Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients : International Anesthesiology Clinics

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Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients

Patton, John W. III MD, MBAa; Burton, Brittany N. MD, MHS, MASa; Milam, Adam J. MD, PhDb; Mariano, Edward R. MD, MASc,d; Gabriel, Rodney A. MD, MASe,f

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International Anesthesiology Clinics 61(1):p 8-15, Winter 2023. | DOI: 10.1097/AIA.0000000000000382
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The Centers for Disease Control and Prevention (CDC) defines health disparities as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”1 Social determinants of health are believed to be a significant driver of health outcomes.2 According to the CDC, “health inequities are reflected in differences in length of life; quality of life; rates of disease, disability and death; severity of disease; and access to treatment.”1 Racism has been identified by the CDC as a serious threat to public health, specifically highlighting the negative impact that racism has had on communities of color. Webster defines racism as “a belief that race is a fundamental determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race.”3 It is important to acknowledge that racism and health care disparities, which have their roots in inequities across social determinants of health, are closely intertwined. People of color fare worse than their White counterparts across many measures of health status.4,5 Access to appropriate health services is an ongoing issue as people of color, particularly those in lower socioeconomic regions, continue to be underinsured.4

In 2020, trauma was among the top four leading causes of death in the United States, followed by heart disease, cancer, and COVID-19.6 For children and younger adults, traumatic accidents and unintentional injury comprised the leading cause of death.7 Injury accounts for more than 150,000 deaths and more than 3 million nonfatal injuries each year,8 and the estimated cost of injuries in 2019 was $4.2 trillion USD.6

Regional anesthesia and acute pain medicine (RAAPM) as a subspecialty is well positioned to decrease trauma-related costs for health care systems by decreasing unanticipated hospitalization, decreasing length of stay, avoiding unnecessary intensive care unit admissions, decreasing postanesthesia care unit stays, and decreasing opioid use and opioid-related side effects that can prolong length of stay.9–11 The potential benefits of RAAPM services apply to both adult and pediatric populations.12 Unfortunately, disparities across the spectrum of health care services that have been well documented for communities of color2,4 also exist for RAAPM. This area of concern takes on a greater sense of urgency given the changing US demographics. As estimated by the Pew Research Center, communities of color will become the majority by 2050.13

The aim of this narrative review is to explore the use of RAAPM for trauma-related injuries in the emergency department, operating room, and intensive care unit, and to describe racial and ethnic health disparities in the context of RAAPM. We present the potential impact of disparities in the use of regional anesthesia on patient outcomes. Episodes of care involving trauma patients, specifically related to pain management, represent opportunities to provide equitable care for the most vulnerable of patients. Finally, we explore strategies to address racial and ethnic health disparities to improve health care for trauma patients, identifying current best practices in the literature and potential opportunities for future research.

Health disparities in acute pain management in the prehospital setting

Disparities in prehospital pain management by patient characteristics (eg, sex, race/ethnicity, socioeconomic status) have been previously described.14–16 Racial minorities, specifically Black and Hispanic patients are less likely to have pain assessed using validated measures and are less likely to receive analgesia in the prehospital period.15,16 Hewes and colleagues examined differences in pain assessment and analgesic administration among 270,000 emergency medical service (EMS) transports; only 30% of patients had pain assessed, and only 15.6% were administered analgesics.15 The same study found that among patients who had pain assessments, Black individuals were less likely to receive pain medications (8.7%) compared with all other groups, with White individuals being most likely to receive pain medications during transport to the hospital (22.4%, P<0.001). In another study of nearly 6400 patients with blunt trauma transported to the hospital by EMS, a vast majority of patients did not have a pain score documented (77%).16 After controlling for several potential confounders (eg, sex, age, race, time EMS spent with the patient, and pain score), race/ethnicity was negatively associated with receiving analgesia such that Black (4%) and Hispanic patients (5%) were less likely than White patients (10%, P<0.001) to receive pain medications; these findings were consistent in the pediatric population with Black children being less likely to be administered pain medications compared with their White counterparts.16 Kennel and colleagues further explored this issue by adjusting for additional confounders, specifically the patient’s health insurance (eg, private, government, no insurance) and urbanicity of where the encounter occurred among a sample of 25,000 EMS encounters from the Oregon Emergency Medical Services Information System; in the adjusted model, Hispanic [odds ratio (OR): 0.79; 95% CI: 0.70-0.90] and Asian patients (OR: 0.69; 95% CI: 0.57-0.84) were less likely to have their pain assessed compared with White patients. In addition, Asian (OR: 0.76; 95% CI: 0.59-0.99), Black (OR: 0.68; 95% CI: 0.58-0.79), and Hispanic patients (OR: 0.79; 95% CI: 0.68-0.93) were less likely to be administered pain medications in the adjusted regression model compared with White patients.14

These findings regarding disparities in pain assessment and administration are consistent with other reported racial differences in prehospital management. A study of nearly 23,000 patients with out-of-hospital cardiac arrest has shown that individuals from predominantly Black (>75% Black) communities have a longer time to first defibrillation compared with individuals in <25% Black communities.17 Among individuals with a shockable rhythm, transport from a predominantly Black neighborhood (>75% Black) was associated with shorter time to ceasing resuscitation efforts when compared with <25% Black communities, despite a faster EMS response time.17 Findings from a study of 864,750 Medicare patients who were transported to the emergency department by EMS revealed that Black and Hispanic patients were more likely to be transported to safety-net hospitals (often lower surgical volume with higher morbidity and mortality) compared with White patients from the same zip code, suggesting that decisions regarding hospital destination may not simply be based on proximity even among patients with highly acute conditions.18

There are many possible contributors to these disparities in prehospital acute pain management, including lack of diversity within the EMS workforce. Consistent with findings in other areas of the medical workforce,19 racial minorities (10% to 13% Hispanic and 3% to 5% Black) and women (35%) are underrepresented among EMS staffing.20 It is well known that lack of diversity is associated with both implicit and explicit biases.21,22 The impact of implicit biases on pain management has been previously demonstrated among physicians and nurses21,22; to date, there is a dearth of literature examining implicit biases among EMS practitioners.23,24 Lack of diversity is also associated with poorer interpersonal communication with patients, especially when the practitioner and patient are of different races,25 which has important implications for clinical outcomes.26

Health disparities in acute pain management in the emergency department

The existence of racial and ethnic disparities in acute pain management in the emergency department has been previously described. Green and colleagues have noted the existence of pain management disparities (ie, perception of patient pain experience, assessment, and treatment) in all health care settings and across all types of pain.27 The sources of pain management disparities are believed to be multifactorial, encompassing patient, health care practitioner, and health care system factors.

Todd and colleagues conducted a retrospective cohort study in an urban emergency department to investigate whether Black patients with isolated long-bone fractures were less likely to receive analgesics compared with White patients with similar extremity fractures.28 They found that 57% of Black patients with extremity fractures received analgesics compared with 74% of White patients with similar fractures (P=0.01).28 Furthermore, the risk of receiving no analgesics was 66% greater for Black patients than for White patients (crude RR: 1.66, 95% CI: 1.11-2.50). The 2 groups had similar baseline characteristics overall, but White patients were more likely to have private insurance. This study was a follow-up study to 2 previous studies, which have shown that Hispanic patients were less likely to receive analgesics compared with White patients and that differences in physicians’ pain assessments could not account for these racial and ethnic disparities in prescribing analgesics.29,30 One possible explanation aside from explicit and implicit biases is cultural differences; Black and Hispanic patients were less likely to request pain medications or report high enough pain scores for treatment.

More recently, Lee and colleagues’ systematic review and meta-analysis of racial and ethnic disparities in the management of acute pain in US emergency departments demonstrated little change in almost 20 years.31 Disparities in prescribing analgesics for the management of acute pain in US emergency departments continue to disproportionately affect racial and ethnic minorities, with Black and Hispanic patients still less likely to receive pain medications. Although included in this study, Asians and “other” racial and ethnic categories were too small to provide robust analyses.31

In an analysis of 2 large, multicenter, prospective cohort studies, Beaudoin and colleagues evaluated pain, pain-related characteristics, and analgesic treatment in Black and non-Hispanic White patients who presented to the emergency department after motor vehicle collision.32 Despite a high burden of acute pain, Black trauma patients in motor vehicle collisions were less likely to receive opioid analgesics and more likely to receive nonsteroidal anti-inflammatory drugs in the emergency department and at discharge. Variables predictive of acute, moderate to severe pain in the emergency department included race, history of depression, sex, body mass index, having less than a high school education, history of chronic opioid use, smoking, and being in a stopped vehicle.32 However, no significant interactions between race and any of the predictors were found. Furthermore, the authors acknowledged that the data suggested that disparities in pain experienced by Black patients could not be explained by socioeconomic status alone as described by Farmer and Frraro.33 Bias may play a role, as Black patients are mistakenly perceived to have lower levels of pain,22 and studies have found that Black patients are more likely to be undertreated for acute pain when compared with other racial and ethnic groups treated for the same conditions.14,31,34

In a cross-sectional analysis, Guedj and colleagues investigated potential racial and ethnic differences in analgesic administration among children with limb fractures or suspected appendicitis,35 adjusting for pain scores, demographics, and other visit covariates. Black and Hispanic children were more likely to have severe initial pain scores (Black 38.7%, Hispanic 33.5%) with limb fractures when compared with White children (23.6%; P<0.001 for limb fractures). In situations of suspected appendicitis, children of color reported higher rates of severe initial pain (Black 49.8%, Hispanic 52.3%) compared with White children (35.1%, P<0.001). Despite this, Black and Hispanic children were less likely to receive opioid analgesia compared with White children in both cohorts.

Although there are several studies reporting racial and ethnic disparities in analgesic pain management in the emergency department, to our knowledge, there are no studies that have specifically investigated racial and ethnic health disparities in regional nerve block utilization for trauma and critical care patients in the emergency department.

Health disparities in acute pain management for abdominal pain with or without trauma

While racial and ethnic minorities have a higher risk of morbidity and mortality following abdominal trauma, there is a paucity of literature on disparities in regional anesthesia utilization for the management of acute pain in trauma. Willer and colleagues evaluated racial/ethnic differences in postoperative outcomes for pediatric patients with abdominopelvic trauma. The investigators showed that among 13,955 children included in the retrospective analysis, Hispanic children had a higher risk of postoperative mortality, and Black children had a higher risk of postoperative morbidity and mortality, when compared with White children.36 This disparity persisted after controlling for comorbidities (eg, age, year of injury, median household income for ZIP code, and insurance status).36 The majority of pain-related studies pertain to disparities in pain management for patients with acute nontraumatic abdominal pain in the emergency department setting. Shah and colleagues examined racial and ethnic differences in the use of analgesics for acute abdominal pain in the emergency department. Of the total 6710 emergency department visits, non-Hispanic Black patients had 19% lower odds of receiving opioids for abdominal pain.34 Similarly, Johnson and colleagues showed that for children presenting to the emergency department with abdominal pain, Black and Hispanic children were less likely to receive analgesics for their pain and were more likely to have a prolonged emergency department length of stay.37

Health disparities in acute pain management for orthopedic trauma

Few studies have evaluated health disparities in regional anesthesia for acute pain management for orthopedic trauma. Most studies highlight disparities in medical management of acute pain in in this population. In a retrospective analysis of 21,069 pediatric patients, Goyal and colleagues show that Black and Hispanic children are less likely to receive opioids or achieve optimal pain reduction for long bone fractures.38 Similarly, Lia and colleagues have demonstrated that Black children were 26% less likely to receive an opioid for acute pain compared with White children.39 Black patients have worse trauma outcomes, such as higher mortality and lower utilization of operative management.40 In a retrospective analysis evaluating 17,156 patients with closed calcaneal fractures, Zelle and colleagues report that Black, Hispanic, and Asian patients are less likely to receive operative management.41 Schairer and colleagues have shown higher rates of operative fixation for orthopedic trauma in patients who were White, privately insured, and of high-income status.42 Benzing and colleagues report no differences in pain scores between White and non-White patients; however, White patients are more likely to receive opioids for pain corresponding to long bone fractures compared with non-White patients.43

Health disparities in acute pain management for thoracic trauma

Thoracic trauma may be caused by blunt injury, with the most common causes being motor vehicle accidents, and penetrating trauma due to stab or gunshot wounds.44 Blunt cardiac trauma is associated with 20% of motor vehicle deaths.45 The extent of injuries in thoracic trauma ranges from grade I (minor electrocardiogram abnormalities) to grade 5 (penetrating wound with more than 50% loss of chamber).46 In a retrospective analysis of the Trauma Quality Improvement Program database, Rebollo Salazar and colleagues report the association of race and insurance status with rib fixation surgery and epidural analgesia in patients with rib fractures.47 They show that Black and Hispanic patients are less likely to receive rib fixation surgery and epidural analgesia for perioperative pain.47 Due to a dearth of data, it is unclear if minority patient populations received less systemic analgesics, neuraxial anesthesia, peripheral nerve blocks, or a combination for the management of perioperative pain. The US Department of Health and Human Services released “Healthy People 2030,” a report identifying critical research gaps to help understand health disparities.48 It is clear that more research is needed to understand disparities in acute pain management among racial and ethnic minority populations suffering from traumatic injuries.

Regional analgesic techniques appropriate in trauma

Pain management for patients who are acutely injured can be particularly challenging. When trauma patients present to hospital systems, especially those who are critically ill, life-saving measures should take precedence over elective pain management procedures such as regional anesthesia even though they may provide better pain control. There are many considerations for anesthesiologists and other members of the care team including but not limited to mental status, cervical spine instability, airway considerations, spectrum of injury, and hemodynamic instability. Timing is critical in the care of the trauma patient. As the critically ill patient’s condition stabilizes, careful consideration of potential analgesic interventions such as regional anesthesia techniques that can provide targeted pain control and avoid unwanted side effects of opioids and other sedatives moves up in priority.

There are many examples of how regional anesthesia techniques can offer effective analgesic options in trauma. In a dedicated review of regional anesthesia for the trauma patient, Gadsden and Warlick49 discuss the potential morbidity and mortality benefits for certain populations of trauma patients, including those with rib fractures, hip and femur fractures, and patients undergoing digital reimplantation. Peripheral nerve blocks offer site-specific, high-quality analgesia without the side effects associated with systemic analgesics. Moreover, continuous peripheral nerve blocks permit titratable target-specific analgesia for an extended period of time when compared with single-injection peripheral nerve blocks, which have a limited duration of analgesic benefit. Gallagher and colleagues have described the use of regional anesthesia for early pain management in a prospective cohort study of US soldiers who suffered combat-related extremity injuries.50 They found that early utilization of regional anesthesia (ie, continuous peripheral nerve blocks) resulted in improved pain control for the first 6 months after injury and lasted up to 24 months when compared with soldiers who received routine, opioid-based, systemic analgesia.50

Neuraxial block techniques are well established for trauma-related pain management in a variety of regions including chest wall, abdomen and pelvis, and lower extremities. Thoracic epidural analgesia has long been believed to be the gold standard for pain management, particularly for thoracic surgery and chest wall injury (eg, rib fractures).51 However, with the transition to minimally invasive surgical procedures (ie, video-assisted thoracic surgery), the continued role of thoracic epidural analgesia has been debated.52 Alternative regional analgesic techniques such as paravertebral blocks and various fascial plane blocks of the chest wall (eg, erector spinae plane block, serratus anterior plane block) have gained in popularity. Continuous thoracic paravertebral blocks have been found to be as effective as thoracic epidurals in managing pain for patients with unilateral rib fractures.53 Reported advantages of newer ultrasound-guided fascial plane blocks are that they are safe, efficient to perform, and reproducible.54 For all trauma patients, especially those who are immobile due to injuries, care pathways typically include pharmacologic prophylaxis against venous thromboembolism and may affect the choice of regional analgesic technique. Table 1 offers a selection of potential regional analgesic techniques that may be applicable for the trauma patient.

Table 1 - Selection of regional analgesic techniques that may be applicable for the trauma patient.
Location of injury Regional analgesic technique options
Upper extremity Brachial plexus blocks and catheters Selective peripheral nerve blocks (eg, suprascapular nerve, median nerve)
Chest wall Thoracic epidural Thoracic paravertebral blocks Intercostal nerve blocks Fascial plane blocks (eg, erector spinae plane, serratus anterior plane)
Abdomen/pelvis Thoracic or lumbar epidural Fascial plane blocks (eg, rectus sheath, transversus abdominis plane, quadratus lumborum)
Hip fracture Lumbar plexus and branch blocks (eg, fascia iliaca, femoral nerve) Pericapsular nerve group (PENG) block
Lower extremity Femoral nerve and adductor canal blocks Sciatic nerve blocks Selective peripheral nerve blocks (eg, genicular nerves, nerves at the ankle for foot injury)

For trauma patients who proceed to surgery, modern enhanced recovery protocols often incorporate regional anesthesia techniques as part of the multimodal analgesic plan.55 The advantage of multimodal analgesia is decreased overreliance on opioids, and regional anesthesia techniques are particularly attractive due to their target specificity and lack of systemic side effects. In the trauma surgery patient, regional analgesia has the potential to decrease hospital length of stay due to better pain control, decrease or avoid critical care admissions, improved pulmonary mechanics, and provide effective acute pain management with knowledge that poorly controlled acute pain is a risk factor for developing chronic pain after surgery.56 For these and other reasons, use of regional anesthesia continues to be an important component of fast-track surgery and enhanced recovery protocols.49,50,57

Racial and ethnic disparities in the use of regional anesthesia among trauma patients is understudied. A team of Canadian investigators evaluated disparities among hip fracture patients, specifically focusing on whether gender was associated with surgical delay of 48 hours or less, preoperative anesthesiology consult, receipt of regional anesthesia, and receipt of neuraxial anesthesia.58 Among the 22,661 patients analyzed over a 2-year period, 71.3% were women; women were less likely to receive geriatric medicine as well as preoperative anesthesiology consultations. However, they did not find a difference in the receipt of regional anesthesia or neuraxial anesthesia, but this study could not evaluate the impact of race and ethnicity as these data were not available.58 Despite the paucity of literature specifically investigating racial and ethnic health disparities in regional anesthesia utilization for trauma patients, racial and ethnic health disparities in the overall care of trauma patients have been previously described and discussed. In the hip fracture population, non-Hispanic Black patients with traumatic hip fractures have a higher incidence of complications, experience longer lengths of stay, and are more likely to experience delays in care compared with non-Hispanic White patients, which may be confounded by differences in hospital characteristics.59 The contribution to disparities attributable to race and ethnicity in the trauma patient is not fully understood, and the presence of racial and ethnic disparities in the utilization of regional anesthesia in this population is completely understudied.

Discussion

Racism continues to be ubiquitous in society, and racial and ethnic disparities are pervasive in healthcare, including RAAPM services for trauma-related injuries in the emergency department, operating room, and intensive care unit (Fig. 1). While research across all aspects of health care is still needed to fully understand the reasons for these disparities and the interconnectedness of the many factors, certain features intrinsic to the trauma patient population argue in favor of prioritizing this group for study. First, trauma patients specifically mentioned in this study include vulnerable groups: children and elderly adults. Trauma patients often do not have input into where they receive care or who provides it. Second, interventions in trauma patients are not scheduled nor elective, and medical decisions must often be made quickly and may therefore be subject to biases. Third, trauma can occur anywhere and is not limited to certain geographic locations or socioeconomic groups. Therefore, universal access to regional anesthesia techniques has to be considered in a long-term strategy to decrease racial and ethnic disparities in usage among trauma patients.

F1
Figure 1:
Health disparities in acute pain management for trauma patients: summary of available literature spanning 3 phases of care (prehospital medicine, emergency department, surgery/ICU); ICU indicates intensive care unit; NSAIDs, nonsteroidal anti-inflammatory drugs.

Implicit biases and stereotypes may have a direct negative impact on patient care. One clear example is the mistaken belief that Black and White patients have biological differences and that Black patients feel less pain, thereby justifying a practitioner’s restricting analgesic interventions.22 Compounding this disparity in pain treatment may be patients’ own cultural beliefs and the lack of patient education specifically combatting misinformation. Previous studies in non-trauma patients show that certain minority patient groups are more likely to refuse regional analgesia.60,61 Other reasons for disparities include differing institutional practices and limited access to regional anesthesia techniques which may be, at least in part, due to lack of resources and RAAPM expertise, lack of diversity in the health care workforce, and lack of racial concordance between patients and health care practitioners.

President Biden and leaders in his administration have named addressing health disparities a top priority as delineated in Executive Order, “Advancing Racial Equity and Support for Underserved Communities Through The Federal Government.”62 Furthermore, the CDC launched Healthy People 2020 with 4 overarching goals, including to “Achieve health equity, eliminate disparities, and improve the health of all groups,” and the CDC plans to track trends in data to shed light on interventions which help reach the initiative’s goals.1,5–7 In organized medicine, the American Medical Association (AMA) also made addressing health disparities a top priority in its mission: “the AMA’s mission is to achieve health equity by mitigating disparity factors in the patient population,” emphasizing the importance of confronting inequities at the health care system and community levels.63 While this statement is not specific to anesthesiology in general or RAAPM in particular, there is a clear need to address disparities in pain management and the use of regional anesthesia in trauma as presented in this article. To develop a strategy, the RAAPM community can look to other industries for examples.

Lessons from successful programs such as LeanIn.Org’s “Allyship at Work” highlight the importance of intentionality and corporate responsibility in addition to individual ownership.64 Organizations and individuals in health care must be intentional about addressing inequities and must implement multifaceted, multipronged interventions that address upstream and downstream factors. If they do not, they will revert to the status quo, which is inequity. Justice, equity, diversity, and inclusion need to be embedded in the fabric of each health care organization and institution. Behavioral change is hard and takes time. Therefore, organizations must be willing to commit time and resources for the long term. A helpful list of recommendations by Chin and colleagues which outline how to address and reduce health concerns can be used as a guide65:

  • Recognize disparities and commit to reducing them.
  • Implement a basic quality improvement structure and process.
  • Make equity an integral component of quality improvement efforts.
  • Design the intervention(s).
  • Implement, evaluate, and adjust the intervention(s).
  • Sustain the intervention(s).

It is beyond the scope of this article to discuss strategies to address all health care disparities, so we have focused on three action items that may improve access and equity in acute pain management for trauma patients. These are: (1) diversifying the medical workforce; (2) addressing unconscious/implicit biases; and (3) implementing community levels of intervention.

Diversifying the medical workforce

Recent diversity in medicine estimates from the Association of American Medical Colleges show that 5.8% and 5.0% of physicians self-identify as Hispanic and Black, respectively.66 However, according to the 2020 United States Census Bureau, these populations accounted for 18.9% and 13.6% of all people living in the United States, respectively, clearly demonstrating the significant underrepresentation of ethnic and racial minorities in the physician workforce.67 Addressing this underrepresentation is essential to the long-term strategy of reducing health disparities because research has shown that racial and ethnic minority physicians are more likely to practice in urban and rural underserved areas and care for uninsured and Medicaid patients.68

Health care system improvements to increase access to equitable trauma care and pain management will require a more diverse anesthesiologist workforce. In 2009, the Liaison Committee on Medical Education published standards aimed to increase diversity among all medical school applicants and matriculating medical students.66 To date, ongoing efforts have not been particularly successful, especially among Black and Native Americans applicants and matriculants. While pipelines and mentorship programs have been created to increase diversity, more research is needed to understand why these efforts have not had the intended outcome.66

While research is clearly needed, racial and ethnic minorities are also underrepresented in this arena. In the United States, the National Institutes of Health (NIH) Center for Scientific Review Study Sections reviews investigator-initiated research applications, determining which studies get funded. In 2011, Ginther and colleagues found that after controlling for potential confounders, Black applicants were 10% less likely to receive NIH R01 funding than their White counterparts.69 In recent years, the NIH has worked to address disparities in research funding, and there has been evidence that such efforts have narrowed the gap. However, the proportion of Black applicants who receive an R01 grant out of all applicants is still only 2%.70

Addressing unconscious/implicit biases

Unconscious and conscious biases are not infrequent among members of the medical workforce and directly contribute to disparities in trauma care and pain management, as previously discussed. However, the impact of these biases on clinical decision-making is unclear. Most studies examining biases and their influence on clinical decision-making utilize clinical vignettes that have inherent limitations.71 An examination of the literature reveals differential management and communication solely based on patient characteristics.72 The trend toward enhanced recovery and multimodal analgesic protocols may in fact reduce disparities as research has shown that pathways and checklists help reduce bias-influenced clinical decision-making.73 Taking online unconscious bias training modules is not enough, and several other strategies have been recommended to mitigate unconscious biases but are beyond the scope of this review.74

Implementing community-levels interventions

Elevating standards in the community for trauma-related pain management to promote regional anesthesia access will also help decrease health disparities and improve outcomes. Liu and colleagues performed a systematic review and meta-analysis of enhanced recovery protocols for hip fracture patients and found that such protocols significantly reduced time to surgery, length of stay, and complication rates without increasing readmission rate or mortality.75 Furthermore, collaborative efforts, such as having emergency medicine physicians perform single-injection peripheral nerve blocks for hip fracture patients on arrival followed by anesthesiologists’ insertion of continuous fascia iliaca blocks, improved pain management outcomes when compared with conventional oral and intravenous analgesics.76 Although logistically challenging at times, evidence supports the use of regional analgesia for trauma patients, and protocolization may effectively reduce physician bias that is associated with health disparities.

In summary, regional anesthesia and analgesia offer many benefits for the trauma patient. However, health disparities in acute pain management, including the use of regional anesthesia techniques, are highly prevalent and span the continuum of trauma care from the prehospital period through emergency department admission and the perioperative period for a variety of patient conditions. Addressing health disparities has been identified as a national priority but will take tremendous effort and resources at all levels: individual, health care system, community, state, and country. This narrative review is not comprehensive and includes the perspectives of minority academic anesthesiologists. Therefore, we freely acknowledge our own biases. As anesthesiologists, however, we are called to care for the most vulnerable of patients and commonly in the setting of acute trauma. We can all agree that they deserve equitable high-quality pain management and perioperative care.

Conflicts of interest

The authors declare that they have nothing to disclose.

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