Pain Management
Oligoanalgesia, the inadequate treatment of pain, disproportionately affects members of minority groups. These racial and ethnic disparities in pain management have been documented in a wide variety of clinical arenas, including post-operative settings, nursing homes and cancer clinics, and for many different types of pain, including acute, cancer, and chronic non-malignant pain.
Although the phenomenon is well-documented, we have far to go in fully understanding the reasons such disparities exist, and more importantly, how to prevent them from occurring. A series of studies in emergency departments may give us some insight into why treatment disparities exist and how we might intervene to prevent their occurrence.
Emergency medicine’s mission is to provide universal and timely care to all members of society and the emergency department environment is characterized by a lack of patient-physician continuity, diagnostic uncertainty, as well as significant time and cognitive demands, all of which may foster suboptimal pain management practices. Given this environment, it is not surprising that the first evidence of ethnic disparities in pain management practices originated in this clinical setting.
In 1993, our emergency room reported that Hispanics with isolated extremity long-bone fractures were twice as likely as non-Hispanic whites to receive no analgesics during their emergency department care (Todd, 1993). This disparity was not explained by difference in patient characteristics, injury severity, or the likelihood of alcohol or drug intoxication. In particular, we were surprised to find that the patient’s primary language appears to have no impact on these disparities.
Although this initial study had several methodologic limitations (single site only, its retrospective nature, and small patient numbers) it suggested that language and communication issues might not pose the barriers we might have suspected, and underlying causes for disparate treatments would be found elsewhere. In a second study, we explicitly tested physicians’ abilities to assess acute pain in Hispanics and non-Hispanic whites, and found no differences (Todd, 1994). It seemed that, at least when prompted, physicians had no more difficulty in accurately assessing pain intensity for Hispanics than for whites.
We conducted a subsequent study of fracture treatment in African-Americans and non-Hispanic whites and found strikingly similar disparities in analgesic prescription and administration (Todd, 2000). Importantly, in this study similar documentation of pain existed in the medical record for both groups, giving further support to the idea that standardized assessments were unlikely to reduce such disparate pain management practices.
Racial and ethnic disparities in healthcare have been the focus of investigation in many areas other than pain management. The recent report from the Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, considered a broad range of such disparities, and issued recommendations to address them (National Academy of Sciences, 2002). Among these were calls to increase the proportion of minorities in the health professions, promote consistency through evidence-based guidelines, and include measures of disparities in performance measurement. Although all would agree that the health professions should better reflect the ethnic makeup of our population, it is unlikely that such efforts will yield immediate results. In the short-term, the latter two suggestions hold great promise and should be pursued within all treatment settings. Evidence-based guidelines will promote consistent treatments for all groups if used; however, there are many barriers to their routine use.
Quality assurance and improvement activities conducted at the institutional level should use ethnic identifiers in order to identify ethnic disparities should they exist. Simply supplying feedback to health care providers may be an effective intervention. At the regional and national levels, health plans should incorporate ethnic identifiers to determine whether evidence of ethnic disparities in pain management exist. Definitions of quality medical care should include the absence of such disparities, and when unmet, large providers should receive notice from third-party purchasers of our services. Finally, health services research should be conducted to identify the most promising interventions to improve the quality of pain management for all our patients, and specifically for racial and ethnic minorities.
References
National Academy of Sciences, Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002, National Academy Press, Washington, D.C.
Todd KH, et al. JAMA 1993;269(12):1537-39
Todd KH, et al. JAMA 1994;271(12):925-8.
Todd KH, et al. Ann Emerg Med 2000;35(1):11-6
PainEDU Newsletter
Vol.33, No.1.
http://www.painedu.org.