When a youngster arrives in the emergency department writhing with belly pain, whether that child receives pain medication can depend on the color of his skin.
Even adjusting for variables such as sex, age, presenting pain level, and access to care, the difference remained, said Tiffani J. Johnson, MD, the pediatric emergency medicine fellow at Children's Hospital of Pittsburgh who presented the study in April at the Pediatric Academic Societies annual meeting.
“The most striking finding was that black children were significantly less likely to receive pain medications when compared with their white counterparts,” said Dr. Johnson, who is also a postdoctoral scholar at RAND-University of Pittsburgh Health Institute. “The emergency department serves as our nation's health care safety net, where all children can receive care regardless of their insurance status, ability to pay, or race.”
Dr. Johnson and her colleagues analyzed 2006–2009 data from the National Ambulatory Medical Care Survey conducted by the Centers for the Disease Control and Prevention's National Center for Health Statistics, analyzing not only the likelihood that a child would receive pain medication but also tests received, length of stay, return to the ED after 72 hours, and admission rates. They included in their survey 2,298 patients younger than 21, or some 8.1 million patients. The race representation was 53 percent white, 23 percent black, and 21 percent Hispanic.
They found that black and Hispanic youngsters were more likely to stay in the emergency department longer than six hours, but all children received the tests at the same level. They were also hospitalized at the same rate. Black children, however, were significantly less likely to receive pain treatment, a fact that remained constant even when they rated their pain at 7 or higher on a 10-point scale.
The study is only the latest in a long list of such studies that show many conditions and pain in particular are treated differently based on a patient's race. The Institute of Medicine in 2002 released a study, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” that defined the problem and called for answers, but those solutions have yet to be defined. (See FastLinks.)
“There are some limitations in being able to say that racism results in this problem,” she said. “You cannot call it a disparity unless it is independent of the patient's access to care. We did try to control for that by looking at the patients' insurance status. We also tried to adjust for clinical factors.”
Dr. Johnson said she hopes to figure out why this and other disparities in care exist. “Are black patients presenting with different disease? That is hard to tell because most of the discharges read simply 'abdominal pain.' It is possible, although unlikely, that black kids are coming to the emergency department with constipation more often than other children,” she said. “I couldn't get to the level of detail.
“We need to do some primary data collection to get more information,” she said, including determining if patient preference plays a role. “Are black patients [or their parents] refusing pain medication more than whites?”
Chet Schrader, MD, the medical director of the emergency department at Baylor Medical Center in Carrollton, TX, and faculty in the JPS Health Network emergency medicine residency, has studied health disparities in the emergency department, and said this inequality does exist for pediatric patients. In adults, we've seen it extended to every chief complaint. The disparity exists. Ethnicities other than whites have differences in care. I think getting to the why is going to be difficult, and I think it's going to require a very upfront conversation in regard to why it is occurring. It's going to require a personal dialogue and some self-critiquing,” he said.
The issue is being addressed in medical schools and residencies with diversity training, he said. “As younger physicians are trained, we will see if it has an impact.”
His studies have found the disparity begins in triage; white and black patients presenting with the same complaints may be triaged differently. The perception of their needs, their complaints, and their care is different, Dr. Schrader said. A qualitative study would be helpful if the researcher could follow the patient from start to finish without biasing the study by watching what happens.
“I don't know how to get to that. It is labor- and time-intensive as well. Over and over again, we are seeing that these disparities continue to exist. Unless we are ready to drill down and have an in-depth look as to why this is happening, we may not get an answer,” said Dr. Schrader, who just finished a practice management and health policy fellowship at the University of Texas Southwestern Medical School in Dallas.
Dr. Johnson said she will continue looking at these issues throughout her career. “Are we in a post-racial era?” she said. “The answer is no. There is a lot of work being done in the adult population, developing interventions, but they are not yet being done in kids.
“We need to do research in children and address those differences,” she said.
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* Read the Institute of Medicine study, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” at http://bit.ly/N7gHRl.
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