Study sheds light on epidural denial

Epidural

E. Andrew Ochroch says his recent study shows African Americans are more likely than other patients to refuse epidural pain relief, even though the method leads to better post-surgical outcomes.

Between 1932 and 1972, nearly 400 African-American men suffering from syphilis were denied treatment.

On the order of the U.S. government.

The men were unwittingly enrolled in the Tuskegee Syphilis Study, a government-run study that aimed, in part, to better understand how the disease, over time, killed its victims. That’s why the men in the study weren’t even told of the existence of penicillin, which was introduced in 1947 and soon became the standard treatment for the disease.

The horrors of the study were revealed by the Washington Star in 1972 and soon led to the establishment of the National Research Act, which set tight new rules for medical studies.

But even today, says one Penn researcher, the mistrust fostered by the Tuskegee disaster might still linger. In a new study, Penn associate professor E. Andrew Ochroch has found that minority patients, especially African Americans, are less likely than others to allow doctors to administer epidural pain relief prior to surgery. Those decisions open up patients to the greater possibility of post-surgical pain and long-term complications, and Ochroch does not discount the possibility that the painful history of Tuskegee may be a significant factor in this alarming trend. Previous studies have shown that African Americans have a much higher awareness of the Tuskegee experiments than whites, and also are less willing to participate in medical trials.

“There is this idea, ‘You just can’t trust the white medical establishment [because of Tuskegee],’” says Ochroch, who serves as director of clinical research in the Department of Anesthesiology and Critical Care. “The question is, how far does that idea reverberate?”

For the study, Ochroch and his team developed a scripted interview to screen prospective surgery patients about what they knew about epidurals and what experiences they had with the technique previously. In total, data was collected from nearly 1,200 patients.

The team found that 64 percent of those surveyed said they would accept an epidural if it was recommended by an anesthesiologist. Thirty-six percent, meanwhile, said they would refuse. When the patients were asked if an additional recommendation from the surgeon would make them consent, acceptance rose to 78 percent. But when examining differences based on race, African American patients were less likely to say they would accept an epidural under any circumstances.

Socio-economic status also influenced consent—patients with full- or part-time jobs, for instance, were more likely to accept the epidural than those who were unemployed—but Ochroch said race was clearly a greater factor.

“We asked them two questions,” Ochroch says. “First, ‘If your anesthesiologist recommended an epidural, would you have it?,’ and then ‘If your surgeon recommended it, would you have it?’ For both questions, African Americans were far more likely to say no than white patients or non-African American patients.”

The problem is, Ochroch says, patients who turn down epidurals are literally putting their health at risk. Patients who receive epidurals during major abdominal or chest surgery generally experience better lung function afterward, which can help them ward off pneumonia. Other studies, meanwhile, have shown that patients who experience high levels of surgical pain are more likely to develop issues with chronic pain as well.

“When you have major upper abdominal or thoracic surgery, you need fairly profound pain relief to breathe and cough to help prevent pneumonia,” Ochroch says. “Those outcomes are clearly better with the epidural. When it comes to comfort level, patients also fare much better with epidurals. If you use the epidural, bowel function returns sooner, too, so they can eat sooner and be discharged sooner.”

With the release of this study, Penn doctors, surgeons and nurses are now stepping up efforts to better educate patients about the benefits of epidural use.

Ochroch hopes the effort can convince even skeptical patients to overcome their concerns, and in the process, help them to a faster, better recovery.

“We’ve tried to step beyond race and say that this is a major issue for all of our patients,” he says.

Originally published on March 6, 2008