US: new evidence that racial and economic factors affect surgical pain management

A retrospective analysis of more than 600 major colorectal surgeries has added further evidence that racial and socioeconomic disparities may occur during surgical care, particularly in pain management.

The report documents the specific ways in which disadvantaged populations receive less optimal pain management and are placed on enhanced recovery protocols later than their wealthier and white counterparts.

“This study demonstrates that process measures, which guide and document each step of care, may be critical factors in preventing differences in care, particularly those due to race and socioeconomic status,” Ira Leeds, research fellow at the Johns Hopkins University School of Medicine and the paper’s co-first author. “We can’t fix what we don’t measure.”

Enhanced recovery after surgery (ERAS) protocols are predefined pathways designed to standardise some aspects of surgical care in order to reduce complications, decrease length of stay and improve overall patient satisfaction.

To determine whether ERAS had an impact, or revealed any racial and socioeconomic disparities after surgery, Leeds and colleagues performed a retrospective analysis of information gathered before and after the implementation of a colorectal ERAS pathway at the Johns Hopkins Hospital.

A total of 639 patient experiences (199 pre-ERAS implementation and 440 post-implementation) were used in the analysis, of surgeries performed between 1 January 2013 and 30 June 2016. The research team collected socioeconomic information, medical diagnoses and surgical outcomes information in Johns Hopkins National Surgical Quality Improvement programme database.

The researchers found that white patients were more likely to have transverse abdominis plane (TAP) blocks or epidurals initiated and maintained than non white patients (57.1 versus 44.1 per cent for initiation; 47.3 versus 34.3 per cent for maintenance).

A similar trend for initiation of pain management was seen for high socioeconomic status patients (55.4 versus 41.5 per cent). Leeds said this suggests that either non white patients declined epidural blocks for pain management at higher rates due to inadequate counselling on the benefits, or that doctors carried implicit biases that led them to offer such pain management options less often to minorities and the poor.

Patients with a high socioeconomic status were placed on an ERAS pathway during scheduling more often than low socioeconomic status patients (69.7 versus 58.5 per cent).

Prior to ERAS implementation, median lengths of stay, complication rates and total number of complications were not statistically different between white and non white patients. Following ERAS implementation, median lengths of stay improved in both whites (a decrease of 1.5 days) and non whites (-1 days) and in patients with high socioeconomic status (-1 days) and low socioeconomic status (-2.0 days).

Following pathway implementation, the median lengths of stay improved in all subgroups with an overall decrease of 1 day, with no statistical difference by race or socioeconomic status.

Leeds says the study results do not prove implicit racial or other bias as the cause of the differences in care, but they should heighten concern about the existence of such disparities and renew attention toward identifying and addressing bias.

Two of the co-authors, Elizabeth Wick and Deborah Hobson from Johns Hopkins, are leading work to enable more than 750 hospitals across the US to implement ERAS in project funded by the Agency for Healthcare Research and Quality.