ED physicians may not be 'colorblind,' research says
Disparities exist in chest pain evaluations
A large, national review of patients presenting to emergency departments with chest pain surprised researchers with what it revealed about disparities in how chest pain patients are evaluated.
When they looked at chest pain patients by race, gender, and type of insurance, researchers saw differences that troubled them, says Liliana Pezzin, PhD, JD, one of the researchers.
But Pezzin, associate professor of medicine at the Medical College of Wisconsin, says what truly shocked her was the magnitude of the disparities. She says that in the report she wrote on the research, she and her coauthors "are careful to say that there's nothing we can do to point out the root causes [i.e., racism, gender discrimination, or economic discrimination]" for the disparities, because there are many causes other than racism or sexism.1
"But even we were surprised at the difference."
Chest pain is the most common initial symptom in patients diagnosed with coronary artery disease. Electrocardiography, chest radiography, oxygen saturation monitoring, and cardiac monitoring are noninvasive, relatively inexpensive tests, considered standard in chest pain patients. But Pezzin and her colleagues found, in their review of chest pain patients who presented to U.S. emergency departments between 1995 and 2000, that these common tests are applied differently based on patients' race, gender, and insurance.
Root cause of disparity unknown
Pezzin and her colleagues drew on data compiled by the National Hospital Ambulatory Health Care Survey of Emergency Departments (NHAMCS-ED) for patients 30 years old or older presenting with chest pain. The retrospective study used a sample of 7,068 patients, which corresponded to 32 million visits nationally throughout the six-year period.
They found that the rate of visits to emergency departments by patients presenting with chest pain increased, and that race, gender, and insurance differences appeared to be factors in the type of care patients received at emergency departments.
Overall, African-American males were 25%–30% less likely to receive any of the tests than non-African-American males.
Gender was also an issue in determining what tests the patients received. African-American women were approximately 5% less likely to have electrocardiography tests than non-African-American men.
African-American women were also 17% less likely to undergo cardiac monitoring, 14% less likely to have oxygen saturation monitoring, and 6% less likely to have chest radiography tests than non-African-American men. Similarly, the rate of testing was lower for non-African-American women than it was for non-African-American men.
"We're careful to say that there's nothing we can do to point out the root causes; we're just documenting the differences, some of which may be explained by differential presentation, or even the ways people of different genders and race communicate their symptoms," she says.
Other findings that point to disparities involving race, gender, and insurance coverage include:
- Use of all forms of diagnostic testing and monitoring, with the exception of oxygen saturation monitoring, decreased among male African-American patients over the review period. Electrocardiography decreased more than 16% among male African-American patients, and they were 26% less likely to be placed on cardiac monitoring in 2000 than they were in 1995;
- Approximately 82% of commercially insured non-African-American men received electrocardiography testing when presenting with chest pain in 2000, nearly a 27% higher proportion than uninsured African-American men, and a 31% higher proportion than African-American men covered by non-commercial forms of insurance.
Not only did insurance status surface as a category in the data, but the type of insurance also appeared to have a role in the administration of tests, Pezzin says.
Patients covered by forms of insurance other than commercial insurance were approximately 13% less likely to undergo electrocardiography. Additionally, patients covered by these forms of insurance were almost 21% less likely to be placed on cardiac monitoring, 23% less likely to have oxygen saturation measured, and more than 13% less likely to receive chest radiography than patients covered by commercial insurance.
"This was a group [the emergency department population] in which there had been no real large study of this kind of disparity," says Pezzin. "What this is setting up is not only to show disparities, but also that there are disparities over time — and that the disparities are not narrowing, but actually getting larger."
Pezzin stresses that there can be many reasons for disparities in the administration of diagnostic tests, including misconceptions about chest pain among different populations, provider behavior, and communication problems between providers and patients.
"But with a set of tests that are relatively inexpensive and relatively standard, the guidelines are clear," she add. "So we need to do more to learn why there are these disparities."
Whereas there might be control factors, such as severity of symptoms, that the physicians would have known but researchers did not, which could have informed physician decisions about testing, decisions based on insurance would be more difficult to justify, Pezzin continues.
"There is no evidence that the underinsured group is presenting with less severe symptoms, yet the difference [in whether they are tested] is pretty marked," she says.
Study a 'biopsy' of disparity
Disparity in the delivery of health care is an ongoing subject of discussion, and is being studied at every point of delivery — office, hospital, diagnosis, treatment, and follow-up.
As Pezzin and her colleagues were reporting their findings, a grand jury inquest in Illinois returned a homicide finding in the death of a 49-year-old African-American woman who died of a heart attack after waiting two hours to be seen in the emergency room of a Waukegan hospital in July 2006. The grand jury's finding in September against Vista Medical Center East is believed to be the first of its kind, and state prosecutors continue to probe whether they will pursue homicide charges against anyone at the hospital.
In the Waukegan case, the coroner found that Beatrice Vance's death was due to a heart attack caused by a blocked artery, but that "delayed and inadequate treatment" contributed to her death. The grand jury said her death was the result of a heart attack, but contributing to it were "gross deviations from the standard of care that a reasonable person would have exercised in this situation" — including the absence of cardiac monitoring or an electrocardiogram during the two hours she was in the emergency room waiting area.
"That case was really amazing," Pezzin comments. Her study, she says, "is a biopsy that shows something is going on that needs to be studied, and relatively quickly, because a large population is being misdiagnosed."
Natural points for follow-up include studying patient-physician communication and looking at standing orders that might affect decisions made before physicians ever see patients who come to the emergency department.
Both surprising and dismaying to Pezzin, she says, is that physicians in the emergency department may not be as "colorblind" as they have always believed.
"We have always heard it said that ED physicians are really colorblind, altruistic people, almost by selection, so it was surprising to find that maybe they're really not," she says. "Maybe we're all as subject to the same biases that are so pervasive elsewhere in society."
Reference
- Pezzin LE, Keyl PE, Green GB. Disparities in the emergency department evaluation of chest pain patients. Acad Emerg Med 2007;14:149-156.
Sources
For more information, contact:
- Liliana Pezzin, PhD, JD, Health Policy Institute, Medical College of Wisconsin (LEP), Milwaukee, WI.
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