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Racial and Ethnic Disparities in the Quality of Pain Care: The Anesthesiologist's Call to Action

Green, Carmen R. M.D.

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ENSURING healthcare quality (i.e., access to health care, effectiveness, and efficacy) while optimizing health and quality of life has tremendous benefits to the individual and to society. However, the Institute of Medicine (IOM) series of books resulting from the Quality of Health Care in America Project provides startling evidence for medical errors, variability in healthcare quality, and a quality gap that puts patients at risk for increased morbidity and mortality.1,2 As documented in the congressionally mandated IOM report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, stark differences in health and the healthcare experience based on race, sex, age, socioeconomic status, and community characteristics exist.3 In an increasingly diverse America, disparities in health and health care are critically important to our nation's colloquial health. The IOM identifies two sources of disparities: (1) healthcare systems and the legal and regulatory climate in which they operate and (2) discrimination such as biases, stereotyping, and uncertainties in clinical communication and decision making.3 Using a statewide database, the article by Glance et al.,4 “Racial Differences in the Use of Epidural Analgesia for Labor,” provides additional evidence for differential access to epidural analgesia. Overall, Glance et al. show that black and Hispanic women were significantly less likely to receive epidural analgesia during labor than white women. Although differential access to labor epidurals based on race were described previously, Glance et al. extend the literature by revealing that these differences persist even when insurance coverage, provider, and clinical characteristics are similar, thereby providing evidence for physician variability in decision making.
Among the many overarching goals stated in Healthy People 2010 is improving health and eliminating disparities in health care for all Americans.5 Several federal agencies (e.g., National Institutes of Health, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality) identified health and healthcare disparities as one of the nation's top strategic priorities. They further supported several initiatives designed to reduce and eliminate disparities in health and health care. Clearly, creating new knowledge directed at understanding and addressing health and healthcare disparities is vitally important. Although the IOM study on healthcare disparities provides information on pain management, the committee's work focused primarily on an acute injury and cancer pain model. Pain has significant socioeconomic, quality of life, and health implications; however, pain as a public health issue, the quality of pain care, access-related factors, physician variability in pain management decision making, and access to analgesics were not addressed in a substantive manner in the IOM reports.
Overall, disparities in health and health care increase healthcare costs and diminish quality of life while increasing morbidity and mortality. The Joint Commission on Accreditation of Hospitals and Healthcare Organizations pain management standards, requiring accredited institutions to ensure that all patients have pain assessed, provided necessary attention to a multitude of factors influencing pain management. Anesthesiologists often lead the continuous quality improvement efforts directed at optimizing pain management in the perioperative period and throughout their institutions. For many advocating for pain management and improvements in the quality of pain care in particular (e.g., patients, researchers, clinicians, pain medicine physicians), the Joint Commission on Accreditation of Hospitals and Healthcare Organizations standards seemed to be the tipping point for addressing pain complaints in a comprehensive and multidisciplinary fashion. However, the literature continues to document suboptimal pain assessment and the undertreatment of pain.6 Furthermore, the literature supports variability in pain management decision making and disparities in pain care for all types of pain, i.e., acute, chronic, and cancer pain, as well as pain associated with terminal illness, especially for racial and ethnic minority persons.
Overwhelmingly, the literature supports that the pain complaints of racial and ethnic minorities, women, and elderly persons are often unheard.6 The cornerstone for quality pain care is pain assessment, but the bulk of the literature supports that minorities are less likely to have their pain assessed, yielding an unequal burden due to pain. When their pain is assessed, minorities often receive less pain medication than their white counterparts, suggesting physician variability in decision making. When receiving a prescription for opioid analgesics, minorities are less able than whites to fill opioid analgesic prescriptions in their local pharmacies, regardless of income.7 Whereas income is protective for whites, income is not protective for higher-income minorities who experience problems similar to those of low-income minorities in obtaining prescription opioid analgesics in their local pharmacies but have less access than low-income whites. Many believe that most health and healthcare disparities are reduced or even eliminated when socioeconomic factors are controlled. Glance et al.4 confirm the role insurance plays in accessing labor epidurals where women with private insurance have the best access to this modality for pain relief. However, consistent with the literature, Glance et al. also reveal that insurance status may not be protective for black women. Although there was no difference in epidural use among black women with private health insurance and black women with Medicaid or no health insurance, black women with private health insurance had the same rates of epidural use as white women without insurance.
Despite the critical importance of race and ethnicity in health and health care and amid the success stories of improvements in quality, continuing disparities in health and health care provide a sobering reminder that we are not there yet. In fact, our failure to attend to disparities based on race, ethnicity, sex, age, insurance, socioeconomic status, and community characteristics contributes to increased morbidity and mortality while increasing healthcare costs. Throughout the perioperative period, anesthesiologists continue to provide innovative leadership in the continuous quality improvement and pain management arenas. However, in an increasingly diverse and aging America, few anesthesiologists have embraced our nation's most important public health and quality of care problems: disparities in health and health care in general and disparities in pain care in particular. The intrinsic value of anesthesiologists addressing disparities in pain care in a substantive manner is tremendous considering their demonstrated expertise in addressing patient safety and reducing medical errors.
The representation of women as well as racial minorities in research and in the healthcare professions (including anesthesiologists) is far less than their representation in the general population. Even more problematic is research showing that most graduating residents believe that they have not received training on how to provide culturally competent care. Therefore, it is not surprising that miscommunications frequently occur with patients leading to the potential for difficulties in providing quality health care. Overall, we know little about how patient factors (e.g., their preferences, language, cultural beliefs, family, support systems, decision making) influence pain care.
Clearly establishing an interdisciplinary pain disparities research agenda is imperative to inform our clinical care if healthcare disparities are to be reduced and eventually eliminated. However, several challenges exist. Only a small percentage of research dollars is directed at health services research, health disparities, and pain research. Racial and ethnic identifiers are infrequently used to monitor health outcomes. However, these indentifiers are critical to understanding variations in quality and variability in decision making if important insights are to be identified to improve the quality of health care for all Americans.
Our ability to reduce and eliminate disparities in pain care has significant public health and policy implications. Toward that end, multidisciplinary approaches are necessary to improve the quality of pain care, thereby reducing and eliminating disparities in care. Clinical and research efforts must be informed by the patient as a full healthcare partner if we are to clarify their preferences and to improve the quality of health care. By improving the quality of pain care for those most vulnerable to variations in quality and decision making, we can improve health and the quality of pain care for all. Real improvements in the quality of pain care will occur when we view the failure to assess and treat pain as a medical error!
Carmen R. Green, M.D.
Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan. carmeng@umich.edu
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References

1. Institute of Medicine of the National Academies, Committee on Quality Health Care in America: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C., National Academies Press, 2001

2. Institute of Medicine of the National Academies: Committee on Quality of Health Care in America, Institute of Medicine: To Err Is Human: Building a Safer Health System. Edited by Kohn LT, Corrigan JM, Donaldson MS. Washington, D.C., National Academies Press, 2000

3. Institute of Medicine of the National Academies: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Edited by Smedley BD, Stith AY, Nelson AR. Washington, D.C., National Academies Press, 2002

4. Glance LG, Wissler R, Glantz C, Osler TM, Mukamel DB, Dick AW: Racial differences in the use of epidural analgesia for labor. Anesthesiology 2007; 106:19–25

5. US Department of Health and Human Services: Healthy People 2010: Understanding and Improving Health. Washington, D.C., Department of Health and Human Services, Government Printing Office, 2000

6. Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, Kalaoukalani DA, Lasch KE, Myers C, Tait RC, Todd KH, Vallerand AH: The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Med 2003; 4:277–94

7. Green CR, Ndao-Brumblay SK, West B, Washington T: Differences in prescription opioid analgesic availability: Comparing minority and white pharmacies across Michigan. J Pain 2005; 6:689–99

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