We have a problem
Myron Yaster MD, Lynne G. Maxwell MD, and Odinakachukwu Ehie MD FASA
When PONV was first recognized as a preventable and treatable anesthetic issue, it wasn’t clear if ondansetron plus minus dexamethasone should be used in ALL patients prophylactically or if it should be reserved for rescue. Was it safe? Was it cost effective? At a SPA meeting in which this issue was being discussed, Dr. Peter Davis of the Children’s Hospital of Pittsburgh and at the time the pediatric anesthesia editor for the journal Anesthesia and Analgesia discussed the “secret study”. Peter discussed a study in which one institution decided to randomly assign patients to either ondansetron or placebo to be given prophylactically, immediately after the induction of anesthesia. There was, however, a third group, namely the children of faculty members and house staff who were not randomized and were simply all given ondansetron. The study was stopped because if ondansetron was good enough for us it should be good enough for everyone. It was never completed or published which is why Peter called it the “secret study”. After his presentation, pretty much the entire world of pediatric anesthesia changed course and everyone was prophylactically treated with ondansetron (and dexamethasone). (Peter I hope I presented this story accurately!)
Ok, today’s editorial1 and paper2 involving adult patients reveals that as anesthesiologists we DON’T treat everyone the same….that Black patients received less antiemetic medication than their White counterparts. As my late and beloved mentor, Dr. Dick Traystman, would always ask: “How can this be?” “How can this continue?” The editorial by Sandberg and Davidson is a must read particularly for academic faculty. The editorial is an interesting review but equally importantly it gives insights into how editors of one of our most important journals think.
I’ve asked Dr. Odi Ehie of the University of California San Francisco, the Vice-Chair of SPA’s Diversity, Equity, and Inclusion committee to assist. Finally, after speaking to other members of the PAAD’s executive council, we’ve decided to add a member or two of the DEI committee to our writers group. More about this in a future PAAD. Myron Yaster MD
Editorial
Sandberg WS, Davidson A. "People, We Have a Problem". Anesthesiology. 2023 Jun 1;138(6):581-584. PMID: 37158650
Original article
White RS, Andreae MH, Lui B, Ma X, Tangel VE, Turnbull ZA, Jiang SY, Nachamie AS, Pryor KO; Multicenter Perioperative Outcomes Group Collaborators. Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study. Anesthesiology. 2023 Jun 1;138(6):587-601. PMID: 37158649
In a large retrospective cohort study from the Multicenter Perioperative Research Group (MPOG) database, White et al. 2 found that Black patients receive perioperative antiemetic administration at a lower rate than White patients. This provocative data cannot be ignored nor its shameful, shocking implications. Indeed, Sandberg and Davidson1 state that this paper is really a call to action. They also provide an explanation as to why it took so long to publish this paper, the results of which, although first presented at the 2019 Annual meeting of the ASA, several years elapsed between initial submission and ultimate acceptance and publication.
The data for this study came from the MPOG database which “had not been constructed to allow distinction between antiemetics administered for postoperative nausea and vomiting prophylaxis and those administered for rescue in the postanesthesia care unit.”1 Some of the patients in this study received ondansetron prophylactically and others for rescue, but this difference could not be determined from the database. “Does this matter? The authors argue not, and that both treatment and prophylaxis would be subject to the same bias. This seems like a plausible idea, and the authors further argue there is in fact no biologic reason to suggest this as a possibility. Any hypothesis that race has an impact on the pharmacology of the drugs we use or the biologic mechanisms underpinning any anesthesia outcome must be driven by what is known about the pharmacogenomics and physiology, and not seen simply as an excuse for disavowing social constructs of race.”1 To the editors and peer reviewers of the journal Anesthesiology, this was a major limitation which needed to be addressed by the authors. This process took a lot of time and effort. The thinking of the reviewers expressed in the editorial merits reading but is beyond what we can summarize in the PAAD. Nevertheless, we think it would be of great value to those of you who are in teaching institutions and/or who conduct clinical research. We think this paper, its editorial, and the implications of the findings would make a great journal club. (And as an aside, we’ve been mulling the idea of a monthly ZOOM SPA journal club and if we decide to proceed we’ll post more information about it in the future.)
Why is this paper so important, as we are talking about PONV and not a life and death treatment? Sandberg and Davidson point out that if “there is no biologic basis for the observed difference in antiemetic treatment (and we have no evidence to assume there is), we should be concerned that discrimination pervades all our activities, including both vigilance and treatment.”1
Are pediatric anesthesiologists different? We wish we could say “YES” but the data, primarily from Dr. Olubukola (“Bukky”) Nafiu, suggests otherwise.3-5 Finally, today’s article by White et al. looked at discrimination based on Black v White. Other social determinants like socioeconomic status, educational attainment, insurance status, wealth or income, unconscious bias, or its interaction with race may be confounders. And what about other minoritized groups, like the Latinx or AAPI community? What about patients with non-English language preferences?
There is much we do not know, but this truly is a wake-up call. Please send your thoughts to Myron who will post in a Friday Reader Response.
References
1. Sandberg WS, Davidson A. "People, We Have a Problem". Anesthesiology. Jun 1 2023;138(6):581-584. doi:10.1097/aln.0000000000004566
2. White RS, Andreae MH, Lui B, et al. Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study. Anesthesiology. Jun 1 2023;138(6):587-601. doi:10.1097/aln.0000000000004549
3. Willer BL, Mpody C, Tobias JD, Nafiu OO. Racial Disparities in Failure to Rescue Following Unplanned Reoperation in Pediatric Surgery. Anesthesia and analgesia. Mar 1 2021;132(3):679-685. doi:10.1213/ane.0000000000005329
4. Sivak E, Mpody C, Willer BL, Tobias J, Nafiu OO. Race and major pulmonary complications following inpatient pediatric otolaryngology surgery. Paediatric anaesthesia. Apr 2021;31(4):444-451. doi:10.1111/pan.14142
5. Mpody C, Willer B, Owusu-Bediako E, Kemper AR, Tobias JD, Nafiu OO. Economic Trends of Racial Disparities in Pediatric Postappendectomy Complications. Pediatrics. Oct 2021;148(4)doi:10.1542/peds.2021-051328