Racial Disparities in Postpartum Pain Management

The association of patient age, race, and demographic features on reported pain and sedation dosing during procedural abortion: A retrospective cohort study

OBJECTIVES

To explore impact of age, racial, demographic, and psychosocial factors on patients' dosage of analgesia and maximum pain score during procedural abortion.

STUDY DESIGN

We performed retrospective chart review of pregnant individuals undergoing procedural abortion at our hospital-based abortion clinic from October 2019 through May 2020. Patients were stratified into age groups,<19 years, 19 to 35 years, and>35 years. We conducted the Kruskal-Wallis H test to evaluate for medication dosing or maximum pain score differences among groups.

RESULTS

We included 225 patients in our study. We found no difference in fentanyl or midazolam dosing by age. The median fentanyl dose was 75 mcg and median midazolam dose was 2 mg in all three groups (p = 0.61, p = 0.99). White patients received higher median midazolam dosing than Black patients (2 and 3 mg, respectively, p < 0.01) despite similar pain scores. Despite no difference in pain scores, patients terminating for genetic anomaly received more fentanyl than those terminating for socioeconomic reasons (75 and 100 mcg, respectively, p < 0.01).

CONCLUSIONS

In our limited study, we found that White race and induced abortion for genetic anomaly were associated with increased medication dosing, though age was not. Multiple demographic and psychosocial factors, as well as perhaps provider bias, play into both a patient's perception of pain and the dosage of fentanyl and midazolam they receive during abortion procedures.

IMPLICATIONS

By acknowledging both patient factors and provider biases in medication dosing, we can provide more equitable abortion care.

Review of racial/ethnic disparities in obstetrics-related anesthesia administration and pain management

While racial/ethnic disparities in maternal outcomes including mortality and severe maternal morbidity are well documented, there is limited information on disparities in obstetric anesthesia practices. This paper reviews literature on racial/ethnic disparities in peripartum anesthesia administration and postpartum pain management. Current literature demonstrates racial/ethnic disparities in several aspects of obstetric anesthesia care including neuraxial administration for vaginal labor pain, neuraxial versus general anesthesia for cesarean delivery, post neuraxial anesthesia complications, postpartum pain management and postdural puncture headache treatment practices. However, many studies are dated or have limited data from single institutions or states. More research on nation-wide racial/ethnic disparities in obstetric anesthesia is needed to understand its broader practice and management in the USA.

Maternal and Delivery Characteristics and Self-Reported Perceived Control During Labor

OBJECTIVE

To evaluate the association between maternal and delivery characteristics and self-reported perceived control during childbirth.

METHODS

A secondary analysis of a multicenter randomized trial was conducted to compare labor induction at 39 weeks of gestation with expectant management in low-risk nulliparous people. Six to 96 hours after delivery, participants who experienced labor completed the Labor Agentry Scale, a validated self-administered questionnaire to ascertain perceived control during childbirth. Scores range from 29 to 203, with higher scores indicating a sense of greater control. Multivariable linear regression was used to determine which maternal and delivery characteristics were associated with the Labor Agentry Scale score. Eligible characteristics included age, self-reported race and ethnicity, marital status, employment status, type of insurance, previous pregnancy loss before 20 weeks of gestation, body mass index (BMI), smoking, alcohol use, mode of delivery, labor pain (0-10 points), and a composite of perinatal death or severe neonatal complications. Significant variables ( P <.05) were retained in the final multivariable model, and adjusted mean differences (95% CIs) between groups were estimated.

RESULTS

Of 6,106 people enrolled in the trial, 6,038 experienced labor, of whom 5,750 (95.2%) completed the Labor Agentry Scale and were included in this analysis. Mean [95% CI] adjusted Labor Agentry Scale scores were significantly lower among those who identified as Asian (-6.4 [-10.5 to -2.3]) or Hispanic (-3.7 [-5.7 to -1.7]) compared with White, smoked compared with did not smoke (-2.8 [-5.5 to -0.1]), had BMIs of 35 or higher compared with less than 30 (-2.0 [-3.8 to -0.2]), were unemployed (-3.15 [-4.76 to -1.55]), did not have private health insurance (-2.61 [-4.47 to -0.76]), underwent operative vaginal (-5.1 [-7.7 to -2.6]) or cesarean (-14.4 [-16.1 to -12.6]) delivery compared with spontaneous vaginal delivery, and reported greater labor pain score of 8 or higher compared with less than 8 (-11.9 [-13.4 to -10.4]). Mean [95% CI] adjusted Labor Agentry Scale scores were significantly higher among people who were employed compared with unemployed (3.2 [1.6-4.8]) and had private compared with nonprivate insurance (2.6 [0.76-4.5]).

CONCLUSION

In nulliparous people at low risk, unemployment, lack of private health insurance, Asian race, Hispanic ethnicity, smoking, operative delivery, and more labor pain were associated with lower perceived control during labor.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT01990612.

Disparities in Pain Management

Health disparities in pain management remain a pervasive public health crisis. Racial and ethnic disparities have been identified in all aspects of pain management from acute, chronic, pediatric, obstetric, and advanced pain procedures. Disparities in pain management are not limited to race and ethnicity, and have been identified in multiple other vulnerable populations. This review targets health care disparities in the management of pain, focusing on steps health care providers and organizations can take to promote health care equity. A multifaceted plan of action with a focus on research, advocacy, policy changes, structural changes, and targeted interventions is recommended.

Racial and ethnic disparities in obstetric anesthesia: a scoping review

PURPOSE

Health disparities continue to affect racial and ethnic marginalized obstetric patients disproportionally with increased risk of Cesarean delivery and pregnancy-related death. Yet, the literature on what influences such disparities in obstetric anesthesia service and its clinical outcomes is less well known. We set out to describe racial and ethnic disparities in obstetric anesthesia during the peripartum period in the USA via a scoping review of the recent literature.

SOURCE

Using the Institute of Medicine's definition of disparities, we searched the National Library of Medicine's PubMed/Medline, Embase, Web of Science, APA PsycINFO, and Google Scholar for articles published between 1 January 2000 and 30 June 2022 to identify literature on racial and ethnic disparities in obstetric anesthesia.

PRINCIPAL FINDINGS

Out of 8,432 articles reviewed, 15 met our inclusion criteria. All but one study was observational. Seven studies were single-institutional while the remaining used multicentre data/databases. All studies compared two or more race and ethnicity classifications. Studies in this review described disparities in the use of labour epidural analgesia, labour epidural request timing, anesthesia for Cesarean deliveries, postpartum pain management, and epidural blood patch for postdural puncture headaches. Several studies reported disparities observed in the unadjusted models becoming no longer significant when adjusted for other covariates.

CONCLUSION

Based on the findings of the present scoping review on racial and ethnic disparities in obstetric anesthesia, we present an evidence map identifying knowledge gaps and propose a future research agenda.

Disparities in postoperative opioid prescribing by race and ethnicity: an electronic health records-based observational study from Northern California, 2015-2020

OBJECTIVES

To examine racial and ethnic disparities in postoperative opioid prescribing.

DATA SOURCES

Electronic health records (EHR) data across 24 hospitals from a healthcare delivery system in Northern California from January 1, 2015 to February 2, 2020 (study period).

STUDY DESIGN

Cross-sectional, secondary data analyses were conducted to examine differences by race and ethnicity in opioid prescribing, measured as morphine milligram equivalents (MME), among patients who underwent select, but commonly performed, surgical procedures. Linear regression models included adjustment for factors that would likely influence prescribing decisions and race and ethnicity-specific propensity weights. Opioid prescribing, overall and by race and ethnicity, was also compared to postoperative opioid guidelines.

DATA EXTRACTION

Data were extracted from the EHR on adult patients undergoing a procedure during the study period, discharged to home with an opioid prescription.

PRINCIPAL FINDINGS

Among 61,564 patients, on adjusted regression analysis, non-Hispanic Black (NHB) patients received prescriptions with higher mean MME than non-Hispanic white (NHW) patients (+ 6.4% [95% confidence interval: 4.4%, 8.3%]), whereas Hispanic and non-Hispanic Asian patients received lower mean MME (-4.2% [-5.1%, -3.2%] and - 3.6% [-4.8%, -2.3%], respectively). Nevertheless, 72.8% of all patients received prescriptions above guidelines, ranging from 71.0 to 80.3% by race and ethnicity. Disparities in prescribing were eliminated among Hispanic and NHB patients versus NHW patients when prescriptions were written within guideline recommendations.

CONCLUSIONS

Racial and ethnic disparities in opioid prescribing exist in the postoperative setting, yet all groups received prescriptions above guideline recommendations. Policies encouraging guideline-based prescribing may reduce disparities and overall excess prescribing.

Maternal psychosocial factors associated with postpartum pain

BACKGROUND

The experience of pain is shaped by a host of psychological, cultural, and social factors. Although pain is the most common postpartum complaint, data on its relationship with psychosocial factors and postpartum pain are limited.

OBJECTIVE

This study aimed to examine the relationship between self-reported postpartum pain scores and patient-level psychosocial factors, including relationship status, pregnancy intendedness, employment, education, and psychiatric diagnosis.

STUDY DESIGN

This was a secondary analysis of data from a prospective observational study of postpartum patients at 1 institution (May 2017 to July 2019) who used an oral opioid at least once during their postpartum hospitalization. Enrolled participants completed a survey, which included questions regarding their social situation (including relationship status), psychiatric diagnoses, and perceptions of their pain control during their postpartum hospitalization. The primary outcome was self-reported overall pain during the postpartum hospitalization (score of 0-100). Multivariable analyses accounted for age, body mass index, nulliparity, and mode of delivery.

RESULTS

In this cohort of 494 postpartum patients, most patients (84.0%) underwent cesarean delivery, and 41.3% of patients were nulliparous. In a pain score of 0 to 100, participants reported a median pain score of 47. On bivariable analyses, there was no significant difference in pain score between patients with and without an unplanned pregnancy or a psychiatric diagnosis. Patients who were unpartnered, those without a college education, and those who were unemployed reported significantly higher pain scores (57.5 vs 44.8 [P<.01], 52.6 vs 44.6 [P<.01], and 53.6 vs 44.6 [P<.01], respectively). In multivariable analyses, patients who were unpartnered and unemployed reported significantly higher adjusted pain scores than patients who were partnered and employed (adjusted beta coefficients: 7.93 [95% confidence interval, 2.29-13.57] vs 6.67 [95% confidence interval, 2.28-11.05]).

CONCLUSION

Psychosocial factors, such as relationship and employment statuses, which are indicators of social support, are associated with the experience of pain postpartum. These findings suggest that addressing social support, such as via enhanced support from the health care team, warrants exploration as a nonpharmacologic means of improving the postpartum pain experience.

Racial bias in cesarean decision-making

BACKGROUND

Category II fetal heart tracing noted during continuous external fetal monitoring is a frequent indication for cesarean delivery in the United States despite its somewhat subjective interpretation. Black patients have higher rates of cesarean delivery and higher rates for this indication. Racial bias in clinical decision-making has been demonstrated throughout medicine, including in obstetrics.

OBJECTIVE

We sought to examine if racial bias affects providers' decisions about cesarean delivery for an indication of category II fetal heart tracings.

STUDY DESIGN

We constructed an online survey study consisting of 2 clinical scenarios of patients in labor with category II tracings. Patient race was randomized to Black and White; the vignettes were otherwise identical. Participants had the option to continue with labor or to proceed with a cesarean delivery at 3 decision points in each scenario. Participants reported their own demographics anonymously. This survey was distributed to obstetrical providers via email, listserv, and social media. Data were analyzed using chi-square tests at each decision point in the overall sample and in subgroup analyses by various participant demographics.

RESULTS

A total of 726 participants contributed to the study. We did not find significant racial bias in cesarean delivery decision-making overall. However, in a scenario of a patient with a previous cesarean delivery, Fisher's exact tests showed that providers <40 years old (n=322; P=.01) and those with <10 years of experience (n=239; P=.050) opted for a cesarean delivery for Black patients more frequently than for White patients at the first decision point. As labor progressed in this scenario, the rates of cesarean delivery equalized across patient race.

CONCLUSION

Younger providers and those with fewer years of clinical experience demonstrated racial bias in cesarean delivery decision-making at the first decision point early in labor. Providers did not show racial bias as labor progressed, nor in the scenario with a patient without a previous cesarean delivery. This bias may be the consequence of provider training with the Maternal-Fetal Medicine Unit Network Vaginal Birth After Cesarean Calculator, developed in 2007, and widely used to estimate the probability of successful vaginal birth after a cesarean delivery. This calculator used race as a predictive factor until it was removed in June 2021. Future studies should investigate if this bias persists following this change, while also focusing on interventions to address these findings.

The past, present, and future of opioid prescribing: perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021

Objective

To describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates.

Methods

Part one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge.

Results

1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients.

Conclusion

Inpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients' actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.

Inequities in Inpatient Obstetrics Pain Management and Evaluation: Age, Race, Mental Health, and Obesity

OBJECTIVE

To evaluate disparities of pain management among patients giving birth in inpatient Obstetrics units based on age, race, BMI, and mental health diagnoses.

METHODS

A retrospective cohort study was performed and included all individuals giving birth at a tertiary-care institution in 2019. Patient-reported pain scores, and inpatient narcotic administration and dosing for pain control were collected. Models were adjusted for race, age, BMI, and diagnoses of anxiety, depression, opioid use disorder, and/or schizophrenia.

RESULTS

4788 Individuals met the inclusion criteria. A higher proportion of African American patients reported severe pain (n = 233/607, 38.4%) and received narcotics (n = 653/1141, 57.2%) compared to patients of other races. Despite controlling for several possible confounders, African American patients (OR 1.55, 95% CI 1.08-2.22), patients with increased BMI (OR 1.02, 95% CI 1.01-1.03), and patients with a mental health diagnosis (OR 2.33, 95% CI 1.32-4.12) were more likely to have worse pain at rest. Older patients were more likely to be administered narcotics (n = 447/757, 59.0%) compared to younger patients (patients aged 18-26: n = 577/1257, 52.3%; patients aged 27-35: n = 1451/2774, 52.3%; p < 0.001), despite younger patients being more likely to have severe pain (OR 1.50; 95% CI 1.20-1.86; p = 0.001).

CONCLUSIONS

Patients who are Non-Hispanic African American and patients with obesity and mental health diagnoses experience inequities in postpartum pain management. Pain is complex and multifactorial and can be impacted by cultural, social, environmental factors and more. Further studies on factors that influence pain perception and management in inpatient obstetrics units are needed.

Frequency and associated symptoms of isthmoceles in women 6 months after caesarean section: a prospective cohort study

PURPOSE

The purpose of this study was to determine the frequency of detection of isthmoceles by ultrasound 6 months after caesarean section (CS) and which symptoms associated with isthmocele formation occur after CS. Subsequently, it was determined how often the ultrasound finding "isthmocele" coincided with the presence of complaints.

METHODS

A prospective multicentre cohort study was conducted with 546 patients from four obstetric centres in Berlin, who gave birth by primary or secondary CS from October 2019 to June 2020. 461 participants were questioned on symptoms 3 months after CS; 329 participants were included in the final follow-up 6 months after CS. The presence of isthmoceles was determined by transvaginal sonography (TVS) 6 months after CS, while symptoms were identified by questionnaire.

RESULTS

Of the 329 women, 146 (44.4%) displayed an isthmocele in the TVS. There was no statistically significant difference in the manifestation of symptoms between the two groups of women with and without isthmocele; however, when expressed on a scale from 1 to 10 the intensity of both scar pain and lower abdominal pain was significantly higher in the set of women that had shown to have developed an isthmocele (p = 0.014 and p = 0.031, respectively).

CONCLUSION

The prevalence of isthmoceles 6 months after CS was 44.4%. Additionally, scar pain and lower abdominal pain were more pronounced when an isthmocele was also observed in the TVS.

TRIAL REGISTRATION

Trial registration number DRKS00024977. Date of registration 17.06.2021, retrospectively registered.

Racial and Ethnic Disparity in Prehospital Pain Management for Trauma Patients

BACKGROUND

Although evidence suggests that racial and ethnic minority (REM) patients receive inadequate pain management in the acute care setting, it remains unclear whether these disparities also occur during the prehospital period. The aim of this study is to assess the impact of race and ethnicity on prehospital analgesic use by emergency medical services (EMS) in trauma patients.

STUDY DESIGN

Retrospective chart review of adult trauma patients aged 18 to 89 years old transported by EMS to our American College of Surgeons-verified level 1 trauma center from 2014 to 2020. Patients who identified as Black, Asian, Native American, or Other for race and/or Hispanic or Latino or Unknown for ethnicity were considered REM. Patients who identified as White, non-Hispanic were considered White. Groups were compared in univariate and multivariate analysis. The primary outcome was prehospital analgesic administration.

RESULTS

A total of 2,476 patients were transported by EMS (47% White and 53% REM). White patients were older on average (46 years vs 38 years; p < 0.001) and had higher rates of blunt trauma (76% vs 60%; p < 0.001). There were no differences in Injury Severity Score (21 vs 20; p = 0.22). Although REM patients reported higher subjective pain rating (7.2 vs 6.6; p = 0.002), they were less likely to get prehospital pain medication (24% vs 35%; p < 0.001), and that difference remained significant after controlling for baseline characteristics, transport method, pain rating, prehospital hypotension, and payor status (adjusted odds ratio [95% CI], 0.67 [0.47 to 0.96]; p = 0.03).

CONCLUSIONS

Patients from racial and ethnic minority groups were less likely to receive prehospital pain medication after traumatic injury than White patients. Forms of conscious and unconscious bias contributing to this inequity need to be identified and addressed.

Factors Associated With Postoperative Opioid Prescribing After Primary Elective Cesarean Section

INTRODUCTION

Guidelines indicate the need to balance the risks of opioid prescribing with the need to adequately manage pain after cesarean section (CS). Although guidelines suggest the need for tailored opioid prescribing, it is unclear whether providers currently tailor opioid prescribing practices given patient-related factors. Thus, research is needed to first understand post-CS pain management and opioid prescribing. The objective of the present study was to identify factors related to CS discharge opioid prescriptions.

MATERIAL AND METHODS

This retrospective cohort study was approved by the Brooke Army Medical Center Institutional Review Board (San Antonio, Texas; #C.2020.094e) on June 23, 2020. Electronic health record data of healthy adult women undergoing primary elective CS, performed under regional neuraxial anesthesia at a single, academic, tertiary medical center from 2018 to 2019, were included. Multivariable regression examined patient and medical factors associated with post-CS opioid prescriptions.

RESULTS

In the present sample (N = 169), 23% (n = 39) of patients did not use opioids postoperatively, while inpatient and almost all of those patients (n = 36) received a discharge prescription for opioids with a median amount of 225 morphine milligram equivalent doses. There was a lack of evidence indicating that patient and medical factors were associated with discharge opioid dose.

CONCLUSION

Patient and medical factors were not associated with post-CS opioid prescribing. Larger studies are needed to better elucidate optimal post-CS pain management in the days and months that follow CS. Such findings are needed to better tailor opioid prescribing, consistent with clinical practice guidelines.

Racial disparities in post-operative pain experience and treatment following cesarean birth

OBJECTIVE

To evaluate racial/ethnic differences in post-operative pain experience and opioid medication use (morphine milligram equivalent) in the first 24 h following cesarean birth.

METHODS

This study was a single-center retrospective cohort of birthing persons who underwent cesarean deliveries between 1/1/16 and 12/31/17. A total of 2,228 cesarean deliveries were analyzed. The primary outcome was average pain, which was the mean of all documented self-reported pain scores (0-10 scale) during the first 24 h post-delivery. The secondary outcome included oral morphine equivalents used in the first 24 h post-delivery. Linear regression was performed to examine whether the race/ethnicity of the birthing parent was associated with mean pain scores and oral morphine equivalents, controlling for confounding variables.

RESULTS

In multivariate analyses non-Hispanic Black birthing persons reported higher mean pain scores (Coefficient: 0.61, 95% confidence interval [0.39-0.82], p < .001]) than non-Hispanic White birthing persons, but received similar quantities of morphine milligram equivalent (Coefficient: -0.98 mg, 95% confidence interval [-5.93-3.97], p = .698]). Non-Hispanic Asian birthing persons reported similar reported mean pain scores to those of non-Hispanic White birthing persons (Coefficient: 0.02 mg, 95% confidence interval [-0.17-0.22], p = .834]), but received less morphine milligram equivalent (Coefficient: -5.47 mg, 95% confidence interval [-10.05 to -0.90], p = .019). When controlling for reported mean pain scores, both non-Hispanic Black (Coefficient: -6.36 mg, 95% confidence interval [-10.97 to -1.75], p = .007) and non-Hispanic Asian birthing persons (Coefficient: -5.66 mg, 95% confidence interval [-9.89 to -1.43], p = .009) received significantly less morphine milligram equivalents.

CONCLUSION

Despite reporting higher mean pain scores, non-Hispanic Black birthing persons did not receive higher quantities of morphine milligram equivalent. Non-Hispanic Asian birthing persons received lower quantities of morphine milligram equivalent despite reporting similar pain scores to non-Hispanic White birthing persons. These differences suggest disparities in post-operative pain management for birthing persons of color in our study population.

Antiracist symptom science: A call to action and path forward

Nurse scientists recognize the experience of racism as a driving force behind health. However, symptom science, a pillar of nursing, has rarely considered contributions of racism. Our objective is to describe findings within symptom science research related to racial disparities and/or experiences of racism and to promote antiracist symptom science within nursing research. In this manuscript, we use an antiracist lens to review a predominant symptom science theory and literature in three areas of symptom science research-oncology, mental health, and perinatal health. Finally, we make recommendations for increasing antiracist research in symptom science by altering (a) research questions, (b) recruitment methods, (c) study design, (d) data analysis, and (e) dissemination of findings. Traditionally, symptom science focuses on individual level factors rather than broader contexts driving symptom experience and management. We urge symptom science researchers to embrace antiracism by designing research with the specific intent of dismantling racism at multiple levels.

Racial Disparities in Donor Human Milk Feedings: A Study Using Electronic Medical Records

Introduction

The aim of this study was to evaluate differences in the use of pasteurized donor human milk (PDHM) by maternal race-ethnicity during postpartum hospitalization using electronic medical records (EMRs).

Materials and Methods

A retrospective cohort study of all live-born infants at our academic research institution from July 1, 2014, to June 30, 2016, was conducted. EMR data were used to determine whether each infant received mother's own milk (MOM), PDHM, or formula. These data were stratified based on whether the infant received treatment in the Neonatal Critical Care Center. Generalized estimating equation models were used to calculate the odds of receiving PDHM by maternal race-ethnicity, adjusting for gestational age, birth weight, insurance, preferred language, nulliparity, and mode of delivery.

Results

Infant feeding data were available for 7097 infants, of whom 49% were fed only MOM during their postpartum hospitalization. Among the 15.9% of infants admitted to neonatal critical care, infants of non-Hispanic Black (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.31-0.72), Hispanic (OR 0.65, 95% CI 0.36-1019), and Other (OR 0.63, 95% CI 0.32-1.26) mothers had lower rates of PDHM feedings than infants of non-Hispanic White mothers in the adjusted models. Among well infants, the use of PDHM was lower among non-Hispanic Black and Hispanic mothers (OR 0.25, 95% CI 0.18-0.36, and OR 0.38, 95% CI 0.26-0.56) compared with non-Hispanic White mothers.

Conclusions

Inequities in exclusive human milk feeding and use of PDHM by maternal race-ethnicity were identified. Antiracist interventions are needed to promote equitable access to skilled lactation support and counseling for PDHM use.

Enhanced Recovery after Surgery Protocol to Improve Racial and Ethnic Disparities in Postcesarean Pain Management

OBJECTIVE

The objective of this study was to assess the efficacy of an enhanced recovery after surgery (ERAS) protocol and determine its effect on racial/ethnic disparities in postcesarean pain management.

STUDY DESIGN

We performed an institutional review board-approved retrospective cohort study of scheduled cesarean deliveries before and after ERAS implementation at a single urban academic institution. Pre-ERAS, all analgesic medications were given postoperatively on patient request. The ERAS protocol included preoperative acetaminophen and celecoxib. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was available as needed, and opioid patient-controlled analgesia was eliminated from the standard order set. The primary outcome was total opioid use in the first 48 hours after cesarean, pre- and post-ERAS, reported in total milliequivalents of intravenous morphine (MME). A secondary analysis of opioid use and pain scores by racial groups was also performed. Chi-square, independent t-tests, analysis of variance, Mann-Whitney U, and Kruskal-Wallis tests were used depending on variable and data normality.

RESULTS

Pre-ERAS and post-ERAS groups included 100 women each. Post-ERAS, total opioid use in 48 hours was less (40.8 vs. 8.6 MME, p < 0.001) and visual analog scale (VAS) pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 maximum at rest: 6.7 vs. 5.3, p < 0.001). Pre-ERAS pain scores differed by race with non-Hispanic Black (NHB) patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, maximum VAS at rest: NHB-7.4, non-Hispanic White-6.6, Hispanic-5.8, Asian-4.4, p = 0.006). Post-ERAS, there were no differences in postoperative pain scores between groups with movement on POD1 and POD2.

CONCLUSION

A standardized ERAS protocol for postcesarean pain decreases opioid use and may improve some racial disparities in postcesarean pain control.

KEY POINTS

· ERAS protocols improve postoperative pain control and lower postoperative opioid use.. · Studies show that there are racial and ethnic disparities in postpartum pain control.. · Protocols standardize care and may decrease the effects of provider implicit bias..

Impact of timing of multimodal analgesia in enhanced recovery after cesarean delivery protocols on postoperative opioids: A single center before-and-after study

STUDY OBJECTIVE

Enhanced recovery after cesarean delivery (ERAC) programs aim to decrease maternal morbidity and aid in maternal recovery and return to baseline. Multimodal analgesia is an important element of ERAC protocols, but no consensus exists on the timing of medication administration. We compared maternal pain outcomes following scheduled cesarean delivery with modification of the timing of administration of multimodal analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.

DESIGN

Before-and-after study.

SETTING

Labor and delivery unit at a single academic institution.

INTERVENTION

NSAIDs and acetaminophen were administered as a fixed-interval alternating regimen every 3 h for the initial ERAC group (ERAC 1) and fixed-interval combined regimen every 6 h for the modified ERAC group (ERAC 2). ERAC 1 and ERAC 2 groups were compared to historical controls (Pre-ERAC).

PATIENTS

520 women undergoing scheduled cesarean delivery (Pre-ERAC n = 179, ERAC 1 n = 179, and ERAC 2 n = 162).

MEASUREMENTS

The primary outcomes were postoperative total and daily opioid utilization as measured in morphine milligram equivalents (MME). Secondary outcomes included postoperative length of stay, maximum pain scores, and racial disparities in care.

MAIN RESULTS

The modified schedule of non-opioid analgesics involving combined administration (ERAC 2) versus alternating administration (ERAC 1) of multimodal analgesia resulted in decreased total postoperative opioid utilization (median = 26.3 vs 52.5 MME, Bonferroni corrected P = 0.002). Total postoperative opioid utilization among the ERAC 2 group was also significantly reduced compared to the Pre-ERAC group (median = 26.3 vs 105.0 MME, Bonferroni corrected P < 0.0001).

CONCLUSIONS

Multidisciplinary teams developing or modifying ERAC protocols for scheduled cesarean delivery should consider a combined administration at fixed intervals of NSAIDs and acetaminophen throughout the hospital stay to optimize postoperative pain management.

Temporal Trends in Postpartum Opioid Prescribing, Opioid Use, and Pain Control Satisfaction

OBJECTIVE

The objective was to assess temporal trends in postpartum opioid prescribing, opioid use, and pain control satisfaction.

STUDY DESIGN

This is a prospective observational study of postpartum patients who delivered at a large tertiary care center (May 2017-July 2019). Inpatient patients were screened for eligibility; those meeting eligibility criteria who used inpatient opioids were approached for prospective survey participation which probed inpatient and outpatient postpartum pain control. The amount of opioids used during inpatient hospitalization and the amount of opioids prescribed at discharge were obtained from medical records. The primary outcome was the difference in opioid prescribing at discharge over time, measured by (1) the proportion of participants who received an opioid prescription at discharge and (2) for those who received an opioid prescription, the total morphine milligram equivalents of the prescription. Additional outcomes were inpatient and outpatient opioid use and patient-reported satisfaction with postpartum pain control. Trends over time were evaluated using nonparametric tests of trend.

RESULTS

Of 2,503 postpartum patients screened for eligibility, a majority (N = 1,425; 60.8%) did not use an opioid as an inpatient. Over the study period, there was a significant decline in the proportion of patients who used an opioid while inpatient (z-score =  - 11.8; p < 0.01). Among these participants enrolled in the prospective survey study (N = 494), there was a significant decline over time in the amount of inpatient opioid use (z-score =  - 2.4; p = 0.02), the proportion of participants who received an opioid prescription upon discharge (z-score =  - 8.2; p < 0.01), and, when an opioid was prescribed at discharge, the total prescribed morphine milligram equivalents (z-score =  - 4.3; p < 0.01). Both inpatient and outpatient satisfactions with pain control were unchanged over this time (z-score = 1.1, p = 0.27; z-score = 1.1, p = 0.29, respectively).

CONCLUSION

In this population, both the frequency and amount of opioid use in the postpartum period declined from 2017 to 2019. This decrease in opioid prescribing was not associated with changes in patient-reported satisfaction with pain control.

KEY POINTS

· From 2017 to 2019, there was a decrease in inpatient and outpatient postpartum opioid use.. · Both the proportion of postpartum patients receiving opioid prescriptions and the amount prescribed decreased.. · Patient satisfaction with postpartum pain control remained unchanged..

Strategies to Promote Racial Healthcare Equity in Pain Medicine: A Call to Action

In the past several years, many national events have illuminated the inequities faced by the Black community in all aspects of life, including healthcare. To close the gap in healthcare equity, it is imperative that clinicians examine their practices for disparities in the treatment of minority patients and for racial injustice and take responsibility for improving any issues. As leaders in pain medicine, we can start by improving our understanding of healthcare disparities and inequities among racial and ethnic minorities and translating that knowledge into a cultural transformation to improve the care of those impacted. In this paper, we identify the areas of medicine in which pain assessment and treatment are not equitably delivered. As we acknowledge these disparities, we will highlight reasons for these incongruences in care and clarify how clinicians can act to ensure that all patients are treated equitably, with equal levels of compassion.

Medical Mistrust in Perinatal Mental Health

Despite the advancement of telemedicine and recent innovations in treatment, minoritized women continue to bear a disproportionate burden of pregnancy-related psychiatric conditions and complications, which the pandemic has further exacerbated. Research demonstrates that medical mistrust and systemic racism play central roles in the underutilization of services by racially and ethnically diverse women during pregnancy and postpartum. To effectively address these disparities, it is imperative to understand the drivers of medical mistrust in perinatal health care systems. This Perspectives article describes the historical context of medical mistrust in psychiatric and obstetric health systems and offers solutions to mitigate mistrust and the impact of systemic racism on perinatal care.

How Can We Get to Equitable and Effective Postpartum Pain Control?

Postpartum pain is common, yet patient experiences and clinical management varies greatly. In the United States, pain-related expectations and principles of adequate pain management have been framed within established norms of Western clinical medicine and a biomedical understanding of disease processes. Unfortunately, this positioning of postpartum pain and the corresponding coping strategies and pain treatments is situated within cultural biases and systemic racism. This paper summarizes the history and existing literature that examines racial inequities in pain management to propose guiding themes and suggestions for innovation. This work is critical for advancing ethical practice and establishing more effective care for all patients.

Maternal mortality in the United States: The pervasive effects of racism

Maternal mortality is a worldwide epidemic, with rates in the United States far surpassing those in similar high-income countries, and years of implicit bias and systemic racism have impacted outcomes for individuals belonging to racial and ethnic minorities. Structural racism must be dismantled to ensure better care for all.

Causes of health inequities

PURPOSE OF REVIEW

A renewed focus on U.S. racial and ethnic maternal health disparities has arisen following high-profile incidents of police violence and antiracism protests which coincided with the coronavirus disease 2019 pandemic, which has exerted a disproportionate effect on minority communities. Understanding the causes of disparities is pivotal for developing solutions.

RECENT FINDINGS

Social determinants of health must be addressed during clinical care; however, race must be used with caution in clinical decision-making. Medicaid expansion has been associated with a decrease in severe maternal morbidity and mortality, especially for racial and ethnic minority women. Indirect obstetric causes are the leading cause of maternal death.

SUMMARY

Policy-level changes and investment in marginalized communities are required to improve access to quality maternity care at all stages, including preconception, interconception, prenatal, intrapartum and postpartum for 12 months after delivery. Improvements in hospital quality and implementation of evidence-based bundles of care are crucial. Clinicians should receive training regarding susceptibility to implicit bias. To support the research agenda, better collection of race and ethnicity data and anesthesia care indicators is a priority (see Video, Supplemental Digital Content 1 {Video abstract that provides an overview of the causes racial and ethnic disparities in maternal health outcomes.} http://links.lww.com/COAN/A85).

Considerations for the Use of Race in Research in Obstetrics and Gynecology

The race variable in research has been the topic of debate in both research and clinical realms. The tension surrounding the discourse of the use of race in research stem from the difficulties in defining race, the limitations of the variable, and the implications for health and racial equity. In this review, we dissect the challenges faced when incorporating race into research and offer a guide for incorporating race in research in a manner that promotes racial and health equity.

Understanding Structural Racism as a Barrier to Living Donor Kidney Transplantation and Transplant Care

Recent Findings

Black and Hispanic patients carry higher burden of kidney disease, yet have lower access to LDKT. Until recently, these differences were thought to be due to medical co-morbidities and variation in transplant center practices. However, recent studies have shown that systemic and structural inequities related to race may be one of the major drivers.

Purpose of Review

In this paper, we examine the definition of race and systemic racism, then describe patient-, transplant center–, and society-level barriers to LDKT. We identify how social determinants, cultural biases and mistrust in medical system, influence behaviors, and provider racial profiling affects all phases of transplant evaluation. Finally, we discuss initiatives to overcome some of these barriers, starting from federal government, national organizations, transplant centers, and community partners.

Summary

Examining structural biases in transplant practices is an important step to developing solutions to address disparities in health care access and outcomes for patients who need and receive transplants.

Development and Validation of a Model to Predict Postdischarge Opioid Use After Cesarean Birth

A model with three predictors readily found in the electronic health record—inpatient opioid use, tobacco use, and depression or anxiety—accurately estimated postdischarge opioid use.

OBJECTIVE:

To develop and validate a prediction model for postdischarge opioid use in patients undergoing cesarean birth.

METHODS:

We conducted a prospective cohort study of patients undergoing cesarean birth. Patients were enrolled postoperatively, and they completed pain and opioid use questionnaires 14 days after cesarean birth. Clinical data were abstracted from the electronic health record (EHR). Participants were prescribed 30 tablets of hydrocodone 5 mg–acetaminophen 325 mg at discharge and were queried about postdischarge opioid use. The primary outcome was total morphine milligram equivalents used. We constructed three proportional odds predictive models of postdischarge opioid use: a full model with 34 predictors available before hospital discharge, an EHR model that excluded questionnaire data, and a reduced model. The reduced model used forward selection to sequentially add predictors until 90% of the full model performance was achieved. Predictors were ranked a priori based on data from the literature and prior research. Predictive accuracy was estimated using discrimination (concordance index).

RESULTS:

Between 2019 and 2020, 459 participants were enrolled and 279 filled the standardized study prescription. Of the 398 with outcome measurements, participants used a median of eight tablets (interquartile range 1–18 tablets) after discharge, 23.5% used no opioids, and 23.0% used all opioids. Each of the models demonstrated high accuracy predicting postdischarge opioid use (concordance index range 0.74–0.76 for all models). We selected the reduced model as our final model given its similar model performance with the fewest number of predictors, all obtained from the EHR (inpatient opioid use, tobacco use, and depression or anxiety).

CONCLUSION:

A model with three predictors readily found in the EHR—inpatient opioid use, tobacco use, and depression or anxiety—accurately estimated postdischarge opioid use. This represents an opportunity for individualizing opioid prescriptions after cesarean birth.

Osteopathic medical students' understanding of race-based medicine

CONTEXT

Race is a social construct, not a biological or genetic construct, utilized to categorize people based on observable traits, behaviors, and geographic location. Findings from the Human Genome Project demonstrated that humans share 99.9% of their DNA; despite this evidence, race is frequently utilized as a risk factor for diagnosis and prescribing practices. Diagnosing and treating people based on race is known as race-based medicine. Race-based medicine perpetuates biases and diverts attention and resources from the social determinants of health that cause racial health inequities. Minimal research has examined medical students' understanding of race-based medicine.

OBJECTIVES

The purpose of this study was to assess osteopathic medical students' knowledge, beliefs, and experiences with race-based medicine.

METHODS

We conducted a descriptive, cross-sectional survey study to assess osteopathic medical students' knowledge, beliefs, and experiences with race-based medicine. An electronic, anonymous survey was distributed to all osteopathic medical students enrolled at a medical school in the Midwest with three campuses during the 2019-2020 academic year. Participants completed a brief demographic questionnaire and the Race-Based Medicine Questionnaire. Descriptive and inferential statistics were conducted utilizing SPSS statistical software version 28.0, and statistical significance was defined as a p<0.05. Open-ended questions were analyzed utilizing content and thematic analyses.

RESULTS

A total of 438 of the 995 osteopathic medical students consented to participate in the study, for a response rate of 44.0%. Among those participants, 221 (52.0%) reported that they had heard of the term "race-based medicine." Familiarity with the term differed by racial background (χ [2] = 24.598, p<0.001), with Black or African American participants indicating greater familiarity with the term compared to all other races. Of the participants familiar with race-based medicine, 79 (44.4%) provided the correct definition for the term; this finding did not differ by any sociodemographic variable. Part of the way through the questionnaire, all participants were provided the correct definition of "race-based medicine" and asked if they thought medical schools should teach race-based medicine. The majority of participants (n=231, 61.4%) supported the teaching of race-based medicine. Qualitative findings elaborated on participants' support or opposition for teaching race-based medicine in medical school. Those in support explained the importance of teaching historical perspectives of race-based medicine as well as race as a data point in epidemiology and its presence on board examinations, whereas those in opposition believed it contradicted osteopathic principles and practice.

CONCLUSIONS

Findings showed half of the participants were familiar with race-based medicine, and among those, less than half knew the definition of the term. Highlighting osteopathic philosophy and its focus on the whole person may be one approach to educating osteopathic medical students about race-based medicine.

Addressing bias and disparities in periviable counseling and care

Addressing bias and disparities in counseling and care requires that we contend with dehumanizing attitudes, stereotypes, and beliefs that our society and profession holds towards people of color, broadly, and Black birthing people in particular. It also necessitates an accounting of the historically informed, racist ideologies that shape present-day implicit biases. These biases operate in a distinctly complex and damaging manner in the context of end-of-life care, which centers around questions related to human pain, suffering, and value. Therefore, this paper aims to trace biases and disparities that operate in periviable care, where end-of-life decisions are made at the very beginning of life. We start from a historical context to situate racist ideologies into present day stereotypes and tropes that dehumanize and disadvantage Black birthing people and Black neonates in perinatal care. Here, we review the literature, address historical incidents and consider their impact on our ability to deliver patient-centered periviable care.

Racial and Ethnic Disparities in the Management of Postdural Puncture Headache With Epidural Blood Patch for Obstetric Patients in New York State

IMPORTANCE

Characterizing and addressing racial and ethnic disparities in peripartum pain assessment and treatment is a national priority.

OBJECTIVE

To evaluate the association of race and ethnicity with the provision and timing of an epidural blood patch (EBP) for management of postdural puncture headache in obstetric patients.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used New York State hospital discharge records from January 1, 1998, to December 31, 2016, from mothers 15 to 49 years of age with a postdural puncture headache after neuraxial analgesia or anesthesia for childbirth. Statistical analysis was performed from February 2020 to February 2022.

EXPOSURES

Patients' race and ethnicity (reported as provided by each participating hospital; the method of determining race and ethnicity [ie, self-reported or not] cannot be determined from the data) were categorized into non-Hispanic White (reference group), non-Hispanic Black, Hispanic, and other race and ethnicity (including Asian and Pacific Islander, American Indian, Alaskan Native, and other).

MAIN OUTCOMES AND MEASURES

The primary outcome was the rate of EBP use. The secondary outcome was the interval (days) between hospital admission and provision of EBP. Odds ratios (ORs) and 95% CIs of EBP use associated with race and ethnicity were estimated using mixed-effect logistic regression models, adjusting for patient and hospital characteristics.

RESULTS

During the study period, 8921 patients (mean [SD] age, 30 [6] years; 1028 [11.5%] Black; 1301 [14.6%] Hispanic; 4960 [55.6%] White; and 1359 [15.2%] other race and ethnicity) with postdural puncture headache were identified among 1.9 million deliveries with a neuraxial procedure. Of these 8921 patients, 4196 (47.0%; 95% CI, 46.0%-48.1%) were managed with an EBP. A total of 2650 White patients (53.4%; 95% CI, 52.0%-54.8%) used an EBP; this rate was significantly higher than that among Hispanic patients (41.7% [543]; 95% CI, 39.9%-44.5%), Black patients (35.7% [367]; 95% CI, 32.8%-38.7%), or patients of other race and ethnicity (35.2% [478]; 95% CI, 32.6%-37.8%). Timing of EBP was at a median of 2 days (IQR, 2-3 days) after hospital admission for White patients compared with a median of 3 days (IQR, 2-4 days) for Hispanic patients, Black patients, and patients of other race and ethnicity (P < .001 for the comparison with White patients). After adjustment for patient and hospital characteristics, the EBP rate was not different between White and Hispanic patients (adjusted OR, 1.11; 95% CI, 0.94-1.30). It was significantly lower for Black patients (adjusted OR, 0.80; 95% CI, 0.67-0.94) and patients of other races and ethnicities (adjusted OR, 0.85; 95% CI, 0.73-0.99).

CONCLUSIONS AND RELEVANCE

In this study, significant racial and ethnic disparities in the management of postdural puncture headache with EBP were observed, with both lower rates and delayed timing, which may be associated with long-term adverse effects.

Textbook typologies: Challenging the myth of the perfect obstetric pelvis

Medical education's treatment of obstetric-related anatomy exemplifies historical sex bias in medical curricula. Foundational obstetric and midwifery textbooks teach that clinical pelvimetry and the Caldwell-Moloy classification system are used to assess the pelvic capacity of a pregnant patient. We describe the history of these techniques-ostensibly developed to manage arrested labors-and offer the following criticisms. The sample on which these techniques were developed betrays the bias of the authors and does not represent the sample needed to address their interest in obstetric outcomes. Caldwell and Moloy wrote as though the size and shape of the bony pelvis are the primary causes of "difficult birth"; today we know differently, yet books still present their work as relevant. The human obstetric pelvis varies in complex ways that are healthy and normal such that neither individual clinical pelvimetric dimensions nor the artificial typologies developed from these measurements can be clearly correlated with obstetric outcomes. We critique the continued inclusion of clinical pelvimetry and the Caldwell-Moloy classification system in biomedical curricula for the racism that was inherent in the development of these techniques and that has clinical consequences today. We call for textbooks, curricula, and clinical practices to abandon these outdated, racist techniques. In their place, we call for a truly evidence-based practice of obstetrics and midwifery, one based on an understanding of the complexity and variability of the physiology of pregnancy and birth. Instead of using false typologies that lack evidence, this change would empower both pregnant people and practitioners.

Validation of the tobacco, alcohol, prescription medication, and other substance use (TAPS) tool with the WHO alcohol, smoking, and substance Involvement screening test (ASSIST)

INTRODUCTION

Community pharmacies are emerging as a valuable setting to identify patients with substance use. Few tools have been specially validated to screen patients in these settings, particularly among those prescribed opioid medications. The goal of this study was to validate the performance of the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool in community pharmacy settings compared to a reference-standard substance use assessment.

METHODS

Participants were recruited while receiving opioid medications (not solely buprenorphine) from 19 pharmacies from a large national chain in Ohio and Indiana. Adults who were not involved in the criminal justice system or receiving cancer treatment were invited to participate in a one-time, cross-sectional, self-administered, health survey which included the TAPS tool. Substance use risks calculated from the TAPS tool were compared with the reference standard, World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) using confusion matrices. We calculated Areas Under the Curve (AUC) of Receiver Operating Characteristics Curves (ROC) to evaluate the TAPS tool's validity.

RESULTS

The TAPS tool showed fair or better discrimination between moderate-risk use and high-risk use for tobacco, alcohol, and prescription opioids (AUCs: 0.75-0.97 and fair or better discrimination between low-risk and moderate-risk use in five of eight subscales, including tobacco, alcohol, marijuana, stimulants, and heroin (AUCs: 0.70-0.92).

CONCLUSION

The TAPS tool detected clinically relevant problem substance use in several drug classes and likely would be a valuable assessment for screening illicit drug use among community pharmacy patients prescribed opioid medications.

Association Between Patient-Prescriber Racial and Ethnic Concordance and Postpartum Pain and Opioid Prescribing

Objective:

To evaluate whether patient-prescriber racial and ethnic concordance is associated with postpartum opioid prescribing patterns and patient-reported pain scores.

Methods

This is a retrospective cohort study of patients who delivered at a tertiary care center between December 1, 2015 and November 30, 2016. Self-identified non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, or Asian patients were included. Patient-prescriber pairs were categorized as racially and ethnically concordant if they shared the same racial and ethnic identity; the prescriber was defined as the obstetrical provider who was responsible for the postpartum discharge of the patient. Multivariable regression models controlling for demographic and clinical confounders were used to assess the relationship of patient-prescriber racial and ethnic concordance with receipt of an opioid prescription and patient-reported pain score at discharge.

Results

Of 10,242 patients included in this analysis, 62.3% identified as NHW, 19.1% Hispanic, 9.7% NHB, and 8.9% Asian. About half (52.8%) of patients were discharged by a racially and ethnically concordant prescriber. Patient-prescriber racial and ethnic concordance was not associated with receipt of an opioid prescription (adjusted odds ratio [aOR] 0.82, confidence interval [95% CI] 0.67–1.00) or reporting a pain score ≥5 (aOR 0.90, 95% CI 0.69–1.16). However, NHB and Hispanic patients were less likely to receive an opioid prescription (aOR 0.73, 95% CI 0.56–0.95; aOR 0.73, 95% CI 0.57–0.92, respectively) and significantly more likely to report a pain score ≥5 (aOR 2.13, 95% CI 1.51–3.00; aOR 1.48 95% CI 1.08–2.01, respectively) than NHW patients, even when accounting for concordance.

Conclusion

Disparities in postpartum opioid prescribing and pain perception are not ameliorated by patient-prescriber racial and ethnic concordance.

Racial disparities in the cost of inpatient spinal cord stimulator surgery among patients in the 2016-2018 National Inpatient Sample

INTRODUCTION

Spinal cord stimulation is a promising therapy for patients with treatment refractory pain syndromes, and a viable alternative to chronic opioid therapy. Racial disparities are well-documented in the field of pain medicine. This study seeks to determine whether racial disparities are present in spinal cord stimulator (SCS) surgery involving inpatient hospital stays in the United States.

OBJECTIVE

The objective of this study was to analyze the effects of race on health care cost and utilization for patients receiving inpatient SCS surgery. We used total charges incurred by the patient to measure cost and length of stay (LOS) to measures hospital utilization for patients undergoing inpatient SCS surgery. We examined cost and utilization for inpatient surgeries involving SCS insertion, removal, and revision across different race demographics.

METHODS

This retrospective cohort study used ICD-10 procedure codes to query for all patients in the 2016-2018 National Inpatient Sample (NIS) who received SCS insertion, removal, and revision surgeries. Univariate analysis was performed in R-studio to assess the relationship between race, LOS, and total charge. Multivariate analysis was also performed in R-studio to adjust for possible confounders.

RESULTS

Hispanic race was associated with higher total charge for inpatient SCS surgery (β=+0.29, p = 3.92e-07). Hospital region was also associated with total charge. The South (β=+0.12, p = 3.7e-03) and the West (β=+0.28, p = 3.8e-09) were associated with higher total charge. The linear model also showed that patients with more comorbidities and complex cases paid higher total charges (β=+0.014, p = 6.2e-04). There was no statistically significant difference in LOS between race demographics.

CONCLUSION

After adjusting for age, gender, type of surgical approach (percutaneous vs. open), household income, insurance coverage, hospital region, and hospital location (urban vs. rural vs. teaching), and comorbidity scores, Hispanic patients had higher total charges for inpatient SCS surgery, but there was no disparity in total charge between white and black patients. White patients were older than minority patients at the time of inpatient SCS surgery.

Ethnic Disparities in Treatment of Chronic Pain in Individuals with Parkinson's Disease Living in the United Kingdom

Background

Over 80% people with Parkinson's disease (PD; PwP) live with chronic pain.

Objective

Whether ethnic disparities in receipt of appropriate analgesia exist among PwP with chronic pain living in the United Kingdom (UK).

Methods

A retrospective datamining of an existing King's PD Pain Questionnaire validation study dataset enrolling 300 PwP.

Results

69 PwP: 23 Black (57% female), 23 Asian (57% female) and 23 White (65% female) had similar pain burden on the King's PD Pain Scale. Significantly more White PwP (83%) received pain relief compared to Black (48%) and Asian (43%) PwP (p = 0.016). The difference was most evident for opioid analgesics (White 43% vs. Black 4% vs. Asian 4%, p ≤ 0.001).

Conclusions

Ethnic disparities in the analgesic use among PwP with chronic pain living in the UK are evident in this retrospective analysis, prompting large‐scale studies and reinforcement of interventions to tackle the impact ethnicity might have on the successful analgesia.

Association of Inpatient Postpartum Opioid Use with Bedside Nurse

INTRODUCTION

Our objective was to assess the association between the nurse providing bedside care and women's postpartum opioid use.

METHODS

Retrospective study of all women who birthed at a single center (December 2015 to November 2016). Patient, prescriber, and clinical data were abstracted. The postpartum nurse and total opioid use during the first 12-hour postpartum shift after birth were determined. A high amount of opioid use was defined as morphine milligram equivalents greater than or equal to 90% for this population (stratified by vaginal and cesarean births). A logistic regression model was fit with covariates entered in a step-wise manner to identify the extent to which individual nurses were associated with a greater likelihood of high opioid use by establishing one model in which the only covariate was nurse (model 1) and assessing whether the addition of patient (model 2), birth (model 3), and prescriber factors (model 4) altered the association. Kendall rank correlation assessed rank changes between models.

RESULTS

Of the 8376 and 2957 women who had vaginal and cesarean births, 17.9% and 10.2%, respectively, had high opioid use. In the vaginal cohort, women cared for by 46 of 200 nurses were significantly less likely to have high opioid use. Following adjustment, patients cared for by 53 of 200 bedside nurses (model 4) had significantly lower odds of having high opioid use. The rank order of nurses, with respect to the likelihood of opioid use, remained similar after adjustment for patient, birth, and prescriber factors (Τ = 0.84). Findings were similar for the cesarean cohort: 35 of 113 nurses were associated with a significantly lower likelihood of their patients having high opioid use, and the rank order remained similar after covariate adjustment (Τ = 0.78).

DISCUSSION

There is significant variation in postpartum women's opioid use based on the nurse that is not explained by patient, birth, or prescriber factors.

Disparities in Mental Health and Well-Being Among Black and Latinx Patients With Kidney Disease

Black and Latinx individuals in the United States are afflicted disproportionately with kidney disease. Because of structural racism, social risk factors drive disparities in disease prevalence and result in worse outcomes among these patient groups. The impact of social and economic oppression is pervasive in physical and emotional aspects of health. In this review, we describe the history of race and ethnicity among black and Latinx individuals in the United States and discuss how these politicosocial constructs impact disparities in well-being and mental health. Lastly, we outline future research, clinical considerations, and policy considerations to eliminate racial and ethnic disparities in well-being among black and Latinx individuals with kidney disease.

Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities

Importance

Non-Hispanic Black individuals are disproportionally covered by Medicaid during pregnancy and, compared with non-Hispanic White individuals, have higher rates of postpartum coverage loss and mortality. Expanded Medicaid coverage under the Affordable Care Act may have increased continuity of coverage and access to care in the critical postpartum period in expansion states.

Objective

To examine the association of Medicaid expansion in Arkansas with continuous postpartum coverage, postpartum health care use, and change in racial disparities in the study outcomes.

Design Setting and Participants

This cohort study with a difference-in-differences analysis compared persons with Medicaid and commercially financed childbirth, stratified by race, using Arkansas' All-Payer Claims Database for persons with a childbirth between 2013 and 2015. Race and ethnicity from birth certificate data were classified as Hispanic, non-Hispanic Black (hereafter Black), non-Hispanic White (hereafter White), and other (including Asian, Native American or Alaska Native, and Pacific Islander) or unknown race. Data were analyzed between June 2020 and August 2021.

Exposures

Medicaid-paid childbirth after January 1, 2014.

Main Outcomes and Measures

Continuous health insurance coverage and the number of outpatient visits during the first 6 months postpartum.

Results

A total of 60 990 childbirths (mean [SD] age of birthing person, 27 [5.3] years; 67% White, 22% Black, and 7% Hispanic) were included, among which 72.3% were paid for by Medicaid and 27.7% were paid for by a commercial payer. Medicaid expansion in Arkansas was associated with a 27.8 (95% CI, 26.1-29.5) percentage point increase in continuous insurance coverage and an increase in outpatient visits of 0.9 (95% CI, 0.7-1.1) during the first 6 months postpartum, representing relative increases of 54.9% and 75.0%, respectively. Racial disparities in postpartum coverage decreased from 6.3 (95% CI, 3.9-8.7) percentage points before expansion to -2.0 (95% CI, -2.8 to -1.2) percentage points after expansion. However, disparities in outpatient care between Black and White individuals persisted after Medicaid expansion (preexpansion difference, 0.4 [95% CI, 0.2-0.6] visits; postexpansion difference, 0.5 [95% CI, 0.4-0.6] visits).

Conclusions and Relevance

In this cohort study with a difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with higher rates of postpartum coverage and outpatient visits and lower racial and ethnic disparities in postpartum coverage. However, disparities in outpatient visits between Black and White individuals were unchanged. Additional policy approaches are needed to reduce racial and ethnic disparities in postpartum care.

Does size matter? Opioid use after laparoscopy for apical pelvic organ prolapse using an 8mm versus 10-12mm accessory port

STUDY OBJECTIVE

To determine if a change in lateral accessory port (LAP) size from 10-12mm to 8mm among women undergoing laparoscopic native tissue pelvic organ prolapse (POP) surgery was effective at reducing opioid use after surgery.

DESIGN

Prospective cohort of women taking part in a POP surgical registry.

SETTING

Tertiary academic hospital in Calgary, Canada.

PATIENTS

Women undergoing laparoscopic uterosacral ligament apical suspensions for stage ≥2 POP with either uterine preservation or concomitant hysterectomy. 92 women were included during a 15-month study period from June 2020 to September 2021.

INTERVENTIONS

Laparoscopic apical suspension using either a 10-12mm or 8mm LAP, with the change occurring at the mid-point of the study period. Fascial defects from 10-12mm ports were closed with a fascial closure device. Perioperative care and technique were otherwise unchanged.

MEASUREMENTS AND MAIN RESULTS

Post-operative opioid use was measured by mean morphine equivalent daily dose (MEDD), accounting for all oral and intravenous opioids used in the first 24-hours post-surgery. 50 cases (54.3%) used a 10-12mm LAP, 42 cases (45.7%) used an 8mm LAP. Mean MEDD after surgery with a 10-12mm LAP was significantly higher than with an 8mm LAP (35.3 (95% CI 24.9-45.6) vs. 13.6 (95% CI 8.0-19.2), p<0.001). Proportion of women who did not require opioids post-operatively was higher in the 8mm group (45.2%, n=19) than the 10-12mm group (18.0%, n=9) (cOR 3.76, 95% CI 1.47-9.66). Similarly, the proportion of women who did not fill an opioid prescription after discharge was higher in the 8mm group (35.7%, n=15) than the 10-12mm group (16.0%, n=8) (cOR 2.92, 95% CI 1.09-7.81). These results remained statistically significant after adjustment for age, body mass index, race/ethnicity, length of procedure, and concomitant procedures performed.

CONCLUSION

Compared to 10-12mm port, use of an 8mm LAP during laparoscopic native-tissue apical POP surgery is associated with decreased opioid use in the first 24 hours after surgery.

Investigating the Use of a Serious Game to Improve Opioid Safety Awareness Among Adolescents: A Quantitative Study

BACKGROUND

The misuse of opioid medications among adolescents is a serious problem in the United States. Serious games (SGs) are a novel way to promote safe and responsible management of opioid medications among adolescents, thereby reducing the number of adolescent opioid misuse cases reported annually.

OBJECTIVE

This study aimed to examine the effect of the SG MedSMA℞T: Adventures in PharmaCity on adolescents' opioid safety knowledge, awareness, behavioral intent, and self-efficacy.

METHODS

A nationally representative sample of adolescents age 12 to 18 years old were recruited online through Qualtrics panels from October to November 2020. Data collection consisted of a pre-game survey, 30 minutes of gameplay, and a post-game survey. The pre- and post-game survey included 66 items examining participants' baseline opioid knowledge, safety, and use, and demographic information. The post-game survey had 25 additional questions regarding the MedSMA℞T game. Gameplay scenarios included five levels intended to mimic adolescents' daily life while educating players about appropriate opioid storage and disposable practices, negative consequences of sharing opioid medications, and use of Narcan®. Survey questions were divided into 10 categories to represent key concepts and summarized into concept scores. Differences in concept scores were described by overall mean (SD) when stratified by gender, race, school, grade, and age. Differences of change in concept score were analyzed using Kruskal-Wallis and correlation tests.

RESULTS

A total of 117 responses were analyzed. Results showed significant improvement on all concept scores except for Narcan® knowledge (mean change = -0.04, SD = 0.29, p = 0.600) and safe storage (mean change = 0.03, SD = 0.20, p = 0.088). Female participants had greater improvement than males for safe disposal (female mean (SD) = 0.12 (0.25), male = 0.04 (0.17), p = 0.050). Male participants had higher improvement than females for misuse behavior (female mean (SD) = 0.05 (0.28) male = 0.14 (0.27), p = 0.043). Perceived knowledge for participants who were non-white or Hispanic had higher improvement than non-Hispanic white participants (non-white mean (SD) = 1.10 (1.06), white = 0.75 (0.91), p = 0.026). Older grades were associated with greater improvement in opioid knowledge (correlation coefficient -0.23 (95% CI -0.40 to -0.05), p = 0.012). There were 28 (23.9%) participants who played all 5 levels of the game and had better improvement in opioid use self-efficacy.

CONCLUSIONS

Findings suggest MedSMA℞T: Adventures in PharmaCity can be used as an effective tool to educate adolescents on the safe and responsible use of prescribed opioid medications. Future testing of the effectiveness of this SG should involve a randomized control trial. Additionally, the feasibility of implementing and disseminating MedSMA℞T: Adventures in PharmaCity in schools and healthcare settings, such as adolescent health or primary care clinics, emergency departments, and pharmacies, should be investigated.

CLINICALTRIAL

The Association between Implementation of an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

OBJECTIVE

This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use.

STUDY DESIGN

We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge.

RESULTS

Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90-195] PRE to 114 [range: 45-168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5-8] vs. POST 5 [range: 3-7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16-30] vs. POST 17.5 [range: 4-25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2-6] vs. POST 3[range: 1-5], p = 0.03).

CONCLUSION

Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients.

KEY POINTS

· An ERAS-CD pathway was associated with decreased opioid use.. · Outpatient opioid consumption after cesarean warrants further study.. · Physician prescribing drives patients' opioid consumption..

Health Professionals Palliative Care Education for Older Adults: Overcoming Ageism, Racism, and Gender Bias

Purpose of review

Most aging Americans lack access to specialist palliative care aimed at those experiencing serious illness and/or high symptom burden at end of life. The curricula used by training programs for all healthcare professions should focus on helping learners develop the primary palliative care skills and competencies necessary to provide compassionate bias-free care for adults with serious illness. We believe there is much opportunity to improve this landscape via the incorporation of palliative care competencies throughout generalist healthcare professional programs.

Recent findings

Several recent publications highlight multiple issues with recruitment and retention of diverse students and faculty into healthcare professional training programs. There are also concerns that the curricula are reinforcing age, race, and gender biases. Due to these biases, healthcare professionals graduate from their training programs with socialized stereotypes unquestioned when caring for older adult minority patients and caregivers.

Summary

Important lessons must be incorporated to assure that bias against age, race, and gender are discovered and openly addressed in healthcare professional’s education programs. This review highlights these three types of bias and their interrelationships with the aim of revealing hidden truths in the education of healthcare professionals. Ultimately, we offer targeted recommendations of focus for programs to address implicit bias within their curricula.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

Cardioprotective medication use in Black and white breast cancer survivors

PURPOSE

Racial disparities in cardiovascular disease and cardiac dysfunction exist amongst breast cancer survivors. This study examined the prevalence of cardioprotective medication use in survivors and identified factors associated with use by race.

METHODS

The analysis included women enrolled in the Women's Hormonal Initiation and Persistence study, a longitudinal observational trial of breast cancer survivors. The study outcome, angiotensin converting enzyme inhibitor (ACEi) or ß-Blocker (BB) use, were ascertained from pharmacy records. Demographic, psychosocial, healthcare, and quality of life factors were collected from surveys and clinical data were abstracted from medical records. Bivariate associations by race and ACEi/BB use were tested using chi square and t tests; logistic regression evaluated multivariable-adjusted associations.

RESULTS

Of the 246 survivors in the sample, 33.3% were Black and most were < 65 years of age (58.4%). Most survivors were hypertensive (57.6%) and one-third received ACEi/BBs. In unadjusted analysis, White women (vs. Black) (OR 0.33, 95% 0.19-0.58) and women with higher ratings of functional wellbeing (OR 0.94, 95% 0.89-0.99) were less likely to use ACEi/BBs. Satisfaction with provider communication was only significant for White women. In multivariable-adjusted analysis, ACEi/BB use did not differ by race. Correlates of ACEi/BB use included hypertension among all women and older age for Black women only.

CONCLUSIONS

After adjusting for age and comorbidities, no differences by race in ACEi/BB use were observed. Hypertension was a major contributor of ACEi/BB use in BC survivors.

Stopping the revolving door: An exploratory analysis of health care super-utilization in gynecologic oncology

The objective of this study was to determine the prevalence of and risk factors for health care super-utilization among gynecologic oncology patients at a single academic hospital. A retrospective cohort study of gynecologic oncology patients with an index unplanned encounter between January and December 2018 was performed. Super-utilizers were defined as patients with 3 or more unplanned hospital encounters during a 12-month period starting at the time of the index unplanned encounter. We identified 553 patients with gynecologic cancer. Of those, 37(7%) met inclusion criteria for super-utilizers accounting for 193/310(62%) of unplanned visits. The median number of unplanned visits was 4 (range 3-24). The most common cancers were uterine (N = 15 (41%)) and ovarian (N = 11 (30%)). Nineteen (51%) super-utilizers had advanced stage disease. Phases of oncologic care at index unplanned encounter included primary diagnosis (N = 24 (65%)), recurrence (N = 10 (27%)), and surveillance (N = 2 (5%)). Twelve super-utilizers (32%) had new diagnoses of cancer without prior therapy, 19(51%) had prior chemotherapy, 17(46%) had prior surgery, and 10(27%) had prior radiation therapy at the time of initial encounter. Fifteen super-utilizers (41%) were in the last year of life. The most common reasons for unplanned encounters were pain (66%) and gastrointestinal symptoms (61%). Multivariable analysis adjusting for key variables demonstrated that Medicaid insurance, ASA classification, and disease status are risk factors for health care super-utilization. The majority of health care utilization occurred during the first year of diagnosis. This exploratory analysis suggests an opportunity to decrease health care utilization, particularly during upfront treatment.