Association Between Perceived Discrimination and Emergency Department Use Among Safety-Net Patients in the Southwestern United States

Is frequent emergency department use a complement or substitute for other healthcare services? Evidence from South Carolina Medicaid enrollees

OBJECTIVE

To compare healthcare services utilization across the healthcare system between frequent and non-frequent emergency department (ED) users among Medicaid enrollees in South Carolina.

STUDY SETTING AND DESIGN

We conducted a retrospective, longitudinal study of individuals with at least one ED visit in 2017 in South Carolina and identified their healthcare services visits over 730 days (2 years) after their first ED visit. We classified individuals based on intensity of ED use: superfrequent (≥9 ED visits/year), frequent (4-8 ED visits/year), and non-frequent ED users (≤3 visits/year). We estimated differences between the three groups of ED users and non-ED hospital and office-based visits using multivariable two-part regression models.

DATA SOURCES AND ANALYTIC SAMPLE

We used statewide Medicaid claims from January 2017 to December 2019 for ED users aged 18-64 years with continuous Medicaid enrollment. We analyzed data on all frequent and superfrequent users and selected a 4:1 random sample among all non-frequent users (~half of all non-frequent users).

PRINCIPAL FINDINGS

The study included 52,845 ED users, of whom 42,764 were non-frequent, 7677 frequent, and 2404 superfrequent users. Within 2 years from the date of their first ED visit, superfrequent ED users averaged 38.3 ED visits, frequent ED users 10.9 ED visits, and non-frequent ED users 2.6 ED visits (p < 0.001). Compared with non-frequent users, frequent and superfrequent ED users had more comorbidities and chronic conditions on average (1.6 vs. 3.5 vs. 6.4, p < 0.001). Both frequent and superfrequent users had more hospital visits beyond the ED overall (marginal effects: 0.23, 95% CI 0.18-0.27; 0.40, 95% CI 0.29-0.50), and more outpatient office visits overall (marginal effects: 4.39, 95% CI 2.52-6.27; 9.23, 95% CI 5.66-12.81), including primary care and most specialists' visits, compared with non-frequent users.

CONCLUSIONS

Frequent ED users utilized non-ED hospital and outpatient office-based healthcare services significantly more than non-frequent ED users. These findings can guide tailored interventions using data across the healthcare system to efficiently coordinate care, contain costs, and improve health outcomes for these individuals.

Development and validation of a questionnaire to evaluate attitudes and beliefs of discrimination by nursing staff

OBJECTIVE

Aim: The purpose of this study is to report on the development and initial psychometric testing of a questionnaire to investigate nurses' discrimination attitudes and beliefs towards people of dif f erent ethnic origins.

PATIENTS AND METHODS

Materials and Methods: The initial stage involved the selection of the questions of the tool after a comprehensive evaluation of the relevant international literature and the tools used in previous related studies. The reliability (forward-backward translation) of the questions was assessed, along with the content, face, and structure. To conduct the study, which was carried out from 07/2021 to 01/2022 a sample consisting of 30 and 2,034 nurses and their assistants was used for the pilot and the fi nal research, respectively.

RESULTS

Results: Given that the Kaiser-Meyer-Olkin (KMO) threshold value of 0.89 was achieved, the sample was considered sufficient and appropriate for factor analysis. A statistically signif i cant result (p<0.001) from Bartlett's test indicated a substantial connection between the questions and conf i rmed that the data were suitable for factor analysis. Twenty statements altogether, with seven possible answers ranging from "totally disagree" to "completely agree," were included in the questionnaire. For the questions, three distinct factors - communication, difficulties, and discrimination - were shown to account for 47.1% of the variability. Reliability analyzes showed satisfactory Cronbach alpha coefficient scores for all factors, ranging from 0.78 to 0.82.

CONCLUSION

Conclusions: The current study demonstrates that the questionnaire we developed is a legitimate and trustworthy instrument for evaluating professional nurses' discriminatory attitudes and beliefs toward individuals from various ethnic backgrounds. The questionnaire can be used to help design interventions to end discrimination, guarantee equitable access to healthcare services, and provide high-quality care for individuals from diverse backgrounds. It can also be used to identify the factors that inf l uence nurses' attitudes and perceptions toward these patient populations.

Care of Sexual and Gender Minorities in the Emergency Department: A Scoping Review

STUDY OBJECTIVE

This scoping review was conducted to collate and summarize the published research literature addressing sexual and gender minority care in the emergency department (ED).

METHODS

Using PRISMA-ScR criteria, an electronic search was conducted of CINAHL, Embase, Ovid Medline, and Web of Science for all studies that were published after 1995 involving sexual and gender minorities, throughout all life stages, presenting to an ED. We excluded non-US and Canadian studies and editorials. Titles and abstracts were screened, and full-text review was performed independently with 4 reviewers. Abstraction focused on study design, demographics, and outcomes, and the resulting data were analyzed using an ad hoc iterative thematic analysis.

RESULTS

We found 972 unique articles and excluded 743 after title and abstract screening. The remaining 229 articles underwent full-text review, and 160 articles were included. Themes identified were HIV in sexual and gender minorities (n=61), population health (n=46), provider training (n=29), ED avoidance or barriers (n=23), ED use (n=21), and sexual orientation/gender identity information collection (n=9).

CONCLUSION

The current literature encompassing ED sexual and gender minority care cluster into 6 themes. There are considerable gaps to be addressed in optimizing culturally competent and equitable care in the ED for this population. Future research to address these gaps should include substantial patient stakeholder engagement in all aspects of the research process to ensure patient-focused outcomes congruent with sexual and gender minority values and preferences.

Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

OBJECTIVES

Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.

METHODS

We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.

RESULTS

Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.

CONCLUSION

Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.

PRACTICE IMPLICATIONS

We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.

Insurance impacts survival for children, adolescents, and young adults with bone and soft tissue sarcomas

Background

While racial/ethnic survival disparities have been described in pediatric oncology, the impact of income has not been extensively explored. We analyzed how public insurance influences 5‐year overall survival (OS) in young patients with sarcomas.

Methods

The University of California San Francisco Cancer Registry was used to identify patients aged 0‐39 diagnosed with bone or soft tissue sarcomas between 2000 and 2015. Low‐income patients were defined as those with no insurance or Medicaid, a means‐tested form of public insurance. Survival curves were computed using the Kaplan‐Meier method and compared using log‐rank tests and Cox models. Causal mediation was used to assess whether the association between public insurance and mortality is mediated by metastatic disease.

Results

Of 1106 patients, 39% patients were classified as low‐income. Low‐income patients were more likely to be racial/ethnic minorities and to present with metastatic disease (OR 1.96, 95% CI 1.35‐2.86). Low‐income patients had significantly worse OS (61% vs 71%). Age at diagnosis and extent of disease at diagnosis were also independent predictors of OS. When stratified by extent of disease, low‐income patients consistently had significantly worse OS (localized: 78% vs 84%, regional: 64% vs 73%, metastatic: 23% vs 30%, respectively). Mediation analysis indicated that metastatic disease at diagnosis mediated 15% of the effect of public insurance on OS.

Conclusions

Low‐income patients with bone and soft tissue sarcomas had decreased OS regardless of disease stage at presentation. The mechanism by which insurance status impacts survival requires additional investigation, but may be through reduced access to care.