Socioeconomic inequality in access to timely and appropriate care in emergency departments

Patient and caregiver characteristics associated with differential use of primary care for children and young people in the UK: a scoping review

OBJECTIVE

To systematically map evidence to answer the research question: What is the relationship between the characteristics of children and young people (CYP) or their caregivers and primary care service use in the UK, taking into account underlying healthcare needs? DESIGN: Scoping review.

SETTING

Primary care.

ELIGIBILITY CRITERIA

English-language quantitative or mixed-methods studies published between 2012 and 2022.

DATA SOURCES

Medline, Embase, Scopus and Web of Science Social Sciences Citation Index, and grey literature.

RESULTS

22 eligible studies were identified, covering general practice (n=14), dental health (n=4), child mental health (MN) services (n=3) and immunisation (n=1). Only eight studies (36%) controlled for variables associated with healthcare need (eg, age, birth weight and long-term conditions). In these, evidence of horizontal inequity in primary care use was reported for CYP living in deprived areas in England, with and without complex needs. Horizontal inequity was also identified in primary care MN referrals for CYP in England identifying as mixed-race, Asian or black ethnicity, compared with their white British peers. No evidence of horizontal inequity was observed, however, in primary care use for CYP in England exposed to parental depression, or for CYP children from low-income households in Scotland. Increasing CYP's age was associated with decreasing primary care use across included studies. No studies were found regarding CYP from Gypsy or Traveller communities, children in care, or those with disabilities or special educational needs.

CONCLUSIONS

There is evidence that socioeconomic factors impact on CYP's primary care use, in particular age, ethnicity and deprivation. However, better quality evidence is required to evaluate horizontal inequity in use and address knowledge gaps regarding primary care use for vulnerable CYP populations and the impact of policy and practice related 'supply side' of primary care.

What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England

BACKGROUND

More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP.

METHODS

We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression.

RESULTS

Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it.

CONCLUSIONS

Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.

Assessing Diversity, Equity, and Inclusion in Patient-Facing Websites in Neurosurgical Departments in the United States

BACKGROUND

Patient-facing websites serve as essential platforms for disseminating information, engaging with patients, and increasing access to neurosurgical resources and services. Diversity, Equity, and Inclusion are at the forefront of issues facing the field of neurosurgery, especially concerning race and gender disparities in regards to providers in the field.

METHODS

Data were collected in regards to the race and gender of patients and providers displayed on the neurosurgery department's patient-facing website in addition to accommodations for disabilities, decreased ability to pay, and language.

RESULTS

Patients who were White were depicted more commonly than those of color (69% vs. 31%, P < 0.00001). White patients also were over-represented when compared with the average demographics of the communities in which the hospitals served (P = 0.03846). Neurosurgical providers who were White outnumbered those of color (70% vs. 30%, P < 0.00001). The racial depiction of providers was comparable with racial disparities currently observed in neurosurgery (P = 0.59612). Female neurosurgery providers were seen less than male providers on patient-facing websites (P < 0.00001) but were seen more commonly on patient-facing websites than the percentage of practicing neurosurgeons they currently comprise (28% vs. 8%, P < 0.00001).

CONCLUSIONS

The results of this study suggest that patient-facing websites of neurosurgical departments are an area of improvement in regards to Diversity, Equity, and Inclusion in the field of neurosurgery. Disparities are noted in regards to the racial depiction of patients and further call to attention racial and gender disparities in the field of neurosurgery.

Resuscitate, not palliate, emergency care

Emergency care in the UK is in crisis, and stories of long waits, poor care and harm have become commonplace. This situation can no longer be ignored. This article looks at some of the ways in which emergency care can be resuscitated.

Socioeconomic status is associated with process times in the emergency department for patients with chest pain

Objective

Emergency department length of stay (EDLOS) is linked to crowding and patient outcomes whereas worse prognosis in low socioeconomic status remains poorly understood. We studied whether income was associated with ED process times among patients with chest pain.

Methods

This was a registry-based cohort study on 124,980 patients arriving at 14 Swedish EDs between 2015 and 2019 with chest pain as their chief complaint. Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles, whether the time to physician assessment exceeded triage priority recommendations as well as EDLOS were evaluated using crude and multivariable regression models adjusted for age, gender, sociodemographic variables, and ED-management circumstances.

Results

Patients with the lowest income were more likely to be assessed by physician later than triage recommendations (crude odds ratio [OR] 1.25 (95% confidence interval [CI] 1.20-1.29) and have an EDLOS exceeding 6 h (crude OR 1.22 (95% CI 1.17-1.27). Among patients subsequently diagnosed with major adverse cardiac events, patients with the lowest income were more likely to be assessed by a physician later than triage recommendations, crude OR 1.19 (95% CI 1.02-1.40). In the fully adjusted model, the average EDLOS was 13 min (5.6%) longer among patients in the lowest income quintile, 4:11 [h:min], (95% CI 4:08-4:13), compared to patients in the highest income quintile, 3:58 (95% CI 3:56-4:00).

Conclusions

Among ED chest pain patients, low income was associated with longer time to physician than recommended by triage and longer EDLOS. Longer process times may have a negative impact due to crowding in the ED and delay diagnosis and timely treatment of the individual patient.

Access to Healthcare and Health Literacy in Croatia: Empirical Investigation

Health literacy is related to different health-related outcomes. However, the nature of the relationship between health literacy and health outcomes is not well understood. One pathway may lead from health literacy to health outcomes by means of access to healthcare. The goal of the current study is to explore the association between health literacy and the particular measure of access to healthcare-unmet medical need-for the first time in Croatia and, to the best of our knowledge, for the first time in the EU context. We use data obtained from face-to-face interviews in a large nationally representative sample of the Croatian population (n = 1000) to estimate the level of health literacy and self-reported access to care and investigate the association between health literacy and self-perceived barriers to access. Our study showed that limited and problematic health literacy is prevalent and associated with higher rates of unmet medical need. Unmet need is largely caused by long waiting lists. It is therefore essential to design health services fitting the needs of those who have limited and/or problematic health literacy as well as enhance health education with the potential of improving the access to care and health outcomes as well as design policies that reduce waiting times.

Mental health adverse events with cannabis use diagnosed in the Emergency Department: what are we finding now and are our findings accurate?

We have previously reviewed the types and numbers of cannabis-associated adverse events that have mental health presentations that are encountered in the Emergency Department. A particular challenge in examining these events is disentangling cannabis use adverse events from adverse events associated with use of multiple recreational substances. Since that review was published, cannabis legalization for recreational use has greatly expanded world-wide and with these changes in the legal climate has come clearer information around the frequency of adverse events seen in the Emergency Department. However, as we examined the current state of the literature, we also examined some of research designs and the biases that may be impacting the validity of the data in this field. The biases both of clinicians and researchers as well as research approaches to studying these events may be impacting our ability to assess the interaction between cannabis and mental health. For example, many of the studies performed examining cannabis-related admissions to the Emergency Department were administrative studies that relied on front line clinicians to identify and attribute that cannabis use was associated with any particular admission. This narrative review provides an overview on what we currently know about mental health adverse events in the Emergency Department with a focus on the mental health impacts both for those with and without a history of mental illness. The evidence that cannabis use can adversely impact genders and sexes differently is also discussed. This review outlines what the most common adverse events related to mental health with cannabis use are; as well as noting the most concerning but much rarer events that have been reported. Additionally, this review suggests a framework for critical evaluation of this field of study going forward.