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2023 HSR&D/QUERI National Conference Abstract

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4105 — Identifying disparities in pain treatment by leveraging geriatric emergency department programming

Lead/Presenter: Tessa Durham,  COIN - West Haven
All Authors: Runels T (COIN, VA Connecticut Health System), Durham T (GRECC, James J. Peters VAMC), Gruber E (Richard L. Roudebush VAMC), Rossomano N (VA Central Office), Haskins K (Richard L. Roudebush VAMC), Vaughan EC (GRECC, Atlanta VAMC), Hwang U (GRECC, James J. Peters VAMC)

Emergency Department (ED) providers (both within and outside VA) struggle to deliver consistent and adequate pain care to older adults with persistent disparities based on race and age. Current medical literature indicates racial disparities in pain treatment suggesting that Black patients receive less than optimal pain care. Previous studies in ED’s indicate that Black patients are up to 45% less likely to be prescribed opioids. We investigate if such disparities exist at the VA by leveraging medication safety programs at VA EDs implemented for older Veterans.

This was an observational evaluation of emergency pain care for older Veterans seen at VA EDS from 2018-2022. ED visit encounters were extracted from the Corporate Data Warehouse based on patient records captured using the Emergency Department Integration Software (EDIS) that tracks and manages the delivery of care at VA EDs. Veteran demographics (age, race), ED encounters, chief complaints (categorized as pain-related versus not), and ED pain care (documentation of pain scores and receipt of discharged analgesic prescriptions [categorized as opioids, non-steroidal anti-inflammatory drugs, acetaminophen, and topical analgesics]) were extracted. Descriptive analytic comparisons were made of ED pain care (documented assessment and treatment) by Geriatric ED (GED) accredited vs non-GED sites, sites that implemented the Enhancing the Quality of Provider Prescribing in the ED (EQUIPPED)(prescriber education, clinical decision support, and audit and feedback) vs non-EQUIPPED sites, and by older (65+ years in age) Black vs. non-Black Veterans.

Over 4 million ED visits were made by 1.2 unique Veterans 65+ years in age; mean age was 74; 23.5% were Black versus non-Black. Out of a total of 110 VA EDs: 44 sites had submitted for or received GED accreditation, 20 sites were EQUIPPED. Older Veterans with pain-related chief complaints seen at GED’s versus non-GED had more pain score documentation (94.53% vs.93.03%). The same occurred at EQUIPPED vs. non-EQUIPPED EDs (96.18% vs. 92.55%). While both GED and EQUIPPED sites prescribed fewer discharge analgesics for pain-related complaints (61.24% GEDs vs. 61.63% non-GEDS; 60.88% EQUIPPED vs.61.75% non-EQUIPPED), we identified disparities in types of analgesics prescribed. Black Veterans (vs. non-Black) were more likely to receive acetaminophen (OR = 1.68 (1.61, 1.68 95% CI)) and less likely to receive opioids (0.67 (0.65, 0.69)), regardless if patients were seen in GED, EQUIPPED, or EDs with neither of these programs.

Implementation of practices to improve older Veteran ED pain care may be mitigating disparities in the identification and treatment of pain. A disparity in the prescription of opioids was identified; however, it is unclear how this aligns with overall quality of care related to pain treatment.

Medication safety programs focused on improving geriatric ED care including minimizing use of potentially inappropriate medications and providing clinical decision support at the time of discharge prescribing in the ED should promote safer and more equitable pain treatment.