Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management

Celeste A Green; Jasmine D Johnson; Christine McKenzie; Alison M Stuebe

doi:10.1089/heq.2022.0180

Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management

Health Equity. 2023 Oct 12;7(1):685-691. doi: 10.1089/heq.2022.0180. eCollection 2023.

Authors

Celeste A Green¹, Jasmine D Johnson², Christine McKenzie³, Alison M Stuebe⁴

Affiliations

¹ Department of Obstetrics and Gynecology, University of Chapel Hill, Chapel Hill, North Carolina, USA.
² Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana, USA.
³ Department of Anesthesiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA.
⁴ Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA.

Abstract

Objective: To quantify the extent to which a standardized pain management order set reduced racial and ethnic inequities in post-cesarean pain evaluation and management.

Methods: We conducted a retrospective cohort study to quantify racial and ethnic differences in pain evaluation and management before (July 2014-June 2016) and after implementation of a standardized post-cesarean order set (March 2017-February 2018). Electronic medical records were queried for pain scores >7/10, number of pain assessments, and opioid, nonsteroidal anti-inflammatory drug (NSAID), and acetaminophen doses. Outcomes were grouped into 0 to <24 and 24-48 h postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black [NHB], non-Hispanic White [NHW], Asian, and other), as documented in the electronic health record. Analyses included logistic regression for the categorical outcome of pain score >7 (severe pain), and linear regression, with propensity score adjustment. Main effect and interaction terms were used to calculate the difference-in-difference in pain process and outcome measures between the baseline and follow-up periods.

Results: After order set implementation (N=888), severe pain remained more common among NHB patients (% pain scores >7 NHW vs. NHB 0 to <24 h: 22% vs. 33%, p=0.003; 24-48 h: 26% vs. 40%, p<0.001). Among all patients, pain management processes changed after implementation of the order set, with overall fewer assessments, less Opioids, and more nonopioid analgesics. However, racial and ethnic inequities in a number of assessments and in treatment were unchanged (all p for interaction >0.05), with the exception of a modest increase in NSAID doses 24-48 h postpartum for Hispanic patients.

Conclusion: A standardized pain management order set reduced overall postpartum opioid use, but did not reduce racial and ethnic disparities in pain evaluation and management. Future work should investigate racial equity-focused education and interventions designed to eliminate disparities in pain management.

Keywords: ERAS; NSAIDs; acetaminophen; disparity; narcotics; opioids.