Understanding Contributors to Racial/Ethnic Disparities in Emergency Department Throughput Times: a Sequential Mixed Methods Analysis

Abstract

BACKGROUND: Ensuring equitable care remains a critical issue for healthcare systems. Nationwide evidence highlights the persistence of healthcare disparities and the need for research-informed approaches for reducing them at the local level. OBJECTIVE: To characterize key contributors in racial/ ethnic disparities in emergency department (ED) throughput times. DESIGN: We conducted a sequential mixed methods analysis to understand variations in ED care throughput times for patients eventually admitted to an emergency department at a single academic medical center from November 2017 to May 2018 (n=3152). We detailed patient progression from ED arrival to decision to admit and compared racial/ethnic differences in time intervals from electronic medical record time-stamp data. We then estimated the relationships between race/ethnicity and ED throughput times, adjusting for several patient-level variables and ED-level covariates. These quantitative analyses informed our qualitative study design, which included observations and semi-structured interviews with patients and physicians. KEY RESULTS: Non-Hispanic Black as compared to non-Hispanic White patients waited significantly longer during the time interval from arrival to the physician's decision to admit, even after adjustment for several ED-level and patient demographic, clinical, and socioeconomic variables (Beta (average minutes) (SE): 16.35 (5.8); p val-ue=.005). Qualitative findings suggest that the manner in which providers communicate, advocate, and prioritize patients may contribute to such disparities. When the race/ethnicity of provider and patient differed, providers were more likely to interrupt patients, ignore their requests, and make less eye contact. Conversely, if the race/ethnicity of provider and patient were similar, providers exhibited a greater level of advocacy, such as tracking down patient labs or consultants. Physicians with no significant ED throughput disparities articulated objective criteria such as triage scores for prioritizing patients. CONCLUSIONS: Our findings suggest the importance of (1) understanding how our communication style and care may differ by race/ethnicity; and (2) taking advantage of structured processes designed to equalize care.

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

“…It is feasible that issues regarding racial bias and inequity not only impact ED treatment, but also inform a patient's decision to come to the ED seeking help for opioid withdrawal; Black patients in opioid withdrawal, fearing stigma, bias, and racism, may avoid the ED in seeking treatment for OUD. Additionally, intrinsic biases may result in ED clinicians spending less time with patients of minoritized racial and ethnic groups (Black patients) or being less likely to use standardized screening tools, limiting opportunities to recognize withdrawal during the patient‐provider interaction 51,52 . Finally, bias and stigma in the health care system may contribute to patient mistrust in the larger medical community and the medications used to treat OUD.…”

Disparities in access to specialty care and emergency department use after hospital discharge to a skilled nursing facility

“…19 Current literature indicates that many physicians, regardless of subspecialty, demonstrate a pro-White anti-Black implicit preference and that when race/ethnicity are concordant between providers and patients, physicians are more likely to consult specialists. 20,21 Further, primary care physicians-who serve as a key point of access for patients to the healthcare system-are less likely to refer non-Hispanic Black patients to specialists. 22 Our findings expand the existing literature that access to subspecialists may be protective.…”

“…Prevailing theories about why unequal care occurs include structural/institutional bias coupled with provider unconscious bias, clinical uncertainty, and stereotyping 19 . Current literature indicates that many physicians, regardless of subspecialty, demonstrate a pro‐White anti‐Black implicit preference and that when race/ethnicity are concordant between providers and patients, physicians are more likely to consult specialists 20,21 . Further, primary care physicians—who serve as a key point of access for patients to the healthcare system—are less likely to refer non‐Hispanic Black patients to specialists 22 …”

Designing and developing a digital equity dashboard for the emergency department

“…The annual National Healthcare Quality and Disparities Report shows that significant racial discrepancies in treatment still exist, with black patients receiving worse care than white patients for almost 40% of quality and safety measures in 2021 10 . National organizations continue to draw much needed attention to examining these inequities in health care delivery, 11,12 and health systems in response have begun stratifying their quality and performance measures 13 by demographic detail to identify existing disparities 14,15 …”

“…10 National organizations continue to draw much needed attention to examining these inequities in health care delivery, 11,12 and health systems in response have begun stratifying their quality and performance measures 13 by demographic detail to identify existing disparities. 14,15 Although EDs may track operational metrics such as wait time, length of stay, door-to-clinician time, and other aspects of care, the lack of more frequent monitoring and data transparency poses barriers to recognizing and confronting patterns of inequity. Currently, data are typically provided in a limited format tailored only to those involved in clinical and financial operations.…”