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IMPACT OF RACE AND ETHNICITY ON EMERGENCY MEDICAL SERVICES ADMINISTRATION OF OPIOID PAIN MEDICATIONS FOR INJURED CHILDREN

Open AccessPublished:October 19, 2022DOI:https://doi.org/10.1016/j.jemermed.2022.10.011

      Abstract

      Background

      Treatment with analgesics for injured children is often not provided or delayed during prehospital transport.

      Objective

      Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children.

      Methods

      We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids.

      Results

      We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2–1.2) and 0.4 (95% CI 0.2–1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids.

      Conclusions

      There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.

      Keywords

      INTRODUCTION

      Nearly 400,000 injured children are transported by emergency medical services (EMS) per year in the United States (
      • Newgard CD
      • Lin A
      • Olson LM
      • et al.
      Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.
      ). EMS providers are trained to recognize, quantify, and manage acute pain in children (
      • Hennes H
      • Kim MK
      • Pirrallo RG.
      Prehospital pain management: a comparison of providers' perceptions and practices.
      ). EMS evidence-based guidelines recommend that all EMS providers should assess pain and provide opioids to injured children with moderate or severe pain (

      Lindbeck G, Shah MI, Braithwaite S, et al. Evidence-based guidelines for prehospital pain management: recommendations. Prehosp Emerg Care doi:10.1080/10903127.2021.2018073

      ). Inadequate management of pain in children is associated with long-term negative effects, including hyperalgesia, emotional trauma, alterations in pain processing, and fear of future medical encounters (
      • Weisman SJ
      • Bernstein B
      • Schechter NL.
      Consequences of inadequate analgesia during painful procedures in children.
      ,
      • Zempsky WT
      • Schechter NL.
      What's new in the management of pain in children.
      ).
      In spite of the importance of prehospital pain management, injured children are often not provided pain medication and provision of opioid analgesia is significantly lower compared with injured adults (
      • Hennes H
      • Kim MK
      • Pirrallo RG.
      Prehospital pain management: a comparison of providers' perceptions and practices.
      ,
      • Lord B
      • Jennings PA
      • Smith K.
      The epidemiology of pain in children treated by paramedics.
      ). Furthermore, among injured children transported by EMS, prior studies have identified specific demographic characteristics as risk factors for receiving less pain management. These characteristics included younger patient age, lower socioeconomic status, and Black race (
      • Hewes HA
      • Dai M
      • Mann NC
      • Baca T
      • Taillac P.
      Prehospital pain management: disparity by age and race.
      ,
      • Whitley GA
      • Hemingway P
      • Law GR
      • Siriwardena AN.
      Ambulance clinician perspectives of disparity in prehospital child pain management: a mixed methods study.
      ,
      • Whitley GA
      • Hemingway P
      • Law GR
      • Wilson C
      • Siriwardena AN.
      Predictors of effective management of acute pain in children within a UK ambulance service: a cross-sectional study.
      ). However, these results were based on retrospective studies and qualitative surveys.
      Our objective was to evaluate patient and provider characteristics related to the administration of opioid pain medications during the prehospital transport of injured children, with a specific focus on evaluating for racial and ethnic disparities.

      MATERIALS AND METHODS

      Study Design and Setting

      We conducted a prospective study enrolling a convenience sample of injured children with scene transport to 1 of 10 urban, academic emergency departments (EDs) between July 2019 and April 2020. The study protocol was approved by the local Institutional Review Boards (IRBs) at 6 sites. The xxx IRB served as the single IRB of record for the remaining 4 sites. EMS providers provided consent to participate in the study. The study was conducted under waiver of written documentation of informed consent for the EMS providers and waiver of consent for the patients.

      Study Setting and Population

      Study sites were affiliated with the Pediatric Emergency Care Applied Research Network and included multiple regions of the United States (
      • Tzimenatos L
      • Kim E
      • Kuppermann N.
      The Pediatric Emergency Care Applied Research Network: a history of multicenter collaboration in the United States.
      ). EMS agencies transporting patients in this study represented a variety of agencies that were fire-based, private, third-service, or public utility systems. All participating EDs were level I pediatric trauma centers.
      We included patients aged 1 month to 18 years who were transported directly by an EMS agency from the scene with a traumatic injury. We excluded patients in traumatic arrest, those with opioid allergies, and pregnant patients.

      Study Procedures and Measurements

      Trained research coordinators at participating hospitals screened and identified eligible patients on arrival to the ED. Once a patient was determined to be eligible for enrollment, the transporting EMS providers completed a brief electronic survey at the time of ED handoff. Survey questions identified prehospital pain interventions given during transport. Survey questions were developed jointly by study investigators and pilot tested by EMS provider focus groups prior to the start of the study. Screening by research coordinators varied across the 10 enrolling sites, between 12 and 19 h per day on weekdays and 8–19 h per day on weekends and holidays.
      We abstracted patient injury and demographic characteristics, including race and ethnicity, from hospital records. Race was coded as White, Black, Other Race, and Not Documented. American Indian or Alaskan Native, Asian, Native Hawaiian or Other Pacific Islander, and multiracial were included as Other Race due to low prevalence within each of those racial groups. Ethnicity was coded as Hispanic or not Hispanic. We collected EMS provider characteristics via provider self-report on the electronic survey.
      Our primary outcome was the administration of prehospital opioid pain medication, which was either fentanyl or morphine. The route of administration could be intravenous, intramuscular, or intranasal.

      Analysis

      We formatted the data and recoded the variables using Stata statistical software, version 13.1 (StataCorp). Descriptive statistics were used to characterize the study population overall. Non-normal interval data were reported with medians and interquartile ranges. We assumed data were missing at random.
      We first evaluated predictor variables on univariate analysis, including patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS [includes nonparamedic EMS providers, such as emergency medical technicians and advanced emergency medical technicians]) and experience (years), and study site with administration of opioid pain medications. To assess the impact of race and ethnicity, we used a multivariate regression model using chained equations to impute missing data for seven predictor variables and one outcome variable with missing data: race (n = 13), ethnicity (n = 13), age (n = 6), gender (n = 6), presence of a fracture (n = 8), EMS level of training (n = 12), years of EMS provider experience (n = 12), and prehospital treatment with opioids (n = 23) (
      • Sullivan TR
      • Lee KJ
      • Ryan P
      • Salter AB.
      Multiple imputation for handling missing outcome data when estimating the relative risk.
      ). Adjusted odds ratios (AOR) and 95% CIs were calculated. We included study site as an auxiliary registry variable to potentially explain missingness of variables included in the multiple imputation model. Ten separate and complete data sets were created through the multiple imputation process.
      We conducted five separate sensitivity analyses to evaluate the robustness of the primary analysis, also using a multivariate regression model using chained equations to impute missing variables. First, we conducted a sensitivity analysis that included only patients with the survey completed by ALS providers because EMS agencies generally do not allow non-ALS providers to administer opioid pain medications. Second, we included only patients that were ultimately diagnosed with humerus, radius, ulna, femur, or tibia fractures to identify patients most likely to require opioid pain medications. Third, we conducted a sensitivity analysis including only patients with prehospital reported moderate to severe pain (4 or higher) to isolate patients reporting higher levels of pain. Fourth, we conducted the primary analysis using complete data only, to check the results using imputed data did not differ greatly. Fifth, we included transport by ALS provider as the primary outcome of interest to evaluate whether racial or ethnic disparities existed in ALS transport.
      We planned to include eight predictor variables, thus we estimated that, given an expected outcome prevalence rate of 25%, we would require a minimum of 320 patients to have 10 outcomes per variable evaluated in the model. Because our sample size estimate was low for the outcome of interest, we increased the sample size to 465 patients to ensure that a sufficient number of patients who received opiates (at least 80 patients) were included in the sample for analysis.

      RESULTS

      Characteristics of the Study Participants

      There were 508 patients who met inclusion criteria, of which 43 were excluded (41 non–scene transport, 1 traumatic arrest, and 1 hypersensitivity to opioid medications), leaving 465 patients enrolled. The mean (SD) age of the cohort was 10 (
      • Zempsky WT
      • Schechter NL.
      What's new in the management of pain in children.
      ) years, 270 patients (59%) were male, and 74 patients (16%) were admitted to the hospital (Table 1). There were 220 White patients (49%), 134 Black patients (34%), and 120 Hispanic patients (27%) (Table 1).
      Table 1Patient and Provider Characteristics of Injured Children Administered Opioid Pain Medications by Emergency Medical Services (n = 465)
      Characteristic (Missing Observations)n (%)
      Patient characteristics
      Age (y), mean (SD) (n = 6)10 (5)
       Younger than 2 y36 (7)
      Male (n = 6)270 (59)
      Race (n = 13)
       White220 (49)
       Black134 (30)
       Other24 (5)
       Not documented74 (16)
      Hispanic (n = 13)120 (27)
      ED disposition (n = 6)
       Discharge369 (80)
       Admission74 (16)
       Eloped9 (2)
       Transfer7 (2)
      Insurance status (n = 13)
       Public259 (57)
       Private165 (37)
       No insurance9 (2)
       Not documented19 (4)
      English speaking (n = 14)402 (89)
      Fracture (n = 8)87 (19)
      Received opioid medications from EMS (n = 23)83 (19)
      Received nonpharmacological intervention (n = 31)227 (52)
      Had pain score assessed (n = 9)364 (80)
      Provider characteristics
       Age (y), mean (SD) (n = 39)33 (9)
       Male (n = 20)345 (78)
       Advanced Life Support provider (n = 12)300 (66)
       Years of experience (n = 12)10 (8)
      ED = emergency department; EMS = emergency medical services.

      Main Results

      Overall, 83 patients (19%) received opioid pain medications during transport. On univariate analysis, older age (2 years or older), fracture, ALS provider, White race, and EMS provider experience (3 years or more) were more likely to receive opioid pain medications, and patients of Black or undocumented races and Hispanic ethnicity were less likely to receive opioid medications (Table 2).
      Table 2Univariate Analysis Comparing Specific Variables and the Receipt of Opioid Pain Medications (n = 442)
      Receipt of opioid pain medications is missing in 23 patients.
      Variable
      Variables refer to patient characteristics except for ALS provider.
      Opioid Pain Medications (n = 83)No Opioid Pain Medications (n = 359)Difference, % (95% CIs)
      n/N
      Differences in denominators are due to missing data.
      % (95% CI)n/N
      Differences in denominators are due to missing data.
      % (95% CI)
      Aged 2 y or older80/8396 (32 to 100)326/35991 (88 to 94)5 (0.6 to 11)
      Male54/8365 (55 to 75)203/35757 (52 to 62)8 (–3 to 20)
      Fracture44/8353 (42 to 64)40/35511 (8 to 15)41 (30 to 53)
      ALS provider75/8291 (85 to 98)217/35861 (56 to 66)31 (23 to 39)
      White race54/8365 (55 to 75)160/35745 (40 to 50)20 (9 to 32)
      Black race16/8319 (11 to 28)113/35732 (27 to 36)–12 (–22 to –3)
      Other race6/837 (2 to 13)18/3575 (3 to 7)2 (–4 to 8)
      Not documented7/838 (2 to 14)66/35718 (14 to 23)–10 (–17 to –3)
      Hispanic ethnicity13/8316 (8 to 23)106/35730 (25 to 34)–14 (–23 to –5)
      Provider experience 3 y or more77/8393 (87 to 98)304/35985 (81 to 88)8 (1 to 15)
      ALS = Advanced Life Support.
      low asterisk Receipt of opioid pain medications is missing in 23 patients.
      Variables refer to patient characteristics except for ALS provider.
      Differences in denominators are due to missing data.
      On adjusted analysis, the AORs for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2–1.2) and 0.4 (95% CI 0.2–1.3), respectively. The presence of a fracture (OR 17.0; 95% CI 7.9–36.7), ALS provider (OR 5.6; 95% CI 1.9–16.7), older patient age (OR 1.1 for each year of age; 95% CI 1.0–1.2), EMS provider experience (OR 1.1 for each year of experience; 95% CI 1.0–1.1), and specific sites (OR range 0.1–4.1) were associated with receiving opioid medication (Table 3). Using the highest-enrolling site as the reference, there were three sites where it was less likely for patients to receive opioid medications during transport (Table 3).
      Table 3Adjusted Odds Ratios from a Multivariate Logistic Regression Using Chained Equations to Impute Missing Variables with Prehospital Opioid Medications as the Outcome (n = 465)
      VariableAdjusted Odds Ratio (95% CIs)
      Fracture17.0 (7.9–36.7)
      ALS provider5.6 (1.9–16.7)
      Patient age (per year)1.1 (1.0–1.2)
      Provider experience (per year)1.1 (1.0–1.1)
      Race
      White race was the most common race and was used as the reference.
       Black0.5 (0.2–1.2)
       Other2.1 (0.5–8.2)
       Not documented0.9 (0.2–3.1)
      Hispanic0.4 (0.2–1.3)
      Male patient0.8 (0.4–1.7)
      Site
      Site 1 had the highest enrollment and was used as the reference site.
       20.2 (0.1–0.6)
       30.2 (0.1–0.8)
       40.5 (0.2–1.5)
       52.1 (0.7–6.5)
       60.3 (0.1–1.7)
       70.2 (0.1–0.9)
       84.1 (0.4–42.0)
       92.5 (0.8–8.4)
       100.1 (0.1–1.1)
      ALS = Advanced Life Support.
      low asterisk White race was the most common race and was used as the reference.
      Site 1 had the highest enrollment and was used as the reference site.
      In our sensitivity analysis including only patients with the survey completed by ALS providers, there were no statistically significant differences associated with race and ethnicity. There were several sites where patients were less likely to receive opioid medications (eTable 1). In the sensitivity analysis evaluating only patients with specific fractures, the AORs for Black race and Hispanic ethnicity were 0.3 (95% CI 0.1–1.7) and 0.2 (95% CI 0.0–1.9), respectively (eTable 2). In the sensitivity analysis including only patients with prehospital reported moderate to severe pain, Hispanic patients were less likely to receive opioid medications compared with non-Hispanic patients (OR 0.3; 95% CI 0.1–0.8) (eTable 3). In the sensitivity analysis using only complete data, the results were not significantly different compared with the primary analysis using imputed data (eTable 4). We also evaluated for disparities in ALS transport and found no differences between races or ethnicities (eTable 5).

      DISCUSSION

      Our study was innovative in that we prospectively evaluated the impact of race and ethnicity on prehospital opioid use across a geographically diverse network of EMS agencies and hospitals. Although our primary adjusted analysis did not find any statistically significant association between race or ethnicity and the administration of prehospital opioid medications, certain aspects of our results should be noted. Black patients had an OR of 0.5 (95% CI 0.2–1.2) and Hispanic patients had an OR of 0.4 (95% CI 0.2–1.3), suggesting the possibility that Black and Hispanic patients were less likely to receive opioid medications compared with White patients, while controlling for several other factors. However, due to smaller numbers (and wide CIs) these findings were not statistically significant.
      Our sensitivity analyses, however, did find some disparities based on race and ethnicity, particularly the analysis limited to patients with moderate to severe pain, in which Hispanic patients were found to be less likely to receive opioids. In other sensitivity analyses, the point estimates were concerning that Black (fracture OR 0.3 and moderate to severe pain OR 0.4) and Hispanic patients (fracture OR 0.2 and moderate to severe pain OR 0.3) were less likely to receive opioid pain medications compared with White patients, but these did not reach statistical significance. These results may be concerning, as these are children in most need of opioid pain medications.
      Prior studies found racial and ethnic disparities in the treatment of pain with analgesic medications. Using the National Emergency Services Information System database to identify patients transported by EMS for painful conditions (e.g., fracture, burn, or penetrating injury), Hewes et al. found that Black children were less likely to be treated with analgesics compared with White patients (
      • Hewes HA
      • Dai M
      • Mann NC
      • Baca T
      • Taillac P.
      Prehospital pain management: disparity by age and race.
      ). In a study using the National Hospital Ambulatory Medical Care Society database, Pletcher et al. found that Black and Hispanic children were less likely to receive opioid pain medications in the ED during a pain-related visit (
      • Pletcher MJ
      • Kertesz SG
      • Kohn MA
      • Gonzales R.
      Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments.
      ). This racial disparity among children being treated in the ED for a painful condition persisted even in hospitals with a high proportion of Black patients (
      • Rasooly IR
      • Mullins PM
      • Mazer-Amirshahi M
      • van den Anker J
      • Pines JM.
      The impact of race on analgesia use among pediatric emergency department patients.
      ). Goyal et al. also found similar racial disparities in pediatric ED patients with long-bone fractures (
      • Goyal MK
      • Johnson TJ
      • Chamberlain JM
      • et al.
      Racial and ethnic differences in emergency department pain management of children with fractures.
      ). Multiple studies in adults have also reported less treatment with opioid medications for Black patients compared with White patients for various painful conditions (
      • Pletcher MJ
      • Kertesz SG
      • Kohn MA
      • Gonzales R.
      Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments.
      ,
      • Heins JK
      • Heins A
      • Grammas M
      • Costello M
      • Huang K
      • Mishra S.
      Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department.
      ,
      • Tamayo-Sarver JH
      • Hinze SW
      • Cydulka RK
      • Baker DW.
      Racial and ethnic disparities in emergency department analgesic prescription.
      ,
      • Berger AJ
      • Wang Y
      • Rowe C
      • Chung B
      • Chang S
      • Haleblian G.
      Racial disparities in analgesic use amongst patients presenting to the emergency department for kidney stones in the United States.
      ).
      The results of our study identified potential areas for improvement. Future studies should further explore racial, ethnic, and socioeconomic disparities using a large, diverse cohort of children transported by EMS providers. Examination of barriers to appropriate pain treatment, whether at the EMS provider or agency level, should be examined. If racial, ethnic, or socioeconomic disparities exist, appropriate education or training may reduce these disparities (
      • Jacobs EA
      • Kohrman C
      • Lemon M
      • Vickers DL.
      Teaching physicians-in-training to address racial disparities in health: a hospital-community partnership.
      ,
      • Taylor YJ
      • Davis ME
      • Mohanan S
      • Robertson S
      • Robinson MD.
      Awareness of racial disparities in diabetes among primary care residents and preparedness to discuss disparities with patients.
      ). Future areas of study should also include the bias that providers may have based on injury type, how level of training impacts care, and reasons for site-to-site variability in practice that may be due to EMS agency culture or bias inherent to geography.
      In our study, patients who were younger and treated by less experienced EMS or non-ALS providers were less likely to receive prehospital opioid pain medications. This may be a result of discomfort among EMS providers with providing opioid pain medications to younger children. Pain assessment and weight estimation is more difficult in younger children (

      Lindbeck G, Shah MI, Braithwaite S, et al. Evidence-based guidelines for prehospital pain management: recommendations. Prehosp Emerg Care doi:10.1080/10903127.2021.2018073

      ). Use of age-appropriate pain assessment scales and age-based or length-based weight estimates may help alleviate some of these gaps of care among younger children. Although non-ALS providers are generally unable to provide prehospital opioid pain medications, we felt it was important to include patients transported by non-ALS providers, as there may be disparities in which children get transported by ALS providers. Our sensitivity analysis, however, did not identify racial or ethnic disparities for ALS transport. We also saw variation of opioid pain treatment between sites, suggesting system-based interventions or training may be useful. Browne et al. reported that incorporation of EMS pain treatment guidelines across EMS agencies led to increased pain assessments and use of appropriate treatment with opioid pain medications (
      • Browne LR
      • Shah MI
      • Studnek JR
      • et al.
      Multicenter evaluation of prehospital opioid pain management in injured children.
      ). Similar implementation of guidelines may reduce pain management variability between sites.

      Limitations

      These results should be interpreted in the context of several limitations. First, race and ethnicity were abstracted from the electronic medical record rather than asking parents or guardians directly, which is considered the preferred method for determining race and ethnicity. Furthermore, this would be the hospital-based assessment of race and ethnicity and not the EMS providers’ perception of patient race and ethnicity. We had 0–5% missing data for key variables, and thus we required the use of multiple imputations to account for missingness. Race was also frequently not documented; it is possible that certain races may be more represented in this group. Due to the relatively small number of outcomes, we were unable to explore other potential predictor variables, such as socioeconomic status, based on patient's home ZIP code, language preference, insurance status, or EMS provider race and ethnicity, which may have been important predictor variables. It was also difficult to control for the severity of pain among patients. However, we did conduct sensitivity analyses limiting the cohort to just those with fractures and those with moderate to severe pain, but this occurred in a relatively small proportion of patients. Finally, we did not assess patient or parental preferences, which may have influenced treatment with opioid pain treatment.

      CONCLUSIONS

      In our multicenter study, there was no statistically significant association between race or ethnicity and the use of opioid pain medications for injured children transported by EMS. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioid pain medications during transport.

      Article Summary

      1. Why is this topic important?
      Prehospital pain medications for injured children are often not provided or delayed. Ensuring equal and appropriate care to all racial and ethnic groups is important.
      2. What does this study attempt to show?
      We evaluated for racial and ethnic disparities related to the administration of opioid pain medications during the prehospital transport of injured children.
      3. What are the key findings?
      There were no statistically significant associations between race or ethnicity and the use of opioid pain medications for injured children transported by emergency medical services (EMS). The presence of a fracture, Advanced Life Support provider, older patient age, EMS provider experience, and site were associated with receiving opioid pain medications during transport.
      4. How is patient care impacted?
      There may be variation of prehospital pain medications in injured children across EMS agencies, providers, and racial and ethnic groups. Future work should be directed toward standardizing treatment to ensure adequate pain control for these patients.

      ACKNOWLEDGMENTS

      This project was supported by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau, Emergency Medical Services for Children Targeted Issues Grant Program under grant H34MC26201 and the Children's Research Institute grant number CRI19701. Information of content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, Department of Health and Human Services, or the US Government.

      Appendix. Supplementary materials

      REFERENCES

        • Newgard CD
        • Lin A
        • Olson LM
        • et al.
        Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.
        JAMA Pediatr. 2021; 175: 947-956
        • Hennes H
        • Kim MK
        • Pirrallo RG.
        Prehospital pain management: a comparison of providers' perceptions and practices.
        Prehosp Emerg Care. 2005; 9: 32-39
      1. Lindbeck G, Shah MI, Braithwaite S, et al. Evidence-based guidelines for prehospital pain management: recommendations. Prehosp Emerg Care doi:10.1080/10903127.2021.2018073

        • Weisman SJ
        • Bernstein B
        • Schechter NL.
        Consequences of inadequate analgesia during painful procedures in children.
        Arch Pediatr Adolesc Med. 1998; 152: 147-149
        • Zempsky WT
        • Schechter NL.
        What's new in the management of pain in children.
        Pediatr Rev. 2003; 24: 337-348
        • Lord B
        • Jennings PA
        • Smith K.
        The epidemiology of pain in children treated by paramedics.
        Emerg Med Australas. 2016; 28: 319-324
        • Hewes HA
        • Dai M
        • Mann NC
        • Baca T
        • Taillac P.
        Prehospital pain management: disparity by age and race.
        Prehosp Emerg Care. 2018; 22: 189-197
        • Whitley GA
        • Hemingway P
        • Law GR
        • Siriwardena AN.
        Ambulance clinician perspectives of disparity in prehospital child pain management: a mixed methods study.
        Health Sci Rep. 2021; 4: e261
        • Whitley GA
        • Hemingway P
        • Law GR
        • Wilson C
        • Siriwardena AN.
        Predictors of effective management of acute pain in children within a UK ambulance service: a cross-sectional study.
        Am J Emerg Med. 2020; 38: 1424-1430
        • Tzimenatos L
        • Kim E
        • Kuppermann N.
        The Pediatric Emergency Care Applied Research Network: a history of multicenter collaboration in the United States.
        Clin Exp Emerg Med. 2014; 1: 78-86
        • Sullivan TR
        • Lee KJ
        • Ryan P
        • Salter AB.
        Multiple imputation for handling missing outcome data when estimating the relative risk.
        BMC Med Res Methodol. 2017; 17: 134
        • Pletcher MJ
        • Kertesz SG
        • Kohn MA
        • Gonzales R.
        Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments.
        JAMA. 2008; 299: 70-78
        • Rasooly IR
        • Mullins PM
        • Mazer-Amirshahi M
        • van den Anker J
        • Pines JM.
        The impact of race on analgesia use among pediatric emergency department patients.
        J Pediatr. 2014; 165: 618-621
        • Goyal MK
        • Johnson TJ
        • Chamberlain JM
        • et al.
        Racial and ethnic differences in emergency department pain management of children with fractures.
        Pediatrics. 2020; 145e20193370https://doi.org/10.1542/peds.2019-3370
        • Heins JK
        • Heins A
        • Grammas M
        • Costello M
        • Huang K
        • Mishra S.
        Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department.
        J Emerg Nurs. 2006; 32: 219-224
        • Tamayo-Sarver JH
        • Hinze SW
        • Cydulka RK
        • Baker DW.
        Racial and ethnic disparities in emergency department analgesic prescription.
        Am J Public Health. 2003; 93: 2067-2073
        • Berger AJ
        • Wang Y
        • Rowe C
        • Chung B
        • Chang S
        • Haleblian G.
        Racial disparities in analgesic use amongst patients presenting to the emergency department for kidney stones in the United States.
        Am J Emerg Med. 2021; 39: 71-74
        • Jacobs EA
        • Kohrman C
        • Lemon M
        • Vickers DL.
        Teaching physicians-in-training to address racial disparities in health: a hospital-community partnership.
        Public Health Rep. 2003; 118: 349-356
        • Taylor YJ
        • Davis ME
        • Mohanan S
        • Robertson S
        • Robinson MD.
        Awareness of racial disparities in diabetes among primary care residents and preparedness to discuss disparities with patients.
        J Racial Ethn Health Disparities. 2019; 6: 237-244
        • Browne LR
        • Shah MI
        • Studnek JR
        • et al.
        Multicenter evaluation of prehospital opioid pain management in injured children.
        Prehosp Emerg Care. 2016; 20: 759-767