Emergency Medicine

Do racial disparities exist at various time points during an emergency department visit for chest pain

a b s t r a c t

Introduction: It is well documented that disparities in patient care based on race and ethnicity are prevalent in the Emergency medical care setting. In most cases these evaluations are patient focused and outcome based. The timeliness of patient treatment in the emergency department (ED) is correlated with patient outcomes. In this study, we sought to evaluate whether the timeliness of care for patients with chest pain across stages of care was impacted by Patient race.

Methods: This was a retrospective evaluation of ED throughput times including adults who presented to one of seventeen EDs in a large healthcare system from January 1, 2019 to December 31, 2019 and met criteria for in- clusion. The effect of race on different intervals of care were assessed. Generalized linear models were used to estimate the effect of race on different intervals of care while controlling for Charlson Comorbidity Index, age, gender, insurance, ED facility type and emergency severity index Acuity level.

Results: A total of 28,705 patients were included, with a mean age of 54 +- 18 years. The majority of patients were White (63%), female (56%) and had Medicare or Medicaid (56%). black patients experienced significantly in- creasED wait times for resident physician examination, advanced practice provider examination, attending phy- sician examination, and ED disposition. There was no difference in time to triage between Black patients and white patients.

Conclusion: Black patients have longer wait times for resident physician evaluation, advanced practice provider evaluation, attending physician evaluation, and ED disposition when presenting to the ED with chest pain.

(C) 2022

patients for minor to moderate severity encounters [3]. Finally, a study by Mahmoudi et al. found evidence that being a minority and lack of in- surance were associated with a longer ED wait time [4].

Racial bias is well documented throughout America’s healthcare sys- tem. It is both a risk factor for disease and a contributor to racial dispar- ities in health [1]. Emergency medical care is no exception. Within the Emergency Department (ED), being Black or African American has been associated with longer wait times from triage assessment to a treatment area [1]. It has also been reported that Black patients and His- panic patients have significantly longer wait times for care in the ED. [2] Additional studies further support that Racial disparity in ED wait times between Black and non-Black patients exists, with evidence showing that Black patients had a significantly longer wait time than White

* Corresponding author at: 1 Akron General Ave., Akron, OH 44307, USA.

E-mail address: [email protected] (E.L. Simon).

    1. Importance

Patients should receive the same level of care when presenting to the ED for treatment regardless of race. We investigated if disparities exist for Black patients in regard to ED throughput by evaluating the time to various points of care when patients present with chest pain.

    1. Goals of This investigation

We hypothesized that Black patients have longer ED throughput time points when presenting for chest pain. Increased ED wait times have been associated with greater risk for short term death and admission to the hospital in patients well enough to leave the ED. [5] Many studies have examined the correlation between race and wait

https://doi.org/10.1016/j.ajem.2022.04.029

0735-6757/(C) 2022

times; however, to our knowledge no study has further examined ED throughpoint time points that may be a source for potential disparities.

  1. Methods
    1. Study design and setting

This was a retrospective chart review of patients age 18 and older presenting to one of seventeen EDs in a large integrated healthcare sys- tem. The healthcare system has 6 freestanding and 11 hospital-based EDs and includes rural, community and urban settings The study was approved by the healthcare system’s Institutional Research Review Board (IRB).

    1. Selection of participants

Patients 18 years of age and older that presented with chest pain between January 1, 2019 and December 31, 2019 met initial criteria for inclusion. Patients without a documented ED disposition or those who eloped, left before treatment complete, had a Trauma activation, or left against medical advice were excluded. We also excluded patients who had wait times of >24 h or ED Disposition times of >24 h because based on daily internal tracking data from our facilities, our ED’s typi- cally do not have times that exceed those. Patients with missing race, ethnicity, Emergency Severity Index acuity level, or ED throughput time points were also excluded. Patients with a chief complaint of chest pain were chosen because these patients require rapid evaluation at triage to determine if there is a potentially life-threatening etiology. Additionally, chest pain is an important topic in emergency medicine as it is one of the most common chief complaints and has potential for significant morbidity and mortality.

    1. Measurements

Data was abstracted from the electronic medical record via auto- mated data abstraction and included demographics (age, race, ethnicity, gender, past medical history to calculate Charlson Comorbidity Index, and insurance coverage) and encounter details (chief complaint, ESI score, disposition, ED facility). ED facility was defined as either free- standing or hospital-based. ED throughput time points abstracted in- cluded time to triage (time from patient registration when they arrive in the ED to when they are seen in triage by a triage nurse), advanced practice provider evaluation, resident physician evaluation, ED attend- ing evaluation, and ED disposition. All provider timepoints were defined as time from patient arrival/registration in the ED to first contact with the provider level.

    1. Outcomes

The primary objective was to evaluate throughput time points dur- ing the ED encounter in patients presenting with chest pain and to de- termine if differences exist between patients when stratified by race.

    1. Analysis

Race was categorized as White, Black, and Other. “Other” included subjects who self-reported a race other than Black or White. Categorical variables are described using frequencies and percentages. Continuous variables are described using mean and standard deviations or median and interquartile range depending on their distribution. Generalized Linear Models were used to estimate the effect of race on different intervals of care while controlling for Charlson Comorbidity index, age, gender, insurance, ED facility type and ESI score. A significance level of

0.05 was assumed for all tests. Analyses were performed using SAS(R)

Software (version 9.4; Cary, NC).

  1. Results

In total, 28,705 patients met inclusion criteria for this study. Table 1 shows demographics and other characteristics of all study participants. The mean age was 53.57, SD 18.03. Majority were White (63%), Female (56%), had Medicare or Medicaid (56%) and were seen at a hospital- based ED (88.5%).

Table 2 shows demographic characteristics for patients based on race. White patients tended to be female, non-Hispanic, had private in- surance and an acuity level of 3 or 4. Black patients tended to be female, non-Hispanic, had Medicare or Medicaid and had an acuity level of 3 or

  1. Charlson Comorbidity index did not differ significantly between White and Black patients. Table 3 shows median ED Throughput times stratified by race.

The average wait times at each interval of care between Whites and Blacks were significantly different except for time to triage when con- trolling for Charlson Comorbidity index, age, gender, insurance, ED facil- ity type and ESI acuity level (Table 4). Blacks had longer wait times than whites with the exception of time to triage (Table 4). On the other hand, there were no significant differences between White and other race on all the time intervals except for time to resident physician evaluation where Other race had longer wait times than White (Table 4). Supple- mentary tables 1-5 address estimates for time to triage, resident physi- cian evaluation, attending physician evaluation, APP evaluation and ED disposition.

4. Discussion

Patients may experience bias, whether implicit or explicit, while in the ED. In one study time pressures were shown to negatively affect di- agnoses and likelihood of referral to a specialists for Black and Hispanic patients who present to a provider with chest pain [6]. Additionally, implicit bias may uphold negative stereotypes of Black patients and affect physician decision making when deciding to provide thromboly- sis for myocardial infarction [7]. Inequities such as these must be iden- tified to address the challenges minorities may face when receiving healthcare that should be equitable for all.

Our study showed that Black patients presenting to the ED for chest pain waited longer to be to be evaluated by a resident physician,

Table 1

Demographics and Baseline Characteristics, n = 28,705.

Variable

Frequency or Mean

Percent or SD

Age

53.57

18.02

Gender

Female

16,006

55.76

Male

12,699

44.24

Race

White

17,954

62.55

Black

9084

31.65

Other

1667

5.81

Ethnicity

Hispanic

1593

5.64

Non-Hispanic

26,666

94.36

Insurance

Medicare/Medicaid

16,199

56.43

Private

12,196

42.49

Other

310

1.08

ED visit in 30 days?

No

23,707

82.59

Yes

ESI

4998

17.41

Level 1 and 2

12,842

44.74

Level 3

15,776

54.96

Level 4

87

0.30

Charlson Comorbidity Index

3.01

3.58

hospital type

Free Standing

3354

11.48

Hospital Based

25,857

88.52

Table 2

Demographics and other Characteristics by Race, n = 28,705.

Variable

White (n = 17,954)

Black (n = 9084)

Other (n = 1667)

p-value

Age

57(42-69)

51(37-63)

49(35-63)

<0.0001

Gender

Female

9446(52.61)

5602(61.67)

958(57.47)

<0.0001

Male

8508(47.39)

3482(38.33)

709(42.53)

Ethnicity

Hispanic

956(5.39)

42(0.47)

595 (39.25)

<0.0001

Non-Hispanic Insurance

Medicare/Medicaid

16,778 (94.61)

8803 (49.03)

8967 (99.53)

6368 (70.10)

921(60.75)

1028(61.67)

<0.0001

Other

225(1.25)

70(0.77)

15(0.90)

Private

ED visit in 30 days?

8926 (49.72)

2646 (29.13)

624(37.43)

No

15,268(85.04)

7062 (77.74)

1377(82.60)

<0.0001

Yes

ESI level Level 1 and 2

2686 (14.96)

8795 (48.99)

2022(22.26)

3182 (35.03)

290(17.40)

865(51.89)

<0.0001

Level 3 and 4

Charlson Comorbidity Index

9159 (51.01)

2(0-4)

5902 (64.97)

2(0-4)

802(48.11)

1(0-4)

<0.0001

Hospital Type

Free Standing

2748(15.31)

414(4.56)

158(9.48)

<0.0001

Hospital Based

15,206(84.69)

8670 (95.44)

1509(90.52)

Statistics presented as median (Interquartile Range) or n (%).

Table 3

Time metrics by race, n = 28,705.

Variable

White

Black

Other

p-value

Time to Triage

3 (1-7)

3 (1-7)

3 (1-7)

0.0788

Time to room

3 (0-11)

3 (0-13)

3 (0-12)

<0.0001

Time to Resident

19 (9-72)

21 (9-72)

25 (11-99)

0.3433

Time to First Provider

8 (4-17)

10 (4-22)

8 (3-18)

<0.0001

Time to Physician

257

278

244

0.5338

Time to APP

(158-400)

9 (4-21)

(144-432)

11 (4-30)

(150-406)

9 (3-22)

<0.0001

Time to First Attending

17 (6-50)

26 (8-72)

16 (6-52)

<0.0001

Time to Inpatient

361

396

348

0.0015

Admission

(255-633)

(283-609)

(245-714)

Time to ED Disposition

174

194

175

<0.0001

(128-238)

(139-269)

(130-231)

Time to ED Departure

228

243

221

<0.0001

(171-303)

(179-336)

(167-290)

Statistics presented as median (Interquartile Range).

attending physician or APP and to be dispositioned from the ED even after controlling for potential confounders. White patients were assigned high acuity level (ESI level 1 or 2) 49% of the time, while Black patient were assigned the same acuity level 35% of the time. In patients with a high acuity level, providers are more likely to see the patient promptly. Patients with low acuity level tend to be seen after pa- tients with high acuity levels, which could lead to increased time to evaluation for Black patients given low acuity levels.. Prior research has also demonstrated that Black patients are assigned higher ESI scores (low acuity level) when compared to Whites [8,9]. While the cause of this difference was not the focus of this study, one prior study revealed

that for patients who presented with chest pain, African Americans, Medicaid patients and uninsured were less likely to be triaged with higher acuity levels [8]. Another study found patients had lower acuity and longer ED wait times after adjusting for age, gender, insurance sta- tus, time of day, day of week, presence of co-morbidities, and Abnormal vital signs [9].

This study reveals differences in throughput time points during an ED visit for chest pain based on race, however, future study of potential confounders and why these inequities may exist is warranted. This study was limited by its retrospective design and that it examined only one chief complaint at one large integrated healthcare system. Our findings may not be generalizable to other Presenting complaints or other healthcare systems.

In conclusion, Black patients were found to have longer wait times at various throughput time points except for initial triage evaluation when presenting to the ED with chest pain. Investigating further whether these disparities lead to increased morbidity and mortality for Black pa- tients is warranted. Healthcare systems should continually strive to pro- vide equitable care for all patients by analyzing practices and effectively addressing disparities where they exist.

Prior presentations

Society for Academic Emergency Medicine 2021 Virtual Meeting.

Funding sources/disclosures

None.

Table 4 Difference in the average wait times at each interval of care between races (White, Black, and Other) after controlling for Charlson Comorbidity index, ESI Level, Gender, Insurance, age and hospital type.

Outcome

Black vs. white

Other vs. White

Estimated Difference

95% CI

Estimated Difference

95% CI

Time to Triage

0.06

-0.13 to 0.25

-0.14

-0.49 to 0.22

Time to Resident

-16.49

-26.17 to -6.82

31.13

4.85 to 57.40

Time to APP

20.11

12.67 to 27.56

-1.85

-15.68 to 11.98

Time to First Attending

3.73

1.88 to 5.58

-3.34

-6.87 to 0.19

Time to ED Disposition

28.21

23.93 to 32.49

-4.31

-12.40 to 3.78

CI = Confidence Interval.

Author contribution statement

CA conceived and designed the study. ELS, KC, and JK contributed to data collection. CM provided statistical advice on study design, analyzed the data. CA, ELS, and TS, drafted the manuscript, and all authors con- tributed substantially to its revision. CA takes responsibility for the paper as a whole.

CRediT authorship contribution statement

Carl Allamby: Writing – review & editing, Writing – original draft, Visualization, Resources, Methodology, Conceptualization. Thomas Scott: Writing – review & editing, Writing – original draft, Methodology. Jessica Krizo: Supervision, Resources, Formal analysis, Data curation. Kathrina Consing: Data curation. Caroline Mangira: Formal analysis, Data curation. Erin L. Simon: Writing – review & editing, Supervision, Methodology, Data curation.

Declaration of Competing Interest

None.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2022.04.029.

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