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Race, postoperative complications, and death in apparently healthy children (aappublications.org)
15 points by BlameKaneda 21 days ago | hide | past | favorite | 7 comments

"BACKGROUND: That African American (AA) patients have poorer surgical outcomes compared with their white peers is established. The prevailing presumption is that these disparities operate within the context of a higher preoperative comorbidity burden among AA patients. Whether these racial differences in outcomes exist among apparently healthy children (traditionally expected to have low risk of post surgical complications) has not been previously investigated."

"CONCLUSIONS: Even among apparently healthy children, being AA is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity."

This caveat in the discussion highlights an important area of policy and research for the impact of structural racism:

> We also acknowledge that we did not explore the site of care where these patients received their surgeries given that previous investigators have shown that minority patients tend to receive care in low-quality, minority-serving hospitals. Site of care is a critical variable that appears to mediate the pathway of the association of race with postoperative morbidity and mortality. Unfortunately, the [National Surgical Quality Improvement Program-Pediatrics] program strongly discourages attempts to identify specific hospitals in the database. Given that site of care is an important potentially modifiable variable and the established knowledge that disparities in surgical care is a pervasive and long-standing problem in our health care system, improving access to high-quality care across every hospital is an important step to reduce the persistent racial disparity in health outcomes in the US.

But let's not forget that many American doctors, individually, are despicable racists who treat black children worse than animals[1]:

> An estimated 0.94 (95% CI, 0.78-1.10) million children were diagnosed as having appendicitis. Of those, 56.8% (95% CI, 49.8%-63.9%) received analgesia of any type; 41.3% (95% CI, 33.7%-48.9%) received opioid analgesia (20.7% [95% CI, 5.3%-36.0%] of black patients vs 43.1% [95% CI, 34.6%-51.4%] of white patients). When stratified by pain score and adjusted for ethnicity, black patients with moderate pain were less likely to receive any analgesia than white patients (adjusted odds ratio = 0.1 [95% CI, 0.02-0.8]). Among those with severe pain, black patients were less likely to receive opioids than white patients (adjusted odds ratio = 0.2 [95% CI, 0.06-0.9]). In a multivariable model, there were no significant differences in the overall rate of analgesia administration by race. However, black patients received opioid analgesia significantly less frequently than white patients (12.2% [95% CI, 0.1%-35.2%] vs 33.9% [95% CI, 0.6%-74.9%], respectively; adjusted odds ratio = 0.2 [95% CI, 0.06-0.8]).

And that many American doctors are plain racist cranks[2]:

> Study 2 demonstrates that, similar to white laypersons in study 1, many white medical students and residents hold beliefs about biological differences between blacks and whites, many of which are false and fantastical in nature, and that these false beliefs are related to racial bias in pain perception. Furthermore, study 2 also reveals that white medical students and residents who endorsed false beliefs showed racial bias in the accuracy of their pain treatment recommendations. Specifically, participants who endorsed more of these beliefs reported that a black (vs. white) target patient would feel less pain and they were less accurate in their treatment recommendations for the black (vs. white) patient. Although the effect sizes for these findings were not large (η2p = 0.03 and 0.04), the practical importance is significant: those endorsing more false beliefs rated the pain of a black (vs. white) patient half a scale point lower and were less accurate in their treatment recommendations 15% of the time.

[1] https://jamanetwork.com/journals/jamapediatrics/article-abst... [2] https://www.pnas.org/content/113/16/4296

I don't know why this is downvoting to the point of being greyed out.

Doc here: nothing in the post above is controversial or new to anyone even vaguely aware of the literature.

It is true, and a major confounder of the study to the point of rendering it utterly fucking useless, that AA = lower SES = shittier hospital.

The remainder of the points in the above post are also heavily corroborated and true - although it should be noted that they suffer from essentially the same bias as the parent article, which OP did not mention. There's also AA = lower SES = hospital that sees a shit-ton of lying addicts come through the doors, making docs distrustful of anyone that can even vaguely fit the stereotype.

It is notable however that the 'docs are racist and give less accurate treatment when biased' bit is not statistically significant.

It's also... just... kind of complicated?

I have a story I'll never forget, from my training days.

We had a lady come in with severe lower back pain, two weeks post-discharge from a complicated UTI. CT she'd gotten during last admit showed some osteoporosis of the lumbar spine. Working hypothesis was UTI, or maybe it ascended to pyelo. Patient had 10/10 please-don't-touch-me-or-look-at-me pain, and a distant (or "distant"?) history of IV drug abuse.

Test test test, okay, not a UTI. Took some fresh imaging exploring the spine some more, and looks like she had a collapsed vertebra. The correlation between loss of spinal integrity of imaging and pain is loose, but, let's look into that.

Also, this lady is constantly asking for more pain meds. There's not enough in the world for this lady.

When we come by to visit her, a couple of times she's... well, it basically looks like "oh, the docs are coming, quick, lay back down and look worse." Nurses confirm.

Conversation in the on-call room, amidst a group of residents and attending that covers pretty much every ethnicity and gender, goes something like:

"She looks like she's exaggerating."

"Nurses say the same."

"Could be. But she could be exaggerating because she's faking, or she could be trying to make sure we don't take her pain less seriously than it deserves, and is afraid if she looks OK for a moment we will."

"That's true. Also, she's black, and I am afraid of unconscious bias that may be playing a role here."

"I too am afraid of that. But she's also being visibly deceptive, and she Does have a history of drug abuse. When she got her pain managed last time she was here, could we have knocked her off the wagon?"

"That history of addiction was ages ago."

"But you can't cure addiction, you can just do your best to stay clean."

etc. Very self-aware, very consciously attempting to not be "despicable racists that treat black children worse than animals."

We consulted pain management, who said our pain management regimen was reasonable.

The result was that we managed to talk ourselves out of chasing her pain with opioids - that is, we kept her at a reasonably high level of analgesia, which she was crying was not at all close to enough - and had interventional radiology give her a vertebroplasty.

24 hours after the procedure she stopped asking for opioids; 48 hours out she left the hospital on motrin. All signs of dubious behavior were utterly gone.

She had just been in pain. We did everything we could to do the right thing. It wasn't enough.

We had a diverse group of physicians. We thought long and hard. We discussed at length the effects of bias. We consulted with outsiders. We debated some more. We did our level best. And we still, I think, fucked up.

All I mean to say is: it's way more complicated than "white doctors are racists are terrible."

The unstated premise that more opioids = better care is questionable at best. In fact is likely that the opposite is true.

> black patients with moderate pain were less likely to receive any analgesia than white patients (adjusted odds ratio = 0.1 [95% CI, 0.02-0.8]).

90% less likely to receive any pain-relieving medication. That's well beyond the gray area of "how much opioids should we give, more or less?"

> In a multivariable model, there were no significant differences in the overall rate of analgesia administration by race.

> There was no statistically significant difference in overall analgesia administration by race, but there was a statistically significant difference in opioid administration by race. Black children with appendicitis were less likely to receive opioid analgesia than white children (12.2% [95% CI, 0.1%-35.2%] vs 33.9% [95% CI, 0.6%-74.9%], respectively; adjusted OR = 0.2 [95% CI, 0.06-0.8]). No other covariates achieved statistical significance in the multivariable model.

There difference between "any analgesia" and "opioids" in the pediatric population is almost entirely "ibuprofen." There was no difference in the administration of ibuprofen.

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