Socioeconomic Status and Analgesia Provision at Discharge Among Children With Long-Bone Fractures Requiring Emergency Care Henry W. Ortega, MD,* Heidi Vander Velden, MS,† Walter Truong, MD,‡ and Joseph L. Arms, MD* Background: Inadequate treatment of painful conditions in children is a significant and complex problem. The objective of this study was to exam- ine the effect of socioeconomic status on the provision of analgesic medi- cines at discharge in children treated emergently for a long-bone fracture. Methods: A retrospective review of all patients during a 1-year period with a long-bone fracture treated in 2 urban pediatric emergency depart- ments (EDs) was performed. Results: Eight hundred seventy-three patients were identified who met our inclusion criteria. Sixty percent of patients received a prescription for an opioid-containing medicine, and 22% received a prescription for an over-the-counter analgesic medicine at ED discharge. Socioeconomic sta- tus had no effect on opioid analgesic prescriptions at discharge. Patients in the lowest-income group were younger, presented to the ED longer after an injury, were likely nonwhite, and had higher rates of over-the-counter analgesic medicine prescriptions provided at discharge. Higher-income pa- tients were likely white and non-Hispanic, presented to the ED sooner, and were less likely to receive a prescription for a nonopioid analgesic medicine. Conclusions: Socioeconomic status is associated with different nonopioid analgesic prescription patterns in children treated in the ED for a long-bone fracture, but had no effect on opioid analgesic prescriptions. Key Words: analgesia, fractures, socioeconomic status (Pediatr Emer Care 2018;00: 00–00) P ain is a common reason for children to seek medical care in the emergency department (ED). 1,2 Despite the high prevalence of ED visits requiring pain control, pain is often poorly assessed and treated in ED settings. 3–7 Inadequate treatment of painful condi- tions in children is a significant problem, and abundant evidence exists that children are less likely than adults to receive analgesic medication for their pain, 5–8 with as few as 2% of children pro- vided a prescription analgesic at ED discharge. 9 Although more than 10 years have passed since the Joint Commission developed standards addressing the assessment and treatment of pain, 10 there continues to be substantial practice variation in the treatment of pain in the ED. 11–14 There is ample evidence that disparities still exist in health care. 15 While inadequate pain management by the medical profes- sion was first reported in a landmark article in 1973 by Marks and Sachar, 16 Todd et al 17 raised concerns about specific racial and ethnic disparities in analgesia provided in the ED for long-bone fractures in adult patients. Since this sentinel study, other investi- gators have reported conflicting results. 18–20 Although racial and ethnic disparities in health care have been well outlined, there is still considerable variability in the evidence to date. Furthermore, many investigators insist that racial health disparities cannot be understood without considering social class and socioeconomic status (SES). 21–23 Understanding the role of SES in the experience and treat- ment of pain is of particular importance when one considers that more than 1 in 5 children in the United States lived in poverty in 2010. 24 Consequently, it is important for physicians to consider the impact of SES on the management of pain in children. Despite this, few studies have examined the impact of SES on the experi- ence of pain in children, 5,25,26 and only 1 study examined differ- ences in analgesic administration in the ED. 26 Unfortunately, there is not enough evidence from these few studies to draw any conclusions about socioeconomic differences in the treatment of pain in children. As acute long-bone fracture is the most common presenting complaint for pediatric ED patients with moderate to severe pain, 27,28 it provides an ideal population to study these issues. Currently, no definitive standard of care exists for the man- agement of fracture-related pain in children discharged from the ED. 11–14 Administration of analgesics influenced by the SES of a patient is an unacceptable practice. An increased awareness of clinical factors that affect the provision of analgesic medicines will contribute to the understanding of this important topic and ulti- mately improve the care of children with fractures. The purpose of this study was to examine the potential associations between SES and the provision of analgesic medications at discharge among children treated in the ED for long-bone fractures. Our hy- pothesis is that there are disparities in the frequency of analgesic prescriptions related to the SES of patients treated for a long- bone fracture. METHODS Study Design and Patient Selection This retrospective review was approved by our institutional review board. Our institution maintains 2 EDs in freestanding, ur- ban, university-affiliated children's hospitals that have a combined annual census of more than 80,000 visits per year. We used our electronic medical records system (CERNER, Kansas City, Mo) data warehouse to obtain data from a convenience sample of pa- tients who were treated for an extremity fracture between January 1 and December 31, 2015, in our pediatric EDs. International Clas- sification of Diseases, Ninth Revision codes 812, 813, 818, 820, 821, 823, 824, 827, and 828 were used to identify eligible patients for this study. Forearm fractures included the fractures of the radius and ulna; elbow fractures included condyle and supracondylar fractures. Humerus fractures included all other fractures of the hu- merus proximal to the condyles. We collected demographic data including age, race, and sex directly from the electronic database. Clinical data, such as time to arrival to ED after injury, type of fracture, plain radiograph From the *Emergency Services, †Research and Sponsored Programs, and ‡Orthopedic Surgery, Children's Minnesota, Minneapolis, MN Disclosure: The authors declare no conflict of interest. Reprints: Henry W. Ortega, MD, Children's Hospitals and Clinics of Minnesota, MS 17-750, Chicago Ave S, Minneapolis, MN 55404 (e‐mail: Henry.ortega@childrensmn.org). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ORIGINAL ARTICLE Pediatric Emergency Care • Volume 00, Number 00, Month 2018 www.pec-online.com 1 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.