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 Race and Ethnicity with Pediatric Postoperative Pain Outcomes

INTRODUCTION

Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes.

METHODS

Medical records of children 0 to ≤ 18 years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference).

PRIMARY OUTCOME

post-anesthesia care unit mean pain score.

SECONDARY OUTCOMES

inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates.

RESULTS

Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score.

CONCLUSIONS

Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.

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.

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

BACKGROUND

Racial and ethnic disparities in health care are well documented in the United States, although evidence of disparities in pediatric anesthesia is limited. We sought to determine whether there is an association between race and ethnicity and the use of intraoperative regional anesthesia at a single academic children's hospital.

METHODS

We performed a retrospective review of all anesthetics at an academic tertiary children's hospital between May 4, 2014, and May 31, 2018. The primary outcome was delivery of regional anesthesia, defined as a neuraxial or peripheral nerve block. The association between patient race and ethnicity (white non-Hispanic or minority) and receipt of regional anesthesia was assessed using multivariable logistic regression. Sensitivity analyses were performed comparing white non-Hispanic to an expansion of the single minority group to individual racial and ethnic groups and on patients undergoing surgeries most likely to receive regional anesthesia (orthopedic and urology patients).

RESULTS

Of 33,713 patient cases eligible for inclusion, 25,664 met criteria for analysis. Three-thousand one-hundred eighty-nine patients (12.4%) received regional anesthesia. One thousand eighty-six of 8884 (13.3%) white non-Hispanic patients and 2003 of 16,780 (11.9%) minority patients received regional anesthesia. After multivariable adjustment for confounding, race and ethnicity were not found to be significantly associated with receiving intraoperative regional anesthesia (adjusted odds ratios [ORs] = 0.95; 95% confidence interval [CI], 0.86-1.06; P = .36). Sensitivity analyses did not find significant differences between the white non-Hispanic group and individual races and ethnicities, nor did they find significant differences when analyzing only orthopedic and urology patients, despite observing some meaningful clinical differences.

CONCLUSIONS

In an analysis of patients undergoing surgical anesthesia at a single academic children's hospital, race and ethnicity were not significantly associated with the adjusted ORs of receiving intraoperative regional anesthesia. This finding contrasts with much of the existing health care disparities literature and warrants further study with additional datasets to understand the mechanisms involved.

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.

Race/Ethnicity and Sex and Opioid Administration in the Emergency Room

BACKGROUND

Although racial/ethnic and sex disparities have been examined in health care generally and pain management more specifically, the combined influence of these sociodemographic factors together has not been well documented. The aim of this study was to examine the association between administration of opioid analgesics in the emergency department (ED) and interaction of race/ethnicity and sex.

METHODS

We conducted a retrospective cohort study using 2010-2014 Center for Disease Control-National Hospital Ambulatory Medical Care Survey data for patients 12-55 years of age presenting to EDs with a primary diagnosis of appendicitis or gallbladder disease as defined by International Classification of Diseases, Ninth Revision codes. The primary outcome was the receipt of opioid analgesic medications. Secondary outcomes included: receipt of nonopioids, receipt of antiemetic medications, wait time to see a provider, and length of visit in the ED. The association between sex and analgesic receipt within Caucasian non-Hispanic and non-Caucasian groups was evaluated adjusting for pain score on presentation, patient age, emergent status, number of comorbidities, time of visit (month, day of the week, standard versus nonstandard working hours, year), and US region.

RESULTS

After exclusions, a weighted sample of 553 ED visits was identified, representing 2,622,926 unique visits. The sample population was comprised of 1,858,035 (70.8%) females and 1,535,794 (58.6%) Caucasian non-Hispanics. No interaction was found in adjusted sampling-weighted model between sex and race/ethnicity on the odds of receiving opioids (P = .74). There was no difference in opioid administration to males as compared to females (odds ratio [OR] = 0.96, 95% CI, 0.87-1.06; P = .42) or to non-Caucasians as compared to Caucasians (OR = 0.99, 95% CI, 0.89-1.10; P = .84). In adjusted weighted models, non-Caucasian males, 123,121/239,457 (51.4%) did not differ from Caucasian non-Hispanic males, 317,427/525,434 (60.4%), on odds of receiving opioids, aOR = 0.88, 95% CI, 0.39-1.99; P = .75. Non-Caucasian females, 547,709/847,675 (64.6%) also did not differ from Caucasian females, 621,638/1,010,360 (61.5%), on odds of receiving opioids, aOR = 1.01, 95% CI, 0.53-1.90; P = .98. Across both sexes, non-Caucasians did not differ from Caucasians on receipt of nonopioid analgesics or antiemetics. Neither wait time to see a provider nor the length of the hospital visit was significantly different between sexes or race/ethnicities.

CONCLUSIONS

Based on National Hospital Ambulatory Medical Care Survey data from 2010 to 2014, there is no statistically significant interaction between race/ethnicity and sex for administration of opioid analgesia to people presenting to the ED with appendicitis or gallbladder disease. These results suggest that the joint effect of patient race/ethnicity and sex may not manifest in disparities in opioid management.

Healthcare provider perceptions of disparities in perioperative care

INTRODUCTION

Many strategies to alleviate racial/ethnic disparities in surgical care target healthcare providers. Yet limited data exists about the perception of disparities among the range of clinical staff who work in perioperative settings. Such information could help initiate conversations about disparities in perioperative care and, if necessary, implement interventions to alleviate them. Our aim was to evaluate the association between sociodemographic characteristics, clinical position (physicians and non-physicians) and perception of perioperative disparities at a large tertiary care center.

METHODS

We surveyed perioperative staff at the institution using an anonymous online survey. Primary outcome was respondents' perception of disparities in perioperative care at the institution due to patients' insurance status/type, ability to speak English, education, and racial/ethnic minority status. The association between clinical position (physician vs. non-physician) and perception of disparities was assessed in bivariate and then multivariable analysis, adjusting for respondents' race, sex, age, and years at the institution. Secondary outcomes included perception of disparities in perioperative care in the United States due to patients' insurance status/type, ability to speak English, education, and racial/ethnic minority status.

RESULTS

217 completed questions that could be analyzed. Among these responders, 101 were physicians (46.5%), 165 (76.0%) were white, and 144 (66.4.%) were female. Bivariate and multivariate analysis revealed that physicians had higher perception of disparities in perioperative care at the institution based on patients' ability to speak English, education, and racial/ethnic minority status. Physicians also had higher perceptions of disparities in perioperative care in the United States than non-physicians.

CONCLUSIONS

Physicians reported higher perceptions of disparities in perioperative care than non-physicians, potentially explained by differences in training or contact with patients. Such findings serve as a first step at examining and discussing disparities in perioperative care and warrant further study.

A limited evaluation of the association of race and anesthetic medication administration: A single-center experience with appendectomies

BACKGROUND

Although it is known that a patient's race may influence their medical care, racial patterns of medication administration in pediatric anesthesia have not been well-studied. The aim of this study was to determine if differences exist between Black and White children with regard to administration of anesthetic and analgesic medications for a single procedure at our institution.

METHODS

We conducted a retrospective review of medications administered to patients for emergency appendectomies at a large academic children's hospital from 2010 to 2015. We examined the association between patient race and administration of preoperative midazolam and intraoperative ondansetron, lidocaine, ketorolac, and weight-based doses of fentanyl and morphine.

RESULTS

During the study period, 1680 patients (1329 White, 351 Black) underwent emergency appendectomy. There were no significant racial differences in administration of intraoperative anesthetic medications between Black and White children. In unadjusted analysis, Black children were less likely to receive preoperative midazolam than White children (OR=0.74 [95% CI, 0.58-0.94], P=.012). After adjusting for confounders, there was no evidence of racial differences in administration of preoperative or intraoperative medications.

CONCLUSION

We did not find a significant difference in preoperative or intraoperative medication administration based on race when we adjusted for age, gender, and attending anesthesiologist practice patterns. We encourage all institutions to monitor their own practice patterns with regard to race.

Risk factors for perioperative mortality and transfusion in sacrococcygeal teratoma resections

BACKGROUND

Sacrococcygeal teratomas are a common congenital tumor. Surgical resection can occur in utero, in the neonatal period, or in the postneonatal period.

AIMS

We describe patient and tumor factors associated with mortality and transfusion in this population.

METHODS

We did a retrospective chart review of patients who underwent sacrococcygeal teratoma resection between January 1998 and March 2016. Demographic data, transfusion data, and tumor characteristics were collected. Descriptive statistics were calculated, and univariate comparisons were performed with chi-square test and Fisher's exact test. Variables significant at univariate level were used in multivariate logistic regression and negative binomial regression.

RESULTS

Of the 112 cases, 6 were in utero repairs, 73 were neonatal repairs, and 33 were repairs at >30 days of life. There was 17%, 1%, and 0% intraoperative mortality and 33%, 5%, and 0% 30-day mortality in the in utero, neonatal, and >30 days of life repairs, respectively. All six patients who died within the first 30 days of life had a postmenstrual age of <32 weeks at time of surgery. All six patients who died had noncystic tumors. Patients with noncystic tumors were more likely to be born prior to 30-week gestation (23/65 vs 6/47; χ² = 7.3; P = 0.007). Gestational age >30 weeks was associated with decreased intraoperative death (0% vs 10%; modified maximum likelihood estimate of OR 0.05; 95% CI 0.002-0.96; P = 0.02). Gestational age >30 weeks (2.4% vs 13.8%; OR 0.15; 95% CI 0.03-0.89; P = 0.04) and cystic morphology (0% vs 9.2%; modified maximum likelihood estimate of OR 0.1; CI 0.01-1.75; P = 0.04) were associated with decreased 30-day mortality and emergent surgery (17.9% vs 1.2%; OR 18; 95% CI 2-162.2; P = 0.004) was associated with increased 30-day mortality. Gestational age >30 weeks (33.7% vs 62.1%; OR 0.27; 95% CI 0.09-0.79; P = 0.02) and Altman class 3-4 (12.1% vs 52.7%; OR 0.1; 95% CI 0.03-0.34; P = 0.0002) were associated with decreased need for transfusion and noncystic tumor was associated with increased transfusion volume (131.6 ml·kg^-1 [95% CI 94-184] vs 63 ml·kg^-1 [95% CI 40-100.1]; P = 0.01).

CONCLUSIONS

Prematurity is associated with increased intraoperative and 30-day mortality. Noncystic tumor morphology was the only significant factor associated with transfusion volume and all six patients who died had transfusion volumes of 240 ml·kg^-1 or greater. In these patients at high risk of mortality due to blood loss, the anesthesia team should be prepared to manage massive transfusion and coagulopathy with blood components and pharmacologic measures.

The outlook of physician histories: J. Marion Sims and 'The Discovery of Anaesthesia'

The fact that doctors have a long tradition of writing medical history to interpret and direct their profession is well established. But readers (particularly modern physician readers) can also understand physician-authored histories as offering commentary and analysis of the world beyond medicine. In this essay, we offer a reading (perhaps a modern one) of J. Marion Sims's 1877 article, 'The Discovery of Anaesthesia' which exemplifies the stance of looking both inward and outward from the medical field. We begin by discussing Sims, including the complicated legacy he left as a physician. Next, we review late 19th-century history with a focus on Reconstruction. Finally, we show how the modern reader can use Sims's article both to trace the first use of ether and nitrous oxide for surgical anaesthesia and to provide a window into the 19th-century medical profession and the post-Civil War period. Through this study, we hope to show how to read both medicine and the world around it in physician histories.

Toward an understanding of the equality of pain: crawford long and the development of anesthesia in antebellum georgia

Dr. Crawford Long's career illustrates the complicated intersection of science, sympathy, medical experimentation, race, and gender within the history of anesthesia in the United States. Considered by many to be the first physician to administer ether for surgical anesthesia, Long anesthetized a broad cross-section of his rural Georgia society, including white men, white women, and enslaved black children. These initial uses of ether can be considered both a racialized and gendered experiment reflective of contemporary thinking as well as a radical expression of equality in the context of medical development and understandings of pain. Emerging from this examination of Long's practices and writing is the narrative of a well-meaning and time-bound doctor, living amidst the shadows of antebellum plantations and confronted by his diverse patients' experience of pain.