Alan Heins

Impact of Physician and Patient Gender on Pain Management in the Emergency Department—A Multicenter Study

OBJECTIVE Pain is a complex experience influenced by factors such as age, race, and ethnicity. We conducted a multicenter study to better understand emergency department (ED) pain management practices and examined the influence of patient and provider gender on analgesic administration. DESIGN Prospective, multicenter, observational study. SETTING Consecutive patients, >or=8-years-old, presenting with complaints of moderate to severe pain (pain numerical rating scale [NRS] > 3) at 16 U.S. and three Canadian hospitals. OUTCOMES MEASURES Receipt of any ED analgesic, receipt of opioids, and adequate pain relief in the ED. RESULTS Eight hundred forty-two patients participated including 56% women. Baseline pain scores were similar in both genders. Analgesic administration rates were not significantly different for female and male patients (63% vs 57%, P = 0.08), although females presenting with severe pain (NRS >or=8) were more likely to receive analgesics (74% vs 64%, P = 0.02). Female physicians were more likely to administer analgesics than male physicians (66% vs 57%, P = 0.009). In logistic regression models, predictors of ED analgesic administration were male physician (odds ratio [OR] = 0.7), arrival pain (OR = 1.3), number of pain assessments (OR = 1.83), and charted follow-up plans (OR = 2.16). With regard to opioid administration, female physicians were more likely to prescribe opioids to females (P = 0.006) while male physicians were more likely to prescribe to males (P = 0.05). In logistic regression models, predictors of opioids administration included male patient gender (OR = 0.58), male patient-physician interaction (OR = 2.58), arrival pain score (OR = 1.28), average pain score (OR = 1.10), and number of pain assessments (OR = 1.5). Pain relief was not impacted by gender. CONCLUSION Provider gender as opposed to patient gender appears to influence pain management decisions in the ED.

Treating Headache Recurrence After Emergency Department Discharge: A Randomized Controlled Trial of Naproxen Versus Sumatriptan

STUDY OBJECTIVE Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given on discharge from an ED. The aim of this study is to compare the efficacy of oral sumatriptan with naproxen for treatment of post-ED recurrent primary headache. METHODS This was a randomized, double-blind efficacy trial. We randomized patients to either naproxen 500 mg or sumatriptan 100 mg for headache recurrence after ED discharge. Patients were eligible if they received parenteral therapy for an acute exacerbation of a primary headache in the ED. Patients who met established criteria for migraine without aura were designated a priori as a homogenous subgroup of interest. We followed all patients by telephone 48 hours after ED discharge. The primary endpoint was the between-group difference in change in pain intensity during the 2-hour period after ingestion of either 500 mg naproxen or 100 mg sumatriptan. This difference was measured on a validated 11-point (0 to 10) verbal numeric rating scale (NRS). Satisfaction with the medication and adverse effects were also assessed. Patients who met criteria for migraine without aura were analyzed twice according to a priori design: once as a homogenous subgroup and then again combined with all other primary headaches. RESULTS Of 410 patients randomized, 383 (93%) had outcome data available for analysis. Two hundred eighty (73%; 95% confidence interval [CI] 68% to 77%) reported headache post-ED discharge and 196 (51%; 95% CI 44% to 58%), including 88 with migraine, took the investigational medication provided to them. The naproxen group improved by a mean of 4.3 NRS points, whereas the sumatriptan group improved by 4.1 points (95% CI for difference of 0.2 points: -0.7 to 1.1 points). Findings were virtually identical among the migraine subset (4.3 versus 4.2 NRS points; 95% CI for difference of 0.1 points: -1.3 to 1.5 points). Seventy-one percent (95% CI 62% to 80%) of naproxen patients and 75% (95% CI 66% to 84%) of sumatriptan patients would want to take the same medication the next time. Adverse effect profiles were also comparable. CONCLUSION In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patients previous experience with the medication.

Physician Race/Ethnicity Predicts Successful Emergency Department Analgesia

UNLABELLED This study investigated the association between effectiveness of ED pain treatment and race of patients, race of providers, and the concordance of patient and provider race, with a prospective, multicenter study of patients presenting to 1 of 20 US and Canadian EDs with moderate to severe pain. Primary outcome is a 2-point or greater reduction in pain intensity, measured with an 11-point verbal scale, considered the minimum clinically important reduction in pain intensity. A total of 776 patients were enrolled. The sample included 57% female, 44% white, 26% black, and 26% Hispanic. The physician was white in 85% of encounters. Arrival pain score (adjusted odds ratio, 1.14; 95% CI 1.06, 1.24), receipt of any ED analgesia (1.59; 95% CI 1.17, 2.17), and physician nonwhite race (1.68; 95% CI 1.10, 2.55) were significant predictors of clinically significant reduction in pain intensity in multivariate analysis. Nonwhite physicians achieved better pain control without using more analgesics. Future research should explore the determinants of this difference in patient response to pain treatment related to provider race including provider characteristics and training that were not measured in this study. This study provided no evidence supporting an effect of racial concordance on the primary outcome. PERSPECTIVE This article presents analysis of predictors of clinically important reduction in pain intensity among emergency department patients, finding nonwhite physicians achieving better pain relief with less analgesia. This finding should encourage researchers to investigate elements of the therapeutic relationship that may be enhanced to achieve better pain relief for patients.

An unusual cause of knee pain discovered at a nurse practitioner clinic

PurposeTo describe an interesting and instructive case of knee pain from nurse practitioner (NP) practice and discuss the epidemiology, pathophysiology, clinical evaluation, and treatment of osteosarcoma. Data sourcesFindings from the history, physical examination, diagnostic testing, and follow-up of the case of an 18-year-old male who first presented with nontraumatic, diffuse left knee pain of 2.5-month duration. ConclusionsAt follow-up, after a trial of conservative treatment, a lesion suspicious for osteosarcoma was seen in the proximal tibia. Osteosarcoma is a rare but dangerous cause of chronic extremity pain, especially in children and adolescents. Implications for practiceNPs must consider malignant bone tumors in the differential diagnosis of traumatic and nontraumatic extremity pain of extended duration, especially in children and adolescents. Thorough, persistent follow-up on recommended tests and referrals is necessary to ensure that important findings are not missed. The care of uninsured patients requires particular attention to cost concerns and access issues.