Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management

Objective: To quantify the extent to which a standardized pain management order set reduced racial and ethnic inequities in post-cesarean pain evaluation and management. Methods: We conducted a retrospective cohort study to quantify racial and ethnic differences in pain evaluation and management before (July 2014-June 2016) and after implementation of a standardized post-cesarean order set (March 2017-February 2018). Electronic medical records were queried for pain scores &gt;7/10, number of pain assessments, and opioid, nonsteroidal anti-inflammatory drug (NSAID), and acetaminophen doses. Outcomes were grouped into 0 to &lt;24 and 24-48&thinsp;h postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black [NHB], non-Hispanic White [NHW], Asian, and other), as documented in the electronic health record. Analyses included logistic regression for the categorical outcome of pain score &gt;7 (severe pain), and linear regression, with propensity score adjustment. Main effect and interaction terms were used to calculate the difference-in-difference in pain process and outcome measures between the baseline and follow-up periods. Results: After order set implementation (<em>N</em>=888), severe pain remained more common among NHB patients (% pain scores &gt;7 NHW vs. NHB 0 to &lt;24&thinsp;h: 22% vs. 33%, <em>p</em>=0.003; 24-48&thinsp;h: 26% vs. 40%, <em>p</em>&lt;0.001). Among all patients, pain management processes changed after implementation of the order set, with overall fewer assessments, less Opioids, and more nonopioid analgesics. However, racial and ethnic inequities in a number of assessments and in treatment were unchanged (all <em>p</em> for interaction &gt;0.05), with the exception of a modest increase in NSAID doses 24-48&thinsp;h postpartum for Hispanic patients. Conclusion: A standardized pain management order set reduced overall postpartum opioid use, but did not reduce racial and ethnic disparities in pain evaluation and management. Future work should investigate racial equity-focused education and interventions designed to eliminate disparities in pain management.