How to Improve Health Disparities in Acute Pain Management in Emergency Departments

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 non-Hispanic/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.

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 also a clinical instructor in Washington, DC and she 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.

This article originally appeared on Clinical Advisor

From the January/February 2023 Issue of Clinical Pain Advisor