The influence of race and socioeconomic factors on patient acceptance of perioperative epidural analgesia.
ABSTRACT Ethnic minorities and patients of lower socioeconomic status may be more averse to the acceptance of epidural analgesia than nonminority counterparts and those of higher socioeconomic status, despite evidence for substantial benefit to the patient.
A scripted telephone survey was developed from the 2000 United States Census by a panel of experts. Contact was attempted at least twice for all patients listed for surgery at the Hospital of the University of Pennsylvania over a 4-mo period.
Three thousand seven hundred thirty-nine patients were called and 1265 subjects were successfully contacted and 1193 consented, whereas 72 refused to participate. Seven hundred sixty-two subjects (64%) would accept an epidural if recommended by an anesthesiologist and 425 (36%) would refuse. If the epidural was recommended by both the anesthesiologist and surgeon acceptance increased to 932 (78.5%). The univariate predictor of refusal of perioperative epidural analgesia was African American race. Univariate predictors of acceptance include full- or part-time employment, total household income >$50,001/yr, college graduate, prior epidural treatment, and knowledge of what an epidural is. When the potential confounders of race, total household income, employment, and education were included in a multivariate logistic regression model, African American race predicted refusal (odds ratio [OR], 0.58; P < 0.006; confidence interval [CI], 0.41-0.81) and was the only factor that predicted refusal or acceptance of epidural analgesia.
Acceptance of perioperative epidural analgesia is strongly affected by race and socioeconomic status. Anesthesiologists need to recognize this potential barrier when trying to maximize patient comfort and outcome.
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ABSTRACT: Continuous wound infiltration (CWI), i.v. patient-controlled analgesia (i.v.-PCA), and epidural analgesia (EDA) are analgesic techniques commonly used for pain relief after open abdominal surgery. The aim of this study was to evaluate the cost-effectiveness of these techniques. A decision analytic model was developed, including values retrieved from clinical trials and from an observational prospective cohort of 85 patients. Efficacy criteria were based on pain at rest (VAS ≤ 30/100 mm at 24 h). Resource use and costs were evaluated from medical record measurements and published data. Probabilistic sensitivity analysis (PSA) was performed. When taking into account all resources consumed, the CWI arm (€ 6460) is economically dominant when compared with i.v.-PCA (€ 7273) and EDA (€ 7500). The proportion of patients successfully controlled for their postoperative pain management are 77.4%, 53.9%, and 72.9% for CWI, i.v.-PCA, and EDA, respectively, demonstrating the CWI procedure to be both economically and clinically dominant. PSA reported that CWI remains cost saving in 70.4% of cases in comparison with EDA and in 59.2% of cases when compared with PCA. Device-related costs of using CWI for pain management after abdominal laparotomy are partly counterbalanced by a reduction in resource consumption. The cost-effectiveness analysis suggests that CWI is the dominant treatment strategy for managing postoperative pain (i.e. more effective and less costly) in comparison with i.v.-PCA. When compared with EDA, CWI is less costly with almost equivalent efficacy. This economic evaluation may be useful for clinicians to design algorithms for pain management after major abdominal surgery.BJA British Journal of Anaesthesia 03/2012; 108(6):998-1005. DOI:10.1093/bja/aes091 · 4.24 Impact Factor
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ABSTRACT: Introduction The aims of this study were to assess racial/ethnic disparities for neuraxial labor analgesia utilization and to determine if preferred spoken language mediates the association between race/ethnicity and neuraxial labor analgesia utilization. Methods We performed a retrospective cohort study of 3129 obstetric patients who underwent vaginal delivery at a tertiary care obstetric center. Bivariate analyses and multivariate logistic regression models were used to assess the relationships between race/ethnicity, preferred spoken language and neuraxial labor analgesia. Results Hispanic ethnicity (adjusted OR, 0.77; 95% CI, 0.61–0.98) and multiparity (adjusted OR, 0.59; 95% CI, 0.51–0.69) were independently associated with a reduced likelihood of neuraxial labor analgesia utilization. When preferred spoken language was controlled for, the effect of Hispanic ethnicity was no longer significant (adjusted OR, 0.84; 95% CI,0.66–1.08) and only non-English preferred spoken language (adjusted OR, 0.82; 95% CI, 0.67–0.99) and multiparity (adjusted OR, 0.59; 95% CI, 0.51–0.69) were associated with a reduced likelihood of neuraxial labor analgesia utilization. Conclusions This study provides evidence that preferred spoken language mediates the relationship between Hispanic ethnicity and neuraxial labor analgesia utilization.International journal of obstetric anesthesia 01/2013; 23(2). DOI:10.1016/j.ijoa.2013.09.001 · 1.85 Impact Factor
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ABSTRACT: OBJECTIVE: The examination that determines if a veteran has service-connected posttraumatic stress disorder (PTSD) affects veterans' lives for years. This study examined factors potentially associated with veterans' perception of their examination's quality. METHODS: Veterans (N=384) being evaluated for an initial PTSD service-connection claim were randomly assigned to receive either a semistructured interview or the examiner's usual interview. Immediately after the interview, veterans completed confidential ratings of the examinations' quality and of their examiners' interpersonal qualities and competence. Extensive data characterizing the veterans, the 33 participating examiners, and the examinations themselves were collected. RESULTS: Forty-seven percent of Caucasian veterans and 34% of African-American veterans rated their examination quality as excellent. African Americans were less likely than Caucasians to assign a higher quality rating (odds ratio=.61, 95% confidence interval=.38-.99, p=.047). Compared with Caucasians, African Americans rated their examiners as having significantly worse interpersonal qualities but not lower competence. Ratings were not significantly related to the veterans' age, gender, marital status, eventual diagnosis of PTSD, Global Assessment of Functioning score, the examiner's perception of the prevalence of malingering, or the presence of a third party during the examination. CONCLUSIONS: Ratings of disability examinations were generally high, although ratings were less favorable among African-American veterans than among Caucasian veterans.Psychiatric services (Washington, D.C.) 01/2013; 64(4). DOI:10.1176/appi.ps.201100526 · 2.81 Impact Factor