Papers

Ethnicity and prescription of analgesia in an accident and emergency department: cross sectional study

Desiree M A Choi, specialist registrar ^a,  Paul Yate, consultant ^a,  Tim Coats, consultant ^b,  Paul Kalinda, manager ^c,  Elizabeth A Paul, lecturer in medical statistics ^d. 

^a Barts and the London NHS Trust, Department of Anaesthetics, Royal London Hospital, London E1 1BB, ^b Accident and Emergency Department, Royal London Hospital, ^c Clinical Effectiveness Unit, Royal London Hospital, ^d St Bartholomew's and the Royal London School of Medicine and Dentistry, Department of Environmental and Preventive Medicine, London E1 2AD

Correspondence to: P Yate Pyate{at}aol.com

Ethnicity can be a risk factor for inadequate administration of analgesia in accident and emergency departments.¹ In an emergency department in Los Angeles, United States, Hispanic patients were twice as likely as non-Hispanic white patients to receive no analgesia.

Around the Royal London Hospital, over 25% of the population is Bangladeshi, and about 60% of the population is white (East London and City Health Authority, unpublished estimates for 1997). We studied prescription of analgesia for patients presenting with isolated long bone fractures to investigate whether Bangladeshi patients are as likely to receive analgesia as white patients. The local ethics committee approved the study.

	Patients and methods

Top Patients and methods Results Comment References

We reviewed the notes of patients aged 15-55 years in whom an isolated long bone fracture had been diagnosed between 1 July 1997 and 30 June 1998. Patients were excluded if the injury had occurred more than six hours before the time of presentation, or if any intoxication with alcohol or drugs or alteration in mental status was observed. Administration of analgesics (dichotomised as any or none), ethnicity, age, sex, mechanism of injury, specific bone fractured, need for reduction of the fracture, and admission to hospital were recorded. Reception staff in the accident and emergency department recorded ethnic category at registration in accordance with categories used in the census. Analysis of variance and the independent samples t test were used for age comparisons and the ² test was used for associations between categorical variables.

	Results

Top Patients and methods Results Comment References

Of 307 subjects, 224 (73%) patients were white and 42 (14%) were Bangladeshi. Eighteen patients (6%) were of other ethnic background. The ethnicity of 23 (7%) patients was not recorded. The table shows age, sex, characteristics of injury, and prescription of analgesics for each ethnic group. Overall, 243 (79.1%) patients received analgesia for long bone fractures. Of the white patients, 175 (78.5%) received analgesia, compared with 34 (81%) of the Bangladeshi patients, a difference of 2.5 percentage points (95% confidence interval -10.5 to 15.5).

The groups were similar in the mechanism of the injury, the fractured bone, admission to hospital, or proportion of patients needing reduction. Although the proportion of male patients was slightly higher in the Bangladeshi group, the difference was not significant, and within each ethnic subgroup male and female patients had similar rates of analgesia (table). The Bangladeshi patients were on average eight years younger than the white patients (P<0.05). But mean age did not differ between patients who received analgesia and those who did not, neither overall nor within each ethnic subgroup.

	Comment

Top Patients and methods Results Comment References

We found no difference between the proportions of Bangladeshi and white patients who received analgesia. Seventy nine per cent of patients with isolated long bone fractures received analgesia, which is consistent with a previous report.¹ We did not directly assess whether the injuries in each ethnic group were equally painful, but factors such as the bone affected, the need for reduction, and rates of admission were broadly similar among the groups. The study was retrospective because we did not want to affect current practice, and we did not measure potential confounding factors. What factors determine prescription of analgesia? Ethnicity could influence pain threshold, communication of pain to healthcare staff, and relationships between patients and staff. A recent review concluded that no ethnic differences were detected in the neurophysiological detection of pain, but there are reports of interethnic variation in the interpretation and expression of pain. ^{2 3} In contrast to Todd et al, however, we found that ethnicity was not a risk factor for underuse of analgesia in isolated long bone fractures in our hospital.

	Acknowledgments

We thank Naomi Barrows, Clinical Effectiveness Unit Project coordinator, for her help with this study.

PY initiated the study and contributed to study design, data analysis, and writing of the paper. DMAC contributed to study design, collected the data, and drafted the paper. TC discussed core ideas and contributed to data interpretation and writing of the paper. PK and EAP contributed to study design, data collection, and analysis. PY is guarantor for the study.

	Footnotes

Funding: none.

Competing interests: None declared.

	References

Top Patients and methods Results Comment References

1.	Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993; 269: 1537-1539[Abstract/Free Full Text].
2.	Zatzick DF, Dimsdale JE. Cultural variations in response to painful stimuli. Pyschosom Med 1990; 52: 544-557.
3.	Greenwald HP. Interethnic differences in pain perception. Pain 1991; 44: 157-163[CrossRef][Medline].

(Accepted 2 January)