A Quality Framework to Address Racial and Ethnic Disparities in Emergency Department Care

Khidir, Hazar; Salhi, Rama A.; Sabbatini, Amber K.; Franks, Nicole; Green, Andrea; Richardson, Lynne D.; Terry, Aisha; Vasquez, Nicholas; Goyal, Pawan; Kocher, Keith E.; Venkatesh, Arjun K.; Lin, Michelle

doi:10.1016/j.annemergmed.2022.08.010

Cited by 17 publications

(13 citation statements)

References 31 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…randomized to the EHR clinical decision pathway were more likely to receive buprenorphine than in control sites, a promising finding as we search for strategies to address health inequities, 39 additionally, establishing quality measures that stratify outcomes by race and ethnicity and forming partnerships with trusted communitybased organizations to reach Black patients who may avoid the ED due to stigma and bias and are evidence-based practices that may increase fidelity and reduce bias. 53 Finally, contrary to prior literature, Hispanic patients in our study received ED buprenorphine at higher rates than both patients who did not identify as Hispanic in the primary analysis and than compared to non-Hispanic White patients in the sensitivity analysis. 54 Results may be due, in part, to the differences in race and ethnicity as dimensions of social identity that are subject to different modes of discrimination, with race typically referring to the physical differences and ethnicity refers to shared values, including language, cultural practices, and beliefs.…”

Section: F I G U R Econtrasting

confidence: 74%

“…Instituting EHR‐based care pathways to standardize buprenorphine administration may help to promote practice consistency. In the EMBED trial subgroup analyses, Black patients in study sites randomized to the EHR clinical decision pathway were more likely to receive buprenorphine than in control sites, a promising finding as we search for strategies to address health inequities, 39 additionally, establishing quality measures that stratify outcomes by race and ethnicity and forming partnerships with trusted community‐based organizations to reach Black patients who may avoid the ED due to stigma and bias and are evidence‐based practices that may increase fidelity and reduce bias 53 …”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Racial and ethnic disparities in emergency department–initiated buprenorphine across five health care systems

Holland

Li²,

Nath

et al. 2023

Academic Emergency Medicine

Self Cite

View full text Add to dashboard Cite

Background Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood. Methods This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity. Results Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45–0.78). This association persisted after adjusting for age, insurance, gender, clinician X‐waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48–0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56–1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non‐Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09–1.83) and adjusted models (aOR 1.41, 95% CI 1.08–1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99–1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64). Conclusions Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non‐Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.

show abstract

Section: F I G U R Econtrasting

confidence: 74%

Section: Discussionmentioning

confidence: 99%

Racial and ethnic disparities in emergency department–initiated buprenorphine across five health care systems

Holland

Li²,

Nath

et al. 2023

Academic Emergency Medicine

Self Cite

View full text Add to dashboard Cite

show abstract

“…Conceptual frameworks currently exist that outline how to evaluate racial and ethnic health equity as a quality metric . Programs focused on ED pediatric readiness are ideally positioned to adopt such a framework because ED pediatric readiness consists of well-defined, largely modifiable factors .…”

Section: Discussionmentioning

confidence: 99%

Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity

Jenkins,

Lin,

Ames

et al. 2023

JAMA Netw Open

View full text Add to dashboard Cite

ImportancePresentation to emergency departments (EDs) with high levels of pediatric readiness is associated with improved pediatric survival. However, it is unclear whether children of all races and ethnicities benefit equitably from increased levels of such readiness.ObjectiveTo evaluate the association of ED pediatric readiness with in-hospital mortality among children of different races and ethnicities with traumatic injuries or acute medical emergencies.Design, Setting, and ParticipantsThis cohort study of children requiring emergency care in 586 EDs across 11 states was conducted from January 1, 2012, through December 31, 2017. Eligible participants included children younger than 18 years who were hospitalized for an acute medical emergency or traumatic injury. Data analysis was conducted between November 2022 and April 2023.ExposureHospitalization for acute medical emergency or traumatic injury.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality. ED pediatric readiness was measured through the weighted Pediatric Readiness Score (wPRS) from the 2013 National Pediatric Readiness Project assessment and categorized by quartile. Multivariable, hierarchical, mixed-effects logistic regression was used to evaluate the association of race and ethnicity with in-hospital mortality.ResultsThe cohort included 633 536 children (median [IQR] age 4 [0-12] years]). There were 557 537 children (98 504 Black [17.7%], 167 838 Hispanic [30.1%], 311 157 White [55.8%], and 147 876 children of other races or ethnicities [26.5%]) who were hospitalized for acute medical emergencies, of whom 5158 (0.9%) died; 75 999 children (12 727 Black [16.7%], 21 604 Hispanic [28.4%], 44 203 White [58.2%]; and 21 609 of other races and ethnicities [27.7%]) were hospitalized for traumatic injuries, of whom 1339 (1.8%) died. Adjusted mortality of Black children with acute medical emergencies was significantly greater than that of Hispanic children, White children, and of children of other races and ethnicities (odds ratio [OR], 1.69; 95% CI, 1.59-1.79) across all quartile levels of ED pediatric readiness; but there were no racial or ethnic disparities in mortality when comparing Black children with traumatic injuries with Hispanic children, White children, and children of other races and ethnicities with traumatic injuries (OR 1.01; 95% CI, 0.89-1.15). When compared with hospitals in the lowest quartile of ED pediatric readiness, children who were treated at hospitals in the highest quartile had significantly lower mortality in both the acute medical emergency cohort (OR 0.24; 95% CI, 0.16-0.36) and traumatic injury cohort (OR, 0.39; 95% CI, 0.25-0.61). The greatest survival advantage associated with high pediatric readiness was experienced for Black children in the acute medical emergency cohort.Conclusions and RelevanceIn this study, racial and ethnic disparities in mortality existed among children treated for acute medical emergencies but not traumatic injuries. Increased ED pediatric readiness was associated with reduced disparities; it was estimated that increasing the ED pediatric readiness levels of hospitals in the 3 lowest quartiles would result in an estimated 3-fold reduction in disparity for pediatric mortality. However, increased pediatric readiness did not eliminate disparities, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care.

show abstract

“…Similar priority queues are commonly used in other industries like call centers or grocery stores with increased waits associated with caller abandonment or reduced grocery purchases just as increased waits in the ED are associated with higher LWBS . However, to improve the quality and equity of emergency care delivery, we need to explore the degree to which queue prioritization or queue adherence may be associated with known disparities and whether these queue jumps are associated with waiting and common ED outcomes …”

Section: Introductionmentioning

confidence: 99%

“…[18][19][20][21] However, to improve the quality and equity of emergency care delivery, we need to explore the degree to which queue prioritization or queue adherence may be associated with known disparities and whether these queue jumps are associated with waiting and common ED outcomes. 22 We examined ED triage equity by characterizing the prevalence of queue jumps, care delays caused by queue jumps, and which patients receive earlier care despite being of lower acuity or arriving later. We specifically explored the association of patient social factors with queue jumping and outcomes including patient LWBS, hallway placement, 72-hour ED revisits, and escalation in care.…”

Section: Introductionmentioning

confidence: 99%

Sociodemographic Disparities in Queue Jumping for Emergency Department Care

Sangal

Khidir

et al. 2023

JAMA Netw Open

Self Cite

View full text Add to dashboard Cite

ImportanceEmergency department (ED) triage models are intended to queue patients for treatment. In the absence of higher acuity, patients of the same acuity should room in order of arrival.ObjectiveTo characterize disparities in ED care access as unexplained queue jumps (UQJ), or instances in which acuity and first come, first served principles are violated.Design, Setting, and ParticipantsRetrospective, cross-sectional study between July 2017 and February 2020. Participants were all ED patient arrivals at 2 EDs within a large Northeast health system. Data were analyzed from July to September 2022.ExposureUQJ was defined as a patient being placed in a treatment space ahead of a patient of higher acuity or of a same acuity patient who arrived earlier.Main Outcomes and MeasuresPrimary outcomes were odds of a UQJ and association with ED outcomes of hallway placement, leaving before treatment complete, escalation to higher level of care while awaiting inpatient bed placement, and 72-hour ED revisitation. Secondary analysis examined UQJs among high acuity ED arrivals. Regression models (zero-inflated Poisson and logistic regression) adjusted for patient demographics and ED operational variables at time of triage.ResultsOf 314 763 included study visits, 170 391 (54.1%) were female, the mean (SD) age was 50.46 (20.5) years, 132 813 (42.2%) patients were non-Hispanic White, 106 401 (33.8%) were non-Hispanic Black, and 66 465 (21.1%) were Hispanic or Latino. Overall, 90 698 (28.8%) patients experienced a queue jump, and 78 127 (24.8%) and 44 551 (14.2%) patients were passed over by a patient of the same acuity or lower acuity, respectively. A total of 52 959 (16.8%) and 23 897 (7.6%) patients received care ahead of a patient of the same acuity or higher acuity, respectively. Patient demographics including Medicaid insurance (incident rate ratio [IRR], 1.11; 95% CI, 1.07-1.14), Black non-Hispanic race (IRR, 1.05; 95% CI, 1.03-1.07), Hispanic or Latino ethnicity (IRR, 1.05; 95% CI, 1.02-1.08), and Spanish as primary language (IRR, 1.06; 95% CI, 1.02-1.10) were independent social factors associated with being passed over. The odds of a patient receiving care ahead of others were lower for ED visits by Medicare insured (odds ratio [OR], 0.92; 95% CI, 0.88-0.96), Medicaid insured (OR, 0.81; 95% CI, 0.77-0.85), Black non-Hispanic (OR, 0.94; 95% CI, 0.91-0.97), and Hispanic or Latino ethnicity (OR, 0.87; 95% CI, 0.83-0.91). Patients who were passed over by someone of the same triage severity level had higher odds of hallway bed placement (OR, 1.01; 95% CI, 1.00-1.02) and leaving before disposition (OR, 1.02; 95% CI, 1.01-1.04).Conclusions and RelevanceIn this cross-sectional study of ED patients in triage, there were consistent disparities among marginalized populations being more likely to experience a UQJ, hallway placement, and leaving without receiving treatment despite being assigned the same triage acuity as others. EDs should seek to standardize triage processes to mitigate conscious and unconscious biases that may be associated with timely access to emergency care.

show abstract

A Quality Framework to Address Racial and Ethnic Disparities in Emergency Department Care

Cited by 17 publications

References 31 publications

Racial and ethnic disparities in emergency department–initiated buprenorphine across five health care systems

Racial and ethnic disparities in emergency department–initiated buprenorphine across five health care systems

Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity

Sociodemographic Disparities in Queue Jumping for Emergency Department Care

Contact Info

Product

Resources

About