Association Between Race and Ethnicity in the Delivery of Regional Anesthesia for Pediatric Patients: A Single-Center Study of 3189 Regional Anesthetics in 25,664 Surgeries

Factors associated with the use of regional anesthesia for calcaneal osteotomy in pediatric patients: A single-center, retrospective cohort study

BACKGROUND

Despite known disparities in pediatric perioperative outcomes, few studies have examined factors associated with the use of regional anesthesia for pediatric orthopedic surgery.

AIMS

This investigation aimed to determine if minority and developmental disability status were associated with the allocation of peripheral nerve blocks in calcaneal osteotomy.

METHODS

We conducted a single-center, retrospective study of records of patients <18 years who underwent calcaneal osteotomy from 2013 to 2023. Regional technique was classified into three groups: popliteal-sciatic single-shot block, popliteal-sciatic catheter, and no block. Patients were classified as either nonminority (white, non-Hispanic) or minority. Developmental disability status was defined based on medical history and classified as binary. Anesthesiologists were classified as "regional" or "nonregional" based on clinical expertise. A Bayesian hierarchical multinomial model with random intercepts for patients and surgeons was used to investigate the association of minority status, developmental disability, and anesthesiologist expertise with block selection.

RESULTS

We analyzed 287 cases in 225 patients; of these, 55% occurred in minority patients and 28% occurred in patients with developmental disability. Catheters were placed in 45% of cases, single shot blocks in 41%, and no block in 14%. Minority and nonminority patients had a similar likelihood of receiving of any block. Patients with developmental disability had a -22% absolute difference of receiving any block (95% credible interval [-38%, -7%]) compared to those without developmental disability (55% vs. 77%), an effect primarily driven by a lower rate of catheter placement in these children. Regional anesthesiologists were more likely to place catheters (23% absolute increase; 36% vs. 13%) and more likely to perform any block in children with developmental disability (30% absolute increase; 67% vs. 37%) than nonregional anesthesiologists.

CONCLUSIONS

Decision-making surrounding the placement of regional anesthesia techniques is complex. In this study, developmental disability status and anesthesiologist experience were associated with a difference in the use of regional anesthesia in patients undergoing calcaneal osteotomy.

Racial and Ethnic Disparities in Regional Anesthesia: A Brief Review

Disparities in regional anesthesia may limit patients' access to appropriate care. We reviewed literature from 2013 to 2023 regarding health disparities in regional anesthesia. While there were some exceptions, patients belonging to racial/ethnic minority groups and those with lower socioeconomic status did not receive regional anesthesia as frequently as their White or higher-income peers. As regional anesthesia continues to emerge as a preferred method of managing chronic pain conditions and providing surgical anesthesia, it is essential to ensure that it is provided equitably across the patient population.

Postanesthesia Care Unit and Anesthetic Management Outcomes Among Patients Undergoing Noncardiac Surgery: Differences by Race and Ethnicity

PURPOSE

To investigate the association of patient race and ethnicity with postanesthesia care unit (PACU) outcomes in common, noncardiac surgeries requiring general anesthesia.

DESIGN

Single tertiary care academic medical center retrospective matched cohort.

METHODS

We matched 1:1 1836 adult patients by race and/or ethnicity undergoing common surgeries. We compared racial and ethnic minority populations (62 American Indian, 250 Asian, 315 Black or African American, 281 Hispanic, and 10 Pacific Islander patients) to 918 non-Hispanic White patients. The primary outcomes were: the use of an appropriate number of postoperative nausea and vomiting (PONV) prophylactics; the incidence of PONV; and the use of a propofol infusion as part of the anesthetic (PROP). Secondary outcomes were: the use of opioid-sparing multimodal analgesia, including the use of regional anesthesia for postoperative pain control; the use of any local anesthetic, including the use of liposomal bupivacaine; the duration until readiness for discharge from the PACU; the time between arrival to PACU and first pain score; and the time between the first PACU pain score of ≥4 and administration of an analgesic. Logistic and linear regression were used for relevant outcomes of interest.

FINDINGS

Overall, there were no differences in the appropriate number of PONV prophylactics, nor the incidence of PONV between the two groups. There was, however, a decreased use of PROP (OR = 0.80; 95% CI: 0.69, 0.94; P = .005), PACU length of stay was 9.56 minutes longer (95% CI: 2.62, 16.49; P = .007), and time between arrival to PACU and first pain score was 2.30 minutes longer in patients from racial and ethnic minority populations (95% CI: 0.99, 3.61; P = .001). There were no statistically significant differences in the other secondary outcomes.

CONCLUSIONS

The rate of appropriate number of PONV prophylactic medications as well as the incidence of PONV were similar in patients from racial and ethnic minority populations compared to non-Hispanic White patients. However, there was a lower use of PROP in racial and ethnic minority patients. It is important to have a health equity lens to identify differences in management that may contribute to disparities within each phase of perioperative care.

Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery

BACKGROUND

Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models.

RESULTS

The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05).

CONCLUSION

There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Examining disparities in regional anaesthesia and pain medicine

In high-resource countries, health disparities exist in both treatment approaches and health outcomes. Race and ethnicity can serve as proxies for other socioeconomic factors and social determinants of health such as income, education, social support, and residential neighbourhood, which strongly influence health outcomes and disparities. In regional anaesthesia and pain medicine, disparities exist across several surgical specialties including obstetrics, paediatrics, and orthopaedic surgery. Understanding these disparities will facilitate development of solutions aimed at eliminating disparities at the patient, physician/provider, and healthcare system levels.

Racial/Ethnic Variability in Use of General Anesthesia for Pediatric Magnetic Resonance Imaging

BACKGROUND

Children increasingly undergo diagnostic imaging procedures, sometimes with general anesthesia (GA). It is unknown whether the use of GA differs by race/ethnicity among children undergoing magnetic resonance imaging (MRI) scans.

METHODS

This is a retrospective cohort study of GA use for pediatric patients from 0 to 21 years of age who underwent MRIs from January 1, 2004 to May 31, 2019. The study sample was stratified into 5 age groups: 0 to 1, 2 to 5, 6 to 11, 12 to 18, and 19 to 21. Analysis was performed separately for each age group.

RESULTS

Among 457,314 MRI patients, 29,108 (6.4%) had GA. In the adjusted regression models, Asian patients aged 0 to 1 (adjusted relative risk [aRR] [95% confidence interval {CI}] of 1.11 [1.05-1.17], P < .001) and aged 2 to 5 (aRR [95% CI], 1.04 [1.00-1.09], P = .03), Black patients aged 2 to 5 (aRR [95% CI], 1.04 [1.01-1.08], P = .02) and aged 6 to 11 (aRR [95% CI], 1.13 [1.06-1.20], P < .001), and Hispanic patients aged 0 to 1 (aRR [95% CI], 1.07 [1.03-1.12], P < .001) were more likely to receive GA for MRIs than White patients.

CONCLUSIONS

Asian, Black, and Hispanic children of some ages were more likely to receive GA during MRI scans than White children in the same age group. Future research is warranted to delineate whether this phenomenon signifies disparate care for children based on their race/ethnicity.

Association of patient characteristics with the receipt of regional anesthesia

BACKGROUND

Regional anesthesia (RA) may improve patient-related outcomes, including decreased operative complications, shortened recovery times, and lower hospital readmission rates. More analyses are needed using a diverse set of databases to examine characteristics associated with the receipt of RA.

METHODS

A national hospital database was queried for patients 18 years or older who underwent total shoulder arthroplasty (TSA), total knee arthroplasty (TKA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, ankle open reduction, and internal fixation and arteriovenous fistula creation between January 2016 and June 2021. Regional techniques included neuraxial anesthesia and various upper and lower extremity peripheral nerve blocks to create a binary variable of RA receipt. Univariate statistics were used to compare characteristics associated based on RA receipt and multivariable regression identified factors associated with RA receipt.

RESULTS

A total of 51 776 patients were included in the analysis, of which 2111 (4.1%) received RA. Factors associated with decreased odds of RA receipt included black race (vs white race; OR 0.73, 95% CI 0.62 to 0.86), other non-white race (vs white race; OR 0.71, 95% CI 0.61 to 0.86), American Society of Anesthesiologists (ASA) class (vs ASA 1; OR 0.85, 95% CI 0.79 to 0.93), and Medicaid insurance (vs private insurance; OR 0.65, 95% CI 0.51 to 0.82) (all p<0.05). When compared with TKA, ACLR (OR 0.67, 95% CI 0.53 to 0.84), ankle open reduction and internal fixation (OR 0.68, 95% CI 0.58 to 0.81), and carpal tunnel release (OR 0.68, 95% CI 0.59 to 0.78) demonstrated lower odds of RA receipt, whereas TSA (OR 1.31, 95% CI 1.08 to 1.58) demonstrated higher odds of RA receipt (all p<0.05).

CONCLUSION

RA use varies with respect to race, insurance status, and type of surgery.

Racial Inequity in Pediatric Anesthesia

Purpose of Review

Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism.

Recent Findings

Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments.

Summary

Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.

Race, ethnicity, and the use of regional anesthesia in cancer patients undergoing open abdominal surgery: A single-center retrospective cohort study

Background

Where applicable, regional anesthesia has been shown to be superior to opioid or non-opioid analgesic modalities alone. However, some studies have shown ethnic-based disparities in the use of regional anesthesia in patients undergoing surgical procedures. In this study of patients who had undergone major oncologic surgery, our main objective was to compare the use of regional anesthesia between patients of different ethnicities.

Methods

A retrospective review of adults who had undergone major open abdominal surgical procedures between 2016 and 2021 was performed. Logistic regression models were used to assess the association between baseline patient characteristics and the use of regional anesthesia.

Results

A total of 4,791 patients were included in the analysis. The median age was 60.5 years [interquartile range, 49, 69], the majority were female (65%), and of American Society of Anesthesiologists Physical Status Class (ASA) 3 (94.7%). Regional anesthesia was used in 2,652 patients (55.4%) and was not associated with race or ethnicity (p = 0.287). Compared to White patients, the odds of regional anesthesia use in other racial/ethnic groups were: Asian {odds ratio (OR) 0.851 [95% confidence interval (CI), 0.660–1.097]; p = 0.2125}, Black/African American [OR 0.807 (95% CI, 0.651–1.001); p = 0.0508], Hispanic/Latino [OR 0.957 (95% CI, 0.824–1.154); p = 0.7676], Other race [OR 0.957 (95% CI, 0.627–1.461); p = 0.8376]. In the multivariable analysis, age [OR 0.995 (95% CI, 0.991–1.000); p = 0.0309] and female gender [OR 1.231 (95% CI, 1.090–1.390); p = 0.0008] were associated with the use of regional anesthesia.

Conclusion

In this single-institution retrospective study of adults who had undergone major open abdominal surgery, the use of regional anesthesia was not associated with race or ethnicity. In the multivariable analysis, age and female gender were associated with the use of regional anesthesia.

Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study

BACKGROUND

Peripheral nerve blocks (PNBs) are used to provide postoperative analgesia after total mastectomy. PNBs improve patient satisfaction and decrease postoperative opioid use, nausea, and vomiting. Few studies have examined whether there is racial-ethnic disparity in the use of PNBs for patients having total mastectomy. We hypothesized that non-Hispanic Asian, non-Hispanic Black, non-Hispanic patients of other races, and Hispanic patients would be less likely to receive a PNB for postoperative analgesia compared to non-Hispanic White patients having total mastectomy. Secondarily, we hypothesized that PNBs would be associated with reduced odds of major complications after total mastectomy.

METHODS

We performed a retrospective cohort study using National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2019. Patients were included if they underwent total mastectomy under general anesthesia. Unadjusted rates of PNB use were compared between race-ethnicity groups. Multivariable logistic regression was performed to determine whether race-ethnicity group was independently associated with receipt of a PNB for postoperative analgesia. Secondarily, we calculated crude and risk-adjusted odds ratios for major complications in patients who received a PNB.

RESULTS

There were 64,103 patients who underwent total mastectomy and 4704 (7.3%) received a PNB for postoperative analgesia. Patients who received a PNB were younger, more commonly women, were less likely to have diabetes and hypertension, and had less disseminated cancer (all P < .05). In our regression analysis, the odds of receiving a PNB differed significantly by race-ethnicity group (P < .001). Non-Hispanic Asian and non-Hispanic Black patients had reduced odds of receiving a PNB compared to non-Hispanic White patients (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.33-0.49 and OR, 0.37 [0.32-0.44]), respectively. Non-Hispanic patients of other races, including American Indian, Alaskan Native, and Pacific Islander, also had reduced odds of receiving a PNB (OR, 0.73 [95% CI, 0.64-0.84]) compared to non-Hispanic White patients, as did Hispanic patients (OR, 0.62 [0.56-0.69]). Patients who received a PNB did not have reduced odds of major complications after mastectomy (crude OR, 0.83 [0.65-1.08]; P = .17 and adjusted OR, 0.85 [0.65-1.10]; P = .21).

CONCLUSIONS

Significant disparity exists in the use of PNBs for postoperative analgesia in patients of different race-ethnicity who undergo total mastectomy in the United States. Continued efforts are needed to better understand the causes of disparity and to ensure equitable access to PNBs.

Race/Ethnicity and Duration of Anesthesia for Pediatric Patients in the US: a Retrospective Cohort Study

BACKGROUND

Previous literature has demonstrated adverse patient outcomes associated with racial/ethnic disparities in health services. Because patients/parents and providers care about the duration of anesthesia, this study focuses on this outcome.

OBJECTIVES

To determine the association between race/ethnicity and duration under anesthesia.

RESEARCH DESIGN

In this retrospective cohort study of data from the Multicenter Perioperative Outcomes Group, White non-Latino was the reference and was compared with Black non-Latino children, Latino, Asian, Native American, Other, and "Unknown" race children.

SUBJECTS

Children aged 3 to 17 years.

OUTCOMES

Induction duration (primary outcome), procedure-end duration, and total duration under anesthesia (secondary outcomes).

RESULTS

Of 37,596 eligible cases, 9,610 cases with complete data were analyzed. The sample consisted of 6,894 White non-Latino patients, 1,021 Black non-Latino patients, 50 Latino patients, 287 Asian patients, 26 Native American patients, 57 "Other" race patients, and 1,275 patients of "Unknown" race. The mean induction time was 11.9 min (SD 5.6 min). In adjusted analysis, Black non-Latino patients had 5% longer induction and procedure-end durations than White non-Latino children (exponentiated beta coefficient [Exp (β)] 1.05, 95% CI: 1.02-1.08, p < 0.01 and Exp (β) 1.08, 95% CI 1.04-1.13, p < 0.01 respectively).

CONCLUSIONS

White non-Latino children had shorter induction and procedure-end durations than Black children. The differences in induction and procedure-end time were small but may be meaningful on a population-health level.

Racial Disparities in Postoperative Outcomes Following Operative Management of Pediatric Developmental Dysplasia of the Hip

BACKGROUND

Developmental dysplasia of the hip in pediatric patients can be managed conservatively or operatively. Understanding patient risk factors is important to optimize outcomes following surgical treatment of developmental dysplasia of the hip. Racial disparities in procedural outcomes have been studied, however, there is scarce literature on an association between race and complications following pediatric orthopaedic surgery. Our study aimed to determine the association between pediatric patients' race and outcomes following operative management of hip dysplasia by investigating 30-day postoperative complications and length of hospital stay.

METHODS

The National Surgical Quality Improvement Program-Pediatric database was utilized from the years 2012 to 2019 to identify all pediatric patients undergoing surgical treatment for hip dysplasia. Patients were stratified into 2 groups: patients who were White and patients from underrepresented minority (URM) groups. URM groups included those who were Black or African American, Hispanic, Native American or Alaskan, and Native Hawaiian or Pacific Islander. Differences in patient demographics, comorbidities, and postoperative outcomes were compared between the 2 cohorts using bivariate and multivariate analyses.

RESULTS

Of the 9159 pediatric patients who underwent surgical treatment for hip dysplasia between 2012 and 2019, 6057 patients (66.1%) were White and 3102 (33.9%) were from URM groups. In the bivariate analysis, compared with White patients, patients from URM groups were more likely to experience deep wound dehiscence, pneumonia, unplanned reintubation, cardiac arrest, and extended length of hospital stay. Following multivariate analysis, patients from URM groups had an increased risk of unplanned reintubation (odds ratio: 3.583; P=0.018).

CONCLUSIONS

Understanding which patient factors impact surgical outcomes allows health care teams to be more aware of at-risk patient groups. Our study found that pediatric patients from URM groups who underwent surgery for correction of hip dysplasia had greater odds of unplanned reintubation when compared with patients who were White. Further research should investigate the relationship between multiple variables including race, low socioeconomic status, and language barriers on surgical outcomes following pediatric orthopaedic procedures.

LEVEL OF EVIDENCE

Level III-retrospective cohort analysis.

On anesthesia and race

Racial tensions continue to ignite social unrest in the United States. Structural racism is increasingly recognized as a public health issue. It is therefore necessary to continue addressing the interaction of race and medicine, including anesthesiology. While many may overlook the impact that racial discrimination has had on the development of anesthesiology, understanding pain through a racialized lens has always been entwined with this medical specialty since its origins. Considering the first public demonstration of ether anesthesia in 1846 occurred 15 years before the American Civil War (1861-1865), it is naïve to pretend that anesthesia has been insulated from racial prejudice. We increasingly recognize the effects of variables, such as housing and education, which are important as social determinants of health. Across ethnic and racial lines, statistically significant differences persist in pain assessment and analgesia delivery. To understand these irregularities without relying on unsupported theories, we must challenge our current understanding of race in medicine. By reviewing the history of anesthesia through a racialized lens, we may better explore our biases and develop strategies towards racially equitable care. This article focuses on anesthesia's roots on the plantation in the American South, the medical perpetuation of racial disparities, and the challenges we face in healthcare today.

Racial and Ethnic Health Services Disparities in Pediatric Anesthesia Practice: A Scoping Review

Racial and ethnic disparities in pediatric anesthesia health services could result in minority children being at increased risk of poor outcomes, such as pain, anxiety, or over-exposure to medications. Yet, a comprehensive understanding of the literature on such disparities does not exist to date. The objective of this study is to describe health services disparities in pediatric anesthetic care in the pre-, intra-, or post-operative period by synthesizing current literature. We searched the National Library of Medicine's PubMed/Medline, Embase, and Web of Science for articles published between January 1, 2007, and May 9, 2020, to identify literature on racial and ethnic health services disparities in pediatric anesthesia. We used the Institute of Medicine's definition of disparities. Health services were related to pre-, intra-, or post-operative anesthetic care of pediatric patients (< 18 years old). Out of 2110 studies, 10 studies met the criteria for inclusion. Nine out of the ten articles were single-institutional observational studies, based at tertiary hospitals. Sample sizes ranged from 74 to 37,618 discrete participants, for a total of 69,350 subjects across all studies. Results of these studies present low-quality evidence and heterogeneous conclusions regarding pediatric anesthesia health services disparities. This review demonstrates the paucity and diversity of research on racial and ethnic disparities in pediatric anesthesia health services and suggests how future work might utilize improved data and rigorous study designs.

Association Between Race and Ethnicity with Intraoperative Analgesic Administration and Initial Recovery Room Pain Scores in Pediatric Patients: a Single-Center Study of 21,229 Surgeries

INTRODUCTION

Perioperative pain may have deleterious effects for all patients. We aim to examine disparities in pain management for children in the perioperative period to understand whether any racial and ethnic groups are at increased risk of poor pain control.

METHODS

Medical records from children ≤ 18 years of age who underwent surgery from May 2014 to May 2018 were reviewed. The primary outcome was total intraoperative morphine equivalents. The secondary outcomes were intraoperative non-opioid analgesic administration and first conscious pain score. The exposure was race and ethnicity. The associations of race and ethnicity with outcomes of interest were modeled using linear or logistic regression, adjusted for preselected confounders and covariates. Bonferroni corrections were made for multiple comparisons.

RESULTS

A total of 21,229 anesthetics were included in analyses. In the adjusted analysis, no racial and ethnic group received significantly more or less opioids intraoperatively than non-Hispanic (NH) whites. Asians, Hispanics, and Pacific Islanders were estimated to have significantly lower odds of receiving non-opioid analgesics than NH whites: odds ratio (OR) = 0.83 (95% confidence interval (CI): 0.70, 0.97); OR = 0.84 (95% CI: 0.74, 0.97), and OR = 0.53 (95% CI: 0.33, 0.84) respectively. Asians were estimated to have significantly lower odds of reporting moderate-to-severe pain on awakening than NH whites: OR = 0.80 (95% CI: 0.66, 0.99).

CONCLUSIONS

Although children of all races and ethnicities investigated received similar total intraoperative opioid doses, some were less likely to receive non-opioid analgesics intraoperatively. Asians were less likely to report moderate-severe pain upon awakening. Further investigation may delineate how these differences lead to disparate patient outcomes and are influenced by patient, provider, and system factors.