Patient sex, racial and ethnic disparities in emergency department triage: A multi-site retrospective study

Trauma, Gender, and End-Of-Life Care: A Propensity-Matched Cohort Study Analyzing Disparities in Withdrawal of Life Support

INTRODUCTION

Men are known to have more severe injuries at younger ages compared to women. However, the relationship between gender and other sociodemographic factors in the context of end-of-life care after traumatic injuries is not well understood.

METHODS

This retrospective observational cohort study utilized data from the American College of Surgeons Trauma Quality Programs in 2022 and included all patients who were 18 y or older while those with missing information on withdrawal of life-sustaining treatment (WLST) were excluded. Descriptive analysis and multiple logistic regression, following propensity score nearest neighbor matching, were performed to determine the association between WLST and gender after traumatic injury.

RESULTS

Among the 843,135 patients who met the inclusion criteria, 43.6% were female. Compared to females, males were younger. A higher proportion of females had Medicare than males (56.7% versus 31.1%). In contrast, other insurance such as private, Medicaid, self-pay, and others were comparatively more frequently utilized by males. Among injury characteristics, assault was more common among males compared to females (11.0% versus 3.0%). Not surprisingly, initial Glasgow Coma Scale and injury severity were comparatively severe among males. WLST was reported in 2.5% of males and 1.9% of females. After propensity score matching, compared to males of age 18-35 y, males of increasing age had higher odds of WLST. Similar trends were seen among females of increasing age compared to males aged 18-35 y. However, the magnitude of the estimates was higher among males. Of note, compared to private insurance, those with Medicare were likelier to have WLST.

CONCLUSIONS

One in every two patients who died after traumatic injury had WLST, whereas males have an increased likelihood of WLST despite matching and adjusting for injury site and severity. These findings suggest a need for policies addressing demographic and insurance-related disparities to ensure equitable end-of-life care across diverse patient populations.

Variation in Emergency Department Physician Admitting Practices and Subsequent Mortality

Importance

An emergency department (ED) physician's decision to admit a patient to the hospital plays a pivotal role in determining the type and intensity of care that patient will receive. ED physicians vary widely in their propensity to admit patients to the hospital, but it is unknown whether higher admission propensities result in lower subsequent mortality rates.

Objective

To measure the variation in ED physicians' admission propensities and estimate their association with patients' subsequent mortality rates.

Design, Setting, and Participants

This cross-sectional study used nationwide Veterans Affairs electronic health record data from January 2011 to December 2019, comparing physicians practicing within the same ED. The study population was composed of patients visiting the ED with 1 of the 3 most frequent chief complaints in US EDs (chest pain, shortness of breath, and abdominal pain). The data analyses were performed from May 2022 to October 2024.

Main Outcomes and Measures

The main outcomes were variation in physicians' adjusted admission rates, short inpatient stays (<24 hours), and 30-day mortality.

Results

The study population included 2098 physicians seeing 2 137 681 patient visits across 105 EDs. The mean (SD) patient age was 63 (15) years, and 9.8% of patients were female. The mean admission rate was 41.2%, and the mean 30-day mortality rate was 2.5%. Physicians' adjusted admission rates varied greatly within the same ED (eg, for chest pain: 90th percentile of physicians, 56.6% admitted vs 10th percentile, 32.6% admitted; difference, 24.0 percentage points), despite finding no association between these adjusted admission rates and patients' prior health status as measured by their Elixhauser Comorbidity Index score before the ED visit. However, patients admitted by physicians with higher admission rates were more likely to be discharged within 24 hours (eg, 31.0% vs 24.8%, respectively), while patients of physicians with higher admission rates had subsequent mortality rates that were no less than those of patients of physicians with lower admission rates.

Conclusions and Relevance

This cross-sectional study demonstrated that ED physicians vary widely in their admission propensity, despite seeing patients with similar prior health status. The results suggest that patients treated by physicians with higher admission propensities are more likely to be discharged after only a short inpatient stay and experience no reduction in subsequent mortality rates.

Association between socioeconomic status and nonurgent presentations to pediatric emergency departments: a retrospective study

BACKGROUND AND IMPORTANCE

Access to healthcare remains a persistent challenge. Socially disadvantaged populations often encounter barriers to care and may frequently seek out emergency departments (EDs), including for nonurgent medical care.

OBJECTIVE

The objective of this study is to study the association between nonurgent presentations to pediatric EDs and patients' socioeconomic environment in an urban setting.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study of all visits to a pediatric ED in eight participating centers of the Paris metropolitan area (France) between 1 January 2017 and 31 December 2021 was carried out. Routinely collected data were analyzed.

EXPOSURE

Socioeconomic status was evaluated using ecological variables defined at the municipality level. These variables were collected from public sources and included a social deprivation index, the accessibility to general practitioners, the proportion of single-parent families, and the proportion of immigrants.

OUTCOME MEASURE AND ANALYSIS

The primary endpoint was a nonurgent ED presentation, defined as being assigned one of the two lowest triage categories on a five-point scale. A multilevel logistic model assessed the association between nonurgent ED presentations and patients' characteristics, socioeconomic environment, and healthcare accessibility.

MAIN RESULTS

Nonurgent visits accounted for 51.6% of the 1 499 108 visits during the study period. The admission rate was 2.1% for nonurgent presentations and 18.8% for urgent presentations. In the final multivariate model (n = 1 412 895 visits), after adjustment for sex, age, time of day, day of the week, month, and year, the risk of nonurgent presentation was significantly higher for children living in less advantaged areas and in areas where the rate of single-parent families was high. It was also higher for children living close to the ED.

CONCLUSION

This extensive retrospective multicenter study emphasizes the increased risk of visiting EDs for nonurgent medical care among children from disadvantaged urban areas.

Identifying Patient Subpopulations with Significant Race-Sex Differences in Emergency Department Disposition Decisions

Background/objectives

The race-sex differences in emergency department (ED) disposition decisions have been reported widely. Our objective is to identify demographic and clinical subgroups for which this difference is most pronounced, which will facilitate future targeted research on potential disparities and interventions.

Methods

We performed a retrospective analysis of 93 987 White and African-American adults assigned an Emergency Severity Index of 3 at 3 large EDs from January 2019 to February 2020. Using random forests, we identified the Elixhauser comorbidity score, age, and insurance status as important variables to divide data into subpopulations. Logistic regression models were then fitted to test race-sex differences within each subpopulation while controlling for other patient characteristics and ED conditions.

Results

In each subpopulation, African-American women were less likely to be admitted than White men with odds ratios as low as 0.304 (95% confidence interval (CI): [0.229, 0.404]). African-American men had smaller admission odds compared to White men in subpopulations of 41+ years of age or with very low/high Elixhauser scores, odds ratios being as low as 0.652 (CI: [0.590, 0.747]). White women were less likely to be admitted than White men in subpopulations of 18 to 40 or 41 to 64 years of age, with low Elixhauser scores, or with Self-Pay or Medicaid insurance status with odds ratios as low as 0.574 (CI: [0.421, 0.784]).

Conclusions

While differences in likelihood of admission were lessened by younger age for African-American men, and by older age, higher Elixhauser score, and Medicare or Commercial insurance for White women, they persisted in all subgroups for African-American women. In general, patients of age 64 years or younger, with low comorbidity scores, or with Medicaid or no insurance appeared most prone to potential disparities in admissions.

Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing

OBJECTIVES

The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting.

MATERIALS AND METHODS

The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results.

RESULTS

The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians).

DISCUSSION

By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities.

CONCLUSION

The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.