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Kids' race may play a role in ER treatment for pain

By Genevra Pittman

NEW YORK (Reuters Health) - Black children who are brought to the emergency room for stomach pain and cramps are less likely than white children to be given painkillers, a new study suggests.

Using records from more than 2,000 ER visits, researchers found that white children and teenagers more often received painkillers available over the counter, such as ibuprofen and acetaminophen (Tylenol), or more powerful opioids, including oxycodone. The difference remained after the severity of children's conditions and various hospital-related factors were taken into account.

Dr. Robert Fortuna, a health services researcher from the University of Rochester Medical Center in New York, said it was "especially concerning" to see that pattern show up among kids.

Fortuna's own work and other studies have found similar racial disparities in painkiller prescribing with adult patients (see Reuters Health story of July 5, 2013 here: http://reut.rs/12r77jH).

"Moving forward, we need to better understand why these disparities exist and work to correct them," he told Reuters Health, noting that blaming the differences on doctors' racial biases would be an "oversimplified response."

"I don't believe the vast majority of physicians knowingly or consciously treat patients differently," he said. But, "The bottom line is that minority children in this study were less likely to receive pain medications, and that's concerning."

Oxycodone and other powerful painkillers have been in the spotlight recently as deaths from overdoses rise and more drugs end up in the hands of people taking them for non-medical purposes.

Dr. Tiffani Johnson from Children's Hospital of Philadelphia and her colleagues said the stressful environment of an ER and lack of an established doctor-patient relationship, combined with the subjective nature of stomach pain, may lead doctors to use mental shortcuts including racial stereotypes when making treatment decisions.

The researchers used data from a national study that surveys hospitals about their ambulatory care and scales up the results to reflect the general U.S. population. Their report included information on 2,298 patients age 21 and under who visited an ER in 2006 to 2009 with stomach pain, cramps or spasms, representing 8.1 million such visits across the country.

Among children in severe pain - defined as a rating of seven or higher on a 10-point scale - 27 percent of white kids were given some type of painkiller, compared to 16 percent of black children and 19 percent of Hispanic children.

Across the board, black children were 39 percent less likely than white children to receive any painkillers and 62 percent less likely to be given a narcotic in particular. Differences between white and Hispanic youth were small enough that they could have been due to chance, according to findings published Monday in Pediatrics.

There were no racial or ethnic disparities in the number of diagnostic tests doctors ordered or in how many children were admitted to the hospital, the researchers found.

However, both black and Hispanic youth were 60 to 70 percent more likely to spend over six hours in the ER, compared to their white counterparts.

For the most part, the researchers could not distinguish between different underlying diagnoses that contributed to stomach pain and may have influenced the results.

Emergency departments are stressful settings, Johnson and her colleagues point out, and research on adults has found that when doctors are under pressure and have little information about a patient, they are "more likely to be influenced by stereotypes and bias."

Parents' preferences regarding medication could be playing a role as well, though the study did not examine that question.

Future research should also look into "system-level factors," including the availability of primary care doctors, specialists, interpreters and pediatric formulations of painkillers in hospitals serving different populations, the authors write.

Johnson's team said their findings can be used to develop and test interventions to target treatment differences. Until then, doctors should be aware of these disparities and "make efforts to address pain control that may be suboptimal among minority children."

Parents know their children best, Fortuna said, and need to be their advocates. He encouraged all parents to have a conversation with the doctor about their child's treatment in the ER.

"Until we can better understand where the system is breaking down, the best way to fight against this bias is to have open and honest communication," he said.

SOURCE: http://bit.ly/cxXOG Pediatrics, online September 23, 2013.

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