1. Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Racial Disparities in Pain Management for Appendicitis Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. Published online September 14, 2015. doi:10.1001/jamapediatrics.2015.1915.

2. Copyright restrictions may apply Background –Racial/ethnic disparities in the management of abdominal pain in emergency departments (EDs) have been reported. However, these studies may be affected by spectrum bias and may reflect racial/ethnic differences in ED use rather than true differences in pain management. –Appendicitis is the most common surgical cause of abdominal pain in children in the ED, and provision of analgesia is considered the standard of care. Study Objective –To investigate racial differences in analgesia administration among children diagnosed as having appendicitis in the ED. Introduction

3. Copyright restrictions may apply Study Design –Repeated cross-sectional study of the National Hospital Ambulatory Medical Care Survey from 2003 to 2010. Setting –Nationally representative sample of EDs. Patients –Children aged 21 years or younger diagnosed as having appendicitis (International Classification of Diseases, Ninth Revision codes 540, 541). Methods

4. Copyright restrictions may apply Methods Outcomes –Racial differences in the following: (1) Any analgesia administration. (2) Opioid administration. Limitations –No documentation if analgesia was offered but declined by patients. –Only pain scores at triage were abstracted. –Cannot account for analgesia received prior to ED arrival. –Race/ethnicity data determined by someone other than the patient.

5. Copyright restrictions may apply Results Demographic Characteristics of Study Population

6. Copyright restrictions may apply Results Multivariable Analysis of Overall Analgesia and Opioid Administration by Race a

7. Copyright restrictions may apply Results Predicted Probabilities for Analgesic and Opioid Administration by Race Stratified by Pain Score and Adjusted for Ethnicity

8. Copyright restrictions may apply Comment Appendicitis pain is undertreated in children. –Only 56.8% of children diagnosed as having appendicitis in the ED received any analgesia. –Only 41.3% received opioid analgesia. No racial differences were found in analgesia administration overall. Black children were less likely to receive opioid analgesia than white children even after adjustment for pain score and triage level. –Adjusted odds ratio = 0.2 (95% CI, 0.06-0.8).

9. Copyright restrictions may apply If you have questions, please contact the corresponding author: –Monika K. Goyal, MD, MSCE, Children’s National Health System, 111 Michigan Ave NW, Washington, DC 20010 (mgoyal@childrensnational.org). Funding/Support This work was supported by grant K23 HD070910 from the National Institutes of Health (Dr Goyal). Conflict of Interest Disclosures None reported. Contact Information