Nageswaran S, Ellis MB, Beveridge MS. Communication Challenges Faced by Spanish-Speaking Caregivers of Children with Medical Complexity: a Qualitative Study. J Racial Ethn Health Disparities 2022; 9:2218-2226. [PMID: 34595676 PMCID: PMC8483426 DOI: 10.1007/s40615-021-01161-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Communication between caregivers and healthcare providers is important in the delivery of high-quality healthcare for children with medical complexity (CMC). Hispanic children face many challenges in access to healthcare services. Our objective was to describe the communication challenges faced by Spanish-speaking parents with limited English proficiency (SSP-LEP). METHODS This was a qualitative study of 70 children of Spanish-speaking caregivers, enrolled in a complex care program of a tertiary care children's hospital in North Carolina. Secondary source data were abstracted logs of care coordination tasks maintained by the program's two bilingual care coordinators for a median observation period of 45 months, and complemented by data from care coordinator interviews. Data were entered and coded in ATLAS.ti. Using thematic content analysis and an iterative process, we identified recurrent themes related to communication challenges of Spanish-speaking caregivers. RESULTS Median age of children was 5 years; 51% were girls; 97% had Medicaid; and 3% were uninsured. Seven children died during the observation period. Three major themes were identified as follows: (1) caregivers faced many communication challenges primarily because of language barrier. (2) Multiple factors at caregiver, provider, and system levels, in addition to language barrier, contributed to communication challenges. (3) Communication challenges had serious consequences for CMC. These consequences were lessened by bilingual coordinators. CONCLUSION SSP-LEP face unique communication challenges resulting in negative impact on the healthcare of their CMC. Bilingual coordinators can help improve communication between SSP-LEP and their healthcare providers. Interventions to address communication challenges of Spanish-speaking caregivers are warranted.
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Affiliation(s)
- Savithri Nageswaran
- Department of Pediatrics, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | | | - Mark S Beveridge
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
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Hartford EA, Carlin K, Rutman LE, Lion KC. Changes in Rates and Modality of Interpreter Use for Pediatric Emergency Department Patients in the COVID-19 Era. Jt Comm J Qual Patient Saf 2021; 48:139-146. [PMID: 35058161 PMCID: PMC8590502 DOI: 10.1016/j.jcjq.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022]
Abstract
Background As the COVID-19 pandemic continues, health care systems around the world have changed care delivery in significant ways. Racial and ethnic disparities have emerged for COVID-19 infection rates, morbidity, and mortality. Inequities in care and underutilization of interpretation for patients who use a language other than English (LOE) for care existed prior to this era. This study sought to evaluate interpreter use in a pediatric emergency department (ED) as changes associated with COVID-19 were implemented. Methods ED records were reviewed from December 1, 2019, to July 31, 2020. Patients were classified as having LOE if they preferred a language other than English and consented to interpretation. Statistical process control was used to analyze changes in interpreter use over time, relative to the onset of COVID-19–related operational changes. Beginning March 1, 2020, in-person interpreters were no longer available and staff were encouraged to communicate from outside the patient room when possible; this change served as the exposure of interest. Interpreter use for LOE patients, overall and by triage acuity level, was the study outcome. Results A total of 26,787 encounters were included. The weekly mean proportion of encounters that used interpretation for patients with LOE increased from 59% to 73% after the onset of COVID-19. This increase met criteria for special cause variation. Interpretation modality changed to being mostly by phone from previously by video or in-person. Conclusion Operational changes in the ED related to COVID-19 were associated with increased interpreter use. Possible explanations include lower patient volumes or changes in model of care that encouraged interpreter use by a variety of modalities.
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Schwartz HEM, Matthay ZA, Menza R, Fernández A, Mackersie R, Stein DM, Bongiovanni T. Inequity in discharge pain management for trauma patients with limited English proficiency. J Trauma Acute Care Surg 2021; 91:898-902. [PMID: 34039923 DOI: 10.1097/ta.0000000000003294] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pain management is critical for optimal recovery after trauma. Previous work at our institution revealed differences in pain assessment by patient language, which may impact management. This study aimed to understand differences in discharge opioid prescribing for trauma patients with limited English proficiency (LEP). METHODS We conducted a cross-sectional study of adult trauma patients discharged to the community from a diverse, urban level 1 trauma center in 2018. Opioid prescriptions were obtained from discharge pharmacy records and converted to standard oral morphine equivalents (OMEs). Multivariable logistic and quantile regression was used to examine the relationship between LEP, opioid prescriptions, and OMEs at discharge, controlling for demographic and clinical characteristics. RESULTS Of 1,419 patients included in this study, 83% were English proficient (EP) and 17% were LEP. At discharge, 56% of EP patients received an opioid prescription, compared with 41% of LEP patients. In multivariable models, EP patients were 1.63 times more likely to receive any opioid prescription (95% CI, 1.17-2.25; p = 0.003). Mean OME was 147 for EP and 94 for LEP patients. In multivariable models, the difference between EP and LEP patients was 40 OMEs (95% CI, 21.10-84.22; p = 0.004). In adjusted quantile regression models, differences in total OMEs increased with the amount of OMEs prescribed. There was no difference in OMEs at the 20th and 40th percentile of total OMEs, but LEP patients received 26 fewer OMEs on average at the 60th percentile (95% CI, -3.23 to 54.90; p = 0.081) and 45 fewer OMEs at the 80th percentile (95% CI, 5.48-84.48; p = 0.026). CONCLUSION Limited English proficiency patients with traumatic injuries were less likely to receive any opioid prescription and were prescribed lower quantities of opiates, which could contribute to suboptimal pain management and recovery. Addressing these disparities is an important focus for future quality improvement efforts. LEVEL OF EVIDENCE Care Management, level IV.
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Affiliation(s)
- Hope E M Schwartz
- From the Department of Surgery, School of Medicine (H.E.M.S.), Department of Surgery (Z.A.M., R. Menza, R. Mackersie, D.M.S., T.B.), Department of Physiological Nursing (R. Menza), and Department of Medicine (A.F.), University of California, San Francisco, San Francisco, California
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Plancarte CA, Hametz P, Southern WN. Association Between English Proficiency and Timing of Analgesia Administration After Surgery. Hosp Pediatr 2021; 11:1199-1204. [PMID: 34654728 DOI: 10.1542/hpeds.2020-005766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric patients from families with limited English proficiency (LEP) are at risk for health care disparities. We examined timeliness of analgesic administration in pediatric postoperative patients with a limb fracture from LEP versus non-LEP families. METHODS This was a retrospective cohort study of children aged 1 year to <18 years of age, hospitalized to the general inpatient floor after surgical correction of single limb fractures between July 2016 and July 2019 were eligible. Patients whose consent was in a non-English language or for whom an interpreter was used were classified as from LEP families. The primary outcome was time to first analgesia. Secondary outcomes included time to first opioid, proportion with any analgesia and opioid analgesia, and number of pain assessments. Associations between LEP and outcomes were tested by using χ2 tests, Kaplan-Meier plots, and Cox proportional hazards models. RESULTS We examined 306 patients, of whom 59 (19%) were from LEP families. Children in LEP families were significantly less likely to receive any analgesia (86.4% vs 96.8%, P ≤ .01) and experienced longer time to first analgesia in unadjusted (hazard ratio = 0.68, 95% confidence interval: 0.50-0.92) and adjusted analyses (hazard ratio = 0.68, 95% confidence interval: 0.50-0.94). There was no significant association between LEP and time to first opioid, proportion given opioid analgesia, or number of pain assessments. CONCLUSION Hospitalized children from LEP families experience a longer time to analgesia administration after surgery. The mechanisms that lead to these differences in care must be identified so that interventions can be designed to address them.
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Affiliation(s)
- Carlos A Plancarte
- Division of Pediatric Hospital Medicine .,Department of Pediatrics.,Monroe Carell Jr Children's Hospital at Vanderbilt
| | - Patricia Hametz
- Division of Pediatric Hospital Medicine.,Department of Pediatrics.,The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - William N Southern
- Division of Hospital Medicine.,Department of Medicine.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Yaster M, Flack SH, Martin LD, Morgan PG. An interview with Dr. Anne Marie Lynn, a pioneering woman in medicine. Paediatr Anaesth 2021; 31:1040-1045. [PMID: 34293231 DOI: 10.1111/pan.14258] [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: 06/29/2021] [Accepted: 07/17/2021] [Indexed: 11/26/2022]
Abstract
Dr. Anne Marie Lynn (1949-present), Professor Emeritus of Anesthesiology, Pain Medicine, and Pediatrics at the University of Washington, Seattle, was one of the most influential women in pediatric anesthesiology of her generation. Dr. Lynn embodies the spirit of discovery and advancement that have created the practice of pediatric anesthesiology as we know it today. A pioneer in pain medicine pharmacology, particularly morphine and ketorolac, her research transformed pediatric anesthesia, pediatric pain medicine, and pediatric intensive care medicine. Through her journal articles, book chapters, national and international lectures, mentoring of residents, fellows, and faculty, and leadership in the Society for Pediatric Anesthesia, she inspired a generation of women and men physicians by demonstrating that gender should not be a barrier to undertaking roles once only held only by men. In 2017, for her many contributions, she was awarded the Society for Pediatric Anesthesia's Myron Yaster lifetime achievement award.
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Affiliation(s)
- Myron Yaster
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Sean H Flack
- Department of Anesthesiology and Pain Medicine, Seattle Children's, University of Washington, Seattle, Washington, USA
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, Seattle Children's, University of Washington, Seattle, Washington, USA
| | - Philip G Morgan
- Department of Anesthesiology and Pain Medicine, Seattle Children's, University of Washington, Seattle, Washington, USA
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Stokes SC, Jackson JE, Beres AL. Impact of Limited English Proficiency on Definitive Care in Pediatric Appendicitis. J Surg Res 2021; 267:284-292. [PMID: 34171564 DOI: 10.1016/j.jss.2021.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/02/2021] [Accepted: 05/07/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limited English proficiency (LEP) is associated with decreased access to healthcare. We hypothesized that LEP children with appendicitis would experience more delays in care than EP children. METHODS Retrospective review of patients <18 y presenting to a tertiary pediatric hospital July 2014-July 2019 with appendicitis. LEP patients were compared to EP patients. The primary outcome was appendiceal perforation. Secondary outcomes included prior pediatrician or emergency department (ED) visits without definitive management, duration of symptoms, length of stay (LOS), initial operative or non-operative management, time from presentation to operation and return to the ED within 30 d. Multivariable regression was performed to evaluate LEP as a predictor of study outcomes. RESULTS A total of 893 patients with appendicitis were identified, 15.6% (n = 140) had LEP. On multivariate regression LEP was not a significant predictor of appendiceal perforation (AOR 1.20, 95% CI 0.79, 1.80, P = 0.390). LEP was a significant predictor of a prior ED or pediatrician visit without definitive management (AOR 2.05, 95 % CI 1.05, 3.98, P= 0.034) and longer LOS (Coefficient 1.01, 95% CI 0.41, 1.61, P= 0.001). LEP was associated with a minimal increase in duration of pain prior to presentation that was not clinically significant and was not associated with initial operative or non-operative management or a significantly longer time between presentation and operation. CONCLUSIONS LEP children did not experience higher rates of appendiceal perforation at our institution, but were more frequently initially evaluated by a pediatrician or at an ED and discharged without definitive management and had longer LOS.
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Affiliation(s)
- Sarah C Stokes
- Department of Surgery, University of California-Davis, Sacramento, California.
| | - Jordan E Jackson
- Department of Surgery, University of California-Davis, Sacramento, California
| | - Alana L Beres
- Department of Surgery, University of California-Davis, Sacramento, California
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Zhao C, Zhang N, Shrestha N, Liu H, Ge M, Luo F. Dexamethasone as a ropivacaine adjuvant to pre-emptive incision-site infiltration analgesia in pediatric craniotomy patients: A prospective, multicenter, randomized, double-blind, controlled trial. Paediatr Anaesth 2021; 31:665-675. [PMID: 33713371 DOI: 10.1111/pan.14178] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/13/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dexamethasone added to incision-site infiltration has been routinely used to reduce pain after tonsillectomy in children. However, this has not been studied in pediatric craniotomy patients yet. We hypothesized that incision-site infiltration with a combination of ropivacaine and dexamethasone might provide superior analgesia to ropivacaine alone in pediatric craniotomy patients. METHODS In this multicenter, double-blind, randomized, controlled trial, children aged 2-12 years, scheduled for craniotomy, were prospectively enrolled at two study centers, from September 2, 2019, to July 5, 2020. Eighty children were randomly assigned (1:1) to either ropivacaine plus dexamethasone group who received pre-emptive incision-site infiltration with 0.2% ropivacaine plus 0.025% dexamethasone, or ropivacaine group who received 0.2% ropivacaine alone. Primary outcome was the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 24 h postoperatively. Primary analysis was performed using the modified intention-to-treat principle. RESULTS Pre-emptive incision-site infiltration with ropivacaine plus dexamethasone had a reduced pain score of 2.0, compared with the pain score of 2.9 in the ropivacaine group, at 24 h postoperatively (mean difference -0.9, 95% confidence interval [CI], -1.7 to -0.2; p = .019). Estimated median of the time of first rescue analgesic demand was 24 h in the ropivacaine plus dexamethasone group and 8.5 h in the ropivacaine group [hazard ratio 0.43, 95% CI 0.24 to 0.08; Log-rank p = .0025]. No adverse events related to incision-site infiltration with dexamethasone were observed in this study. DISCUSSION Dexamethsone reduces the local production of pro-inflammatory factors after tissue damage and as a ropivacaine adjuvant for incision-site infiltration reduced the pain scores by 31% at 24 h postoperatively. The results were similar to several prior studies on to tonsillectomy patients. However, this changes on pain scores might has limited clinical significance. CONCLUSIONS The addition of dexamethasone to ropivacaine for preoperative incision-site infiltration has better postoperative analgesic effect than ropivacaine alone in pediatric craniotomy patients.
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Affiliation(s)
- Chunmei Zhao
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Nijia Zhang
- Department of Pediatric Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Niti Shrestha
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongbing Liu
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Ge
- Department of Pediatric Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Boylen S, Cherian S, Gill FJ, Leslie GD, Wilson S. Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review. JBI Evid Synth 2021; 18:1360-1388. [PMID: 32813387 DOI: 10.11124/jbisrir-d-19-00300] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of the review was to identify, critically appraise and synthesize evidence on the impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency. INTRODUCTION A key strategy to facilitate effective communication between limited-English-proficient migrant and refugee families and healthcare providers is the use of professional interpreters. Despite awareness of the importance of professional interpreters, interpreters are underutilized. This results in suboptimal care, including poor access to health care, increased risk of serious medical events, increased admission to hospital and inadequate health literacy. INCLUSION CRITERIA Limited-English-proficient migrant, refugee or asylum-seeker families with a hospitalized child aged 0 to 18 years, who had used a professional interpreter, were considered for this review. Comparators included standard care or no interpreter, and reported results of comparisons of the duration, frequency or mode of interpreter delivery. Outcomes were length of stay in hospital, unplanned readmission rates to hospital, non-attendance at hospital clinic appointments and ambulatory care, child and/or parent satisfaction with care in hospital, adherence to treatment, medication errors, and other adverse events relating to patient safety. The review considered all studies conducted using a quantitative approach. METHODS A three-step search strategy was used. Databases were searched in December 2018 for published and unpublished articles. Studies published in English were considered for inclusion. The recommended JBI approach to critical appraisal, study selection, data extraction and data synthesis was used. RESULTS Six articles reporting results from three randomized controlled trials and one observational study were included. Studies were undertaken in the United States involving Spanish-speaking participants. Three studies were in emergency departments. There was a total of 1813 families, of whom 1753 had limited English proficiency. Migrant and refugee families with limited English proficiency reported greater satisfaction with aspects of care when a professional interpreter service was used compared with using ad hoc interpreters. Using professional in-person interpreters resulted in a shorter total emergency department throughput time compared to using professional interpreters via telephone. There was no difference in concordance of child's discharge diagnoses between parents assigned professional interpreters and those assigned bilingual physicians. Video interpretation provided better understanding of diagnoses than phone interpretation. CONCLUSION There is evidence that use of ad hoc interpreters or no interpreter is inferior to use of professional interpreters of any mode. Although video and in-person interpreters are more favorable for some outcomes, mode of delivery may not be as important as the fact that a professional interpreter is being used. The mode of professional interpreter delivery should be based on accessibility, availability, language requirements and patient preference. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42017058161.
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Affiliation(s)
- Susan Boylen
- 1School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, Australia 2The Western Australian Group for Evidence Informed Healthcare Practice: A JBI Centre of Excellence 3Perth Children's Hospital, Child and Adolescent Health Service, Perth, Australia 4Division of Paediatrics, University of Western Australia, Perth, Australia
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Heydari F, Namvar D, Heydari F, Heydari F, Van P. Use of Interpreter Services Among Farsi-Speaking Podiatric Patients and Adherence to the Pain Management Plan. J Am Podiatr Med Assoc 2021; 111:442231. [PMID: 32756906 DOI: 10.7547/18-003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with limited English proficiency (LEP) encounter many health disparities and inequalities due to the lack of effective communication. The lack of effective communication places patients with LEP at higher risk for noncompliance with the treatment plan. Pain is one of the main common health issues, and patients with LEP have difficulties reporting their pain and adhering to the plan of care due to the lack of effective communication. METHODS We measured the effectiveness of using a professional interpreter during office visits for Farsi-speaking patients with LEP to improve pain management and adherence with follow-up visits. In this single-sample quasi-experimental study, 16 Farsi-speaking participants with LEP who visited a podiatric medical office for foot pain rated their pain level at the initial visit and after the intervention during the first follow-up visit. Participants were provided with a professional Farsi-speaking interpreter during the visit. RESULTS Overall, patients reported lower mean ± SD levels of pain during the follow-up visit (4.19 ± 2.29) than at the initial visit (6.56 ± 2.03). Of all of the participants, 75% attended the follow-up appointment, demonstrating that most of the participants adhered to the plan of care. CONCLUSIONS The use of a professional interpreter during an office visit for patients with LEP was associated with improved pain management outcomes and increased adherence to the treatment plan.
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Gaba M, Vazquez H, Homel P, Likourezos A, See F, Thompson J, Rizkalla C. Language Barriers and Timely Analgesia for Long Bone Fractures in a Pediatric Emergency Department. West J Emerg Med 2021; 22:225-231. [PMID: 33856304 PMCID: PMC7972388 DOI: 10.5811/westjem.2020.9.48431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/26/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Long bone fractures are common painful conditions often managed in the pediatric emergency department (PED). Delay to providing effective pediatric pain management is multifactorial. There is limited information regarding how the issue of language spoken impacts the provision of adequate and timely institution of analgesia. We sought to determine whether there is a difference between English-speaking and non-English speaking patients with respect to time to pain management for long bone fractures in a multi-ethnic urban PED. Methods We conducted a retrospective cohort study of consecutive cases over 29 months of children <18 years old who presented to the PED with a first-time long bone fracture. A correlation of multiple clinical variables with timeliness to providing analgesia as a primary outcome was determined. We performed regression analysis to eliminate confounding and to determine the magnitude of each variable’s effect on the outcome. Results We analyzed a total of 753 patient cases (power 0.95). Regression analysis showed that the variable of English vs non-English language spoken was the most significant predictor of timeliness to pain management (p < 0.001). There was a significant difference in median time to triage measurement of pain score (1 minute vs 4 minutes for English vs non-English speakers [p < 0.001]); median time to initial analgesia (4 minutes vs 13 minutes for English vs non-English speakers (p < 0.001]); and median time to opioid analgesia (32 minutes vs 115 minutes for English vs non-English speakers (p < 0.001]), respectively. All measurements of time were from the creation of a patient’s electronic health record. Just 30% of all patients received an opioid analgesic for treatment of long bone fractures, including only 37% with moderate triage pain scores. Conclusion Delay to receiving analgesic medications in pediatric patients with long bone fractures can be augmented by language barriers. Time to providing analgesia for long bone fractures is significantly delayed in non-English speaking families, contributing to disproportionate care in the PED. Furthermore, use of opioid analgesia for fractures in children remains poor.
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Affiliation(s)
- Michelle Gaba
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Hector Vazquez
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | | | - Antonios Likourezos
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Francis See
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Jess Thompson
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Christine Rizkalla
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
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Dixit AA, Elser H, Chen CL, Ferschl M, Manuel SP. Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy. CHILDREN (BASEL, SWITZERLAND) 2020; 7:E163. [PMID: 33020409 PMCID: PMC7600632 DOI: 10.3390/children7100163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/20/2022]
Abstract
Race and ethnicity are associated with disparities in pain management in children. While low English language proficiency is correlated with minority race/ethnicity in the United States, it is less frequently explored in the study of health disparities. We therefore investigated whether English language proficiency influenced pain management in the post-anesthesia care unit (PACU) in a cohort of children who underwent laparoscopic appendectomy at our pediatric hospital in San Francisco. Our primary exposure was English language proficiency, and our primary outcome was administration of any opioid medication in the PACU. Secondary outcomes included the amount of opioid administered in the PACU and whether any pain score was recorded during the patient's recovery period. Statistical analysis included adjusting for demographic covariates including race in estimating the effect of language proficiency on these outcomes. In our cohort of 257 pediatric patients, 57 (22.2%) had low English proficiency (LEP). While LEP and English proficient (EP) patients received the same amount of opioid medication intraoperatively, in multivariable analysis, LEP patients had more than double the odds of receiving any opioid in the PACU (OR 2.45, 95% CI 1.22-4.92). LEP patients received more oral morphine equivalents (OME) than EP patients (1.64 OME/kg, CI 0.67-3.84), and they also had almost double the odds of having no pain score recorded during their PACU recovery period (OR 1.93, CI 0.79-4.73), although the precision of these estimates was limited by small sample size. Subgroup analysis showed that children over the age of 5 years, who were presumably more verbal and would therefore undergo verbal pain assessments, had over triple the odds of having no recorded pain score (OR 3.23, CI 1.48-7.06). In summary, English language proficiency may affect the management of children's pain in the perioperative setting. The etiology of this language-related disparity is likely multifactorial and should be investigated further.
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Affiliation(s)
- Anjali A. Dixit
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA 98105, USA;
| | - Holly Elser
- School of Medicine, Stanford University, Stanford, CA 94309, USA;
| | - Catherine L. Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143, USA; (C.L.C.); (M.F.)
| | - Marla Ferschl
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143, USA; (C.L.C.); (M.F.)
| | - Solmaz P. Manuel
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143, USA; (C.L.C.); (M.F.)
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Jette CG, Rosenbloom JM, Wang E, De Souza E, Anderson TA. Association Between Race and Ethnicity with Intraoperative Analgesic Administration and Initial Recovery Room Pain Scores in Pediatric Patients: a Single-Center Study of 21,229 Surgeries. J Racial Ethn Health Disparities 2020; 8:547-558. [PMID: 32621098 DOI: 10.1007/s40615-020-00811-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 06/18/2020] [Accepted: 06/26/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Perioperative pain may have deleterious effects for all patients. We aim to examine disparities in pain management for children in the perioperative period to understand whether any racial and ethnic groups are at increased risk of poor pain control. METHODS Medical records from children ≤ 18 years of age who underwent surgery from May 2014 to May 2018 were reviewed. The primary outcome was total intraoperative morphine equivalents. The secondary outcomes were intraoperative non-opioid analgesic administration and first conscious pain score. The exposure was race and ethnicity. The associations of race and ethnicity with outcomes of interest were modeled using linear or logistic regression, adjusted for preselected confounders and covariates. Bonferroni corrections were made for multiple comparisons. RESULTS A total of 21,229 anesthetics were included in analyses. In the adjusted analysis, no racial and ethnic group received significantly more or less opioids intraoperatively than non-Hispanic (NH) whites. Asians, Hispanics, and Pacific Islanders were estimated to have significantly lower odds of receiving non-opioid analgesics than NH whites: odds ratio (OR) = 0.83 (95% confidence interval (CI): 0.70, 0.97); OR = 0.84 (95% CI: 0.74, 0.97), and OR = 0.53 (95% CI: 0.33, 0.84) respectively. Asians were estimated to have significantly lower odds of reporting moderate-to-severe pain on awakening than NH whites: OR = 0.80 (95% CI: 0.66, 0.99). CONCLUSIONS Although children of all races and ethnicities investigated received similar total intraoperative opioid doses, some were less likely to receive non-opioid analgesics intraoperatively. Asians were less likely to report moderate-severe pain upon awakening. Further investigation may delineate how these differences lead to disparate patient outcomes and are influenced by patient, provider, and system factors.
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Affiliation(s)
- Christine G Jette
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA
| | - Julia M Rosenbloom
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA
| | - Elizabeth De Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA
| | - T Anthony Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.
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Russell EA, Tsai C, Linton JM. Children in Immigrant Families: Advocacy Within and Beyond the Pediatric Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020; 21:100779. [PMID: 32922213 PMCID: PMC7480259 DOI: 10.1016/j.cpem.2020.100779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the United States, 1 in 4 children lives in an immigrant family. State and national policies have historically precluded equitable access to health care among children in immigrant families. More recently, increasingly restrictive policies, political rhetoric, and xenophobic stances have made immigrant families less able to access health care and less comfortable in attempting to do so, thus increasing the likelihood that patients will present to the emergency department. Once in the emergency department, language, cultural, and health literacy barriers make providing high-quality care potentially challenging for some families. Emergency care professionals can therefore glean critical insight regarding inequities from clinical work to inform advocacy and policy changes at institutional, community, regional, and national levels.
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Affiliation(s)
- Eric A Russell
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Carmelle Tsai
- Department of Pediatrics, Division of Emergency Medicine, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie M Linton
- Department of Pediatrics and Assistant Dean for Admissions, University of South Carolina School of Medicine Greenville and Prisma Health Children's Hospital, Greenville, SC
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Hartford EA, Anderson AP, Klein EJ, Caglar D, Carlin K, Lion KC. The Use and Impact of Professional Interpretation in a Pediatric Emergency Department. Acad Pediatr 2019; 19:956-962. [PMID: 31394260 PMCID: PMC6855248 DOI: 10.1016/j.acap.2019.07.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 04/29/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with limited English proficiency (LEP) experience worse health care outcomes compared to English proficient (EP) patients, and professional interpretation is underutilized in clinical settings. The objectives of this study were to describe patterns of interpreter use in a pediatric emergency department (ED), to determine factors associated with its use, and to examine differences in outcomes between EP families and those with LEP. METHODS ED encounters for LEP and EP patients were reviewed in a retrospective cohort study design over a 15 month period. Generalized estimating equations were used to compare patient encounters and factors associated with interpreter use. RESULTS Interpreter use for families who preferred a non-English language was 45.4%. Use of interpretation was less likely during busier times of day (odds ratio [OR] 0.85, confidence interval [CI] 0.78-0.93), with a lower triage acuity (OR 0.66, CI 0.62-0.70), and with each increasing year of patient age (OR 0.97, CI 0.96-0.98). LEP patients who did not receive interpretation were less likely to be admitted than EP patients (OR 0.69, 0.62-0.78). Patients of LEP families, with or without interpretation, were more likely to be transferred to the ICU within 24 hours of admission than patients of EP families (OR 1.76, 1.07-2.90; 1.85, 1.08-3.18) suggesting that an aspect of clinical severity may have been missed in the ED. CONCLUSIONS Professional interpretation is currently underutilized in this ED for patients with LEP, and important differences in outcomes exist between LEP and EP patients. Factors associated with interpreter use will inform ongoing improvement efforts.
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Affiliation(s)
- Emily A Hartford
- Seattle Children's Hospital, University of Washington, Seattle, Wash.
| | - Andrea P Anderson
- Seattle Children's Hospital, University of Washington, Seattle, Wash
| | - Eileen J Klein
- Seattle Children's Hospital, University of Washington, Seattle, Wash
| | - Derya Caglar
- Seattle Children's Hospital, University of Washington, Seattle, Wash
| | - Kristy Carlin
- Seattle Children's Hospital, University of Washington, Seattle, Wash
| | - K Casey Lion
- Seattle Children's Hospital, University of Washington, Seattle, Wash
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Linton JM, Green A, Chilton LA, Duffee JH, Dilley KJ, Gutierrez JR, Keane VA, Krugman SD, McKelvey CD, Nelson JL. Providing Care for Children in Immigrant Families. Pediatrics 2019; 144:peds.2019-2077. [PMID: 31427460 DOI: 10.1542/peds.2019-2077] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Children in immigrant families (CIF), who represent 1 in 4 children in the United States, represent a growing and ever more diverse US demographic that pediatric medical providers nationwide will increasingly encounter in clinical care. Immigrant children are those born outside the United States to non-US citizen parents, and CIF are defined as those who are either foreign born or have at least 1 parent who is foreign born. Some families immigrate for economic or educational reasons, and others come fleeing persecution and seeking safe haven. Some US-born children with a foreign-born parent may share vulnerabilities with children who themselves are foreign born, particularly regarding access to care and other social determinants of health. Therefore, the larger umbrella term of CIF is used in this statement. CIF, like all children, have diverse experiences that interact with their biopsychosocial development. CIF may face inequities that can threaten their health and well-being, and CIF also offer strengths and embody resilience that can surpass challenges experienced before and during integration. This policy statement describes the evolving population of CIF in the United States, briefly introduces core competencies to enhance care within a framework of cultural humility and safety, and discusses barriers and opportunities at the practice and systems levels. Practice-level recommendations describe how pediatricians can promote health equity for CIF through careful attention to core competencies in clinical care, thoughtful community engagement, and system-level support. Advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for CIF.
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Affiliation(s)
- Julie M. Linton
- Departments of Pediatrics and Public Health, School of Medicine Greenville, University of South Carolina, Greenville, South Carolina
- Department of Pediatrics, School of Medicine, Wake Forest University, Winston-Salem, North Carolina; and
| | - Andrea Green
- Larner College of Medicine, The University of Vermont, Burlington, Vermont
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Zhao C, Jia Y, Jia Z, Xiao X, Luo F. Pre-emptive scalp infiltration with ropivacaine plus methylprednisolone versus ropivacaine alone for relief of postoperative pain after craniotomy in children (RP/MP vs RP): a study protocol for a randomised controlled trial. BMJ Open 2019; 9:e027864. [PMID: 31230016 PMCID: PMC6596953 DOI: 10.1136/bmjopen-2018-027864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Pre-emptive scalp infiltration with local anaesthetics is the simplest and most effective method to prevent postoperative incisional pain. However, local infiltration of an anaesthetic only provides relatively short-term pain relief. Methylprednisolone (MP) treatment, administered as an adjuvant at the wound site, has been shown to provide satisfactory pain management after lumbar laminectomy. However, there is no evidence regarding the efficacy of MP infiltration for the relief of postoperative pain after craniotomy. Currently, postoperative pain after craniotomy in children is undertreated. Therefore, we aim to investigate whether pre-emptive scalp infiltration with ropivacaine (RP) plus MP is superior to RP alone to improve postoperative pain after craniotomy in children. METHODS AND ANALYSIS The RP/MP versus RP trial is a prospective, single-centre, randomised, parallel-group study of 100 children aged 8-18 years undergoing intracranial surgery. Participants will be randomly allocated to receive pre-emptive scalp infiltration with either RP plus MP or RP alone. The primary outcome will be the cumulative fentanyl dose administered by patient-controlled intravenous analgesia within 24 hours postoperatively. The secondary outcomes will include postoperative Numerical Rating Scale scores, pain control satisfaction scores, length of stay and adverse events. Data will be analysed by the intention-to-treat principle. ETHICAL APPROVAL AND DISSEMINATION The study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (Approval Number: KY 2018-066-02). The results will be disseminated in international academic meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03636165; Pre-results.
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Affiliation(s)
- Chunmei Zhao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yitong Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zipu Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiong Xiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Neonatal Intensive Care Unit discharge preparedness among families with limited english proficiency. J Perinatol 2019; 39:135-142. [PMID: 30341402 DOI: 10.1038/s41372-018-0255-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/25/2018] [Accepted: 10/01/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We compared the Neonatal Intensive Care Unit discharge preparedness of families with and without Limited English Proficiency (LEP). STUDY DESIGN We performed a retrospective analysis of discharged families. Each family's discharge preparation was self-assessed on the day of discharge, and the discharging nurse assessed the family's overall emotional and technical discharge preparedness all on 9-point Likert scales. Families were considered not prepared for discharge if they rated themselves or the nurse rated their preparedness as <7 on the Likert scale. RESULTS Among 1307 discharged families, 90 had LEP. The odds of being prepared for discharge were the same for both groups (aOR = 0.62, 95% CI: 0.27-1.41; p = 0.258). In multivariable analyses, families with LEP were less likely to be prepared with technical baby care skills (aOR = 0.32, 95% CI: 0.13-0.81). CONCLUSION Families with LEP are at higher risk and may require special attention when preparing for NICU discharge.
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Evans YN, Rafton SA, Michel E, Ebel BE. Provider Language Proficiency and Decision-Making When Caring for Limited English Proficiency Children and Families. J Natl Med Assoc 2018; 110:212-218. [DOI: 10.1016/j.jnma.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 06/05/2017] [Accepted: 06/07/2017] [Indexed: 11/29/2022]
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Drevdahl DJ. Impersonating culture: The effects of using simulated experiences to teach cultural competence. J Prof Nurs 2018; 34:195-204. [DOI: 10.1016/j.profnurs.2017.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 09/27/2017] [Accepted: 10/14/2017] [Indexed: 10/18/2022]
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de Moissac D, Bowen S. Impact of Language Barriers on Quality of Care and Patient Safety for Official Language Minority Francophones in Canada. J Patient Exp 2018; 6:24-32. [PMID: 31236448 PMCID: PMC6572938 DOI: 10.1177/2374373518769008] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction The risks to patient safety and quality of care faced by members of linguistic minority groups have been well-documented. However, little research has focused on the experience of official language minorities in Canada. Methods This multiple method study (online and paper-based surveys combined with semi-structured individual interviews with patients and interpreters-health navigators) explored the experience of minority Francophones living in 4 Canadian provinces. Results Patients and interpreters-navigators described experiences where language barriers contributed to poorer patient assessment, misdiagnosis and/or delayed treatment, incomplete understanding of patient condition and prescribed treatment, and impaired confidence in services received. Reliance on Google Translate and ad hoc, untrained interpreters are commonly reported, in spite of evidence highlighting the risks associated with such practice. Conclusion Increased awareness that the risks of language barriers apply to official language minorities is essential.
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Affiliation(s)
| | - Sarah Bowen
- Applied Research and Evaluation Consultant, Centreville, Nova Scotia, Canada
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Abstract
BACKGROUND The relationship between limited English proficiency (LEP) and worse pediatric health outcomes is well documented. OBJECTIVES To determine the relationship between LEP status and pediatric hospital readmissions. METHODS We performed a retrospective cohort analysis of children ≤ 18 years old admitted to a tertiary children's hospital from 2008 to 2014. The main exposure was LEP status. Independent variables included sex, age, race/ethnicity, insurance, median household income, surgical/medical status, severity of illness (SOI), the presence of a complex chronic condition, and length of stay. Primary outcome measures were 7- and 30-day readmission. RESULTS From 67 473 encounters, 7- and 30-day readmission rates were 3.9% and 8.2%, respectively. LEP patients were more likely to be younger, poorer, and Hispanic; have lower SOI; and government-subsidized insurance. Adjusted odds for 7- or 30-day readmission for LEP versus English-proficient (EP) patients were 1.00 (P = .99) and 0.97 (P = .60), respectively. Hispanic ethnicity (adjusted odds ratio [aOR]: 1.26 [P = .002] and 1.14 [P = .02]), greater SOI (aOR: 1.04 [P < .001] and 1.05 [P < .001]), and the presence of a complex chronic condition (aOR: 2.31 [P < .001] and 3.03 [P < .001]) were associated with increased odds of 7- and 30-day readmission, respectively. White LEP patients had increased odds of 7- and 30-day readmission compared with white EP patients (aOR: 1.46 [P = .006] and 1.32 [P = .007]) and the poorest LEP patients had increased odds of 7- and 30-day readmission compared with the poorest EP patients (aOR: 1.77 [P = .04] and 2.00 [P < .001]). CONCLUSIONS This is the first large study evaluating the relationship between LEP and pediatric hospital readmission. There was no increased risk of readmission in LEP patients compared with EP patients.
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Affiliation(s)
- Mindy Ju
- Divisions of Pediatric Critical Care Medicine and
| | - Nathan Luna
- Divisions of Pediatric Critical Care Medicine and
| | - K T Park
- Pediatric Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Cramer E. The Impact of Professional Language Interpreting in Midwifery Care: A Review of the Evidence. INTERNATIONAL JOURNAL OF CHILDBIRTH 2017. [DOI: 10.1891/2156-5287.7.1.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND: Patients’ limited proficiency in the language of health care providers is known to be associated with health care disparities. Reluctance to use professional interpreting is documented across a wide range of health care professionals. Most of the literature on the effect of interpreting practices has focused on non-midwifery contexts.OBJECTIVE: To review the evidence regarding how using professional interpreters impacts the midwifery care of women with limited dominant language proficiency (LDLP).METHODS: Eligible studies were identified using searches of MEDLINE, CINAHL, and Maternity and Infant Care, then analyzed and assessed for applicability to midwifery.RESULTS: 40 eligible papers, and two systematic reviews containing 48 additional papers, were included. The use of professional interpreters was found to support all aspects of the midwife’s direct role, with some complex findings on woman-centered communication during interpreted encounters. The use of ad hoc interpreters, or no interpreting, undermines all aspects of midwifery care for women with LDLP.IMPLICATIONS: Midwifery care should be enhanced by increasing midwives’ use of professional interpreters; future research should consider how best to achieve this or investigate the comparative efficacy of more complex interventions, such as interpreter-doulas.
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Abstract
PURPOSE OF REVIEW As the cultural and linguistic diversity of the United States grows, a greater number of patients with limited English proficiency will enter the healthcare system. Best practices for the care of these individuals include identification of their language assistance needs and prompt provision of interpreter services. This review will summarize the legal basis for providing language access in the healthcare setting, discuss the impact of interpretation services on clinical care, and explore the effects of language barriers on health outcomes. RECENT FINDINGS There has been greater awareness of language as an important and independent determinant in the racial and ethnic disparities that exist in healthcare. Studies have shown that there is suboptimal identification of patients who require linguistic assistance and, as such, there are missed opportunities to bridge language gaps with many of our patients. The lack of interpretation, or use of informal, untrained interpreters, has significant effects on patient safety, quality of care, and patient satisfaction. SUMMARY Though federal and regulatory guidelines mandate meaningful access to language services, such processes are still a work in progress in many healthcare settings. Further research and quality improvement initiatives are needed to provide clinicians the knowledge and skills needed to effectively communicate with their limited English proficient patients.
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Hill DL, Carroll KW, Dai D, Faerber JA, Dougherty SL, Feudtner C. Identifying Communication-Impaired Pediatric Patients Using Detailed Hospital Administrative Data. Hosp Pediatr 2016; 6:456-467. [PMID: 27381628 DOI: 10.1542/hpeds.2015-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Pediatric inpatients with communication impairment may experience inadequate pain and symptom management. Research regarding potential variation in care among patients with and without communication impairment is hampered because existing pediatric databases do not include information about patient communication ability per se, even though these data sets do contain information about diagnoses and medical interventions that are probably correlated with the probability of communication impairment. Our objective was to develop and evaluate a classification model to identify patients in a large administrative database likely to be communication impaired. METHODS Our sample included 236 hospitalized patients aged ≥12 months whose ability to communicate about pain had been assessed. We randomly split this sample into development (n = 118) and validation (n = 118) sets. A priori, we developed a set of specific diagnoses, technology dependencies, procedures, and medications recorded in the Pediatric Health Information System likely to be strongly associated with communication impairment. We used logistic regression modeling to calculate the probability of communication impairment for each patient in the development set, assessed the model performance, and evaluated the performance of the 11-variable model in the validation set. RESULTS In the validation sample, the classification model showed excellent classification accuracy (area under the receiver operating characteristic curve 0.92; sensitivity 82.6%; 95% confidence interval, 74%-100%; specificity 86.3%; 95% confidence interval, 80%-97%). For the complete sample, the predicted probability of communication impairment demonstrated excellent calibration with the observed communication impairment status. CONCLUSIONS Hospitalized pediatric patients with communication impairment can be accurately identified in a large hospital administrative database.
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Affiliation(s)
- Douglas L Hill
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Karen W Carroll
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Dingwei Dai
- Infomatics, Independence Blue Cross, Philadelphia, Pennsylvania
| | - Jennifer A Faerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Susan L Dougherty
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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Moore M, Jimenez N, Rowhani-Rahbar A, Willis M, Baron K, Giordano J, Crawley D, Rivara FP, Jaffe KM, Ebel BE. Availability of Outpatient Rehabilitation Services for Children After Traumatic Brain Injury: Differences by Language and Insurance Status. Am J Phys Med Rehabil 2016; 95:204-13. [PMID: 26259055 DOI: 10.1097/phm.0000000000000362] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to explore associations between English proficiency, insurance status, outpatient rehabilitation service availability, and travel time for children with traumatic brain injury. DESIGN The authors used an ecologic cross-sectional design. Data were analyzed from a cohort of 82 children with moderate to severe traumatic brain injury and rehabilitation providers in Washington State. Main measures included availability and travel time to services. RESULTS Less than 20% of providers accepted children with Medicaid and provided language interpretation. Mental health services were most limited. Adjusted for median household income, multilingual service availability was lowest in counties with greater language diversity; for every 10% increase in persons older than 5 yrs speaking a language other than English at home, there was a 34% decrease in availability of multilingual services (prevalence ratio, 0.66; 95% confidence interval, 0.48-0.90). Adjusted for education and Medicaid status, children from Spanish-speaking families had significantly longer travel times to services (mean, 16 additional minutes to mental health; 9 to other therapies). CONCLUSIONS Children in households with limited English proficiency and Medicaid faced significant barriers in availability and proximity of outpatient rehabilitation services. Innovative service strategies are needed to equitably improve availability of rehabilitation for children with traumatic brain injury. Similar studies in other regions will inform one's understanding of the scope of these disparities.
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Affiliation(s)
- Megan Moore
- From the Harborview Injury Prevention and Research Center (MM, NJ, AR-R, KB, FPR, KMJ, BEE), School of Social Work (MM), Departments of Anesthesiology and Pain Medicine (NJ), Pediatrics (FPR, KMJ, BEE), Epidemiology (AR-R, BEE), Rehabilitation Medicine (KMJ), and Neurological Surgery (KMJ), University of Washington, Seattle, Washington; Department of Sociology, Boston College, Chestnut Hill, Massachusetts (MW); and Brain Injury Alliance of Washington, Seattle, Washington (JG, DC)
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Zamora-Kapoor A, Omidpanah A, Monico E, Buchwald D, Harris R, Jimenez N. The Role of Language Use in Reports of Musculoskeletal Pain Among Hispanic and Non-Hispanic White Adolescents. J Transcult Nurs 2015; 28:144-151. [PMID: 26682571 DOI: 10.1177/1043659615623326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This study examined the role of English language use in the reported frequency of musculoskeletal pain among Hispanic and non-Hispanic White youth. METHOD This is a secondary data analysis using a cross-sectional sample of 12,189 Hispanic and non-Hispanic White adolescents recruited for the National Longitudinal Study of Adolescent to Adult Health. Respondents were classified into three groups: (a) English-speaking non-Hispanic Whites, (b) English-speaking Hispanics, and (c) Spanish-speaking Hispanics. RESULTS After controlling for body mass index and demographic, socioeconomic, and behavioral variables, Spanish-speaking Hispanics reported the least frequent musculoskeletal pain ( OR = 0.415, 95% CI [0.361, 0.477]; p < .001), followed by English-speaking Hispanics ( OR = 0.773, 95% CI [0.690, 0.865]; p < .001). CONCLUSION The experience of musculoskeletal pain is a physiological as well as a cultural phenomenon. IMPLICATIONS FOR PRACTICE Health care providers should consider the role of language use in reports of pain in Hispanic and non-Hispanic White adolescents.
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Affiliation(s)
- Anna Zamora-Kapoor
- 1 University of Washington, Seattle, WA, USA.,2 Washington State University, Seattle, WA, USA
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Rabbitts JA, Palermo TM, Zhou C, Mangione-Smith R. Pain and Health-Related Quality of Life After Pediatric Inpatient Surgery. THE JOURNAL OF PAIN 2015; 16:1334-1341. [PMID: 26416163 DOI: 10.1016/j.jpain.2015.09.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/11/2015] [Accepted: 09/12/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Around 4 million children undergo inpatient surgery in the United States each year, however little is known about the impact of surgery and postoperative pain on children's health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2 to 18 years (mean = 9.6 years), 50% male, 56% white, admitted to surgical services at a children's hospital enrolled in the study. Parent participants reported on sociodemographics, child HRQOL, and pain characteristics at baseline and 1 month after discharge. Although most of the children recovered to baseline by 1 month after hospital discharge, 23% of children had a significant decline in HRQOL. Logistic regression analyses found that increasing child age (odds ratio = 2.1 for age 13-18 years) and the presence of moderate-severe postsurgical pain at 1 month (odds ratio = 5.7) were significantly associated with deterioration in HRQOL from baseline to 1-month follow-up (P < .05 for each variable). Although HRQOL returns to the baseline level for most children, a sizeable proportion have significant deterioration in HRQOL associated with continued postsurgical pain at 1 month after hospital discharge from surgery. PERSPECTIVE This study addresses an important gap in the literature, examining pain and health-related quality of life in a broad population of children undergoing a wide range of inpatient surgeries. Evaluation of inpatient health services from a patient and family perspective is essential in evaluating outcomes of surgical care.
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Affiliation(s)
- Jennifer A Rabbitts
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington.
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
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