Variation in emergency department wait times for children by race/ethnicity and payment source

Acute pediatric appendicitis in black and white: clinical disparities, impact and future recommendations

Racial and ethnic disparities have long been studied in the delivery of healthcare. One such avenue is acute pediatric appendicitis, which continues to be an area of significant and continual research. Because of its routine clinical presentation and standardized management, acute pediatric appendicitis serves as an appropriate proxy for studying discrepancies in healthcare. Our review therefore aims to comprehensively highlight the various dimensions of its clinical management subject to disparities, their collective clinical impact, and future recommendations to mitigate it.

Racial differences in triage assessment at rural vs urban Maine emergency departments

Data continue to accumulate demonstrating that those belonging to racialized groups face implicit bias in the emergency care delivery system across many indices, including triage assessment. The Emergency Severity Index (ESI) was developed and widely implemented across the US to improve the objectivity of triage assessment and prioritization of care delivery; however, research continues to support the presence of subjective bias in triage assessment. We sought to assess the relationship between perceived race and/or need for translator and assigned ESI score and whether this was impacted by hospital geography. We performed retrospective EMR-based review of patients presenting to urban and rural emergency departments of a health system in Maine with one of the top ten most common chief complaints (CC) across a 5-year period, excluding psychiatric CCs. We used multivariable regression to analyze the relationships between perceived race, need for translator, and gender with ESI score, wait time, and hallway bed assignments. We found that patients perceived as non-white were more likely to receive lower acuity ESI scores and have longer wait times as compared to patients perceived as white. Patients perceived as female were more likely to receive lower acuity scores and wait longer to be seen than patients perceived as male. The need for an interpreter was associated with increased wait times but not significantly associated with ESI score. After stratification by hospital geography, evidence of subjective bias was limited to urban emergency departments and was not evident in rural emergency departments. Further investigation of subjective bias in emergency departments in Maine, particularly in urban settings, is warranted.

Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies

STUDY OBJECTIVE

Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses.

RESULTS

Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission.

CONCLUSION

Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.

Racial and Ethnic Disparities in Emergency Department Wait Times for Headache

Headache is a common complaint of individuals seeking treatment in the emergency department (ED). Because pain is subjective, medical evaluation is susceptible to implicit bias that can lead to disparities in wait times. The aim of this study was to determine whether there are racial and ethnic disparities in ED wait times for headache. Our study used the 2015-2018 National Hospital Ambulatory Care Surveys (NHAMCS), a nationally representative sample of ambulatory care visits to EDs. Our sample consisted of visits made by adults for headaches, which were identified using ICD-10 diagnosis codes and NHAMCS reason for visit codes. There were 12,301,655 ED visits for headache represented by our sample. The mean wait time for headache visits was 38.1 min (95%CI: 31.1, 45.0). The mean wait time for Non-Hispanic White patients, non-Hispanic Black patients, Hispanic patients, and the other race and ethnicity groups were 34.7 min (95%CI: 27.5, 42.0), 46.4 min (95%CI: 26.5, 66.4), 37.9 min (95%CI: 19.4, 56.3), and 21.0 min (95%CI: 6.3, 35.7) respectively. After controlling for patient- and hospital-level covariates, visits by non-Hispanic Black patients had 40% (95%CI: -0.01, 0.81, p = 0.056) longer wait times and visits by Hispanic patients had 39% (95%CI: -0.03, 0.80, p = 0.068) longer wait times than visits by non-Hispanic White patients. While our findings suggest that there may be longer wait times for visits by non-Hispanic Black and Hispanic patients compared to visits by non-Hispanic White patients, further research is needed to confirm these findings and determine causes of wait times disparities in the ED.

Healthcare utilization is increased in children living in urban areas, with ethnicity-related disparities: A big data analysis study

This study aimed to investigate differences in pediatric healthcare utilization in Israel over 10 years by examining differences across populations defined by living environment and ethnicity. Data was obtained from the Clalit Health Care data warehouse, covering over 250,000 children residing in Haifa and Western Galilee districts. The population groups were categorized based on ethnicity (Jewish vs Arab) and residential settings (urban vs rural). Healthcare utilization was consistently higher among Jewish than Arab children, irrespective of the specific dimension analyzed. Additionally, urban-dwelling children exhibited higher usage rates than those residing in rural areas in all investigated dimensions. However, Jewish children showed significantly about 18% lower hospitalization rates than Arab children across all years (P < 0.001). No significant differences in hospitalizations were observed between urban and rural children (RR 0.999, CI (0.987-1.011)). Notably, the study revealed reduced antibiotic consumption and hospitalizations over the years for all populations. Additionally, we found that Arab children and those living in rural areas had reduced access to healthcare, as evidenced by 10-40% fewer physician visits, laboratory tests, and imaging (P < 0.001).    Conclusion: This study highlights the substantial population-based disparities in healthcare utilization among children in Israel despite the equalizing effect of the national health insurance law. Rural and low socioeconomic populations seem to have reduced healthcare access, showing decreased healthcare utilization. Consequently, it is imperative to address these disparities and implement targeted interventions to enhance healthcare access for Arab children and rural communities. The decline in antibiotic usage and hospitalizations suggests positive trends in pediatric health care, necessitating ongoing efforts to ensure equitable access and quality of care for all populations. What is Known: • Healthcare systems worldwide vary in coverage and accessibility, including Israel, which stands out for its diverse population. • Existing research primarily focuses on healthcare utilization among adults, leaving a need for comprehensive data on children's healthcare patterns globally. What is New: • Investigating over 250,000 children, this study reveals higher healthcare utilization among Jewish and urban children across all dimensions. • Despite Israel's national health insurance law, the study underscores the significant population-based disparities in healthcare utilization.

Designing Worthy Waiting Spaces: A Cross-Cultural Study of Waiting Room Features and Their Impact on Women's Affective States

OBJECTIVE

This study examines the impact of ambulatory waiting room characteristics on patients' emotional states and investigates whether these states are universally experienced or influenced by social and cultural factors among women aged 18-35 from the three largest demographic groups in the United States: Black, Hispanic/Latina, and White.

BACKGROUND

Patients typically spend more time waiting for routine medical appointments than receiving care, and evidence suggests that waiting can reinforces power dynamics that benefit privileged groups, leading to different experiences for minority women seeking preventative care. Still, literature addressing the impact of waiting areas is largely limited to universal measures, and little is known about how different ethnic/race groups respond to waiting spaces.

METHODS

This inquiry used a questionnaire assessing 15 waiting room characteristics and testing four variables (furniture arrangement, room-scale, color saturation, and quantity of positive distractions) in a 2 × 3 quasiexperiment using a fractional randomized block design with 24 waiting room images.

FINDINGS

Responses from 1,114 participants revealed mutual preferences for sociopetal seating, positive distractions, neutral colors, and welcoming and calming environments. Yet, Black participants indicated significantly greater importance in seeing ethnically/racially similar patients and healthcare providers and strategies that promote transparency, including image-based provider directories and views into the clinic.

CONCLUSION

By investigating the impact of the waiting room environment on patient affect and comparing perceptions across three demographic groups of women, this study offers insights into potential strategies for improving access to preventative care services by creating more welcoming ambulatory care waiting environments.

Prehospital Transport Time and Outcomes for Pediatric Trauma: A National Study

INTRODUCTION

Historically, emergency medical services have aimed to deliver trauma patients to definitive care within the 60 min (min) "Golden Hour" to optimize survival. There is little evidence to support or refute this for pediatric trauma. The objective of this investigation was to describe national trends in prehospital transport time, in relation to the "Golden Hour," and pediatric trauma outcomes.

METHODS

Retrospective cohort study of patients (<15 y old) receiving emergency medical services trauma transport between 2017 and 2019. Transport time (less than or greater than 60 min) was the exposure variable, and analyses were adjusted for injury severity score (ISS). Continuous variables with a normal distribution were compared by t-test was and skewed variables were compared by Mann-Whitney U-test. Categorical variables were compared by Chi-Square test.

RESULTS

54,489 patients met our criteria: 49,628 blunt and 4861 penetrating. Most patients (62.2%) had transport times less than 60 min: 30,389 (61.2%) blunt and 3479 (71.6%) penetrating. The overall mortality rate was 1.6%, 1.2% for blunt and 5.5% for penetrating. For blunt trauma, mortality was higher for transport times less than 60 min (1.5%). For penetrating trauma, mortality was lower for transport times less than 60 min (0.7%). Mean ISS was greater for blunt (7.9) compared to penetrating trauma (7.1), and greater for both trauma types with transport times less than 60 min. For both trauma types, mean length of stay was significantly longer for transport times greater than 60 min, when adjusting for ISS (P < 0.001).

CONCLUSIONS

We did not find evidence that prehospital transport within the "Golden Hour" had a substantial association with survival, though it may be associated with length of stay. There are many factors contributing to trauma outcomes, so efforts should continue to expand access and pediatric readiness.

Utilization of Proximate Healthcare Facilities and Children's Wait Times in Senegal: An IV-Tobit Analysis

Universal health coverage (UHC) defines individuals' timely access to healthcare services without suffering any health-related financial constraints. The Senegalese government has shown commitments towards achievement of UHC as a way of improving access by the population to quality healthcare services. This is very pertinent for promoting some indicators of under-five health in Senegal. Therefore, this study analyzed the factors influencing sick children's utilization of the nearest healthcare facilities and their wait times in Senegal. The data were from the Service Provision Assessment (SPA) survey, which was conducted in 2018. The instrumental Tobit regression model was used for data analysis. The results showed that 63.50% and 86.01% of the children utilized health posts and publicly owned facilities, respectively. Also, 98.46% of the children utilized urban facilities. The nearest facilities were utilized by 74.55%, and 78.19% spent less than an hour in the facilities. The likelihood of using the nearest healthcare facilities significantly reduced (p < 0.05) with caregivers' primary education, higher education, residence in some regions (Fatick, Kaokack, Saint Louis, Sediou, and Tambacounda), and use of private/NGO not-for-profit facilities, but increased with not having visited any other providers, residence in the Kaffrie region, vomiting symptoms, use of health centers, and use of health posts. Moreover, treatment wait times significantly increased (p < 0.05) with the use of nearest facilities, residence in some regions (Diourbel, Kaokack, Matam and Saint Louis), use of private for-profit facilities, use of private not-for-profit facilities, and urban residence, but decreased with secondary education, use of health centers, use of health posts, vomiting symptoms, and showing other symptoms. It was concluded that reduction in wait times and utilization of the nearest healthcare facilities are fundamental to achieving UHC in Senegal. Therefore, more efforts should be integrated at promoting regional and sectoral equities through facilitated public and private healthcare investment.

Differences in the Patterns of Care Between Emergency Department Visits with and Without a Physician

BACKGROUND

A variety of clinicians practice in emergency departments (EDs). Although most ED patients prefer seeing physicians, a subset sees no physician.

OBJECTIVES

We sought to determine the factors that predict when an ED patient is seen by at least one physician and compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.

METHODS

We used 11 years of cross-sectional data from the National Hospital Ambulatory Medical Care Survey and focused on the sample of ED patient visits seen by at least one physician and those seen by no physician. We used bivariate statistics to compare characteristics between samples and used multivariate logistic regression analysis to identify the factors that predicted being seen by a physician. Finally, we compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.

RESULTS

Approximately 10% of the sample was not seen by any physician. Patients seen by at least one physician had, on average, 0.8 more diagnostic services ordered/provided and 0.1 more procedures provided compared with patients who were not seen by any physician. Patients seen by at least one physician had longer visits by 29.4 min, on average, and had increased odds of being hospitalized (adjusted odds ratio 3.9, 95% confidence interval 2.9-5.2).

CONCLUSIONS

A variety of patient and hospital characteristics influenced whether ED patients were seen by physicians. Diagnostic services, procedures, visit length, and hospital admission differed by physician presence. Findings have implications for ED practice and future research.

Racial Inequities in Sepsis Mortality Among Children in the United States

BACKGROUND

Racial inequities influence health outcomes in the United States, but their impact on sepsis outcomes among children is understudied. We aimed to evaluate for racial inequities in sepsis mortality using a nationally representative sample of pediatric hospitalizations.

METHODS

This population-based, retrospective cohort study used the 2006, 2009, 2012 and 2016 Kids' Inpatient Database. Eligible children 1 month to 17 years old were identified using sepsis-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes. We used modified Poisson regression to evaluate the association between patient race and in-hospital mortality, clustering by hospital and adjusting for age, sex and year. We used Wald tests to assess for modification of associations between race and mortality by sociodemographic factors, geographic region and insurance status.

RESULTS

Among 38,234 children with sepsis, 2555 (6.7%) died in-hospital. Compared with White children, mortality was higher among Hispanic (adjusted relative risk: 1.09; 95% confidence interval: 1.05-1.14), Asian/Pacific Islander (1.17, 1.08-1.27) and children from other racial minority groups (1.27, 1.19-1.35). Black children had similar mortality to White children overall (1.02, 0.96-1.07), but higher mortality in the South (7.3% vs. 6.4%; P < 0.0001). Hispanic children had higher mortality than White children in the Midwest (6.9% vs. 5.4%; P < 0.0001), while Asian/Pacific Islander children had higher mortality than all other racial categories in the Midwest (12.6%) and South (12.0%). Mortality was higher among uninsured children than among privately insured children (1.24, 1.17-1.31).

CONCLUSIONS

Risk of in-hospital mortality among children with sepsis in the United States differs by patient race, geographic region and insurance status.

Racial and Ethnic Disparities in Emergency Department Wait Times for Children: Analysis of a Nationally Representative Sample

OBJECTIVE

To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED).

METHODS

We performed a cross-sectional study of ED encounters of children (<18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity.

RESULTS

We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76-0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83-1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63-0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64-0.89), and the Midwest region (HR 0.77, 95% CI 0.69-0.87). No differences in wait times were observed for children of Black race or other races.

CONCLUSIONS

Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.

Race and the emergency department management of febrile seizures

To determine if racial disparities exist in the management of febrile seizures in a large pediatric emergency department (ED), We performed a retrospective cross-sectional analysis of children 6 months to 6 years-old who presented to the ED with a febrile seizure over a 4-year period. Multivariate logistic regression models were built to examine the association between race and the primary outcome of neuroimaging, and secondary outcomes of hospital admission and abortive anticonvulsant prescription at ED discharge. There were 980 ED visits during the study period. Overall, 4.0% of children underwent neuroimaging and 11.1% were admitted. Of the 871 children discharged from the ED, 9.4% were prescribed an abortive anticonvulsant. There were no differences by race in neuroimaging or hospital admission. However, black children were less likely to be prescribed abortive anticonvulsants (adjusted odds ratio [aOR] 0.47; 95% confidence interval [CI]: 0.23-0.96) compared to non-black peers, when adjusting for demographic and clinical confounders. Stratification by insurance revealed that this disparity existed in Medicaid-insured patients (aOR 0.33, 95% CI: 0.14-0.78) but not in privately-insured patients. We found no racial disparities in neuroimaging or hospital admission among ED patients with febrile seizures. We did find racial disparities in our secondary outcome of abortive anticonvulsant prescription, driven primarily by individuals on Medicaid insurance. This pattern of findings may reflect the lack of standardized recommendations regarding anticonvulsant prescription, in contrast to the guidelines issued for other ED management decisions. Further investigation into the potential for treatment guidelines to reduce racial disparities is needed.

Disposition disparities in an urban tertiary emergency department

OBJECTIVE

To explore disparities between Māori and non-Māori patients with respect to triage acuity and disposition based on presenting complaint.

METHODS

This was a retrospective review of 5788 (n = 594 Māori, n = 5194 non-Māori) ED visits in February 2021, extracted from the hospital data warehouse.

RESULTS

Māori were triaged similarly to non-Māori but were less likely to be admitted compared to non-Māori: relative risk 0.87 (0.78, 0.97), P = 0.008.

CONCLUSION

Māori were less likely to be admitted for similar presenting complaints, despite similar triage acuity. Further research is required to determine the reasons for this apparent inequity.

Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality

BACKGROUND

Racial disparities in trauma care have been reported for a range of outcomes, but the extent to which these remain after accounting for socioeconomic and environmental factors remains unclear. The objective of this study was to evaluate the unique contributions of race, health insurance, community distress, and rurality/urbanicity on trauma outcomes after carefully controlling for specific injury-related risk factors.

METHODS

All adult (age, ≥18 years) trauma patients admitted to a single Level I trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed. Primary outcomes were mortality, rehabilitation referral, and receipt of opioids in the emergency department. Demographic, socioeconomic, and injury characteristics as well as indicators of community distress and rurality based on home address were abstracted from a trauma registry database.

RESULTS

Analyses revealed that Black patients (n = 13,073) were younger, more likely to be male, more likely to suffer penetrating injuries, and more likely to suffer assault-based injuries compared with White patients (n = 10,946; all p < 0.001). In adjusted analysis, insured patients had a 28% lower risk of mortality (odds ratio, 0.72; p = 0.005) and were 92% more likely to be referred for postdischarge rehabilitation than uninsured patients (odds ratio, 1.92; p = 0.005). Neither race- nor place-based factors were associated with mortality. However, post hoc analyses revealed a significant race by age interaction, with Black patients exhibiting more pronounced increases in mortality risk with increasing age.

CONCLUSION

The present findings help disentangle the social determinants of trauma disparities by adjusting for place and person characteristics. Uninsured patients were more likely to die and those who survived were less likely to receive referrals for rehabilitation services. The expected racial disparity in mortality risk favoring White patients emerged in middle age and was more pronounced for older patients.

LEVEL OF EVIDENCE

Prognostic and epidemiological, Level III.

Racial and Language Disparities in Pediatric Emergency Department Triage

OBJECTIVE

The aim of this study was to assess the impact race and language have on emergency department (ED) triage scores while accounting for illness severity. We hypothesized that non-White and non-English-speaking patients were assigned lower-acuity triage scores compared with White and English-speaking patients, respectively.

METHODS

We used a chart review-based retrospective cohort study design, examining patients aged 0 to 17 years at our pediatric ED from July 2015 through June 2016. Illness severity was measured using a truncated Modified Pediatric Early Warning Score calculated from patient vital signs. We used univariate and multivariate multinomial logistic regression to assess the association between race and language with Emergency Severity Index scores.

RESULTS

Our final data set consisted of 10,815 visits from 8928 patients. Non-Hispanic (NH) White patients accounted for 34.6% of patients. In the adjusted analyses, non-White patients had significantly reduced odds of receiving a score of 2 (emergency) (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.33-0.49) or 3 (urgent) (OR, 0.5; 95% CI, 0.45-0.56) and significantly higher odds of receiving a score of 5 (minor) (OR, 1.34; 95% CI, 1.07-1.69) versus a score of 4 (nonurgent). We did not find a consistent disparity in Emergency Severity Index scores when comparing English- and non-English-speaking patients.

CONCLUSIONS

We confirm that non-White patients receive lower triage scores than White patients. A more robust tool is required to account for illness severity and will be critical to understanding whether the relationship we describe reflects bias within the triage system or differences in ED utilization by racial groups.

Racial/Ethnic Differences in Pediatric Emergency Department Wait Times

OBJECTIVES

Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences.

METHODS

We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure.

RESULTS

Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)].

CONCLUSIONS

In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

Examining emergency department inequities in Aotearoa New Zealand: Findings from a national retrospective observational study examining Indigenous emergency care outcomes

OBJECTIVE

There is increasing evidence that EDs may not operate equitably for all patients, with Indigenous and minoritised ethnicity patients experiencing longer wait times for assessment, differential pain management and less evaluation and treatment of acute conditions.

METHODS

This retrospective observational study used a Kaupapa Māori framework to investigate ED admissions into 18/20 District Health Boards in Aotearoa New Zealand (2006-2012). Key pre-admission variable was ethnicity (Māori:non-Māori), and outcome variables included: ED self-discharge; ED arrival to assessment time; hospital re-admission within 72 h; ED re-presentation within 72 h; ED length of stay; ward length of stay; access block and mortality (in ED or within 10 days of ED departure). Generalised linear regression models controlled for year of presentation, sex, age, deprivation, triage category and comorbidity.

RESULTS

Despite some ED process measures favouring Māori, for example arrival to assessment time (mean difference -2.14 min; 95% confidence interval [CI] -2.42 to -1.86) and access block (odds ratio [OR] 0.89, 95% CI 0.87-0.91), others showed no difference, for example self-discharge (OR 0.98, 95% CI 0.97-1.00). Despite this, Māori mortality (OR 1.60, 95% CI 1.50-1.71) and ED re-presentation (OR 1.11, 95% CI 1.09-1.12) were higher than non-Māori.

CONCLUSION

To our knowledge, this is the most comprehensive investigation of acute outcomes by ethnicity to date in New Zealand. We found ED mortality inequities that are unlikely to be explained by ED process measures or comorbidities. Our findings reinforce the need to investigate health professional bias and institutional racism within an acute care context.

Pain Reduction Emergency Protocol: A Prospective Study Evaluating Impact of a Nurse-initiated Protocol on Pain Management and Parental Satisfaction

OBJECTIVES

Pain control remains suboptimal in pediatric emergency departments (EDs). Only 60% of pediatric patients requiring pain medications receive them in the ED, with an average time of administration being 90 minutes after arrival. Although pain protocols (PP) have been proposed and evaluated in children with long-bone fractures, data on PP utility for general pediatric patients with acute pain are limited. Our objective is to introduce a nursing-initiated PP with medication algorithms for use in triage, measure the improvement in management of severe pain on arrival to the ED and determine the effect on parental satisfaction.

METHODS

Prospective prestudy and poststudy conducted from June to October 2017. Patients aged 3 to 17 years presenting to a large tertiary pediatric ED with acute pain were eligible. Preprotocol demographics, clinical data, and pain interventions were obtained over a 6-week period. A convenience sample of parents completed a satisfaction survey rating their experience with ED pain management during this time. In the 4-week intervention phase, the PP was introduced to our ED nurses. Postintervention data were collected in the same fashion as the preintervention phase. Analysis was done using independent sample t test and χ2 models.

RESULTS

There were 1590 patients evaluated: preprotocol (n = 816), postprotocol (n = 774). Approximately 10% more patients with severe pain received pain medication in the post-PP sample compared with pre-PP (85.6% and 75.9% respectively). Parental satisfaction was higher in patients who received analgesic medications within 90 minutes of arrival to the ED (P = 0.007).

CONCLUSIONS

The introduction of a PP in the ED setting improved the treatment of pain. There was a significant increase in patients with severe pain receiving analgesic medications. Additionally, parents were more satisfied if their children received pain medication in a more timely fashion. Pediatric EDs should consider introducing PPs to improve appropriate and timely administration of pain medication in triage.

Decreased Racial and Ethnic Disparities in Emergency Department Wait Time in the United States

BACKGROUND

Previous data over an extended period indicated that Black and Hispanic patients waited significantly longer than their White counterparts to see a qualified practitioner in US emergency departments (EDs).

OBJECTIVE

The objective of this study was to assess recent trends and sources of racial and ethnic disparities in patient wait time to see a qualified practitioner in US EDs.

DATA SOURCES

Publicly available ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2003-2017.

RESEARCH DESIGN

A retrospective cross-sectional analysis of a nationally representative sample of visits to US EDs from 2003 to 2017. Joinpoint statistical analysis and survey-weighted regression were used to assess changes in ED wait time by race/ethnic group over time.

PRINCIPAL FINDINGS

For non-Hispanic White patients, median ED wait time increased annually by 1.3 minutes from 2003 through 2008, decreased by 3.0 minutes from 2008 through 2012, and decreased by 1.7 minutes from 2012 to 2017. For non-Hispanic Black patients, median wait time increased annually by 2.0 minutes from 2003 through 2008, decreased by 3.8 minutes from 2008 through 2015, and remained fairly unchanged from 2015 through 2017. For Hispanic patients, the trend in median wait time remained statistically unchanged from 2003 through 2009. It decreased by annually by 4.7 minutes from 2009 to 2012 and by 1.5 minutes from 2012 through 2017. By the end of 2017, median ED wait time decreased to under 20 minutes across all 3 groups.

CONCLUSIONS

Over time, ED wait times decreased to under 20 minutes across all racial and ethnic groups between 2003 and 2017. Observed disparities were largely the result of where minority populations accessed care and disappeared over time.

A Retrospective Study of Disparities in an Academic Ophthalmic Emergency Department

Purpose Emergency medicine is a common access point to health care; disparities in this care by demographic characteristics, including race and ethnicity, may affect outcomes. The Massachusetts Eye and Ear (MEE) Emergency Department (ED) is a subspecialty emergency department; data from this site can be utilized to better understand social determinants of quality ophthalmic care.

Design This is a retrospective cross sectional cohort study in the MEE ED examining patient visits from June 1, 2016 to June 30, 2019.

Methods Using the electronic medical record system, all unique visits were identified between June 1, 2016 and June 30, 2019 (inclusive); patient demographics (sex, race, ethnicity [Hispanic vs. non-Hispanic], primary care provider [PCP] status, insurance type, zip code, primary language), date of visit, triage category and outcomes (final diagnosis, visit duration, and next visit at MEE within 3 months of the ED visit) were collected. Kaplan-Meier plots were used to visualize likelihood of follow-up visit to MEE for urgent patients based on demographics. Multivariate linear regression was used to examine factors affecting visit durations, as stratified by urgency, and Cox proportional hazards regression was used to establish hazard ratios for next visit to MEE.

Results Of the 46,248 ophthalmology ED initial visits, only triage status, season of visit, out-of-state residency, Medicare coverage, and Medicaid coverage led to statistically significant differences in visit durations for urgent visits compared with the respective reference groups. Similar trends persisted within the non-urgent visit cohort for visit durations. Residency, insurance coverage, season of visit, race, PCP status, and sex were identified as statistically significant predictors of the likelihood of a follow-up visit.

Conclusion Data from an ophthalmic emergency department suggest that demographic factors do impact patient visit duration and time to follow-up visit. These findings suggest a continued need for attention to social determinants of health and equitable care of patients within ophthalmology.

Racial/Ethnic Disparities in Triage Scores Among Pediatric Emergency Department Fever Patients

OBJECTIVES

Emergency department (ED) triage scores are assigned to patients in a short period based on assessment of need for lifesaving measures, risk and pain levels, resource needs, and vital signs. Racial/ethnic disparities have been found across a number of outcomes but are not consistent across all studies. This study examines pediatric ED cases reporting fever, a commonly reported triage symptom, to explore racial/ethnic and age disparities in triage score assignment.

METHODS

This study uses the 2009-2015 National Hospital Ambulatory Medical Care Survey, an annual national sample of ED visits in the United States. Pediatric cases where fever is the sole reported reason for visit are analyzed for racial/ethnic disparities, controlling for sex, age, insurance status, body temperature, region, and hospital type.

RESULTS

Among all pediatric fever cases, temperature is the sole significant predictor of triage scores. However, non-Hispanic (NH) black pediatric patients older than 1 year have approximately 22% greater risk of being given a less urgent triage score relative to NH white patients.

CONCLUSIONS

Findings suggest racial disparities in the triage of NH black pediatric patients older than 1 year for fever. Although fever is a single and often non-life-threatening condition, especially after infancy, findings of racial disparities in triage scores suggests a need for further evaluation of the assignment of patient urgency in emergency medicine.

Pediatric non-urgent emergency department visits and prior care-seeking at primary care

BACKGROUND

We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits.

METHODS

We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics.

RESULTS

Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit.

CONCLUSIONS

Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.

Prolonged Emergency Department Length of Stay for US Pediatric Mental Health Visits (2005-2015)

BACKGROUND AND OBJECTIVES

Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non-mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits.

METHODS

We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005-2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression.

RESULTS

From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non-mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69-4.44); there was no difference in LOS by payer type.

CONCLUSIONS

The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.

Racial/ethnic disparities in emergency department wait times in the United States, 2013-2017

BACKGROUND

Previous research shows that Black and Hispanic patients have longer ED wait times than White patients, but these data do not reflect recent changes such as the Affordable Care Act. In addition, previous research does not account for the non-normal distribution of wait times, wherein a sizable subgroup of patients seen promptly and those not seen promptly experience long wait times.

METHODS

We utilized National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets (2013-2017) to examine mean ED wait time comparing visits by Black, Hispanic, and Asian patients to White patients. Using a two-part regression model, we adjusted for patient, hospital, and health system factors, and estimated differences, for each of five triage levels, in (a) likelihood of waiting at least 5 min and (b) difference in wait time among those not seen promptly.

RESULTS

Our cohort included 38,800 White, 14,838 Black, 10,619 Hispanic, and 1257 Asian patient visits. Black (triage level 3) and Hispanic (triage levels 3 and 4) patients had longer mean wait times than White patients. Adjusted likelihood of not being seen promptly was lower among Blacks (triage levels 3, 4 and 5), Hispanics (triage level 5) and Asians (triage level 5) compared to Whites. Among those waiting at least 5 min, adjusted wait time was longer among Blacks in triage level 3 (5.2 min, 95% CI, 1.3 to 9.0) and level 4 (2.5 min, 95% CI, 0.2 to 4.9), Hispanics in triage level 4 (4.7 min, 95% CI, 1.7 to 7.7) and Asians in triage level 5 (16.3 min, 95% CI, 0.6 to 31.9) compared to Whites.

CONCLUSIONS

Minority patients were less likely to wait to be seen, but waited longer if not seen promptly. These data exhibit that ED wait time disparities persist for African American and Hispanic patients and extend this observation to Asian patients.

The Effect of Homelessness on Patient Wait Times in the Emergency Department

BACKGROUND

Prolonged emergency department (ED) wait times could potentially lead to increased morbidity and mortality. While previous work has demonstrated disparities in wait times associated with race, information about the relationship between experiencing homelessness and ED wait times is lacking.

OBJECTIVES

The purpose of this study was to explore the relationship between residence status (undomiciled vs. domiciled) and ED wait times. We hypothesized that being undomiciled would be associated with longer wait times.

METHODS

We obtained data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2017. We compared wait times in each triage category using t tests. We used multivariate linear regression to explore associations between residence status and wait times while controlling for other patient- and hospital-level variables.

RESULTS

On average, undomiciled patients experienced significantly longer mean ED wait times than domiciled patients (53.4 vs. 38.9 min; p < 0.0001). In the multivariate model, undomiciled patients experienced significantly different wait times by 15.5 min (p = 0.0002). Undomiciled patients experienced increasingly longer waits vs. domiciled patients for the emergent and urgent triage categories (+33.5 min, p < 0.0001, and +22.7 min, p < 0.0001, respectively).

CONCLUSIONS

Undomiciled patients experience longer ED wait times when compared with domiciled patients. This disparity is not explained by undomiciled patients seeking care in the ED for minor illness, because the disparity is more pronounced for urgent and emergent triage categories.

Patient Race/Ethnicity and Diagnostic Imaging Utilization in the Emergency Department: A Systematic Review

PURPOSE

Diagnostic imaging often is a critical contributor to clinical decision making in the emergency department (ED). Racial and ethnic disparities are widely reported in many aspects of health care, and several recent studies have reported a link between patient race/ethnicity and receipt of imaging in the ED.

METHODS

The authors conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching three databases (PubMed, Embase, and the Cochrane Library) through July 2020 using keywords related to diagnostic imaging, race/ethnicity, and the ED setting, including both adult and pediatric populations and excluding studies that did not control for the important confounders of disease severity and insurance status.

RESULTS

The search strategy identified 7,313 articles, of which 5,668 underwent title and abstract screening and 238 full-text review, leaving 42 articles meeting the inclusion criteria. Studies were predominately conducted in the United States (41), split between adult (13) and pediatric (17) populations or both (12), and spread across a variety of topics, mostly focusing on specific anatomic regions or disease processes. Most studies (30 of 42 [71.4%]) reported an association between Black, African American, Hispanic, or nonwhite race/ethnicity and decreased receipt of imaging.

CONCLUSIONS

Despite heterogeneity among studies, patient race/ethnicity is linked with receipt of diagnostic imaging in the ED. The strength and directionality of this association may differ by specific subpopulation and disease process, and more efforts to understand potential underlying factors are needed.

Disparities in the Use of Emergency Department Advanced Imaging in Medicare Beneficiaries

OBJECTIVE. The purpose of our study was to assess potential disparities in the utilization of advanced imaging during emergency department (ED) visits. MATERIALS AND METHODS. This retrospective study was conducting using 5% Research Identifiable Files. All CT and MRI (together defined as "advanced imaging") examinations associated with ED visits in 2015 were identified for continuously enrolled Medicare beneficiaries. Individuals with medical claims 30 days before the index ED event were excluded, and encounters that occurred in hospitals without advanced imaging capabilities were also excluded. Patient characteristics were identified using Medicare files and hospital characteristics using the American Hospital Association Annual Survey of Hospitals. Multivariate logistic regression was used for the analysis. RESULTS. Of 86,976 qualifying ED encounters, 52,833 (60.74%) ED encounters were for female patients; 29.03% (n = 25,245) occurred at rural hospitals and 15.81% (n = 13,750) at critical access hospitals. Race distribution was 83.13% White, 11.05% Black, and 5.82% Other. Compared with ED patients at urban hospitals, those at rural and critical access hospitals were 6.9% less likely (odds ratio [OR] = 0.931, p = 0.015) and 18.0% less likely (OR = 0.820, p < 0.0001), respectively, to undergo advanced imaging. Compared with White patients, Black patients were 31.6% less likely (OR = 0.684, p < 0.0001) to undergo advanced imaging. Relative to their urban counterparts, both White (OR = 0.941, p = 0.05) and Black (OR = 0.808, p = 0.047) rural ED patients were less likely to undergo advanced imaging. CONCLUSION. Among Medicare beneficiaries receiving care in U.S. EDs, significant disparities exist in advanced imaging utilization. Although imaging appropriateness was not investigated, these findings suggest inequity. Further research is necessary to understand why consistent health benefits do not translate into consistent imaging access among risk-adjusted ED patients.

Examining emergency department inequities: Descriptive analysis of national data (2006-2012)

OBJECTIVE

Internationally, Indigenous and minoritised ethnic groups experience longer wait times, differential pain management and less evaluation and treatment for acute conditions within emergency medicine care. Examining ED Inequities (EEDI) aims to investigate whether inequities between Māori and non-Māori exist within EDs in Aotearoa New Zealand (NZ). This article presents the descriptive findings for the present study.

METHODS

A retrospective observational study framed from a Kaupapa Māori positioning, EEDI uses secondary data from emergency medicine admissions into 18/20 District Health Boards in NZ between 2006 and 2012. Data sources include variables from the Shorter Stays in ED National Research Project database and comorbidity data from NZ's National Minimum Dataset. The key predictor of interest is patient ethnicity with descriptive variables, including sex, age group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and trauma status.

RESULTS

There were a total of 5 972 102 ED events (1 168 944 Māori, 4 803 158 non-Māori). We found an increasing proportion of ED events per year, with a higher proportion of Māori from younger age groups and areas of high deprivation compared to non-Māori events. Māori also had a higher proportion of self-referral and were triaged to be seen within a longer time frame compared to non-Māori.

CONCLUSION

Our findings show that there are different patterns of ED usage when comparing Māori and non-Māori events. The next level of analysis of the EEDI dataset will be to examine whether there are any associations between ethnicity and ED outcomes for Māori and non-Māori patients.

The influence of patient race on the use of diagnostic imaging in United States emergency departments: data from the National Hospital Ambulatory Medical Care survey

BACKGROUND

An established body of literature has shown evidence of implicit bias in the health care system on the basis of patient race and ethnicity that contributes to well documented disparities in outcomes. However, little is known about the influence of patient race and ethnicity on the decision to order diagnostic radiology exams in the acute care setting. This study examines the role of patient race and ethnicity on the likelihood of diagnostic imaging exams being ordered during United States emergency department encounters.

METHODS

Publicly available data from the National Hospital Ambulatory Medical Care Survey Emergency Department sample for the years 2006-2016 was compiled. The proportion of patient encounters where diagnostic imaging was ordered was tabulated by race/ethnicity, sub-divided by imaging modality. A multivariable logistic regression model was used to evaluate the influence of patient race/ethnicity on the ordering of diagnostic imaging controlling for other patient and hospital characteristics. Survey weighting variables were used to formulate national-level estimates.

RESULTS

Using the weighted data, an average of 131,558,553 patient encounters were included each year for the 11-year study period. Imaging was used at 46% of all visits although this varied significantly by patient race and ethnicity with white patients receiving medical imaging at 49% of visits and non-white patients at 41% of visits (p < 0.001). This effect persisted in the controlled regression model and across all imaging modalities with the exception of ultrasound. Other factors with a significant influence on imaging use included patient age, gender, insurance status, number of co-morbidities, hospital setting (urban vs non-urban) and hospital region. There was no evidence to suggest that the disparate use of imaging by patient race and ethnicity changed over the 11-year study time period.

CONCLUSION

The likelihood that a diagnostic imaging exam will be ordered during United States emergency department encounters differs significantly by patient race and ethnicity even when controlling for other patient and hospital characteristics. Further work must be done to understand and mitigate what may represent systematic bias and ensure equitable use of health care resources.

Placebo hypoalgesia: racial differences

No large-cohort studies that examine potential racial effects on placebo hypoalgesic effects exist. To fill this void, we studied placebo effects in healthy and chronic pain participants self-identified as either African American/black (AA/black) or white. We enrolled 372 study participants, 186 with a diagnosis of temporomandibular disorder (TMD) and 186 race-, sex-, and age-matched healthy participants to participate in a placebo experiment. Using a well-established paradigm of classical conditioning with verbal suggestions, each individual pain sensitivity was measured to calibrate the temperatures for high- and low-pain stimuli in the conditioning protocol. These 2 temperatures were then paired with a red and green screen, respectively, and participants were told that the analgesic intervention would activate during the green screens to reduce pain. Participants then rated the painfulness of each stimulus on a visual analog scale ranging from 0 to 100. Racial influences were tested on conditioning strength, reinforced expectations, and placebo hypoalgesia. We found that white participants reported greater conditioning effects, reinforced relief expectations, and placebo effects when compared with their AA/black counterparts. Racial effects on placebo were observed in TMD, although negligible, short-lasting, and mediated by conditioning strength. Secondary analyses on the effect of experimenter-participant race and sex concordance indicated that same experimenter-participant race induced greater placebo hypoalgesia in TMDs while different sex induced greater placebo hypoalgesia in healthy participants. This is the first and largest study to analyze racial effects on placebo hypoalgesia and has implications for both clinical research and treatment outcomes.

Evaluation of Wait Time in the Children's Emergency and Outpatient Units of a Tertiary Hospital in Southeast Nigeria

Background:

Promptness of intervention in the emergency room (ER) or outpatient unit is a major determinant of outcome in acutely ill children. Time is, therefore, of the essence in trying to reduce complications and mortality associated with children.

Methods:

This was a cross-sectional study conducted in the children ER and the children outpatient unit of the Enugu State University Teaching Hospital (ESUTH), Enugu, Southeast Nigeria. Waiting time defined as the time between arrival and doctor consultation was calculated.

Results:

A total of 248 respondents were enrolled during the study period. In the emergency unit, majority (67.5%) of the respondents' sick children were attended to almost immediately, while 13.3% and 19.3% waited for ≤10 and >10 min, respectively, before being attended to by a doctor. The mean waiting time in the emergency unit was approximately 9.27 ± 29.2 min (95% confidence interval [CI]: 2.90–15.65 min) with a range of 0–56 min. In the outpatient unit, the mean waiting time was 12.67 ± 15.3 min (95% CI: 10.31–15.01 min) with a time range of 5–245 min. Eighty-five (51.5%) of the 165 respondents waited for <10 min, 60 (36.4%) waited for between 10 and 30 min, while 20 (12.1%) waited for >30 min before their sick children were attended by a doctor.

Conclusion:

The mean waiting times reported in this study in the emergency and outpatient units of the ESUTH were within acceptable standards. However, there were cases where the waiting time in both children's units was exceptionally long. There is need for continued monitoring and evaluation of waiting times in these units for prompt attention to patients.

Do dog breeds differ in pain sensitivity? Veterinarians and the public believe they do

Humans do not respond to the pain of all humans equally; physical appearance and associated group identity affect how people respond to the pain of others. Here we ask if a similar differential response occurs when humans evaluate different individuals of another species. Beliefs about pain in pet dogs (Canis familiaris) provide a powerful test, since dogs vary so much in size, shape, and color, and are often associated with behavioral stereotypes. Using an on-line survey, we asked both the general public and veterinarians to rate pain sensitivity in 28 different dog breeds, identified only by their pictures. We found that both the general public and veterinarians rated smaller dogs (i.e. based on height and weight) as being more sensitive to pain; the general public respondents rated breeds associated with breed specific legislation as having lower pain sensitivity. While there is currently no known physiological basis for such breed-level differences, over 90% of respondents from both groups indicated belief in differences in pain sensitivity among dog breeds. We discuss how these results inform theories of human social discrimination and suggest that the perception of breed-level differences in pain sensitivity may affect the recognition and management of painful conditions in dogs.

Multistate model of the patient flow process in the pediatric emergency department

Objectives

The main purpose of this paper was to model the process by which patients enter the ED, are seen by physicians, and discharged from the Emergency Department at Nationwide Children’s Hospital, as well as identify modifiable factors that are associated with ED lengths of stay through use of multistate modeling.

Methods

In this study, 75,591 patients admitted to the ED from March 1^st, 2016 to February 28^th, 2017 were analyzed using a multistate model of the ED process. Cox proportional hazards models with transition-specific covariates were used to model each transition in the multistate model and the Aalen-Johansen estimator was used to obtain transition probabilities and state occupation probabilities in the ED process.

Results

Acuity level, season, time of day and number of ED physicians had significant and varying associations with the six transitions in the multistate model. Race and ethnicity were significantly associated with transition to left without being seen, but not with the other transitions. Conversely, age and gender were significantly associated with registration to room and subsequent transitions in the model, though the magnitude of association was not strong.

Conclusions

The multistate model presented in this paper decomposes the overall ED length of stay into constituent transitions for modeling covariate-specific effects on each transition. This allows physicians to understand the ED process and identify which potentially modifiable covariates would have the greatest impact on reducing the waiting times in each state in the model.

Disparities in Emergency Department Wait Time Among Patients with Mental Health and Substance-Related Disorders

This study examined disparities in emergency department (ED) wait time for patients with mental health and substance-related disorders (PwMHSDs), using data from the 2009-2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). Wait time was defined as the time between arrival at ED and being seen by an ED provider. Results from multivariable regression models show racial disparities, with non-Hispanic Black PwMHSDs experiencing longer ED wait time, compared to non-Hispanic White PwMHSDs. A temporal decline in ED wait time was also observed over the study period. The findings of this study have implications for informing the development of policies tailored at facilitating the delivery of equitable emergency care services to all PwMHSDs.

Examining emergency department inequities: Do they exist?

OBJECTIVES

Ethnic inequities in health outcomes have been well documented with Indigenous peoples experiencing a high level of healthcare need, yet low access to, and through, high-quality healthcare services. Despite Māori having a high ED use, few studies have explored the potential for ethnic inequities in emergency care within New Zealand (NZ). Healthcare delivery within an ED context is characterised by time-pressured, relatively brief, complex and demanding environments. When clinical decision-making occurs in this context, provider prejudice, stereotyping and bias are more likely. The examining emergency department inequities (EEDI) research project aims to investigate whether clinically important ethnic inequities between Māori and non-Māori exist.

METHODS

EEDI is a retrospective observational study examining ED admissions in NZ between 2006 and 2012 (5 976 126 ED events). EEDI has been designed from a Kaupapa Māori Research position.

RESULTS

The primary data source is the existing Shorter Stays in Emergency Department National Research Project (SSED) dataset that will be combined with clinical information extracted from NZ's National Minimum Dataset. The key predictor variable is patient ethnicity with other covariates including: sex, age-group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co-morbidities. Generalised linear regression models will be used to investigate the associations between pre-admission variables and the measures of ED care, and to examine the contribution of each measure of ED care on ethnic inequities in mortality.

CONCLUSION

The present study will provide the largest, most comprehensive investigation of ED outcomes by ethnicity to date in NZ.

Healthcare disparities amongst vulnerable populations of Arabs and Jews in Israel

The complex nature of studying health and healthcare disparities in general, and in the context of the Israeli healthcare system in particular, is depicted in two recent IJHPR articles. The first examines Emergency Department (ED) waiting times in a tertiary children’s hospital and the second examines disparities in the health care for people with schizophrenia of an ethnic-national minority. Contrary to other Israeli studies on wide disparities in health and healthcare, these studies show no disparities -  ED waiting times did not differ among Arab and Jewish children and report no differences in performance of Hemoglobin A1C tests or in surgical interventions in patients with cardiovascular disease between Arabs and Jews with schizophrenia. Thus, the studies reflect areas of equitable health care delivery within the Israeli healthcare system.

Future studies should account for the fact that the phenomena of health and healthcare disparities is complex and should utilize rigorous methodologies to take into consideration the various factors that may affect the manifestation of differences amongst population groups. As a result, they may help detect disparities which may otherwise be missed.

Outpatient Office Wait Times And Quality Of Care For Medicaid Patients

The time patients spend in a doctor's waiting room prior to a scheduled appointment is an important component of the quality of the overall health care experience. We analyzed data on twenty-one million outpatient visits obtained from electronic health record systems, which allowed us to measure time spent in the waiting room beyond the scheduled appointment time. Median wait time was a little more than four minutes. Almost one-fifth of visits had waits longer than twenty minutes, and 10 percent were more than thirty minutes. Waits were shorter for early-morning appointments, for younger patients, and at larger practices. Median wait time was 4.1 minutes for privately insured patients and 4.6 minutes for Medicaid patients. After adjustment for patient and appointment characteristics, Medicaid patients were 20 percent more likely than the privately insured patients to wait longer than twenty minutes, with most of this disparity explained by differences in practices and providers they saw. Wait times for Medicaid patients relative to privately insured patients were longer in states with relatively lower Medicaid reimbursement rates. The study complements other work that suggests that Medicaid patients face some additional barriers in the receipt of care.

Leaving the emergency department without complete care: disparities in American Indian children

BACKGROUND

Children who leave the emergency department (ED) without complete evaluation or care (LWCET) have poorer outcomes in general. Previous studies have found that American Indian (AI) children have higher rates of LWCET than other racial or ethnic groups. Therefore, this study aims to examine LWCET in AI children by exploring differences by ED location and utilization patterns.

METHODS

This is a retrospective cohort study of five EDs in the upper Midwest between June 2011 and May 2012. We included all visits by children aged 0-17 who identified as African American (AA), AI or White. Logistic regression was used to determine differences in LWCET by race and ED location controlling for other possible confounding factors including sex, age, insurance type, triage level, distance from ED, timing of visit, and ED activity level.

RESULTS

LWCET occurred in 1.73% of 68,461 visits made by 47,228 children. The multivariate model revealed that AIs were more likely to LWCET compared to White children (Odds Ratio (OR) = 1.62, 95% Confidence Interval (CI) = 1.30-2.03). There was no significant difference in LWCET between AA and White children. Other factors significantly associated with LWCET included triage level, distance from the ED, timing of visit, and ED activity level.

CONCLUSION

Our results show that AI children have higher rates of LWCET compared to White children; this association is different from other racial minority groups. There are likely complex factors affecting LWCET in AI children throughout the upper Midwest, which necessitates further exploration.

Equality of care between First Nations and non-First Nations patients in Saskatoon emergency departments

Objective

Studies show that First Nations patients have worse health outcomes than non-First Nations patients, raising concerns that treatment within the healthcare system, including emergency care, is inequitable.

Methods

We performed a retrospective chart review of Status First Nations and non-First Nations patients presenting to two emergency departments in Saskatoon, Saskatchewan with abdominal pain and a Canadian Triage and Acuity Scale score of 3. From 190 charts (95 Status First Nations and 95 non-First Nations), data extracted included time to doctor, time to analgesia, length of stay, specialist consult, bloodwork, imaging, physical exam and history, and disposition. Univariate comparisons and multiple regression modelling were performed to compare care outcomes between patient groups. Equivalence testing comparing time intervals was also undertaken.

Results

No statistically significant differences in presentation characteristics were observed, although Status First Nations subjects showed a greater tendency towards weekend presentation and younger age. Care parameters were similar, although a marginally significant difference was observed in Status First Nations versus non-First Nations subjects for imaging (46% versus 60%, p=0.06), which resolved on adjustment for age and weekend presentation. Time to physician was found to be similar among First Nations patients on equivalence testing within a 15-minute margin.

Conclusion

In this study, First Nations patients presenting with abdominal pain did not receive delayed care. There were no detectable differences in the time-related care parameters/variables that were provided relative to non-First Nations patients. Meaningful and important qualitative factors need to be examined in the future.

Patient-level Factors and the Quality of Care Delivered in Pediatric Emergency Departments

OBJECTIVE

Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient-level factors.

METHODS

This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect.

RESULTS

In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (-0.65 points in quality, 95% confidence interval [CI] = -1.24 to -0.06) and upper respiratory symptoms (-0.68 points in quality, 95% CI = -1.30 to -0.07).

CONCLUSION

We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.

Waiting on Others: Gender in the Medical Waiting Room

In this article, I describe how gendered interactions and power dynamics play out in medical waiting rooms. While people are spending time idle, waiting for the next thing to happen (i.e., to check in, to see the doctor, to pay), social processes continue to occur and reinforce these gendered interactions and dynamics. Using data collected from ethnographic observations of medical waiting rooms in the Midwestern United States, this article illustrates that waiting offers another opportunity to understand the subtle ways that gendered expectations and hierarchies are perpetuated. Patients, their friends, and families do gender in medical waiting rooms through the amount of auditory and physical space they take up and the ways in which they behave and respond to the actors and expectations in this space.

Emergency Department waiting times in a tertiary children's hospital in Israel: a retrospective cohort study

Background

The purpose of this study was to assess ethnic differences in Emergency Department (ED) waiting times between Jewish and Arab children in a tertiary childrens’ hospital in Israel.

Methods

This was a retrospective cohort study of all children who were admitted to the pediatric ED of the largest hospital in northern Israel, between January 2011 and December 2015. Univariate and multivariate analyses were used to assess the strength of association between ethnicity category and waiting time. The following were tested as possible confounders: triage category, age, gender, time of arrival category. The effect of nurse-patient ethnic concordance was assessed.

Results

Full data were available in 82,883 patients, 55,497 (67.0%) Jews and 27,386 (33.0%) Arabs. Jews and Arabs had a similar median waiting time of 38 min (interquartile range [IQR] 22–63 and IQR 21–61, respectively). Ethnicity was not associated with a change in waiting time (p = 0.36). Factors that most influenced shorter waiting time were triage category 1 (change in waiting time: −25.5%; 95% confidence interval [CI]: −29.3 to −21.7), or triage category 2 (change in waiting-time: −21.8%; 95% CI: -23.7 to −20.05). Factors that most influenced longer waiting time were patient arrival during the morning shift period (change in waiting time: 5.45%; 95% CI: 4.59 to 6.31), or during the evening shift period (change in waiting time: 4.46%; 95% CI: 3.62 to 5.29). Ethnic discordance between triage nurses and patients did not yield longer waiting times.

Conclusion

In this large pediatric cohort, ethnic differences in ED waiting time were not found.

Emergency Department Utilization by Children in the USA, 2010-2011

INTRODUCTION

Epidemiological surveillance data for emergency department (ED) visits by children are imperative to guide resource allocation and to develop health policies that advance pediatric emergency care. However, there are sparse population-based data on patient-level information (e.g., the number of children who present to the emergency department [ED]). In this context, we aimed to investigate both the patient- and visit-level rates of ED utilization by children.

METHODS

This was a retrospective cohort study using population-based multipayer data - state ED databases (SEDD) and state inpatient databases (SID) - from six geographically-dispersed U.S. states (California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all children aged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visit rate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDD and SID data. We also repeated the analysis using the 2010 data to determine the consistency of the results across different years.

RESULTS

In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states. At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of these children, 25% presented to EDs 2-3 times per year with an approximately 1.5-fold variation across the states (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At the visit-level, 6.7 million ED visits were made by children in 2011 - 34 ED visits per 100 children annually. ED visits by children accounted for 22% of all ED visits (including both adults and children), with a relatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the 2010 data gave similar results for the ED utilization by children.

CONCLUSION

By using large population-based data, we found a substantial burden of ED visits at both patient- and visit-levels. These findings provide a strong foundation for policy makers and professional organizations to strengthen emergency care for children.

Infection-related mortality in Hispanic and non-Hispanic children with cancer

BACKGROUND

Hispanic children with cancer experience poorer survival than their White counterparts. Infection is a known cause of cancer-related mortality; however, little is known about the risk of infection-related death among Hispanic children with cancer. We examine the association of Hispanic ethnicity with infection-related mortality and life-threatening events among children with cancer.

PROCEDURE

For a cohort of all pediatric cancer patients diagnosed from 1986 to 2012 and treated at a single tertiary care center, we obtained national death records to determine all-cause mortality and infection-related mortality, as well as intensive care unit (ICU) admissions as a surrogate for life-threatening events. Cox proportional hazard models assessed all-cause mortality and infection-related mortality using ethnicity as the main independent variable. ICU admission rates were modeled using a zero-inflated Poisson regression model. Models were adjusted for gender, diagnosis year, age, residential location, and diagnosis.

RESULTS

Of 6,198 patients, 741 (12%) were Hispanic. Mean follow-up was 11 years (SD = 8.04). There were 1,205 deaths, with 193 attributable to infection. Differences in all-cause mortality between Hispanic and non-Hispanic patients did not reach significance (hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.96-1.36). However, Hispanic patients were 68% (HR = 1.68, 95% CI: 1.16-2.43) more likely to have an infection-related cause of death. Hispanic ethnicity was statistically associated with a higher rate of ICU admissions (rate ratio = 1.32, 95% CI: 1.12-1.56).

CONCLUSION

Hispanic pediatric cancer patients were more likely to have an infection-related death and higher rates of ICU admissions than non-Hispanic patients. Infection may be an overlooked contributor to poorer outcomes among Hispanic patients.

Racial Differences in Pediatric Emergency Department Triage Scores

BACKGROUND

Racial disparities are frequently reported in emergency department (ED) care.

OBJECTIVES

To examine racial differences in triage scores of pediatric ED patients. We hypothesized that racial differences existed but could be explained after adjusting for sociodemographic and clinical factors.

METHODS

We examined all visits to two urban, pediatric EDs between August 2009 and March 2010. Demographic and clinical data were electronically extracted from the medical record. We used logistic regression to analyze racial differences in triage scores, controlling for possible covariates.

RESULTS

There were 54,505 ED visits during the study period, with 7216 (13.2%) resulting in hospital admission. White patients accounted for 36.4% of visits, African Americans 28.5%, Hispanics 18.0%, Asians 4.1%, and American Indians 1.8%. After adjusting for potential confounders, African American (adjusted odds ratio [aOR] 1.89, 95% confidence interval [CI] 1.69-2.12), Hispanic (aOR 1.77, 95% CI 1.55-2.02), and American Indian (aOR 2.57, 95% CI 1.80-3.66) patients received lower-acuity triage scores than Whites. In three out of four subgroup analyses based on presenting complaints (breathing difficulty, abdominal pain, fever), African Americans and Hispanics had higher odds of receiving low-acuity triage scores. No racial differences were detected for patients with presenting complaints of laceration/head injury/arm injury. However, among patients admitted to the hospital, African Americans (aOR 1.47, 95% CI 1.13-1.90) and Hispanics (aOR 1.71, CI 1.22-2.39) received lower-acuity triage scores than Whites.

CONCLUSION

After adjusting for available sociodemographic and clinical covariates, African American, Hispanic, and American Indian patients received lower-acuity triage scores than Whites.