Quantitative Research Critique 1

Quantitative Research Critique

Andy Thorne

Western Connecticut State University

NUR-504 Research
March 1, 2023
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Introduction to Critique

The article that will be subject to qualitative review in this paper is entitled “Physician

self-identified race and opioid prescription practices in upper extremity injuries in the pediatric

emergency department” by Langham et al. This article was published in the Heliyon Journal,

which I am no familiar with but proports to consider any paper that is “reporting scientifically

accurate and valuable research, which adheres to accepted ethical and scientific publishing

standards”. Articles published in this journal are simultaneously published in another journal

called “ScienceDirect”. Articles from these journals are also indexed for search in PubMed.

The purpose of this review is to continue to research if there is a disparity in pain

medication administration between Black, Indigenous, and People of color and Non-hispanic

Whites.

Abstract

The abstract included in this study provided a summary of the paper overall. Included

was a background of the of the study, in this case stated that there has been evidence of minority

children receiving less opioid medication than their White counterparts. Given the sensitive

nature of a topic like this, I feel it would have been appropriate to include more information in

the background section of the abstract as a person that was reading only the asbstract may not be

able to gleam the importance of the study from the one sentence background statement.

The abstract also included the objective/purpose of the study, which in this case was not

worded as a hypothesis or a PICO question, instead expressing what they were attempting to

determine. The methods of research, results and conclusion were also included in the abstract.

This practice can save time for the person trying to get as much information about a study as
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possible in the least amount of time. With that said, however, the abstract (and the study overall)

seem to downplay the fact that while there is not a “statistically significant” difference in how

opioids are prescribed, there is still a marked difference. Another thing observed in this article is

the lack of definitions pertaining to the operational terms that were used to guide their search.

Introduction of Article

The introduction to this article begins by explaining the difficulties faced by those

attempting to control the pain of patients in the pediatric ED. It continues by explaining that the

disparity in the care received by patients depending on their race and how this can contribute to

poorer outcomes, stress, and lower life expectancy among other things.

The introduction also goes further in depth about the objective of the study, in this case to

determine if self-identified race makes a difference relative to the race of the patient and also the

race of the prescriber.

It is also important to note that the authors of this study chose to make it very specific to

the treatment of long bone fractures. This choice was not explained in the article, and it was also

noted that the authors were Pediatric doctors in the ED, not Orthopedic doctors.

Methodology

This study was conducted using a cross-sectional, retrospective review of electronic

medical records (EMR’s). In addition to this, surveys were provided to physicians to determine if

there was a difference in practice dependent on the race of the patient and the prescriber.

The methods section also describes the population that this study was conducted on,

including the locations. This study was conducted at 3 locations within the same hospital
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network, a Level 1 trauma center, a Level 2 trauma center, and a Community Hospital.

Participation of the patients was dependent on the participation of the physician that saw the

patient.

Data from the EMR was used to determine the race of the patient and to only include

patients from the age range of 2-15 who were presented to the ED from the years 2017 to 2020.

Using ICD-10 codes to find only those with specific fractures to be included in the study.

It is not known whether the study could have been conducted without the physician

essentially having the final say in what patients were included, but I do believe that the results

may have been influenced by this choice. With the physicians knowing the purpose of the study,

they could have exempted themselves from it for reasons unknown to the reader.

The determination of opioid prescription only included medications that were prescribed

to the patient after discharge, the study did not include medications that were prescribed during

the actual hospital visit. The reasons for this omission were also not explained.

The data and statistics were analyzed using bivariate analysis utilizing Wilcoxon rank-

sum test, with mean difference using the Chi-squared test of Fisher’s exact test. Only ratios with

confidence of 95% or higher were reported along with p-values with 0.05 being used to

determine statistical significance.

Validity

With an initial sample size of 9225 (later truncated down to 2754) patients and 94

providers, the study relied on the self-reporting of the providers race to determine the outcome of

the study. While impractical, the validity of the study may have been more sound if the
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consenting providers were interviewed in person after the online survey was conducted to ensure

that there were no errors or confusion involved when self-reporting race.

Regarding the sample size representing the broader population, this study did not specify

whether the sample size was inline with the population of the surrounding area.

Results

In this study it was found that there was no statistically significant difference in the

prescribing of opioids to Non-Hispanic Black (NHB) patients and Non-Hispanic White (NHW)

Patients. It was also found that there was no statistically significant difference in the prescribing

of opioids by Non-Hispanic Black providers and Non-Hispanic White providers. That being

stated, it was found that NHB patients are less likely to receive opioid than NHW patients, it was

also found the NHB providers are less likely to provide opioid to NHB patients than NHW

patients. Of note, the article states that most patients that received an opioid were seen by a

NHW provider, but it also states that most patients that did not receive an opioid were seen by a

NHW provider. Clarification of these seemingly contradictory statements would have provided

further insight into the claims that they were making.

The results portion of the article does present the data collection into numerous tables,

with all variables being accounted for.

Discussion

The discussion portion of the study reviews and reiterates the findings that were

presented in the results section of the article, with the authors discussing that there may appear to

be more of a disparity in subjective pain as opposed to objective pain when taking into

consideration other studies. It also brings up the fact that there is little in the way of research into
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the topic presented in this study regarding pediatric patients.

The discussion portion brings to light the fact that the institution where this study took

place does not have order sets (a general set of orders for the provider including labs,

medications, and treatments) at their disposal. They hypothesize that the inclusion of order sets

may help to mitigate some of the disparities found when treating patients of different

demographics for the same thing.

Limitations of the Study

There were several limitations addressed by the authors of this study. These included the

study only being conducted within one healthcare system, and due to that, the results may not be

able to be generalized to the overall population as a whole. There is the potential that

medications, diagnostic classification codes, and other information inputted into the EMR could

have contained errors. This could have been avoided by interviewing and collecting data at the

point of care, but this would have been extremely impractical and time consuming beyond the

capabilities of those conducting the study.

Another limitation is the fact that there was no tracking of medications that were given

during the actual hospital stay. The study does not, however, discuss the reason for this omission.

This study also does not discuss the reason for such a high level of specificity in regard to the

area of injury. The study does not define what is considered non-Hispanic Black and non-

Hispanic White. Furthermore, in reference to the survey provided to the physician, the survey did

not ask the respondent to specify their race. As one of the findings showed the NHB patients

were less likely to receive opioid medication from NHB providers, I believe that it would have

been beneficial to see what the ethnicity breakdown of those providers was. This is important
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data as face value implies that there is also an negative implicit bias among NHB providers when

prescribing to NHB patients.

Conclusion

In conclusion the authors stated that their ae disparities in the prescription of opioid pain

medication depending on the ethnicity and race of the patient. It was also found that NHB

patients with severe fractures had a lower chance of getting opioid pain medication from non-

White physicians.

I agree with the authors of this study when they state that it is important to do further

research into this topic to ensure that minorities get the appropriate care that they deserve.

Implications for Future Research and Future Direction

The results of this study are inline with others researching the topic of disparities. While

it was limited due to several factors, these do not appear to have influenced the study in a

significant way. The suggestion of having order sets for patients with common injuries is a good

idea in theory, as it should reduce the chances of differing treatment. But it should be noted that

the provider can choose to not utilize the order set provided. This would still lead to the same

result of disparity in care.

As with other studies, the primary recommendations should include education and

training, with emphasis on recognizing and “reprogramming” implicit biases when they are

noted to occur. Patient care should not have to suffer do to the bias and prejudices of those

providing the care.

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References

Langham, J., Holmes, S., Figueroa, J., Iyer, S., Lazarus, S., Gillespie, S., & Sulton, C. (2023).

Physician self-identified race and opioid prescription practices in upper extremity injuries

in the Pediatric Emergency Department. Heliyon, 9(2).

https://doi.org/10.1016/j.heliyon.2023.e13351