Racial and ethnic disparities and acute perioperative pain management. I am Karen Smith, a doctoral completion student at the Middle Tennessee School of Anesthesia in Madison, Tennessee. I have no financial relationships with any commercial interests related to the content of this activity, nor will I discuss off-label use during my presentation. As a result of this presentation, you should be able to describe the history of racial ethnic bias and acute perioperative pain, identify disparities in acute pain management in the perioperative and ER settings resulting in racial ethnic disparities, and discuss the physiological and psychological sequelae of poorly managed acute perioperative pain. Special thanks to Dr. Hallie Evans, my project chair, Dr. Edwin Oroke, the recipient of this year's Researcher of the Year Award, and my content expert, and Dr. Bill Johnson, the CNAP Completion Program Director. This project is R.B. exempt. The annual economic cost of pain in the United States is well over $600 billion, and that's with a B, billion dollars. This figure encompasses the incremental costs of healthcare directly due to pain, for example, prolonged PACU stay, extended hospital stay, unanticipated hospital admission, and ER visits, all resulting in higher healthcare utilization, and additionally, the indirect costs stemming from delayed return to daily living function, disabilities, and essentially lost income, resulting in lost productivity. Acute perioperative pain leads to physiological and psychological implications. Minorities are at increased risk. Historically, the quality of healthcare has been heavily influenced by practitioners' attitudes, practices, and beliefs. In the early 1800s, physicians, who were also plantation owners, tried to use science to try to prove physiological differences between Black and white people. They insisted that Black bodies were composed and functioned differently than white bodies. Over the years, physicians and scientists embraced these unproven theories. More than 150 years after the end of slavery, fallacies and deception of African-American immunity to pain and weakened lung function continue to show up in modern-day education and clinical practice. Two of the most steadfast physiological myths, Black people are impervious to pain and people of color have weakened lung capacity that can only be strengthened through hard work, remain ingrained in contemporary medical education and clinical practice to this very day. For example, the incentive spirometer. Standard spirometry results are automatically corrected for race. These controls are built into the incentive spirometer software for the assumption that Black people and people of Asian descent have less lung capacity than white people. Correction factors of 10-15% for individuals labeled Black and 4-6% for individuals labeled Asian. Race correction is still taught to medical students and described in the textbooks as scientific fact and standard practice. Implicit bias. This is defined as the unconscious and often involuntary attitudes and beliefs that influence behavior and cognitive thought processes. Implicit bias is initiated early in life and is upheld by repetitive exposure to societal norms and stereotypes. Some of the literature states that initiation is early as three to seven years of age. It can be expressed directly as in clutching one's purse when approaching a Black man or indirectly, for example, expressing more care and attention to a white patient as opposed to a Black patient. Although subconscious, these attitudes and stereotypes determine how information about an individual from a group is processed, influenced in judgment and decision-making. Implicit bias among healthcare providers can result in discriminatory behavior resulting in healthcare disparities. Race has varying definitions that have changed over time because race is a social construct. Race along with other demographic data is used by researchers, healthcare organizations, policymakers and healthcare providers as a means of monitoring quality of care, inequity and predicting risk. Race is also used as a predictor of societal and behavioral norms. Despite the fact that humans are over 99% genetically identical, the U.S. government and numerous institutions and organizations continue to classify persons into various racial categories based on physical traits. For example, the U.S. Census Bureau currently classifies people into five races, American Indian or Alaska Native, Asian, Afro-American or Black, Native Hawaiian or Pacific Islanders and White. While physical features may appear in higher frequencies in some populations, there is not a single gene code for a racial category. Although race has no biological meaning, the term does hold some social significance. The exclusion of the human race from health and medical research may disregard inequities in population health, thereby masking health disparities. Ethnicity. Ethnicity is defined as a designated group of people in a society possessing shared cultural factors to include your background, your beliefs, your behaviors and your language. The National Institute of Health recognized two categories of ethnicity, Hispanic and non-Hispanic. The question is often asked, what's the difference between the two, race and ethnicity? It's a simple answer. Race is inherited and ethnicity is learned. The PICO format was used to address the clinical research question that I had. In African-American surgical patients experiencing acute perioptic pain in the hospital setting, is there decreased opioid medication administration for pain management when compared to non-Hispanic Whites, leading to untreated or undertreated pain and increased hospital stay or readmission? Essentially, I ended up researching minorities, considering Black and Brown Americans. Given my research material increased depth and breadth, the amount of material retrieved when I was solely looking for African-American population was minuscule. A comprehensive search was completed using the inclusion and exclusion criteria initially to address the differences in perioptic pain management of the African-American patient population as opposed to the non-Hispanic White. A Google search along with searching references for articles reviewed resulted in 91 articles. From this search, following abstraction, a prisma flow diagram noted to your left was created to identify eight records. The most consistent inequity reported was insubstantial analgesia administration to the minority patient. The non-Hispanic White patient received significantly increased total doses of analgesia in opioid form when compared to the minority patient. This inequity was noted in all settings to include orthopedics, obstetrics, and ENT. There was no significant difference found with non-opioid analgesia administration. The patient-controlled analgesia pump was introduced into the postoperative setting in an attempt to standardize the management of pain. Since the treatment of postoperative pain with PRN meds requires patient-provider interaction, it was difficult to determine if ethnic differences in the amount of narcotic received was associated with the patient-related behavior from the patient or the provider's perception of the patient's pain. The reduction of interaction between the patient and the provider was an attempt to minimize patient-related influence of pain perception by the provider, and it also gave the patient a sense of increased control in their treatment process. Nevertheless, studies revealed no difference in self-administered analgesic dose amounts, although non-Hispanic Whites were prescribed higher doses of opioid drugs in the PCA pump than Blacks and Hispanics. In the last 10 years, random controlled trials have been available in the form of provider-focused virtual case vignettes specifically intended to evaluate provider pain assessment and treatment decisions. The majority of these studies agree that false beliefs about racial bias continue to shape the provider's perception and the treatment of minority patients. Additionally, disparities in the occurrence of revisit complications were identified. Three of the studies found evidence of a postoperative relationship between unplanned readmissions to the emergency department after discharge, a primary pain diagnosis, and ethnicity. Limitations and gaps. This subject matter is somewhat taboo, and I found that research literature is not available in abundance. Overall, the data available to evaluate assessment and treatment of pain in the acute care setting is pretty weak. There is a need for availability of clinical research with increased strength and validity. Currently, only 1% of funded research is directed at evaluating racial and ethnic minorities. As projected by the year 2050, 54% of the U.S. population will be people of color. Research should reflect this demographic shift. It is no longer acceptable to do research without including a racially and ethnically diverse population. Increasing the participation of minorities in research is imperative. CRNAs such as myself administer over 50 million anesthetics each year and are ethically held responsible to act in the best interest of the patient. This comes from the Code of Ethics from the Certified Registered Nurse Anesthetists. This statement does not only apply to the practice of CRNA in the clinical setting, it also encompasses nurse anesthesia, related administrative roles, educational roles, and research activities. The CRNA has the personal responsibility to understand, uphold, and adhere to these ethical standards of conduct. There is a significant gap between the evaluation and treatment of acute pain in the non-Hispanic white versus the African-American. In 1999, the Institute of Medicine assessed and revealed the extent of discipline and quality of health care services received by minorities. Yet here we stand, two decades later, over two decades later actually, and the results still hold true to this very day. This space, educational awareness among anesthesia providers, is necessary to promote and provide culturally competent pain management and thereby improving clinical outcomes. Some recommendations for practice. Let's just start with individual accountability. Increased self-awareness of personal implicit bias through education thereby increases self-efficacy. Incorporation of yearly cultural competency training, beginning with implicit association testing, is used to gauge one's baseline presence of subconscious bias, and continuing with training that measures the quality of treatment in the real-world setting. Provider practice should be focused on assessing and holistically treating each individual patient. As stated earlier, it is the duty and moral obligation of the anesthesia provider to ensure compassionate, patient-centered anesthesia pain management and related care. The suggested use of perioperative patient and family education in a plan of care tailored to the individual and the surgical procedure encourages buy-in from the patient and it optimizes quality of care and outcomes. Workforce development through identification, recruitment, and retention of diverse clinicians increases the number of healthcare workers from a variety of racial and ethnic backgrounds. With the aforementioned change noted to our society, the healthcare profession needs to be able to mirror these changes. As the literature suggests, for the minority patient, treatment by a clinician of non-white race is one of the strongest predictors of reduced pain intensity, attaining better pain control with a lower dose of opioid algesia. Individual accountability is of vital importance, but nevertheless, it must be accompanied by policies and system changes in the healthcare setting to eliminate disparities successfully. Strategic imperatives must be initiated with employment at the community, state, and national levels to combat widening disparities. Key details of a successful model include forming strategic, multidisciplinary partnerships with community-based organizations, community leaders, and education in the most vulnerable communities, and disseminating this information at your level of practice or involvement. At the local level, with your other CRNAs in your community, at the state level, getting involved in your state association, at the national level, as with the AANA, or even internationally, linking up with the International Federation of Nurse Anesthetists. Accelerating health impact increases the focus of subpopulation most affected by pain disparities. Assistance from leadership or federal agencies, state and local governments, healthcare providers, and health professional organizations must be employed to adopt a successful model for system change. In conclusion, optimal perioptic pain management for all is critically important from a public health and a policy perspective. Long-term effects of healthcare inequities are costly, not only to us as a nation, but also to each individual patient, leading to decreased productivity and ultimately decreased quality of life. Ethnic minorities remain in the highest risk category for inadequate treatment resulting in inadequate pain control. Personal awareness, starting at a personal level, assessing your own level of bias, at the community level, and at the state and national levels are warranted. Thank you for your time and your attention.

racial disparities

pain management

implicit bias

cultural competency

healthcare policy