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Approximately 151 million patients visited emergency departments (EDs) in 2019 and the most common complaint was abdominal pain, according to data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).1 Even though acute pain is a common concern triggering ED visits, the undertreatment of pain remains an emergency medicine issue.2 In 2019, non-Hispanic Black people visited EDs at twice the rate of non-Hispanic White people.1,2 However, research suggests that racial/ethnic minority patients and women often receive fewer pain medications for acute pain than non-Hispanic White men.3-7

In the 1990s, increased efforts to treat pain as the fifth vital sign were intended to improve pain treatment.8 Although overuse of opioids precipitated an epidemic, racial/ethnic and sex treatment differences persisted.2-4 Unconscious biases of clinicians may attribute to these treatment differences.6-7,9-10


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Emergency medicine clinicians may be susceptible to treatment biases because of their chaotic work environment with multiple interruptions. These clinicians treat patients unknown to them and must rely on previous experiences, evidence-based medicine, and instincts to make quick, justifiable medical decisions for patients possibly experiencing life-threatening conditions. Because of their need to make quick decisions, many clinicians rely heavily on cognitive heuristics to make treatment choices.7 Cognitive heuristics are mental shortcuts that rely on intuitive thinking, known better as gut instinct. However, heavy reliance on cognitive heuristics may lead to unconscious or implicit biases when caring for patients.7 The purpose of the current study was to evaluate whether racial/ethnic minority patients and women received different acute pain treatments compared with non-Hispanic  White men in an ED that serves a diverse population.

Methods

The retrospective chart review included data from adult patients (aged 18 years and older) treated at a large Level 1 trauma center in northern Virginia from January 1, 2018, to December 21, 2019. A total of 180,210 adult ED visits occurred during the study period, and 19,624 patients had a chief complaint of abdominal pain

Exclusion criteria included critical patients categorized as Code STEMI (ST-elevated myocardial infarction),11 Code stroke,12 or trauma team activations. Patients were also excluded if they were pregnant, treated for chronic pain, or sought psychiatric care or inpatient detoxification treatment.

Before analysis, the data were stripped of patient identifiers and a unique code was assigned to each patient encounter. Patients were categorized by self-reported sex, race, and ethnicity. The sex category included female and male patients; no other genders met the study’s inclusion criteria. The races reported by patients included non-Hispanic/Latino White, non-Hispanic/Latino Black or African American, Hispanic/Latino, Asian, Middle Eastern, American Indian or Alaskan Native, Pacific Islander or Native Hawaiian, more than 1 race, or other. For this analysis, race categories were combined to include non-Hispanic/Latino White, non-Hispanic/Latino Black, Asian, or other, which included all other racial categories.

Ethnicity was reported as Hispanic/Latino or non-Hispanic/Latino and patients had the option to report Hispanic/Latino for both race and ethnicity. For the current study, racial and ethnic Hispanic/Latino groups were combined into 1 group of Hispanic/Latino ethnicity. Patients’ records that were missing data for sex, race, and ethnicity were excluded. Additional data collected from patients’ charts included age, patient acuity level, diagnosis, and disposition information.

The primary outcome measures were pain score and pain medication. Specifically, the patient’s pain was reported using the numerical pain scale (0-10). Based on the pain scale score, the pain was rated as mild (1-3), moderate (4-6), or severe (7-10). Patients’ records that were missing a pain score or those with a pain score of 0 were excluded from the analysis. Pain medication data included time of ED arrival to medication ordered by the clinician, type of medications given to patients, and length of stay (LOS) in the ED. The type of medication was divided into 2 categories: nonopioids and opioids. Nonopioids included acetaminophen, ibuprofen, naproxen, aspirin, and ketorolac. Opioids included tramadol, hydrocodone, oxycodone, morphine, hydromorphone, and fentanyl. The opioid category also included combined medications, such as hydrocodone-acetaminophen, oxycodone-acetaminophen, or acetaminophen-codeine. 

Statistical analyses were conducted using SPSS Statistics version 27 (IBM Corp., Armonk, NY). A P <.05 was considered significant. Cross-tabulation tables were used to evaluate the relationship between abdominal pain diagnoses and other independent variables. An χ2 test was performed when applicable. A 1-way analysis of variance (ANOVA) was used to calculate differences in pain treatment among racial/ethnic groups. If homogeneity of variances was violated, a Welch ANOVA was performed. An independent samples t test was used to calculate differences in pain treatment between sexes. If homogeneity of variances was violated, the Welch t test was performed. A 2-way ANOVA was used to calculate treatment differences between combined sex and racial/ethnic groups.

Results

A total of 19,624 ED visits with the chief complaint of abdominal pain and data from 17,401 ED visits were included in the current study after exclusion criteria. The patients ranged in age from 18 to 101 years. Hispanic/Latino patients had the youngest mean age of 39.84 years (95% CI, 39.45-40.24) and accounted for 41.5% of the 18 to 44 age group (Figure 1). The remaining mean ages were 50.71 years (95% CI, 49.80-51.63) for Asian patients, 49.85 years (95% CI, 49.36-50.33) for non-Hispanic/Latino White patients, 42.73 years (95% CI, 41.86-43.59) for other patients, and 42.71 years (95% CI, 42.05-43.37) for non-Hispanic/Latino Black patients. Women had a mean age of 44.31 years (95% CI, 43.95-44.65), which was younger than that for men (46.37 years; 95% CI, 45.93-46.80).

A majority of patients identified as non-Hispanic/Latino White, non-Hispanic/Latino Black, Hispanic/Latino, or Asian (Figure 2). A smaller number of patients identified as other (871/17401, 0.05%), Middle Eastern (365/17401, 2%), more than 1 race (186/17401, 1%), American Indian or Alaskan Native (29/17401, 0.002%), or Native Hawaiian or Pacific Islander (31/17401, 0.002%); these patients were grouped into the category labeled other (1482/17401, 8.5%). Most patients were female (10778/17401, 61.9%). Most women were Hispanic/Latino (3845/10778, 35.3%), and most men were non-Hispanic/Latino White (2547/6524, 39%). 

The majority of patients were assigned an acuity level of 3; however, non-Hispanic/Latino White patients were given an acuity level of 2 at a higher rate than non-Hispanic/Latino Black, Hispanic/Latino, and other patients (Table 1). More than half of patients (11369/17401, 65.3%) reported severe pain on arrival at the ED. Patients’ acuity level by sex was also examined (Table 2). Patients with a pain rating of 10 received pain medications faster than patients with any other pain rating (Table 3).

Acute Pain Emergency Department Table 1 and 2
Acute Pain Emergency Department Table 3

Overall, 60% (10436/17401) of patients were treated with either a nonopioid medication (3700/17401, 21.3%) or opioid medication (6965/17401, 38.7%), whereas 40% (6965/17401) of patients did not receive any pain medications. Non-Hispanic/Latino White patients received more opioid medications than racial/ethnic minorities (Table 4). The differences persisted when factoring in the pain rating. Non-Hispanic/Latino White patients with a severe pain rating were more likely to receive opioids than non-Hispanic/Latino Black, Hispanic/Latino, and Asian patients with severe pain, (P =.03). 

Acute Pain in Emergency Department Table 4

Some ethnic/racial minority patients waited longer for room assignments on arrival at the ED. Non-Hispanic/Latino White patients were assigned a room 8.5 minutes faster than Hispanic/Latino patients (95% CI, 6.16-10.83) and 3.83 minutes faster than Asian patients (95% CI, 0.37-7.30). No differences were found between non-Hispanic/Latino Black patients (2.46 minutes; 95% CI, 0.73-5.65) or other patients (3.42 minutes; 95% CI, 0.28-7.11).

Hispanic/Latino patients waited 7.53 (95% CI, 2.27-12.79) minutes longer than non-Hispanic/Latino White patients before receiving their first pain medication. No statistical differences in time to first pain medication were found between non-Hispanic/Latino White patients and non-Hispanic/Latino Black patients (4.58 minutes; 95% CI, 2.74-11.89), Asian patients (6.40 minutes; 95% CI, 1.80-14.60), and other patients (0.19 minutes; 95% CI, 8.40-8.78).

Non-Hispanic/Latino White patients experienced a longer LOS than all racial/ethnic minority patients (Table 4). They remained in the ED 15.08 minutes longer than non-Hispanic/Latino Black patients (95% CI, 4.23-25.89), 22.12 minutes longer than Hispanic/Latino patients (95% CI, 14.23-30.01), and 29.87 minutes longer than other patients (95% CI, 17.37-42.37). No significant difference was found in the LOS between non-Hispanic/Latino White patients (335.29 minutes; 95% CI, 331.15-339.43) and Asian patients (334.59 minutes; 95% CI, 326.47-342.70).

Women waited 9 minutes longer than men for their first dose of medication after arrival (95% CI, 5.71-12.31). Women were also less likely to receive an opioid medication. Fewer women (27.9%) than men (36.4%) were admitted to the hospital.

A statistically significant interaction effect between sex and racial/ethnic group was found for the type of medication given, (P =.03). Both non-Hispanic/Latino White men and women were more likely to receive opioids than men or women from other racial/ethnic groups. No interaction effect was found for the time of first medication after arrival, number of medications given, or LOS (Table 4). 

The most common diagnosis was nonspecific abdominal pain (6051/17401, 34.8%), which included far more visits than the second most common diagnosis of colitis (1201/17401, 6.9%) (Figure 3). The top 10 diagnoses accounted for 70% of the diagnoses (12181/17401) at discharge. Significantly more women were diagnosed with cholelithiasis, urinary tract infection, and cholecystitis, whereas significantly more men were diagnosed with kidney stones. A greater number of Hispanic/Latino patients were diagnosed with cholelithiasis (305/613, 49.8%), urinary tract infection (243/559, 43.4%), cholecystitis (190/398, 47.7%), and ovarian cysts (166/475, 34.9%) than non-Hispanic/Latino White patients. A greater percentage of non-Hispanic/Latino White patients were diagnosed with bowel obstruction, colitis, and kidney stones.