How to Improve Health Disparities in Acute Pain Management in EDs

Retrospective chart review shows health disparities in acute pain management among racial/ethnic minority patients and women in an emergency department.

Approximately 151 million patients visited emergency departments (EDs) in 2019 and the most common complaint was abdominal pain, according to data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).1 Even though acute pain is a common concern triggering ED visits, the undertreatment of pain remains an emergency medicine issue.2 In 2019, non-Hispanic Black people visited EDs at twice the rate of nonHispanic White people.1,2 However, research suggests that racial/ethnic minority patients and women often receive fewer pain medications than non-Hispanic White men.3-7

In the 1990s, increased efforts to treat pain as the fifth vital sign were intended to improve pain treatment.8 Although overuse of opioids precipitated an epidemic, racial/ethnic and sex treatment differences persisted.2-4 Unconscious biases of clinicians may attribute to these treatment differences.6-7,9-10

Emergency medicine clinicians may be susceptible to treatment biases because of their chaotic work environment with multiple interruptions. These clinicians treat patients unknown to them and must rely on previous experiences, evidencebased medicine, and instincts to make quick, justifiable medical decisions for patients possibly experiencing life-threatening conditions. Because of their need to make quick decisions, many clinicians rely heavily on cognitive heuristics to make treatment choices.7 Cognitive heuristics are mental shortcuts that rely on intuitive thinking, known better as gut instinct. However, heavy reliance on cognitive heuristics may lead to unconscious or implicit biases when caring for patients.7 The purpose of the current study was to evaluate whether racial/ethnic minority patients and women received different acute pain treatments compared with non-Hispanic White men in an ED that serves a diverse population.

Methods

The retrospective chart review included data from adult patients (aged 18 years and older) treated at a large Level 1 trauma center in northernVirginia from January 1, 2018, to December 21, 2019. A total of 180,210 adult ED visits occurred during the study period, and 19,624 patients had a chief complaint of abdominal pain.

Exclusion criteria included critical patients categorized as Code STEMI (ST-elevated myocardial infarction),11 Code stroke,12 or trauma team activations. Patients were also excluded if they were pregnant, treated for chronic pain, or sought psychiatric care or inpatient detoxification treatment.

Before analysis, the data were stripped of patient identifiers and a unique code was assigned to each patient encounter. Patients were categorized by self-reported sex, race, and ethnicity. The sex category included female and male patients; no other genders met the study’s inclusion criteria.The races reported by patients included non-Hispanic/Latino White, non-Hispanic/Latino Black or African American, Hispanic/

Latino, Asian, Middle Eastern, American Indian or Alaskan Native, Pacific Islander or Native Hawaiian, more than 1 race, or other. For this analysis, race categories were combined to include non-Hispanic/Latino White, non-Hispanic/Latino Black,Asian, or other, which included all other racial categories.

Ethnicity was reported as Hispanic/Latino or non-Hispanic/ Latino and patients had the option to report Hispanic/Latino for both race and ethnicity. For the current study, racial and ethnic Hispanic/Latino groups were combined into 1 group of Hispanic/Latino ethnicity. Patients’ records that were missing data for sex, race, and ethnicity were excluded. Additional data collected from patients’ charts included age, patient acuity level, diagnosis, and disposition information.

The primary outcome measures were pain score and pain medication. Specifically, the patient’s pain was reported using the numerical pain scale (0-10). Based on the pain scale score, the pain was rated as mild (1-3), moderate (4-6), or severe (7-10). Patients’ records that were missing a pain score or those with a pain score of 0 were excluded from the analysis. Pain medication data included time of ED arrival to medication ordered by the clinician, type of medications given to patients, and length of stay (LOS) in the ED. The type of medication was divided into 2 categories: nonopioids and opioids. Nonopioids included acetaminophen, ibuprofen, naproxen, aspirin, and ketorolac. Opioids included tramadol, hydrocodone, oxycodone, morphine, hydromorphone, and fentanyl. The opioid category also included combined medications, such as hydrocodone-acetaminophen, oxycodone-acetaminophen, or acetaminophen-codeine.

Statistical analyses were conducted using SPSS Statistics version 27 (IBM Corp., Armonk, NY). A P <.05 was considered significant. Cross-tabulation tables were used to evaluate the relationship between abdominal pain diagnoses and other independent variables. An χ2 test was performed when applicable. A 1-way analysis of variance (ANOVA) was used to calculate differences in pain treatment among racial/ethnic groups. If homogeneity of variances was violated, a Welch ANOVA was performed. An independent samples t test was used to calculate differences in pain treatment between sexes. If homogeneity of variances was violated, the Welch t test was performed. A 2-way ANOVA was used to calculate treatment differences between combined sex and racial/ethnic groups.

A total of 19,624 ED visits with the chief complaint of abdominal pain and data from 17,401 ED visits were included in the current study after exclusion criteria. The patients ranged in age from 18 to 101 years. Hispanic/Latino patients had the youngest mean age of 39.84 years (95% CI, 39.45-40.24) and accounted for 41.5% of the 18 to 44 age group (Figure 1).

The remaining mean ages were 50.71 years (95% CI, 49.8051.63) for Asian patients, 49.85 years (95% CI, 49.36-50.33) for non-Hispanic/Latino White patients, 42.73 years (95% CI, 41.86-43.59) for other patients, and 42.71 years (95% CI, 42.05-43.37) for non-Hispanic/Latino Black patients. Women had a mean age of 44.31 years (95% CI, 43.95-44.65), which was younger than that for men (46.37 years; 95% CI, 45.93-46.80).

A majority of patients identified as non-Hispanic/Latino White, non-Hispanic/Latino Black, Hispanic/Latino, or Asian (Figure 2). A smaller number of patients identified as other (871/17401, 0.05%), Middle Eastern (365/17401, 2%), more than 1 race (186/17401, 1%), American Indian or Alaskan Native (29/17401, 0.002%), or Native Hawaiian or Pacific Islander (31/17401, 0.002%); these patients were grouped into the category labeled other (1482/17401, 8.5%). Most patients were female (10778/17401, 61.9%). Most women were Hispanic/Latino (3845/10778, 35.3%), and most men were non-Hispanic/Latino White (2547/6524, 39%).

The majority of patients were assigned an acuity level of 3; however, non-Hispanic/Latino White patients were given an acuity level of 2 at a higher rate than non-Hispanic/Latino Black, Hispanic/Latino, and other patients (Table 1, page 12). More than half of patients (11369/17401, 65.3%) reported severe pain on arrival at the ED. Patients’ acuity level by sex was also examined (Table 2, page 12). Patients with a pain rating of 10 received pain medications faster than patients with any other pain rating (Table 3, page 13).

Overall, 60% (10436/17401) of patients were treated with either a nonopioid medication (3700/17401, 21.3%) or opioid medication (6965/17401, 38.7%), whereas 40% (6965/17401) of patients did not receive any pain medications. Non-Hispanic/Latino White patients received more opioid medications than racial/ethnic minorities (Table 4, page 13). The differences persisted when factoring in the pain rating. Non-Hispanic/Latino White patients with a severe pain rating were more likely to receive opioids than non-Hispanic/ Latino Black, Hispanic/Latino, and Asian patients with severe pain, (P =.03).

Some ethnic/racial minority patients waited longer for room assignments on arrival at the ED. Non-Hispanic/Latino White patients were assigned a room 8.5 minutes faster than Hispanic/Latino patients (95% CI, 6.16-10.83) and 3.83 minutes faster than Asian patients (95% CI, 0.37-7.30). No differences were found between non-Hispanic/Latino Black patients (2.46 minutes; 95% CI, 0.73-5.65) or other patients (3.42 minutes; 95% CI, 0.28-7.11).

Hispanic/Latino patients waited 7.53 (95% CI, 2.27-12.79) minutes longer than non-Hispanic/Latino White patients before receiving their first pain medication. No statistical differences in time to first pain medication were found between non-Hispanic/Latino White patients and non-Hispanic/ Latino Black patients (4.58 minutes; 95% CI, 2.74-11.89), Asian patients (6.40 minutes; 95% CI, 1.80-14.60), and other patients (0.19 minutes; 95% CI, 8.40-8.78).

Non-Hispanic/Latino White patients experienced a longer LOS than all racial/ethnic minority patients (Table 4). They remained in the ED 15.08 minutes longer than non-Hispanic/ Latino Black patients (95% CI, 4.23-25.89), 22.12 minutes longer than Hispanic/Latino patients (95% CI, 14.23-30.01),

TABLE 1. Emergency Department Summary Data for Patients by Race/Ethnicity

AMA, against medical advice; LPTC, left prior to treatment complete

Data are reported as no. (%) of total in each column a Data missing for 6 non-Hispanic/Latino White patients, 3 Hispanic/Latino patients, and 1 Asian patient b Data missing for 5 non-Hispanic/Latino White patients, 2 Hispanic/Latino patients, and 2 Other patients c Includes patients sent to the operating room, admitted for observation or for inpatient admission, and transferred to another facility

TABLE 2. Emergency Department Summary Data for Patients by Sex

AMA, against medical advice; LPTC, left prior to treatment complete

Data are reported as number (%) of total in each column a Data missing for 4 women and 6 men b Data missing for 7 women and 2 men c Includes patients sent to the operating room, admitted for observation or for inpatient admission, and transferred to another facility

TABLE 3. Pain Treatment Data for Patients by Pain Score

TABLE 4. Pain Treatment Data for Patients by Racial/Ethnic Group and Sex

a Significant difference between total non-Hispanic/Latino White and racial/ethnic minority patients (P <.05) b Significant difference between total Hispanic/Latino and non-Hispanic/Latino White (P <.05) and 29.87 minutes longer than other patients (95% CI, 17.37-42.37). No significant difference was found in the LOS between non-Hispanic/Latino White patients (335.29 minutes; 95% CI, 331.15-339.43) and Asian patients (334.59 minutes; 95% CI, 326.47-342.70).

Women waited 9 minutes longer than men for their first dose of medication after arrival (95% CI, 5.71-12.31).Women were also less likely to receive an opioid medication. Fewer women (27.9%) than men (36.4%) were admitted to the hospital. A statistically significant interaction effect between sex and racial/ethnic group was found for the type of medication given, (P =.03). Both non-Hispanic/Latino White men and women were more likely to receive opioids than men or women from other racial/ethnic groups. No interaction effect was found for the time of first medication after arrival, number of medications given, or LOS (Table 4).

The most common diagnosis was nonspecific abdominal pain (6051/17401, 34.8%), which included far more visits than the second most common diagnosis of colitis (1201/17401, 6.9%) (Figure 3).The top 10 diagnoses accounted for 70% of the diagnoses (12181/17401) at discharge. Significantly more women were diagnosed with cholelithiasis, urinary tract infection, and cholecystitis, whereas significantly more men were diagnosed with kidney stones. A greater number of Hispanic/ Latino patients were diagnosed with cholelithiasis (305/613, 49.8%), urinary tract infection (243/559, 43.4%), cholecystitis (190/398, 47.7%), and ovarian cysts (166/475, 34.9%) than non-Hispanic/Latino White patients. A greater percentage of non-Hispanic/Latino White patients were diagnosed with bowel obstruction, colitis, and kidney stones.

Discussion

The current retrospective chart review found a significant difference in pain management between non-Hispanic/Latino White patients and racial/ethnic minority patients and women.

Non-Hispanic/Latino White patients were more likely to receive opioids during their ED visit than non-Hispanic/ Latino Black, Hispanic/Latino, Asian, or other racial/ethnic groups. Furthermore, women waited longer for pain medications and received fewer opioid medications.These observed treatment differences support previous studies that indicated disparities in acute pain treatment for minority and female populations.2-6

When patients arrive at an ED, they receive a brief initial assessment by a nurse, who assigns an acuity level using the Emergency Severity Index (ESI) triage algorithm.13 Patients requiring direct lifesaving intervention are considered level 1.13 Level 1 is the most objective; the remaining 4 levels are assessed using objective and subjective patient evaluations that require experience, clinical gestalt, and vital signs review. Since the decision to categorize a patient as level 2 or 3 is subjective, assessment of these acuity levels may be biased.

In the current study, non-Hispanic/Latino White patients were assigned a higher acuity level than those in racial/ ethnic minority groups, which suggests that non-Hispanic/ Latino White patients presented with more urgent needs and required more resources. However, Zhang et al noted racial disparities in ESI assignment, where non-Hispanic/Latino White patients were assigned more urgent ESI levels than non-Hispanic/Latino Black and other minority patients.14

Unfortunately, because of bias in the subjective component of the ESI, minority patients may receive lower acuity scores than their non-Hispanic/Latino White counterparts. For the same reason, a higher percentage of men than women in the current study were assigned a level 2 acuity score. As with racial/ethnic minority patients, gender bias may also influence the ESI score during triage. Study results also showed that racial/ethnic minority patients had a shorter LOS than nonHispanic/Latino White patients. One possible explanation for this result is that more non-Hispanic/Latino White patients were assigned higher acuity levels, which likely required more complex treatments and more resources that increased the LOS. Overall, the role of bias and its relation to quick, efficient care of racial/ethnic minority patients remains unclear.

Hispanic/Latino patients also waited longer for pain medications after arrival at the ED. A possible factor contributing to these longer wait times may be an existing language barrier. The population served by the hospital in northern Virginia in the current study is diverse and includes more than 728,000 immigrants.15 This foreign-born population accounts for 31% of the local population, which is higher than the state (13%) and US (14%) averages.15,16 Eight of 10 immigrants are from Asian or Latin American countries; the most common country of origin is El Salvador (12%).15 A large percentage of these immigrants are highly educated and speak English “very well.”15 However, 4 out of 10 immigrants speak English at lower levels.15 Of those in the Hispanic/Latino community, 53% are not fluent in English and require interpretation assistance when seeking care.17

Women of all racial/ethnic groups in the current study also waited longer than men to receive pain medications after arrival.These results support those of Chen et al,18 who found women waited longer than men to receive medication for acute abdominal pain in the ED.Treatment of abdominal pain in women is complex.Although clinicians perform pelvic examinations on women presenting with this complaint,19 abdominal and pelvic causes of pain must be considered as possible diagnoses. In general, pelvic examinations should not delay pain medications, but this delay for women may be caused by clinicians waiting for results of a pregnancy test. If the patient is pregnant, it changes the differential diagnosis and limits safe medication treatment options.

Women were less likely than men to receive opioid medications.The finding suggests that a woman’s pain is considered less severe than a man’s pain in the ED setting, resulting in more opiate use in men. Samulowitz et al20 reported that clinicians often undertreat women’s pain because these patients may not be taken seriously. Because of traditional gender norms for women, clinicians may consider their pain symptoms as complaining, malingering, emotional, hysterical, or psychogenic.20 In contrast, men are seen as stoic, pain tolerant, and less likely to seek health care, which makes their pain complaints seem more severe to clinicians.20,21 Therefore, the undertreatment of acute pain in women may be related to gender biases. Similarly, unconscious biases of clinicians may also affect how racial/ ethnic minority patients are treated.

Limitations

One limitation of the current study is related to the study design. It is a single-center retrospective chart review, so it limits generalizability. Furthermore, data extracted during a chart review is limited by the information originally recorded in the electronic medical record. Although the use of technology in health care makes it easier to aggregate large data sets of patient treatments, extracting that data to determine the full extent of the patient’s health care treatment can be tedious. Another limitation of the current study is that the race/ethnicity or gender of the clinician ordering the pain medication was not recorded. Research suggests that patients prefer being treated by clinicians who look like them, which creates a more trustworthy relationship between parties.22,23 However, additional research is needed to determine how race/ethnicity or gender of the clinician or nursing staff affects treatment. The current study is also limited regarding medication data since all medications given to the patient were not recorded. For several abdominal conditions, patients are typically given medications other than anti-inflammatory or opiate medications.24,25 For instance, the gastrointestinal cocktail (viscous lidocaine, aluminum hydroxide, and magnesium hydroxide) and intravenous famotidine are often given for gastritis. Dicyclomine, an antispasmodic, is usually provided for abdominal spasms.

Poll Position

In 2019, which racial/ethnic group had the highest rate of ED visits?

Patients with urinary tract infections are often given phenazopyridine for bladder spasms. Although these medications treat pain, they were not evaluated in the current study.

Conclusion

The current retrospective chart review evaluated whether racial/ethnic minority patients and women received different acute pain treatments from non-Hispanic/Latino White men in the ED. Results indicated that non-Hispanic/Latino White patients were more likely to receive opioids, and women waited longer for pain medications and received fewer opioid medications. Treatment of pain is complicated because no objective way to determine pain intensity is available. The clinician must rely on subjectivity and trust the patient’s perception of pain based on a basic rating system from 0 to 10 points.7 This lack of objectivity for determining pain intensity creates treatment biases such as less or delayed treatment for racial/ ethnic minority patients and women. ■

Kimberly Sapre, DMSc, PA-C, CAQ-EM, is a medical consultant for an insurtech company. She is a clinical instructor in Washington, DC, and practices emergency medicine in Falls Church, Virginia. She has 11 years of experience as a PA with previous experience in neurosurgery and interventional pain medicine.

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