1
|
Imbroane MR, Badrinathan A, Friedl SL, Mo A, Tran A, Carrane H, Tseng ES, Ho VP. A critical view: Examining disparities regarding timely cholecystectomy. Surgery 2024:S0039-6060(24)00540-3. [PMID: 39218740 DOI: 10.1016/j.surg.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 06/14/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Implicit bias may prevent patients with abdominal pain from receiving optimal workup and treatment. We hypothesized that patients from socially disadvantaged backgrounds would be more likely to experience delays in receiving operative treatment for cholecystitis. To study this question, we examined factors related to having a prior emergency department presentation for abdominal pain (prior emergency department visit) within 3 months of urgent cholecystectomy. METHODS We performed a retrospective analysis of consecutive patients who received an urgent cholecystectomy at an urban safety net public hospital between July 2019 and December 2022. The main outcome of interest was prior emergency department visit within 3 months of index cholecystectomy. We examined patient age, sex, race, ethnicity, preferred language, insurance, and employment status. Bivariate comparisons and logistic regression were used to determine the relationship between patient factors and prior emergency department visit. RESULTS Of 508 cholecystectomy patients, 138 (27.2%) had a prior emergency department visit in the 3 months preceding their surgery. In bivariate analysis, younger age, Black race, Hispanic ethnicity, non-English preferred language, and type of insurance (P < .05) were associated with prior emergency department visit. In regression, younger age, Black race, Hispanic ethnicity, and having Medicare or being uninsured were associated with higher odds of having a prior emergency department visit. CONCLUSION More than 1 in 4 patients had an evaluation for abdominal pain within 3 months of having an urgent cholecystectomy, and these patients were more likely to be from socially disadvantaged backgrounds. Standardized evaluation pathways for abdominal pain are needed to reduce disparities from institutional or implicit bias.
Collapse
Affiliation(s)
| | | | - Sophia L Friedl
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Allison Mo
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Andrew Tran
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Hope Carrane
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Esther S Tseng
- Department of Surgery, The MetroHealth System, Cleveland, OH. https://twitter.com/esthertsengmd
| | - Vanessa P Ho
- Department of Surgery, The MetroHealth System, Cleveland, OH; Center for Health Equity Engagement, Education, and Research, Population Health and Equity Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH.
| |
Collapse
|
2
|
Middleton KK, Turner A. Racial and Ethnic Disparities in Sports Medicine and the Importance of Diversity. Clin Sports Med 2024; 43:233-244. [PMID: 38383106 DOI: 10.1016/j.csm.2023.07.005] [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] [Indexed: 02/23/2024]
Abstract
Within orthopedics surgery as a specialty, sports medicine is one of the least diverse surgical subspecialties. Differences in minority representation between patient and provider populations are thought to contribute to disparities in care, access, and outcomes.
Collapse
Affiliation(s)
| | - Alex Turner
- University of Texas Southwestern Medical School, Dallas, TX, USA
| |
Collapse
|
3
|
Flores MW, Sharp A, Lu F, Cook BL. Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System. J Racial Ethn Health Disparities 2024; 11:719-729. [PMID: 36892815 PMCID: PMC9997438 DOI: 10.1007/s40615-023-01555-z] [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: 11/08/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.
Collapse
Affiliation(s)
- Michael William Flores
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Amanda Sharp
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Center for Mindfulness and Compassion, Cambridge Health Alliance, Cambridge, MA, USA
| | - Frederick Lu
- Boston University School of Medicine, Boston, MA, USA
| | - Benjamin Lê Cook
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
4
|
Thompson T, Stathi S, Buckley F, Shin JI, Liang CS. Trends in Racial Inequalities in the Administration of Opioid and Non-opioid Pain Medication in US Emergency Departments Across 1999-2020. J Gen Intern Med 2024; 39:214-221. [PMID: 37698724 PMCID: PMC10853122 DOI: 10.1007/s11606-023-08401-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Despite initiatives to eradicate racial inequalities in pain treatment, there is no clear picture on whether this has translated to changes in clinical practice. OBJECTIVE To determine whether racial disparities in the receipt of pain medication in the emergency department have diminished over a 22-year period from 1999 to 2020. DESIGN We used data from the National Hospital Ambulatory Medical Care Survey, an annual, cross-sectional probability sample of visits to emergency departments of non-federal general and short-stay hospitals in the USA. PATIENTS Pain-related visits to the ED by Black or White patients. MAIN MEASURES Prescriptions for opioid and non-opioid analgesics. KEY RESULTS A total of 203,854 of all sampled 625,433 ED visits (35%) by Black or White patients were pain-related, translating to a population-weighted estimate of over 42 million actual visits to US emergency departments for pain annually across 1999-2020. Relative risk regression found visits by White patients were 1.26 (95% CI, 1.22-1.30; p<0.001) times more likely to result in an opioid prescription for pain compared to Black patients (40% vs. 32%). Visits by Black patients were also 1.25 (95% CI, 1.21-1.30; p<0.001) times more likely to result in non-opioid analgesics only being prescribed. Results were not substantively altered after adjusting for insurance status, type and severity of pain, geographical region, and other potential confounders. Spline regression found no evidence of meaningful change in the magnitude of racial disparities in prescribed pain medication over 22 years. CONCLUSIONS Initiatives to create equitable healthcare do not appear to have resulted in meaningful alleviation of racial disparities in pain treatment in the emergency department.
Collapse
Affiliation(s)
- Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, SE9 2UG, UK.
- Centre for Inequalities, University of Greenwich, London, SE9 2UG, UK.
| | - Sofia Stathi
- Centre for Inequalities, University of Greenwich, London, SE9 2UG, UK
| | - Francesca Buckley
- Centre for Chronic Illness and Ageing, University of Greenwich, London, SE9 2UG, UK
- Centre for Inequalities, University of Greenwich, London, SE9 2UG, UK
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| |
Collapse
|
5
|
Boley S, Sidebottom A, Stenzel A, Watson D. Racial Disparities in Opioid Administration Practices Among Undifferentiated Abdominal Pain Patients in the Emergency Department. J Racial Ethn Health Disparities 2024; 11:416-424. [PMID: 36795292 DOI: 10.1007/s40615-023-01529-1] [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] [Received: 10/21/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVES The purpose of this study was to examine racial disparities in opioid prescribing practices for patients presenting to the emergency department (ED) with a common chief complaint of abdominal pain. METHODS Treatment outcomes were compared for non-Hispanic White (NH White), non-Hispanic Black (NH Black), and Hispanic patients seen over 12 months in three emergency departments in the Minneapolis/St. Paul metropolitan area. Multivariable logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI) to measure the associations between race/ethnicity and outcomes of opioid administration during ED visits and discharge opioid prescriptions. RESULTS A total of 7309 encounters were included in the analysis. NH Black (n = 1988) and Hispanic patients (n = 602) were more likely than NH White patients (n = 4179) to be in the 18-39 age group (p < 0. 001). NH Black patients were more likely to report public insurance than NH White or Hispanic patients (p < 0.001). After adjusting for confounders, patients who identified as NH Black (OR: 0.64, 95% CI: 0.56-0.74) or Hispanic (OR: 0.78, 95% CI: 0.61-0.98) were less likely to be given opioids during their ED encounter when compared to NH White patients. Similarly, NH Black patients (OR: 0.62, 95% CI: 0.52-0.75) and Hispanic patients (OR: 0.66, 95% CI: 0.49-0.88) were less likely to receive a discharge opioid prescription. CONCLUSIONS These results confirm that racial disparities exist in the ED opioid administration within the department as well as at discharge. Future studies should continue to examine systemic racism as well as interventions to alleviate these health inequities.
Collapse
Affiliation(s)
- Sean Boley
- Emergency Care Consultants, Minneapolis, MN, USA.
| | | | - Ashley Stenzel
- Care Delivery Research, Allina Health, Minneapolis, MN, USA
| | - David Watson
- Research Institute, Children's Minnesota, Minneapolis, MN, USA
| |
Collapse
|
6
|
Bergan DE, Rojas A, Briggs I, Andersen E. Framing and Policymaker Evaluations of the Opioid Crisis. HEALTH COMMUNICATION 2023; 38:2604-2616. [PMID: 35816366 DOI: 10.1080/10410236.2022.2093555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Several extremely influential theories, including the multiple streams approach and punctuated equilibrium theory, predict that dramatic policy change occurs when problems are reframed. However, there is little direct evidence of how framing messages influence policymaker attitudes, perceptions, and behaviors. In an online survey of local policymakers in Illinois, we find that different media frames of the opiate epidemic influence policymaker attitudes and attributions of responsibility. We conclude with some implications for framing theory and its role in theories of policymaking.
Collapse
Affiliation(s)
- Daniel E Bergan
- Department of Communication & James Madison College, Michigan State University
| | - Alan Rojas
- Department of Political Science, Roosevelt University
| | - Ian Briggs
- James Madison College, Michigan State University
| | | |
Collapse
|
7
|
Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Seymour RB. Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices. Appl Clin Inform 2023; 14:961-972. [PMID: 38057261 PMCID: PMC10700149 DOI: 10.1055/s-0043-1776879] [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: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices. METHODS We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing. RESULTS This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing. CONCLUSION A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.
Collapse
Affiliation(s)
- Meghan K. Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Michael E. Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Donna M. Kazemi
- School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Joseph R. Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
| | - Rachel B. Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
| | | |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Crowley AP, Sun C, Yan XS, Navathe A, Liao JM, Patel MS, Pagnotti D, Shen Z, Delgado MK. Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions. Acad Emerg Med 2023; 30:809-818. [PMID: 36876410 DOI: 10.1111/acem.14717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. METHODS The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. RESULTS Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. CONCLUSIONS Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.
Collapse
Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Amol Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - David Pagnotti
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zijun Shen
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
10
|
Pekas D, Telken W, Sahmoun AE, Beal JR. Association Between Race and Usage of Pain Medications in Children With Long Bone Fractures in US Emergency Departments, 2011-2019. Pediatr Emerg Care 2023; 39:393-396. [PMID: 37159330 DOI: 10.1097/pec.0000000000002958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the association between race and analgesic administration for children with long bone fracture (LBF) in US emergency departments. Previous studies have shown conflicting results regarding association between race and analgesic administration for pediatric LBFs. METHODS We conducted a retrospective analysis of pediatric emergency department visits for LBF using the 2011-2019 National Hospital Ambulatory Medical Care Survey-Emergency Department. We investigated the diagnostic workup and analgesic prescription rate among White, Black, and other pediatric emergency department visits for LBF. RESULTS Of the estimated 292 million pediatric visits to US emergency departments from 2011 to 2019, 3.1% were LBFs. Black children were less likely to be seen for a LBF than White or other children (1.8% vs 3.6% and 3.1%, P < 0.001). There was no association between race and subjective pain scale ( P = 0.998), triage severity ( P = 0.980), imaging (x-ray, P = 0.612; computed tomography scan, P = 0.291), or analgesic administration (opioids, P = 0.068; nonsteroidal antiinflammatory drugs/acetaminophen, P = 0.750). Trend analysis showed a significant decrease in opioid administration for pediatric LBF from 2011 to 2019 ( P < 0.001), with 33.0% receiving opioids. CONCLUSIONS There was no association between race and analgesic administration, including opioids, or diagnostic workup in pediatric LBF. In addition, there was a significant downtrend in opioid administration for pediatric LBF from 2011 to 2019.
Collapse
Affiliation(s)
- Devon Pekas
- From the University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Wyatt Telken
- From the University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Abe E Sahmoun
- Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, ND
| | - James R Beal
- Department of Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| |
Collapse
|
11
|
Chen Q, Maher CG, Rogan E, Machado G. Management of low back pain in Australian emergency departments for culturally and linguistically diverse populations from 2016 to 2021. Emerg Med J 2023:emermed-2022-212718. [PMID: 37085180 DOI: 10.1136/emermed-2022-212718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Disparate care in the ED for minority populations with low back pain is a long-standing issue reported in the USA. Our objective was to compare care delivery for low back pain in Australian EDs between culturally and linguistically diverse (CALD) and non-CALD patients. METHODS This is a retrospective review of medical records of the ED of three public hospitals in Sydney, New South Wales, Australia from January 2016 to October 2021. We included adult patients diagnosed with non-serious low back pain at ED discharge. CALD status was defined by country of birth, preferred language and use of interpreter service. The main outcome measures were ambulance transport, lumbar imaging, opioid administration and hospital admission. RESULTS Of the 14 642 included presentations, 7656 patients (52.7%) were born overseas, 3695 (25.2%) preferred communicating in a non-English language and 1224 (8.4%) required an interpreter. Patients born overseas were less likely to arrive by ambulance (adjusted OR (aOR) 0.68, 95% CI 0.63 to 0.73) than Australian-born patients. Patients who preferred a non-English language were also less likely to arrive by ambulance (aOR 0.82, 95% CI 0.75 to 0.90), yet more likely to be imaged (aOR 1.12, 95% CI 1.01 to 1.23) or be admitted to hospital (aOR 1.16, 95% CI 1.04 to 1.29) than Native-English-speaking patients. Patients who required an interpreter were more likely to receive imaging (aOR 1.43, 95% CI 1.25 to 1.64) or be admitted (aOR 1.49, 95% CI 1.29 to 1.73) compared with those who communicated independently. CALD patients were generally less likely to receive weak opioids than non-CALD patients (aOR range 0.76-0.87), yet no difference was found in the use of any opioid or strong opioids. CONCLUSION Patients with low back pain from a CALD background, especially those lacking English proficiency, are significantly more likely to be imaged and admitted in Australian EDs. Future interventions improving the quality of ED care for low back pain should give special consideration to CALD patients.
Collapse
Affiliation(s)
- Qiuzhe Chen
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Eileen Rogan
- Canterbury Hospital, Campsie, New South Wales, Australia
| | - Gustavo Machado
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Chen Q, Vella SP, Maher CG, Ferreira GE, Machado GC. Racial and ethnic differences in the use of lumbar imaging, opioid analgesics and spinal surgery for low back pain: A systematic review and meta-analysis. Eur J Pain 2023; 27:476-491. [PMID: 36585947 DOI: 10.1002/ejp.2075] [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: 07/08/2022] [Revised: 12/06/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVE There is a substantial gap between evidence and clinical care for low back pain (LBP) worldwide despite recommendations of best practice specified in clinical practice guidelines. The aim of this systematic review was to identify disparities associated with race or ethnicity in the use of lumbar imaging, opioid analgesics, and spinal surgery in people with LBP. DATABASES AND DATA TREATMENT We included observational studies which compared the use of lumbar imaging, opioid analgesics, and spinal surgery for the management of non-serious LBP between people from different racial/ethnic populations. We searched in MEDLINE, EMBASE and CINAHL from January 2000 to June 2021. Risk of bias of included studies was appraised in six domains. For each type of care, we pooled data stratified by race and ethnicity using random effects models. RESULTS We identified 13 eligible studies; all conducted in the United States. Hispanic/Latino (OR 0.69, 95%CI 0.49-0.96) and Black/African American (OR 0.59, 95%CI 0.46-0.75) people with LBP were less likely to be prescribed opioid analgesics than White people. Black/African Americans were less likely to undergo or be recommended spinal surgery for LBP (OR 0.47, 95%CI 0.33-0.67) than White people. There was a lack of high certainty evidence on racial/ethnic disparities in the use of lumbar imaging. CONCLUSION This review reveals lower rate of the use of guideline-discordant care, especially opioid prescription and spinal surgery, in racial/ethnic minority populations with LBP in the United States. Future studies in other countries evaluating care equity for LBP are warranted. PROSPERO Registration ID: CRD42021260668. SIGNIFICANCE This systematic review and meta-analysis revealed that people with low back pain from the minority racial/ethnic backgrounds were less likely to be prescribed opioid analgesics and undergo spinal surgery than the majority counterparts. Strategic interventions to improve the access to, and the value of, clinical care for minority populations with low back pain are warranted.
Collapse
Affiliation(s)
- Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Simon P Vella
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| |
Collapse
|
13
|
Bradford JM, Cardenas TC, Edwards A, Norman T, Teixeira PG, Trust MD, DuBose J, Kempema J, Ali S, Brown CV. Racial and Ethnic Disparity in Prehospital Pain Management for Trauma Patients. J Am Coll Surg 2023; 236:461-467. [PMID: 36408977 DOI: 10.1097/xcs.0000000000000486] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although evidence suggests that racial and ethnic minority (REM) patients receive inadequate pain management in the acute care setting, it remains unclear whether these disparities also occur during the prehospital period. The aim of this study is to assess the impact of race and ethnicity on prehospital analgesic use by emergency medical services (EMS) in trauma patients. STUDY DESIGN Retrospective chart review of adult trauma patients aged 18 to 89 years old transported by EMS to our American College of Surgeons-verified level 1 trauma center from 2014 to 2020. Patients who identified as Black, Asian, Native American, or Other for race and/or Hispanic or Latino or Unknown for ethnicity were considered REM. Patients who identified as White, non-Hispanic were considered White. Groups were compared in univariate and multivariate analysis. The primary outcome was prehospital analgesic administration. RESULTS A total of 2,476 patients were transported by EMS (47% White and 53% REM). White patients were older on average (46 years vs 38 years; p < 0.001) and had higher rates of blunt trauma (76% vs 60%; p < 0.001). There were no differences in Injury Severity Score (21 vs 20; p = 0.22). Although REM patients reported higher subjective pain rating (7.2 vs 6.6; p = 0.002), they were less likely to get prehospital pain medication (24% vs 35%; p < 0.001), and that difference remained significant after controlling for baseline characteristics, transport method, pain rating, prehospital hypotension, and payor status (adjusted odds ratio [95% CI], 0.67 [0.47 to 0.96]; p = 0.03). CONCLUSIONS Patients from racial and ethnic minority groups were less likely to receive prehospital pain medication after traumatic injury than White patients. Forms of conscious and unconscious bias contributing to this inequity need to be identified and addressed.
Collapse
Affiliation(s)
- James M Bradford
- From the Dell Medical School at the University of Texas at Austin, Austin, TX
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Wilson J, Agha O, Wiggins AJ, Diaz A, Jones KJ, Feeley BT, Pandya NK, Wong SE. Gender and Racial Diversity Among the Head Medical and Athletic Training Staff of Women's Professional Sports Leagues. Orthop J Sports Med 2023; 11:23259671221150447. [PMID: 36846816 PMCID: PMC9944185 DOI: 10.1177/23259671221150447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background Despite increased awareness for promoting diversity, orthopaedics remains one of the least diverse specialties. Studying health care providers in women's professional sports provides a unique opportunity to analyze gender and racial diversity. Hypotheses There would be low female and minority representation across the various women's professional sports leagues. There would be an increased number of female head certified athletic trainers (ATCs) when compared with head team physicians (HTPs). Study Design Cross-sectional study. Methods We evaluated the perceived race and sex of designated HTPs and ATCs in the Women's National Basketball Association, National Women's Soccer League, and National Women's Hockey League. Type of doctorate degree, specialty, and years in practice were also collected. Kappa (κ) coefficient measurements were used to determine interobserver agreement on race. Categorical and continuous variables were analyzed using chi-square and t tests, respectively. Results There were significantly more female ATCs than female HTPs (74.1% vs 37.5%; P = .01). Minority representation between HTPs and ATCs was not significantly different (20.8% vs 40.7%; P = .13). Black HTPs (12.5%) and Black ATCs (22.2%) composed the largest proportion among the minority groups. There was high interobserver agreement of perceived race across HTPs (κ = 1.0) and ATCs (κ = 0.95). Conclusion Although there were more female ATCs than HTPs in women's professional sports leagues, both cohorts lack perceived racial diversity. These data suggest an opportunity for diversification in medical and training staff of women's professional sports.
Collapse
Affiliation(s)
- Jasmin Wilson
- Department of Orthopaedic Surgery, University of California–San
Francisco, San Francisco, California, USA
| | - Obiajulu Agha
- Department of Orthopaedic Surgery, University of California–San
Francisco, San Francisco, California, USA
| | - Anthony J. Wiggins
- Department of Orthopaedic Surgery, University of California–San
Francisco, San Francisco, California, USA
| | - Agustin Diaz
- Department of Orthopaedic Surgery, University of California–San
Francisco, San Francisco, California, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, University of California–Los
Angeles. Los Angeles, California, USA
| | - Brian T. Feeley
- Department of Orthopaedic Surgery, University of California–San
Francisco, San Francisco, California, USA
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California–San
Francisco, San Francisco, California, USA
| | - Stephanie E. Wong
- Department of Orthopaedic Surgery, University of California–San
Francisco, San Francisco, California, USA.,Stephanie E. Wong, MD, Department of Orthopaedic Surgery,
University of California–San Francisco, 1500 Owens St, San Francisco, CA 94158,
USA ()
| |
Collapse
|
15
|
Langham J, Holmes S, Figueroa J, Iyer S, Lazarus S, Gillespie S, Sulton C. Physician self-identified race and opioid prescription practices in upper extremity injuries in the pediatric emergency department. Heliyon 2023; 9:e13351. [PMID: 36814623 PMCID: PMC9939590 DOI: 10.1016/j.heliyon.2023.e13351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 01/09/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Background Minority children have been shown to receive fewer opioid analgesics for acute pain. Objective Assess if both White and non-White physicians prescribe fewer opioids to non-White children presenting to the pediatric emergency department (PED) with upper extremity (UE) fractures. Methods Patients with acute UE fractures were evaluated. Attending physicians provided their self-identified race and consented to analysis of their opioid prescribing practices. Primary outcome was receipt of an opioid prescription at discharge. Bivariate analyses measured the association between patient race and receipt of an opioid prescription; further analysis evaluated the effect of physician race on prescription practices. Generalized linear models measured these associations while controlling for confounders. Results Thirty-four percent of eligible patients (2754/8155) were discharged with an opioid prescription. There was no statistically significant difference in odds of being discharged with an opioid prescription for non-Hispanic Black (NHB) compared to non-Hispanic White (NHW) patients. There was no statistically significant difference in odds of prescribing opioids by both White physicians and non-White physicians. In patients with the most severe fractures, requiring sedation for reduction, NHB patients had lower odds of receiving an opioid prescription (OR 0.80; 95% CI: 0.65-0.98). Conclusion Within our institution, NHB patients received fewer opioid prescriptions at discharge for UE fractures. There is no statistically significant association between NHB race and odds of receiving an opioid prescription. In patients sedated for fracture reductions, NHB patients had lower odds of receiving an opioid prescription and non-White physicians had lower odds of prescribing opioids to NHB patients compared to NHW patients.
Collapse
Affiliation(s)
- Joseph Langham
- Emory University School of Medicine, Pediatric Emergency Medicine, Atlanta, GA, USA
- Corresponding author. Emory University School of Medicine, Pediatric Emergency Medicine, Atlanta, GA 404-210-5657, USA.
| | - Sherita Holmes
- Emory University School of Medicine, Pediatric Emergency Medicine, Atlanta, GA, USA
| | | | - Srikant Iyer
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah Lazarus
- Pediatric Emergency Medicine Physician, Atlanta, GA, USA
| | | | - Carmen Sulton
- Emory University School of Medicine, Pediatric Emergency Medicine, Atlanta, GA, USA
| |
Collapse
|
16
|
Jarman AF, Hwang AC, Schleimer JP, Fontenette RW, Mumma BE. Racial Disparities in Opioid Analgesia Administration Among Adult Emergency Department Patients with Abdominal Pain. West J Emerg Med 2022; 23:826-831. [PMID: 36409944 PMCID: PMC9683779 DOI: 10.5811/westjem.2022.8.55750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Racial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients' self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States. METHODS This was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019-December 31, 2020. We collected demographic and clinical information, including patients' race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient's race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival. RESULTS We studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival. CONCLUSION Hispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia.
Collapse
Affiliation(s)
- Angela F. Jarman
- University of California, Davis School of Medicine, Department of Emergency Medicine, Davis, California
| | - Alexander C. Hwang
- University of California, Davis School of Medicine, Department of Emergency Medicine, Davis, California
- David Grant Medical Center, Travis Air Force Base, Fairfield, California
| | - Julia P. Schleimer
- University of California, Davis School of Medicine, Violence Prevention Research Program, Department of Emergency Medicine, Davis, California
- University of California, Davis, University of California Firearm Violence Research Center, Davis, California
| | - Roderick W. Fontenette
- University of California, Davis School of Medicine, Department of Emergency Medicine, Davis, California
- David Grant Medical Center, Travis Air Force Base, Fairfield, California
| | - Bryn E. Mumma
- University of California, Davis School of Medicine, Department of Emergency Medicine, Davis, California
| |
Collapse
|
17
|
Dickerson-Young T, Uspal NG, Prince WB, Qu P, Klein EJ. Racial and Ethnic Differences in Ondansetron Use for Acute Gastroenteritis in Children. Pediatr Emerg Care 2022; 38:380-385. [PMID: 35353794 DOI: 10.1097/pec.0000000000002610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is limited research examining racial/ethnic disparities in antiemetic use for acute gastroenteritis (AGE). We assessed racial/ethnic differences in the care of children with AGE. METHODS The Pediatric Health Information System was used to conduct a retrospective cohort study of children 6 months to 6 years old with AGE seen in participating emergency departments from 2016 to 2018. Cases were identified using International Classification of Diseases, Tenth Revision codes. The primary outcome was administration of ondansetron, secondary outcomes were administration of intravenous (IV) fluids and hospitalization, and primary predictor was race/ethnicity. Multivariable logistic regression followed by a mixed model adjusted for sex, age, insurance, and hospital to examine the association of race/ethnicity with each outcome. RESULTS There were 78,019 encounters included; 24.8% of patients were non-Hispanic White (NHW), 29.0% non-Hispanic Black (NHB), 37.3% Hispanic, and 8.9% other non-Hispanic (NH) race/ethnicity. Compared with NHW patients, minority children were more likely to receive ondansetron (NHB: adjusted odds ratio, 1.36 [95% confidence interval, 1.2-1.55]; Hispanic: 1.26 [1.1-1.44]; other NH: 1.22 [1.07-1.4]). However, minority children were less likely to receive IV fluids (NHB: 0.38 [0.33-0.43]; Hispanic: 0.44 [0.36-0.53]; other NH: 0.51 [0.44-0.61]) or hospital admission (NHB: 0.37 [0.29-0.48]; Hispanic: 0.41 [0.33-0.5]; other NH: 0.52 [0.41-0.66]). Ondansetron use by hospital ranged from 73% to 95%. CONCLUSIONS This large database analysis of emergency departments around the nation found that NHW patients were less likely to receive ondansetron but more likely to receive IV fluids and hospital admission than minority patients. These findings are likely multifactorial and may represent bias, social determinants of health, access to care, or illness severity among other possible causes.
Collapse
Affiliation(s)
| | | | | | - Pingping Qu
- Biostatistics Epidemiology and Analytics in Research (BEAR), Seattle Children's Research Institute, Seattle, WA
| | | |
Collapse
|
18
|
How Can We Get to Equitable and Effective Postpartum Pain Control? Clin Obstet Gynecol 2022; 65:577-587. [PMID: 35703219 DOI: 10.1097/grf.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Postpartum pain is common, yet patient experiences and clinical management varies greatly. In the United States, pain-related expectations and principles of adequate pain management have been framed within established norms of Western clinical medicine and a biomedical understanding of disease processes. Unfortunately, this positioning of postpartum pain and the corresponding coping strategies and pain treatments is situated within cultural biases and systemic racism. This paper summarizes the history and existing literature that examines racial inequities in pain management to propose guiding themes and suggestions for innovation. This work is critical for advancing ethical practice and establishing more effective care for all patients.
Collapse
|
19
|
Nelson R, Kittel J, Mahoui I, Thornberry D, Dunkman A, Sams M, Adler D, Jones CMC. Racial differences in treatment among patients with acute headache treated in the emergency department and discharged home. Am J Emerg Med 2022; 60:45-49. [DOI: 10.1016/j.ajem.2022.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/10/2022] [Accepted: 05/21/2022] [Indexed: 11/16/2022] Open
|
20
|
Codner JA, Falconer EA, Ashley DW, Sweeney JF, Saeed MI, Langer JM, Shaffer VO, Finley CR, Solomon G, Sharma J. Georgia Quality Improvement Programs Multi-Institutional Collection of Postoperative Opioid Data Using ACS-NSQIP Abstraction. Am Surg 2022; 88:1510-1516. [PMID: 35333645 DOI: 10.1177/00031348221082286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Excessive postoperative opioid prescribing contributes to opioid misuse throughout the US. The Georgia Quality Improvement Program (GQIP) is a collaboration of ACS-NSQIP participating hospitals. GQIP aimed to develop a multi-institutional opioid data collection platform as well as understand our current opioid-sparing strategy (OSS) usage and postoperative opioid prescribing patterns. METHODS This study was initiated 7/2019, when 4 custom NSQIP variables were developed to capture OSS usage and postoperative opioid oral morphine equivalents (OMEs). After pilot collection, our discharge opioid variable required optimization for adequate data capture and was expanded from a free text option to 4 drop-down selection variables. Data collection then continued from 2/2020-5/2021. Logistic regression was used to determine associations with OSS usage. Average OMEs were calculated for common general surgery procedures and compared to national guidelines. RESULTS After variable optimization, the percentage where a total discharge prescription OME could be calculated increased from 26% to 70% (P < .001). The study included 820 patients over 10 operations. There was a significant variation in OSS usage between GQIP centers. Laparoscopic cases had higher odds of OSS use (1.92 (1.38-2.66)) while OSS use had lower odds in black patients on univariate analysis (.69 (.51-.94)). On average 7 out of the 10 cases had higher OMEs prescribed compared to national guidelines recommendations. CONCLUSION Developing a multi-institutional opioid data collection platform through ACS-NSQIP is feasible. Preselected drop-down boxes outperform free text variables. GQIP future quality improvement targets include variation in OSS use and opioid overprescribing.
Collapse
Affiliation(s)
- Jesse A Codner
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Elissa A Falconer
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Dennis W Ashley
- Department of Surgery, 5223Navicent Health Medical Center, Macon, GA, USA
| | - John F Sweeney
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Muhammad I Saeed
- Department of Surgery, 1421Augusta University School of Medicine, Augusta, GA, USA
| | - Jason M Langer
- Department of Surgery, 232321Phoebe Putney Memorial, Albany, GA, USA
| | - Virginia O Shaffer
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Charles R Finley
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Gina Solomon
- Department of Surgery, Georgia Quality Improvement Program, Atlanta, GA, USA
| | - Jyotirmay Sharma
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
21
|
Abstract
The United States healthcare system underperforms in healthcare access, quality, and cost resulting in some of the poorest health outcomes among comparable countries, despite spending more of its gross national product on healthcare than any other country in the world. Within the United States, there are significant healthcare disparities based on race, ethnicity, socioeconomic status, education level, sexual orientation, gender identity, and geographic location. COVID-19 has illuminated the racial disparities in health outcomes. This article provides an overview of some of the main concepts related to health disparities generally, and in orthopaedics specifically. It provides an introduction to health equity terminology, issues of bias and equity, and potential interventions to achieve equity and social justice by addressing commonly asked questions and then introduces the reader to persistent orthopaedic health disparities specific to total hip and total knee arthroplasty.
Collapse
Affiliation(s)
- Susan Salmond
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
| | - Caroline Dorsen
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
| |
Collapse
|
22
|
Akbarian M, Khani A, Eghbalpour S, Uversky VN. Bioactive Peptides: Synthesis, Sources, Applications, and Proposed Mechanisms of Action. Int J Mol Sci 2022; 23:ijms23031445. [PMID: 35163367 PMCID: PMC8836030 DOI: 10.3390/ijms23031445] [Citation(s) in RCA: 121] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 02/01/2023] Open
Abstract
Bioactive peptides are a group of biological molecules that are normally buried in the structure of parent proteins and become active after the cleavage of the proteins. Another group of peptides is actively produced and found in many microorganisms and the body of organisms. Today, many groups of bioactive peptides have been marketed chemically or recombinantly. This article reviews the various production methods and sources of these important/ubiquitous and useful biomolecules. Their applications, such as antimicrobial, antihypertensive, antioxidant activities, blood-lipid-lowering effect, opioid role, antiobesity, ability to bind minerals, antidiabetic, and antiaging effects, will be explored. The types of pathways proposed for bioactive applications will be in the next part of the article, and at the end, the future perspectives of bioactive peptides will be reviewed. Reading this article is recommended for researchers interested in various fields of physiology, microbiology, biochemistry, and nanotechnology and food industry professionals.
Collapse
Affiliation(s)
- Mohsen Akbarian
- Department of Chemistry, National Cheng Kung University, Tainan 701, Taiwan;
| | - Ali Khani
- Department of Radiation Sciences, Faculty of Applied Medicine, Iran University of Medical Sciences, Tehran 1449614535, Iran;
| | - Sara Eghbalpour
- Department of Obstetrics and Gynecology Surgery, Babol University of Medical Sciences, Babol 4717647745, Iran;
| | - Vladimir N. Uversky
- Department of Molecular Medicine and Health Byrd Alzheimer’s Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
- Correspondence: ; Tel.: +1-(813)-974-5816
| |
Collapse
|
23
|
McLane P, Barnabe C, Mackey L, Bill L, Rittenbach K, Holroyd BR, Bird A, Healy B, Janvier K, Louis E, Rosychuk RJ. First Nations status and emergency department triage scores in Alberta: a retrospective cohort study. CMAJ 2022; 194:E37-E45. [PMID: 35039386 PMCID: PMC8900783 DOI: 10.1503/cmaj.210779] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 11/04/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous studies have found that race is associated with emergency department triage scores, raising concerns about potential health care inequity. As part of a project on quality of care for First Nations people in Alberta, we sought to understand the relation between First Nations status and triage scores. METHODS We conducted a population-based retrospective cohort study of health administrative data from April 2012 to March 2017 to evaluate acuity of triage scores, categorized as a binary outcome of higher or lower acuity score. We developed multivariable multilevel logistic mixed-effects regression models using the levels of emergency department visit, patient (for patients with multiple visits) and facility. We further evaluated the triage of visits related to 5 disease categories and 5 specific diagnoses to better compare triage outcomes of First Nations and non-First Nations patients. RESULTS First Nations status was associated with lower odds of receiving higher acuity triage scores (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.92-0.94) compared with non-First Nations patients in adjusted models. First Nations patients had lower odds of acute triage for all 5 disease categories and for 3 of 5 diagnoses, including long bone fractures (OR 0.82, 95% CI 0.76-0.88), acute upper respiratory infection (OR 0.90, 95% CI 0.84-0.98) and anxiety disorder (OR 0.67, 95% CI 0.60-0.74). INTERPRETATION First Nations status was associated with lower odds of higher acuity triage scores across a number of conditions and diagnoses. This may reflect systemic racism, stereotyping and potentially other factors that affected triage assessments.
Collapse
Affiliation(s)
- Patrick McLane
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.
| | - Cheryl Barnabe
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Leslee Mackey
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Lea Bill
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Katherine Rittenbach
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Brian R Holroyd
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Anne Bird
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Bonnie Healy
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Kris Janvier
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Eunice Louis
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| | - Rhonda J Rosychuk
- Alberta Health Services (McLane, Rittenbach, Holroyd), Strategic Clinical Networks; Department of Emergency Medicine (McLane, Mackey, Holroyd), University of Alberta, Edmonton, Alta.; Departments of Medicine and of Community Health Sciences (Barnabe) University of Calgary; Alberta First Nations Information Governance Centre (Bill); Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Yellowhead Tribal Council (Bird), Edmonton, Alta.; Blackfoot Confederacy Tribal Council (Healy), Standoff, Alta.; Organization of Treaty 8 First Nations of Alberta (Janvier), Edmonton, Alta.; Maskwacis Health Services (Louis), Maskwacis, Alta.; Department of Pediatrics (Rosychuk), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta
| |
Collapse
|
24
|
Connelly M, Glynn EF, Hoffman MA, Bickel J. Rates and Predictors of Using Opioids in the Emergency Department to Treat Migraine in Adolescents and Young Adults. Pediatr Emerg Care 2021; 37:e981-e987. [PMID: 31246788 DOI: 10.1097/pec.0000000000001851] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to determine the rate and context in which opioids are used to treat migraine in adolescents and young adults seen in emergency care settings. METHODS Data from 2010 to 2016 in the Cerner Health Facts electronic health record data warehouse were analyzed using multilevel logistic regression to estimate the population likelihood of an opioid being used in the emergency department (ED) to treat a primary diagnosis of migraine in adolescents and young adults and to evaluate the extent to which this likelihood varies as a function of characteristics of the patient (age, sex, race, and insurance), encounter (referral source, provider specialty, and encounter duration and year), and ED (region, setting, size, payer mix, and academic status). RESULTS The study identified 14,494 eligible ED encounters with unique patients, of which 23% involved an opioid. Likelihood of being treated with opioids was significantly higher for patients who were older, female, white, and seen by a surgeon and who had longer encounters and encounters earlier in the time period sampled. Sites varied widely in percentage of encounters involving opioids (mean, 26.4% ± 20.1%; range, 0-100%), with higher rates associated with smaller sites with relatively higher proportions of commercially insured patients. CONCLUSIONS Use of opioids in the ED to treat migraine in youth is fairly common, with rate variation reflecting broader trends in for whom opioids tend to be more likely to be prescribed. These findings may be helpful for benchmarking and informing quality improvement efforts aimed at reducing unwarranted opioid exposure in youth.
Collapse
Affiliation(s)
- Mark Connelly
- From the Children's Mercy Kansas City, Kansas City, MO
| | | | | | | |
Collapse
|
25
|
Al-Dulaimi R, Duong PA, Chan BY, Fuller MJ, Ross AB, Dunn DP. Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009-2018 data from the NHAMCS. Emerg Radiol 2021; 29:125-132. [PMID: 34713355 DOI: 10.1007/s10140-021-01991-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. MATERIALS AND METHODS Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. RESULTS Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. CONCLUSION Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.
Collapse
Affiliation(s)
- Ragheed Al-Dulaimi
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Phuong-Anh Duong
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Brian Y Chan
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Matthew J Fuller
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew B Ross
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Dell P Dunn
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.
| |
Collapse
|
26
|
Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients. J Emerg Med 2021; 61:637-648. [PMID: 34690022 DOI: 10.1016/j.jemermed.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/19/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain. OBJECTIVES Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis. METHODS We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. RESULTS Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90. CONCLUSIONS Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.
Collapse
|
27
|
Rambachan A, Fang MC, Prasad P, Iverson N. Racial and Ethnic Disparities in Discharge Opioid Prescribing From a Hospital Medicine Service. J Hosp Med 2021; 16:589-595. [PMID: 34613895 PMCID: PMC8494281 DOI: 10.12788/jhm.3667] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Differential opioid prescribing patterns have been reported in non-White patient populations. However, these disparities have not been well described among hospitalized medical inpatients. OBJECTIVE To describe differences in opioid prescribing patterns among inpatients discharged from the general medicine service based on race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS For this retrospective study, we performed a multivariable logistic regression for patient race/ethnicity and whether patients received an opioid prescription at discharge and a negative binomial regression for days of opioids prescribed at discharge. The study included all 10,953 inpatients discharged from the general medicine service from June 2012 to November 2018 at University of California San Francisco Medical Center who received opioids during the last 24 hours of their hospitalization. MAIN OUTCOMES AND MEASURES We examined two primary outcomes: whether a patient received an opioid prescription at discharge, and, for patients prescribed opioids, the number of days dispensed. RESULTS Compared with White patients, Black patients were less likely to receive an opioid prescription at discharge (predicted population rate of 47.6% vs 50.7%; average marginal effect [AME], -3.1%; 95% CI, -5.5% to -0.8%). Asian patients were more likely to receive an opioid prescription on discharge (predicted population rate, 55.6% vs 50.7%; AME, +4.9; 95% CI, 1.5%-8.3%). We also found that Black patients received a shorter duration of opioid days compared with White patients (predicted days of opioids on discharge, 15.7 days vs 17.8 days; AME, -2.1 days; 95% CI, -3.3 to -0.9). CONCLUSION Black patients were less likely to receive opioids and received shorter courses at discharge compared with White patients, adjusting for covariates. Asian patients were the most likely to receive an opioid prescription.
Collapse
Affiliation(s)
- Aksharananda Rambachan
- Division of Hospital MedicineUniversity of California, San Francisco, San Francisco, California
- Corresponding Author: Aksharananda Rambachan, MD, MPH;
| | - Margaret C Fang
- Division of Hospital MedicineUniversity of California, San Francisco, San Francisco, California
| | - Priya Prasad
- Division of Hospital MedicineUniversity of California, San Francisco, San Francisco, California
| | - Nicholas Iverson
- Division of Hospital Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| |
Collapse
|
28
|
Wiggins AJ, Agha O, Diaz A, Jones KJ, Feeley BT, Pandya NK. Current Perceptions of Diversity Among Head Team Physicians and Head Athletic Trainers: Results Across US Professional Sports Leagues. Orthop J Sports Med 2021; 9:23259671211047271. [PMID: 34660831 PMCID: PMC8516385 DOI: 10.1177/23259671211047271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/02/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Discrepancies in race, ethnicity, and sex among health care providers and their patients have been shown to affect the patient-provider relationship as well as the quality of care. Currently, minority and female representation among orthopaedic surgeons remains low. Given the large proportion of minority athletes and their degree of public visibility, professional sports serves as an important arena within which to analyze the diversity of health care providers. PURPOSE To describe and evaluate the current level of diversity of head team physicians (HTPs) and head athletic trainers (ATCs), primarily in terms of race and sex, within men's professional sports leagues in the United States. STUDY DESIGN Cross-sectional study. METHODS Five major US professional sports leagues were evaluated: National Basketball Association, National Football League, National Hockey League, Major League Soccer, and Major League Baseball. Publicly available data were collected to identify the HTPs and head ATCs for each team within these leagues. Two independent observers analyzed photographs and names of these individuals to determine his or her perceived race and sex, with disagreements being resolved by a third independent observer. Other physician data collected included graduate degree(s), specialty, and number of years in practice. Kappa coefficients (κ) were employed to evaluate interobserver reliability. Chi-square, Fisher exact, and t tests were used for statistical comparisons across leagues. RESULTS The κ values for perceived race were 0.85 for HTPs and 0.89 for head ATCs, representing near-perfect interobserver agreement. Minorities comprised 15.5% of HTPs and 20.7% of ATCs (P = .24). Women comprised 3.9% of HTPs and 1.3% of head ATCs (P = .017). The majority of HTPs were orthopaedic surgeons with medical doctorates. Female HTPs had significantly fewer years in practice compared with male HTPs (15.0 ± 4.9 vs 23.1 ± 9.6; P = .04). CONCLUSION The lead physicians and athletic training providers for men's professional sports teams demonstrated low rates of minority and female representation, denoting a highly visible area for discussing the role of increased diversity in health care.
Collapse
Affiliation(s)
- Anthony J. Wiggins
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Obiajulu Agha
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Agustin Diaz
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Brian T. Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
29
|
Abstract
OBJECTIVES Health disparities between racial and ethnic groups have been documented in Canada, the United States, and Australia. Despite evidence that differences in emergency department (ED) care based on patient race and ethnicity exist, there are no comprehensive literature reviews in this area. The objective of this review is to provide an overview of the literature on the impact of patient ethnicity and race on the processes of ED care. METHODS A scoping review was conducted to capture the broad nature of the literature. A database search was conducted in MEDLINE/PubMed, EMBASE, CINAHL Plus, Social Sciences Citation Index, SCOPUS, and JSTOR. Five journals and reference lists of included articles were hand searched. Inclusion and exclusion criteria were defined iteratively to ensure literature captured was relevant to our research question. Data were extracted using predetermined variables, and additional extraction variables were added as familiarity with the literature developed. RESULTS Searching yielded 1,157 citations, reduced to 153 following removal of duplicates, and title and abstract screening. After full-text screening, 83 articles were included. Included articles report that, in EDs, patient race and ethnicity impact analgesia, triage scores, wait times, treatments, diagnostic procedure utilization, rates of patients leaving without being seen, and patient subjective experiences. Authors of included studies propose a variety of possible causes for these disparities. CONCLUSIONS Further research on the existence of disparities in care within EDs is warranted to explore the causes behind observed disparities for particular health conditions and population groups in specific contexts.
Collapse
|
30
|
Beck AS, Svirsky L, Howard D. 'First Do No Harm': physician discretion, racial disparities and opioid treatment agreements. JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2020-107030. [PMID: 34330795 DOI: 10.1136/medethics-2020-107030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
The increasing use of opioid treatment agreements (OTAs) has prompted debate within the medical community about ethical challenges with respect to their implementation. The focus of debate is usually on the efficacy of OTAs at reducing opioid misuse, how OTAs may undermine trust between physicians and patients and the potential coercive nature of requiring patients to sign such agreements as a condition for receiving pain care. An important consideration missing from these conversations is the potential for racial bias in the current way that OTAs are incorporated into clinical practice and in the amount of physician discretion that current opioid guidelines support. While the use of OTAs has become mandatory in some states for certain classes of patients, physicians are still afforded great leeway in how these OTAs are implemented in clinical practice and how their terms should be enforced. This paper uses the guidelines provided for OTA implementation by the states of Indiana and Pennsylvania as case studies in order to argue that giving physicians certain kinds of discretion may exacerbate racial health disparities. This problem cannot simply be addressed by minimising physician discretion in general, but rather by providing mechanisms to hold physicians accountable for how they treat patients on long-term opioid therapy to ensure that such treatment is equitable.
Collapse
Affiliation(s)
| | - Larisa Svirsky
- Department of Philosophy, Brandeis University, Waltham, Massachusetts, USA
| | - Dana Howard
- Center for Bioethics, The Ohio State University OSUMC, Columbus, Ohio, USA
| |
Collapse
|
31
|
Abstract
OBJECTIVES The aim of this study was to determine if a racial disparity exists in the administration of an analgesic, time to receiving analgesic, and type of analgesic administered to children with long-bone fractures. Prior studies have reported the existence of racial disparity but were mostly in adult and urban populations. METHODS This is a retrospective chart review of 727 pediatric patients (aged 2-17 years) with International Classification of Diseases, Ninth Revision (or 10th revision) codes for long-one fractures in an emergency department that cares for a suburban and rural population between January 2013 and January 2016. Logistic regression was used to estimate the odds ratio of receiving no analgesic versus receiving an analgesic and receiving a nonopioid versus opioid drug. Linear regression analysis was performed to study the relationship between race and time to receive the analgesic, after adjusting for sex, age, insurance type, and mechanism of injury. RESULTS Of the 727 children, 27% of them did not receive analgesics regardless of race. 27% (164/605) of white children, 25% (8/31) of African American children, and 24% (12/49) of Hispanic children did not receive analgesics. African Americans are 12% more likely (odds ratio [OR], 1.12; 95% confidence interval [CI], 0.48-2.61) to receive an analgesic compared with whites, and Hispanics are 22% more likely (OR, 1.22; 95% CI, 0.60-2.45) to receive an analgesic than whites. African Americans are 26% less likely (OR, 0.74; 95% CI, 0.31-1.75) to receive an opioid versus a nonopioid compared with whites, and Hispanics are 92% more likely (OR, 1.92; 95% CI, 0.91-4.17). Mean wait time across all races was 69 minutes, with no statistical difference between groups. CONCLUSIONS This study showed no statistical significance in the receipt or type of analgesic or wait time for pediatric long-bone fractures between race in a major academic level 1 trauma children's hospital, despite previous literature citing otherwise. This study augments to the few studies conducted in a rural setting. It is also one of the few studies that analyzed pain management in a large pediatric population as well as used waiting time to receive analgesic as an outcome measure. Overall, we found a mean wait time of 69 minutes for analgesic administration regardless of race, suggesting the need for more prompt pain management across all races for the management of long-bone fracture in the pediatric population.
Collapse
|
32
|
Kosik KB, Bowers LC, Hoch MC, Humphries RL, Thurza MP, Bain KA, Slone S, Gribble PA. Pain Medication Administered and Prescribed to Patients With an Ankle Sprain Treated in an Emergency Department: A Record-Based Cohort Study. J Emerg Nurs 2021; 47:609-620.e3. [PMID: 33618903 DOI: 10.1016/j.jen.2020.12.011] [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: 09/29/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Recent data indicate that patients treated in the emergency department for an ankle sprain receive multiple medications. However, research has not been able to accurately identify all the medications because of study limitations. The primary purpose of this study was to document the type of medication, number of doses, and number of encounters given a prescription at discharge or instructions to take over-the-counter medication. The secondary purpose was to determine if the proportion of encounters given each type of medication varied on the basis of age, sex, race, and year. METHODS A retrospective record-based cohort study design was used to review the electronic medical records (N = 1740) of encounters reporting to a southeast academic level 1 trauma center and diagnosed with an ankle sprain between 2013 and 2017. All relevant data were extracted for nonsteroidal anti-inflammatory drugs, muscle relaxants, opioids, and nonopioid analgesics. RESULTS Fifty-eight percent of the encounters had at least 1 dose of medication administered in the emergency department. Twenty-eight percent received a prescription at discharge, and 54.5% were instructed to take over-the-counter medication. Cumulatively, opioids accounted for most of the medications, but the yearly rates declined from 2013 to 2017. A greater proportion of patients aged ≤15 years received nonsteroidal anti-inflammatory drugs or nonopioid analgesics. Most of the patients aged >15 years received opioid medication. DISCUSSION Patients are primarily given an opioid or nonsteroidal anti-inflammatory drug in the emergency department. Fewer patients receive a prescription at discharge but are regularly instructed to take over-the-counter medication.
Collapse
|
33
|
Brown JH, Torres HP, Maddi RD, Williams JL, Dibaj SS, Liu D, Bruera E. Cancer Patients' Perceived Difficulties Filling Opioid Prescriptions After Receiving Outpatient Supportive Care. J Pain Symptom Manage 2020; 60:915-922. [PMID: 32569832 PMCID: PMC7305512 DOI: 10.1016/j.jpainsymman.2020.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Limited access to opioids for patients with cancer has been reported as a potential unintended consequence of recent regulations restricting opioid use and prescribing practices. To our knowledge, there are a limited number of peer-reviewed studies that evaluate the perceived difficulties of the patients with cancer when filling their opioid prescription. To understand these difficulties, we surveyed patients receiving opioids in our outpatient supportive care center (SCC). OBJECTIVES The primary objective of this study was to evaluate cancer patients' perceptions of overall difficulties when filling their opioid prescription. Secondary objectives included determining associations between patient characteristics and difficulty and comparing difficulty between filling opioid and nonopioid prescriptions. METHODS Patients with cancer receiving opioids that had been seen two times or more at our SCC were asked to complete a survey. The information collected included patient demographics, clinical characteristics, and patients' experiences filling their opioid prescription. RESULTS The patients' median age was 60 years; 54% were female and 69% were white. Forty-four patients (32%) reported that they have experienced difficulty filling their opioid prescription. More than 25% of those 44 patients perceived difficulty from interactions with the pharmacy and/or pharmacist. Forty-six patients (33%) reported more difficulty filling their opioid prescriptions than filling their nonopioid prescriptions. CONCLUSION This study provides evidence that patients with cancer visiting our SCC perceived difficulties obtaining their opioid prescriptions. The results suggest that negative interactions with the pharmacy and/or pharmacist contribute to their perceived difficulty. Additional research is needed to further characterize the contributors of the difficulties patients with cancer face in filling their opioid prescriptions.
Collapse
Affiliation(s)
- Jessica H Brown
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hilda P Torres
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rama D Maddi
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet L Williams
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Seyedeh S Dibaj
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| |
Collapse
|
34
|
Ehwerhemuepha L, Donaldson CD, Kain ZN, Luong V, Fortier MA, Feaster W, Weiss M, Tomaszewski D, Yang S, Phan M, Jenkins BN. Race, Ethnicity, and Insurance: the Association with Opioid Use in a Pediatric Hospital Setting. J Racial Ethn Health Disparities 2020; 8:1232-1241. [PMID: 33000430 DOI: 10.1007/s40615-020-00882-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND This study examined the association between race/ethnicity and health insurance payer type with pediatric opioid and non-opioid ordering in an inpatient hospital setting. METHODS Cross-sectional inpatient encounter data from June 2013 to June 2018 was retrieved from a pediatric children's hospital in Southern California (N = 55,944), and statistical analyses were performed to determine associations with opioid ordering. RESULTS There was a significant main effect of race/ethnicity on opioid and non-opioid orders. Physicians ordered significantly fewer opioid medications, but a greater number of non-opioid medications, for non-Hispanic African American children than non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic White pediatric patients. There was also a main effect of health insurance payer type on non-opioid orders. Patients with government-sponsored plans (e.g., Medi-Cal, Medicare) received fewer non-opioid prescriptions compared with patients with both HMO and PPO coverage. Additionally, there was a significant race/ethnicity by insurance interaction on opioid orders. Non-Hispanic White patients with "other" insurance coverage received the greatest number of opioid orders. In non-Hispanic African American patients, children with PPO coverage received fewer opioids than those with government-sponsored and HMO insurance. For non-Hispanic Asian patients, children with PPO were prescribed more opioids than those with government-sponsored and HMO coverage. CONCLUSION Findings suggest that the relationship between race/ethnicity, insurance type, and physician decisions opioid prescribing is complex and multifaceted. Given that consistency in opioid prescribing should be seen regardless of patient background characteristics, future studies should continue to assess and monitor unequitable differences in care.
Collapse
Affiliation(s)
- Louis Ehwerhemuepha
- Department of Information Systems, Children's Hospital of Orange County, CA, 92868, Orange, USA
| | - Candice D Donaldson
- Department of Psychology, Chapman University, Orange, CA, 92866, USA
- Center on Stress & Health, University of California Irvine, Orange, CA, 92868, USA
| | - Zeev N Kain
- Center on Stress & Health, University of California Irvine, Orange, CA, 92868, USA
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, 92697, USA
- Children's Hospital of Orange County, Orange, CA, 92868, USA
| | - Vivian Luong
- Department of Psychology, Chapman University, Orange, CA, 92866, USA
- Center on Stress & Health, University of California Irvine, Orange, CA, 92868, USA
| | - Michelle A Fortier
- Center on Stress & Health, University of California Irvine, Orange, CA, 92868, USA
- Children's Hospital of Orange County, Orange, CA, 92868, USA
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA, 92697, USA
| | - William Feaster
- Department of Information Systems, Children's Hospital of Orange County, CA, 92868, Orange, USA
| | - Michael Weiss
- Population Health, Children's Hospital of Orange County, Orange, CA, 92868, USA
| | - Daniel Tomaszewski
- School of Pharmacy Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, 90089, USA
| | - Sun Yang
- School of Pharmacy, Department of Pharmacy Practice, Chapman University, Orange, CA, 92868, USA
| | - Michael Phan
- School of Pharmacy, Department of Biomedical and Pharmaceutical Sciences, Chapman University, Orange, CA, 92868, USA
| | - Brooke N Jenkins
- Department of Psychology, Chapman University, Orange, CA, 92866, USA.
- Center on Stress & Health, University of California Irvine, Orange, CA, 92868, USA.
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, 92697, USA.
| |
Collapse
|
35
|
Curatolo M. Common Biological Modulators of Acute Pain: An Overview Within the AAAPT Project (ACTTION-APS-AAPM Acute Pain Taxonomy). PAIN MEDICINE 2020; 21:2394-2400. [PMID: 32747929 DOI: 10.1093/pm/pnaa207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) project relies on the identification of modulators to improve characterization and classification of acute pain conditions. In the frame of the AAAPT effort, this paper presents an overview of common biological modulators of acute pain. METHODS Nonsystematic overview. RESULTS Females may experience more acute pain than males, but the clinical significance may be modest. Increasing age is associated with decreasing analgesic requirement and decreasing pain intensity after surgery and with higher risk of acute low back pain. Racial and ethnic minorities have worse pain, function, and perceived well-being. Patients with preexisting chronic pain and opioid use are at higher risk of severe acute pain and high opioid consumption. The OPRM1 gene A118G polymorphism is associated with pain severity and opioid consumption, with modest quantitative impact. Most studies have found positive associations between pain sensitivity and intensity of acute clinical pain. However, the strength of the association is unclear. Surgical techniques, approaches, and complications influence postoperative pain. CONCLUSIONS Sex, age, race, ethnicity, preexisting chronic pain and opioid use, surgical approaches, genetic factors, and pain sensitivity are biological modulators of acute pain. Large studies with multisite replication will quantify accurately the association between modulators and acute pain and establish the value of modulators for characterization and classification of acute pain conditions, as well as their ability to identify patients at risk of uncontrolled pain. The development and validation of quick, bed-side pain sensitivity tests would allow their implementation as clinical screening tools. Acute nonsurgical pain requires more investigation.
Collapse
Affiliation(s)
- Michele Curatolo
- Department of Anesthesiology & Pain Medicine, Harborview Injury Preventions and Research Center (HIPRC), University of Washington, Seattle, Washington, USA
| |
Collapse
|
36
|
Wentz AE, Wang RRC, Marshall BDL, Shireman TI, Liu T, Merchant RC. Variation in opioid analgesia administration and discharge prescribing for emergency department patients with suspected urolithiasis. Am J Emerg Med 2020; 38:2119-2124. [PMID: 33071098 PMCID: PMC7704692 DOI: 10.1016/j.ajem.2020.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/03/2020] [Accepted: 07/03/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Previous research has suggested caution about opioid analgesic usage in the emergency department (ED) setting and raised concerns about variations in prescription opioid analgesic usage, both across institutions and for whom they are prescribed. We examined opioid analgesic usage in ED patients with suspected urolithiasis across fifteen participating hospitals. METHODS This is a secondary analysis of a clinical trial including adult ED patients with suspected urolithiasis. In multilevel models accounting for clustering by hospital, we assessed demographic, clinical, state-level, and hospital-level factors associated with opioid analgesic administration during the ED visit and prescription at discharge. RESULTS Of 2352 participants, 67% received an opioid analgesic during the ED visit and 61% were prescribed one at discharge. Opioid analgesic usage varied greatly across hospitals, ranging from 46% to 88% (during visit) and 34% to 85% (at discharge). Hispanic patients were less likely than non-Hispanic white patients to receive opioid analgesics during the ED visit (OR 0.72, 95% CI 0.55-0.94). Patients with higher education (OR 1.29, 95% CI 1.05-1.59), health insurance coverage (OR 1.27, 95% CI 1.02-1.60), or receiving care in states with a prescription drug monitoring program (OR 1.64, 95% CI 1.06-2.53) were more likely to receive an opioid analgesic prescription at ED discharge. CONCLUSION We found marked hospital-level differences in opioid analgesic administration and prescribing, as well as associations with education, healthcare insurance, and race/ethnicity groups. These data might compel clinicians and hospitals to examine their opioid use practices to ensure it is congruent with accepted medical practice.
Collapse
Affiliation(s)
- Anna E Wentz
- Brown University School of Public Health, Department of Epidemiology, Box G-121-3, Providence, RI 02912, USA.
| | - Ralph R C Wang
- Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Brandon D L Marshall
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA.
| | - Theresa I Shireman
- Brown University School of Public Health, Health Services Policy & Practice, Providence, RI, USA.
| | - Tao Liu
- Brown University School of Public Health, Data & Statistics Core of Brown Alcohol Research Center on HIV (ARCH), Providence, RI, USA.
| | - Roland C Merchant
- Harvard Medical School, Brigham and Women's Hospital Department of Emergency Medicine, Boston, MA, USA.
| |
Collapse
|
37
|
Lee J, Jotwani R, S White R. The economic cost of racial disparities in chronic pain. J Comp Eff Res 2020; 9:903-906. [DOI: 10.2217/cer-2020-0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jane Lee
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, NY 10065, USA
| | - Rohan Jotwani
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, NY 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, NY 10065, USA
| |
Collapse
|
38
|
Long W, Shattuck B, Bauler L. Spontaneous iliac vein rupture in the setting of a long dwelling intravenous vena cava filter. Forensic Sci Med Pathol 2020; 16:693-696. [PMID: 32676755 DOI: 10.1007/s12024-020-00278-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 11/27/2022]
Abstract
Venous thromboembolism impacts as many as 600,000 individuals each year in the United States, leading to significant morbidity and mortality. While typically treated with anticoagulants, retrievable inferior vena cava (IVC) filters may also be used for acute prevention of pulmonary embolism. The FDA recommends removing IVC filters within 29-54 days because long dwelling filters are associated with serious complications from the filter itself, such as perforation of adjacent structures and filter fracture. We report an unusual case in which a patient had an inferior venous cava filter in place for two years before experiencing spontaneous rupture of the left iliac vein. There was no evidence of filter migration or inferior venous cava perforation. Spontaneous iliac vein ruptures are rare, with fewer than 50 reported cases, and are not typically seen with a long-dwelling IVC. This case describes a unique complication of retrievable filters and highlights the importance of retrieving filters as soon as the acute danger of pulmonary embolism has resolved.
Collapse
Affiliation(s)
- Winnie Long
- Western Michigan University Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, 49008, USA
| | - Brandy Shattuck
- Department of Pathology, Western Michigan University Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, 49008, USA
| | - Laura Bauler
- Department of Biomedical Sciences and Department of Medical Education, Western Michigan University Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, 49008, USA.
| |
Collapse
|
39
|
Kline JA, Lin MP, Hall CL, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Runyon MS, Wang H, Courtney DM. Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging. J Patient Exp 2020; 7:386-394. [PMID: 32821799 PMCID: PMC7410137 DOI: 10.1177/2374373519838529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED). METHODS Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education. RESULTS We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics. CONCLUSION Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.
Collapse
Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michelle P Lin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Erin Dehon
- Department of Emergency Medicine, University of Mississippi, Jackson, MS, USA
| | - Damon R Kuehl
- Department of Emergency Medicine, Virginia Tech-Carilion, Roanoke, VA, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama, Birmingham, AL, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Hao Wang
- Department of Emergency Medicine, John Peter Smith Hospital, Ft. Worth, TX, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University School of Medicine, Chicago, IL, USA
| |
Collapse
|
40
|
|
41
|
Johnson JD, Asiodu IV, McKenzie CP, Tucker C, Tully KP, Bryant K, Verbiest S, Stuebe AM. Racial and Ethnic Inequities in Postpartum Pain Evaluation and Management. Obstet Gynecol 2019; 134:1155-1162. [PMID: 31764724 DOI: 10.1097/aog.0000000000003505] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate whether the frequency of pain assessment and treatment differed by patient race and ethnicity for women after cesarean birth. METHODS We performed a retrospective cohort study of all women who underwent cesarean birth resulting in a liveborn neonate at a single institution between July 1, 2014, and June 30, 2016. Pain scores documented and medications administered after delivery were grouped into 0-24 and 25-48 hours postpartum time periods. Number of pain scores recorded, whether any pain score was 7 of 10 or greater, and analgesic medication administered were calculated. Models were adjusted for propensity scores incorporating maternal age, body mass index, gestational age, nulliparity, primary compared with repeat cesarean delivery, classical hysterotomy, and admission to the neonatal intensive care unit. RESULTS A total of 1,987 women were identified, and 1,701 met inclusion criteria. There were 30,984 pain scores documented. Severe pain (7/10 or greater) was more common among black (28%) and Hispanic (22%) women than among women who identified as white (20%) or Asian (15%). In the first 24 hours after cesarean birth, non-Hispanic white women had more documented pain assessments (adjusted mean 10.2) than, black, Asian, and Hispanic women (adjusted mean 8.4-9.5; P<.05). Results at 25-48 hours were similar, compared with non-Hispanic white women (adjusted mean 8.3). Black, Asian, and Hispanic women and women who were identified as other all received less narcotic medication at 0-24 hours postpartum (adjusted mean 5.1-7.5 oxycodone tablet equivalents; P<.001-.05), as well as at 25-28 hours postpartum. CONCLUSION Racial and ethnic inequities in the experience, assessment and treatment of postpartum pain were identified. A limitation of our study is that we were unable to assess the role of patient beliefs about expression of pain, patient preferences with regards to pain medication, and beliefs and potential biases among health care providers.
Collapse
Affiliation(s)
- Jasmine D Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina, Chapel Hill, North Carolina; the Department of Family Health Care Nursing, University of California-San Francisco, San Francisco, California; and the University of North Carolina School of Medicine, the Carolina Global Breastfeeding Institute and the Department of Maternal and Child Health, Gillings School of Global Public Health, and the University of North Carolina School of Social Work, Chapel Hill, North Carolina
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Aronowitz SV, Mcdonald CC, Stevens RC, Richmond TS. Mixed studies review of factors influencing receipt of pain treatment by injured black patients. J Adv Nurs 2019; 76:34-46. [DOI: 10.1111/jan.14215] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 07/12/2019] [Accepted: 08/28/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Robin C. Stevens
- School of Nursing University of Pennsylvania Philadelphia PA USA
| | | |
Collapse
|
43
|
Romanelli RJ, Shen Z, Szwerinski N, Scott A, Lockhart S, Pressman AR. Racial and Ethnic Disparities in Opioid Prescribing for Long Bone Fractures at Discharge From the Emergency Department: A Cross-sectional Analysis of 22 Centers From a Health Care Delivery System in Northern California. Ann Emerg Med 2019; 74:622-631. [PMID: 31272820 DOI: 10.1016/j.annemergmed.2019.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/29/2019] [Accepted: 05/09/2019] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We examine racial and ethnic differences in opioid prescribing and dosing for long bone fractures at emergency department (ED) discharge. METHODS We conducted an electronic health records-based cross-sectional study of adults with long bone fractures who presented to the ED across 22 sites from a health care delivery system (2016 to 2017). We examined differences in opioid prescribing at ED discharge and, among patients with a prescription, differences in opioid dosing (measured as morphine milligram equivalents) by race/ethnicity, using regression modeling with statistical adjustment for patient, fracture, and prescriber characteristics. RESULTS A total of 11,576 patients with long bone fractures were included in the study; 64.4% were non-Hispanic white; 16.4%, 7.3%, 5.8%, and 5.1%, respectively, were Hispanic, Asian, black, and of other or unknown race; and 65.6% received an opioid at discharge. After adjusting for other factors, rates of opioid prescribing were not different by race/ethnicity; however, among patients with an opioid prescription, total morphine milligram equivalent units prescribed were 4.3%, 6.0%, and 8.1% less for Hispanics, blacks, and Asians relative to non-Hispanic whites. CONCLUSION Racial and ethnic minority groups with long bone fractures receive similar frequencies of opioid prescriptions at discharge, with a small potency difference. How this affects pain relief and why it happens is unclear.
Collapse
Affiliation(s)
- Robert J Romanelli
- Sutter Health, Palo Alto Medical Foundation Research Institute, Palo Alto, CA.
| | - Zijun Shen
- Sutter Health, Division of Research, Development & Dissemination, Walnut Creek, CA
| | - Nina Szwerinski
- Sutter Health, Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Alexandra Scott
- Sutter Health, Division of Research, Development & Dissemination, Walnut Creek, CA
| | | | - Alice R Pressman
- Sutter Health, Division of Research, Development & Dissemination, Walnut Creek, CA
| |
Collapse
|
44
|
Abstract
African Americans experience a greater burden of acute pain than non-Hispanic white individuals across of variety of acute medical conditions, but it is unknown whether this is the case after trauma. We evaluated pain, pain-related characteristics (eg, peritraumatic distress), and analgesic treatment in 2 cohorts of individuals (African American [n = 931] and non-Hispanic white [n = 948]) presenting to the emergency department (ED) after a motor vehicle collision. We performed a propensity-matched analysis (n = 796 in each group) to assess racial differences in acute pain in the ED. In multivariable models conducted within the matched sample, race was associated with moderate to severe axial pain (odds ratio [OR] 3.2; 95% confidence interval [CI]: 2.1-5.0, P < 0.001) and higher average numerical rating scale scores (1.3; 95% CI: 1.1-1.6; P < 0.001). After adjustment for pain and other covariates, non-Hispanic white patients were more likely to receive an opioid analgesic in the ED (OR 2.0; 95% CI: 1.4-3.0, P < 0.001) or at discharge (OR 4.9; 95% CI: 3.4-7.1, P < 0.001) and also less likely to receive an NSAID in the ED (OR 0.54; 95% CI: 0.38-0.78; P = 0.001) or at discharge (0.31; 95% CI: 0.43-0.84). Racial differences in the severity of acute posttraumatic pain after a motor vehicle collision are not explained by factors such as socioeconomic status or crash characteristics. Despite a higher burden of acute pain, African Americans were less likely to receive opioid analgesics and more likely to receive NSAIDs. Further work is needed to understand the relationship between pain severity, disparities in analgesic treatment, and longer term outcomes, such as post-motor vehicle collision chronic pain.
Collapse
|
45
|
de Angelis P, Kaufman EJ, Barie PS, Narayan M, Smith K, Winchell RJ. Disparities in Timing of Trauma Consultation: A Trauma Registry Analysis of Patient and Injury Factors. J Surg Res 2019; 242:357-362. [PMID: 31132627 DOI: 10.1016/j.jss.2019.04.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/10/2019] [Accepted: 04/25/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Efficient trauma systems rely on field and emergency department (ED) personnel to triage patients to the appropriate level of care. Undertriage puts patients at risk, whereas overtriage results in system strain. Although much research has focused on prehospital triage, little is known about trauma triage processes within the ED. We investigated the timing of trauma consultation in the ED of a level I trauma center. We hypothesized that patient characteristics and injury type would be associated with time to consultation, with women, Black patients, older patients, and those with head and torso injuries experiencing longer time to consult. MATERIALS AND METHODS Patients aged ≥18 y referred to the trauma service via consultation were recruited retrospectively. Bivariable and multivariable negative binomial regressions were used to assess the association between patient and injury characteristics and time to consult. We used multivariable logistic regression adjusted for patient and injury characteristics to assess for association between time to consult and mortality and length of stay. RESULTS Among 588 adult consult patients, median time to consult was 177 min (interquartile range 106-265). In multivariable analysis, Black patients had longer time to consult (incidence rate ratio [IRR] 1.33, 95% confidence interval [CI] 1.10, 1.60) as did women (IRR 1.15, 95% CI 1.02, 1.29). Head injury was associated with shorter time to consult (IRR 0.81, 95% CI 0.71, 0.92). Time to consult was not associated with mortality or length of stay. CONCLUSIONS Patient demographics and injury characteristics influenced the timing of trauma consultation. More robust criteria for equitable evaluation of patients are needed to eliminate disparities, prevent delays, and streamline care.
Collapse
Affiliation(s)
- Paolo de Angelis
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Elinore J Kaufman
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY.
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Mayur Narayan
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Kira Smith
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Robert J Winchell
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| |
Collapse
|
46
|
Racial/Ethnic Disparities in Pain Burden and Pain Management in the Context of Opioid Overdose Risk. CURR EPIDEMIOL REP 2019. [DOI: 10.1007/s40471-019-00202-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
47
|
McCallum KJ, Jackson D, Walthall H, Aveyard H. Exploring the quality of the dying and death experience in the Emergency Department: An integrative literature review. Int J Nurs Stud 2018; 85:106-117. [DOI: 10.1016/j.ijnurstu.2018.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 10/16/2022]
|
48
|
Pain and itch outcome trajectories differ among European American and African American survivors of major thermal burn injury. Pain 2018; 158:2268-2276. [PMID: 28796116 DOI: 10.1097/j.pain.0000000000001029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
More than half of individuals experiencing major thermal burn injury (MThBI) receive an autologous skin graft (autograft), in which skin is removed from a healthy "donor" site and transplanted to the burn site. Persistent pain and itch at the graft site are major causes of suffering and disability in MThBI survivors. African Americans have a higher risk of MThBI, and in other clinical settings African Americans experience a greater burden of pain and itch relative to European Americans. However, to our knowledge, ethnic differences in skin graft site pain and itch outcomes after MThBI have not been assessed. We evaluated skin graft site pain and itch severity (0-10 Numeric Rating Scale [NRS]) over 1 year in a prospective multicenter cohort sample of African Americans and European Americans. In adjusted linear mixed models, African Americans experienced a slower rate of pain resolution in the acute phase of recovery (β = -0.05 vs -0.08 NRS points per day, P < 0.001), which resulted in a higher pain severity in the persistent phase of recovery (NRS mean difference = 1.21, 95% confidence interval [0.12-2.29]), although not statistically significant after correction for multiple comparisons. African Americans also experience greater itch severity in 6 weeks to 12 months after burn injury compared with European Americans (NRS mean difference = 1.86 [0.80-2.93]), which results from a faster rate of itch development in African Americans in the acute recovery phase after burn injury. Future studies may improve outcomes in African Americans and lead to new pathogenic insights that benefit all burn injury survivors.
Collapse
|
49
|
Ranapurwala SI, Naumann RB, Austin AE, Dasgupta N, Marshall SW. Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base. Pharmacoepidemiol Drug Saf 2018; 28:4-12. [PMID: 29862602 DOI: 10.1002/pds.4564] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/29/2018] [Accepted: 05/03/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE The ongoing opioid epidemic has claimed more than a quarter million Americans' lives over the past 15 years. The epidemic began with an escalation of prescription opioid deaths and has now evolved to include secondary waves of illicit heroin and fentanyl deaths, while the deaths due to prescription opioid overdoses are still increasing. In response, the Centers for Disease Control and Prevention (CDC) moved to limit opioid prescribing with the release of opioid prescribing guidelines for chronic noncancer pain in March 2016. The guidelines represent a logical and timely federal response to this growing crisis. However, CDC acknowledged that the evidence base linking opioid prescribing to opioid use disorders and overdose was grades 3 and 4. METHODS Motivated by the need to strengthen the evidence base, this review details limitations of the opioid safety studies cited in the CDC guidelines with a focus on methodological limitations related to internal and external validity. RESULTS Internal validity concerns were related to poor confounding control, variable misclassification, selection bias, competing risks, and potential competing interventions. External validity concerns arose from the use of limited source populations, historical data (in a fast-changing epidemic), and issues with handling of cancer and acute pain patients' data. We provide a nonexhaustive list of 7 recommendations to address these limitations in future opioid safety studies. CONCLUSION Strengthening the opioid safety evidence base will aid any future revisions of the CDC guidelines and enhance their prevention impact.
Collapse
Affiliation(s)
- Shabbar I Ranapurwala
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca B Naumann
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna E Austin
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nabarun Dasgupta
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephen W Marshall
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
50
|
Scarborough B, Smith CB. Optimal pain management for patients with cancer in the modern era. CA Cancer J Clin 2018; 68:182-196. [PMID: 29603142 PMCID: PMC5980731 DOI: 10.3322/caac.21453] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 02/22/2018] [Accepted: 03/02/2018] [Indexed: 11/18/2022] Open
Abstract
Pain is a common symptom among patients with cancer. Adequate pain assessment and management are critical to improve the quality of life and health outcomes in this population. In this review, the authors provide a framework for safely and effectively managing cancer-related pain by summarizing the evidence for the importance of controlling pain, the barriers to adequate pain management, strategies to assess and manage cancer-related pain, how to manage pain in patients at risk of substance use disorder, and considerations when managing pain in a survivorship population. CA Cancer J Clin 2018;68:182-196. © 2018 American Cancer Society.
Collapse
Affiliation(s)
- Bethann Scarborough
- Brookdale Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Cardinale B. Smith
- Brookdale Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, NY, NY
- Division of Hematology/Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| |
Collapse
|