AUTHORS
Ava Pierce, MD, Professor, Associate Chair, Diversity and Inclusion, Emergency Medicine, University of Texas Southwestern, Dallas
Marquita Norman, MBA, MD, Associate Professor, Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
Juan Rendon, MD, Assistant Professor, Emergency Medicine, University of Texas Southwestern, Dallas
Danielle Rucker, MD, Emergency Medicine Resident, University of Texas Southwestern, Dallas
Larissa Velez, MD, Professor, Vice Chair, Education, Emergency Medicine, University of Texas Southwestern, Dallas
PEER REVIEWER
Robert Powers, MD, MPH, Professor of Medicine and Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA
EXECUTIVE SUMMARY
- Chronic stress can lead to biologic changes that can result in hypertension, high cholesterol, and exaggerated effects of aging.
- Health disparities lead to variations in care in the emergency department (ED). These include delays in pain medication, lower doses of pain medication, less use of diagnostic testing, and differences in outcomes.
- Health disparities have a complex and multifactorial basis. Reducing health disparities is possible by using standardized protocols and by increased use of shared decision-making.
- Emergency departments can reduce the impact of health disparities and social determinants of health by providing social services at the time of ED visit.
— Sandra M. Schneider, MD, FACEP, Editor
Introduction
It is projected that people of color, defined as Black, American Indian or Alaska Native, Hispanic, Native Hawaiian or other Pacific Islander, and Asian, will account for more than half of the U.S. population in 2050. As the population becomes more diverse, addressing health disparities and understanding the social determinants of health is increasingly important.1
Disparities in Health
Health disparities are differences in health and healthcare between populations. These differences are closely linked to social, economic, and/or environmental disadvantages. Disparities occur across a broad spectrum of descriptors, including race/ethnicity, socioeconomic status, age, location, gender, disability status, gender identity, and sexual orientation. Health disparities affect individual patients and limit overall gains in public health.1
For the purposes of this article, the terms white and non-white, which are the currently accepted terms, will be used interchangeably with terms like Black, African American, Hispanic, etc. The terms Hispanic, Latino(a), and Latinx also are used interchangeably. LGB, LGBT, and LGBTQ are equally used interchangeably, according to the term used in each paper cited.
Importance of Diversity, Equity, and Inclusion
Diversity in medicine involves inclusiveness, mutual respect, and multiple perspectives, with a goal of attaining health equity. Diversity means being mindful of inclusion of all aspects of human differences, such as race, ethnicity, socioeconomic status, language, nationality, gender, gender identity, sexual orientation, religion, geography, veteran status, need for accommodations, and age. Inclusion is essential for successfully achieving diversity. Inclusion is achieved by nurturing the climate and culture of the institution through professional development, education, policy, and practice. An inclusive environment fosters belonging, respect, and value for all and encourages engagement and connection throughout the institution and the community it serves.
Equity involves providing patients and the workforce the things that they need to be successful. It does not involve providing everyone the same things, but instead meeting individual needs. Equity assures that those in the workforce can attain their full potential by promoting fair treatment and proactively working to remove barriers that have prevented full participation by some segments of the population. Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This involves removing measurable, systemic, avoidable, and unjust differences in healthcare access, utilization, quality, and outcomes between groups stemming from differences in levels of social advantage and disadvantage.2
A diverse workforce is more able to deliver equitable care by providing:
- greater recognition of inequitable care;3
- improved access to care with increased practices in areas that are underserved, including rural areas and minority communities;4,5
- improved learning environments for diverse learners;6
- increased cultural competence/sensitivity;7
- a greater chance for physician-patient concordance.8,9
Factors Associated with Health Disparities
The social determinants of health are societal and economic factors that affect the health of individuals and communities. Ultimately, they are responsible for some health inequities, since in most societies resources and opportunities are not equally distributed. Health inequities are the “unfair and avoidable differences in health status seen within and between populations.”10
Virtually every aspect of society plays a role in overall health. This includes where people are born; where they live, grow, and age; and where they get educated, work, and play. It also includes the social structures and economic systems that shape these locations and communities.10 (See Table 1 for examples, available online: https://bit.ly/3FnaAtS)
The Roles of Stress and Discrimination in Health
All of these situations result in higher levels of chronic stress. In general, chronic stressors are worse than acute ones. Stress can be intergenerational (sometimes called “historical stress”), meaning that a past stressor causes stress in other family members not directly involved. Acute stress can include anticipatory stress, which is the worry and rumination on a situation that might result in racism or discrimination.14
There is increasing evidence that stress can induce biological “wear and tear,” or allostatic load. Stress can induce a pro-inflammatory response, including the production of interleukin-6 and C-reactive protein, induce higher blood pressure, and produce unfavorable cholesterol profiles.15-17 Stress also has been associated with changes in epigenetic processes that suppress or express genes and change telomere length.18 Telomeres protect DNA against damage, and their shortening is a measure of aging. Early life socioeconomic disadvantages and stress seem to be particularly problematic, but these effects are all cumulative.19
Gender, race/ethnicity, education, income, disability, and sexual orientation may be independent contributors to health disparities.10 Disparities also are associated with certain medical diagnoses, including human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome, viral hepatitis, sexually transmitted infections (STIs), intravenous drug use, substance use disorders (SUDs), tuberculosis, and obesity.20 Incarceration also has been noted as a factor for health disparities.
For example, African Americans, and to some extent, Latinos, are less likely to receive appropriate heart medications, undergo coronary artery bypass graft, receive peritoneal dialysis or kidney transplantation, and receive intensive care. There are racial differences in cancer care and in the delivery of analgesia, and differences in HIV care, with minorities receiving less antiretrovirals and less Pneumocystis jiroveci pneumonia prophylaxis. All of these disparities lead to higher mortality.13 Other important areas of disparities in healthcare include pediatric care, maternal care, mental healthcare, nursing home access, and rehabilitation care. Surgical decision in the selection of care options for minorities may result in fewer desired procedures (such as revascularizaton) and more undesirable procedures (such as amputation and orchiectomy).13
Discrimination is associated with poorer mental health status, with delays in seeking care and lower adherence to medical treatment. Discrimination also is associated with higher rates of SUDs, such as ethanol, drugs, and smoking. It leads to lower intensity and quality of care, even when adjusted for disease stage and other clinical parameters.21 Delays in seeking care and lack of seeking preventive care can be the result of internalized racism (self-stigmatization) — when one accepts the dominant society stereotype of a minority group. Finally, aggressive behavior and conduct disorders can contribute to interpersonal violence and traumatic injury or death.
Drivers of disparities can be at the provider level, including physician and provider personal bias/prejudice against minorities, greater clinical uncertainty when interacting with minority patients, and beliefs/stereotypes held by the provider about the behavior or health of minorities.22 Several studies have demonstrated that racial and ethnic minorities have less shared decision-making, less patient-centered care, and more physician verbal dominance in the encounters.23
Medical care is not the only determinant of health. All of the social and environmental factors discussed earlier play a critically important role in the overall health of individuals. They are powerful determinants and represent the intersection of medical care and public health. The subject is hard to study: It is complex and multifactorial, and there can be a long lag between exposure and effect. It also is difficult to obtain information across many sectors and public agencies, such as education, planning, housing, labor, and health.24
In opposition to these negative forces, there are many identified positive societal factors that counterbalance and lessen the negative social determinants of health. These include strong family and social support, a sense of self-esteem and self-efficacy, and resilience.25,26 When basic needs are met by routes other than income, then the effect of poverty is diminished. Health improves incrementally as social position and education improve. This has been measured as life expectancy based on educational attainment and as infant mortality rates based on educational attainment.27 Finally, genetics can be protective, and some negative genetic predispositions may need modifiable environmental triggers.
Healthy People 2030 (report available at https://www.cdc.gov/nchs/about/factsheets/factsheet-hp2030.htm) identifies five key areas in which to work so these health disparities can be reduced or eliminated:
1. Healthcare access and quality: access to and understanding of health services and individual’s own health. This includes primary care access, emergency health access, health insurance coverage, and health literacy.
2. Education access and quality: measured by graduation from high school, enrollment in higher education, education attainment, language, and literacy. Work on early childhood education and child development and improvements in job training.
3. Social and community context: improvements in cohesion within a community, civic participation, and conditions in the workplace; decreased discrimination and decreased incarceration rates.
4. Economic stability: improvements in income and socioeconomic status, coupled with lower cost of living, food security, and housing stability.
5. Neighborhood and built environment: work on improved quality of housing, access to transportation, availability of healthy foods, better air and water quality, more availability of recreation, and access to media and technology, as well as efforts to lower neighborhood crime and violence.
Workforce Environment and Diversity Effects on Health Disparities
The number of underrepresented in medicine (URiM) physicians continues to be far less than their percentages in the population. However, racial and ethnic minority patients are four times more likely to receive their healthcare from non-white physicians than white physicians, and URiM physicians have a greater percentage of their patients coming from minority communities.28 Although Black and Hispanic physicians account for a very small percentage of the physician population, they care for 25% of Black patients and 23% of Hispanic patients.29 Increasing the diversity of the medical workforce may help to elucidate better understanding of racial and ethnic health disparities.21,30
Specific medical conditions and vulnerable populations commonly seen in the emergency department (ED) are reviewed in the following sections. (See Table 2.)
Table 2. Disparities in Health: Conditions | |
Condition |
Health Disparity |
Trauma |
Although trauma care should be considered as an equalizer when it comes to healthcare disparities, data have shown that non-white patients have worse trauma-related outcomes than white patients. |
Cerebrovascular accident |
African Americans and Hispanics have a higher frequency of stroke, a higher mortality rate after a stroke, and a larger incidence of risk factors, including diabetes and hypertension. |
Cardiac disease |
Door-to-therapy times are significantly longer for African American, Hispanic, and Asian patients who receive thrombolytics or percutaneous coronary intervention. |
Pain management |
Black and Hispanic patients were less likely than white patients to receive analgesia for acute pain. |
Mental health |
Wait times for non-Hispanic Black patients with mental health and substance use disorders are significantly longer than for non-Hispanic white patients. |
COVID-19 |
Black and Latinx patients account for a disparate percentage of morbidity and mortality. |
Diabetes mellitus |
Racial and ethnic minorities bear the brunt of the diabetes epidemic: higher prevalence, worse disease control, and more complications. |
Maternal mortality |
Non-Hispanic Black patients die during childbirth or within one year postpartum at a rate three to four times higher than that of non-Hispanic white and Latina patients. |
Hypertension |
According to the U.S. National Health and Nutrition Examination Survey, non-Hispanic Blacks are more likely to be diagnosed with hypertension compared to non-Hispanic whites. |
Asthma |
Mortality rates among Black and Puerto Rican patients with asthma are three times higher than the rates among white patients. |
Trauma
Although many low-income and non-white patients historically have been faced with a lack of access to healthcare resources, trauma care should be considered as an equalizer when it comes to healthcare disparities because of equal access to emergency medical treatment that is federally mandated. Unfortunately, multiple studies have shown that non-white patients have worse trauma-related outcomes, in both mortality and post-trauma function, than white patients.31 A few factors involved in this healthcare disparity include mechanisms of injury, insurance status, access to trauma centers, and physician implicit bias.
In adolescents presenting to the ED for head and neck trauma, sports and motor vehicle incidents are the mechanism of injury more commonly seen in white patients, whereas assault is seen more commonly in Black patients.32 Data show that non-white workers are at increased risk of occupational injury. One specific study examined the incidence of back and extremity injuries in workers and found that Hispanic workers were twice as likely to develop back and upper extremity injuries as white workers.33
Insurance status also plays a role when it comes to trauma outcomes in both adult and pediatric patients. Uninsured patients have a significantly increased risk of mortality when compared to insured patients.34 Compared to urban areas and major cities, rural areas are associated with significantly decreased access to trauma care.35 Additionally, in urban geographical regions, Black-majority neighborhoods also appear to have consistent disparities in access to trauma centers.36
A study conducted at a community-based Level II trauma center demonstrated that race was associated with a statistically significant difference in the treatment of pain from long bone fractures. In this study, non-white patients were less likely to receive opioid pain medications than white patients, raising concern for physician bias in the management of acute pain.37 Another study, which used a multivariable analysis, demonstrated that Black patients had longer wait times for a trauma consultation in the ED of a Level I trauma center.38
Understanding the disparities seen in the access, mechanisms of injury, treatments, and outcomes can allow emergency care clinicians the opportunity to identify and investigate the social determinants of health involved that underlie these discrepancies.
Cerebrovascular Accidents
Stroke is a leading cause of death in the United States and is a major cause of serious disability for adults.39,40 About 795,000 people in the United States have a stroke each year.40 African Americans and Hispanics have a higher frequency of stroke, a higher mortality rate after a stroke, and a larger incidence of risk factors, including diabetes and hypertension (HTN).41 Disparities in access to care or quality of care may result in different rates of stroke mortality.
Differences in socioeconomic status and insurance coverage, cultural and language barriers, mistrust of the healthcare system, the lack of diversity of the workforce, and system limitations all may contribute to these disparities.42 Studies have shown that minorities use emergency medical services (EMS) systems less, have delayed arrival to the ED, have longer waiting times in the ED, and have lower rates of thrombolytic administration for acute ischemic stroke. Although unmeasured factors may play a role in these delays, the presence of bias in the delivery of care cannot be excluded.42 The disparity in thrombolysis essentially disappeared when patients were evaluated within the recommended window of treatment.43,44 This provides an example of where standardization of care could minimize poor outcomes.45 Minorities have equal access to rehabilitation services, although they experience longer stays and have poorer final functional status than whites. Minorities also are inadequately treated with both primary and secondary stroke prevention strategies compared to whites.42
Cardiac Disease
Cardiovascular disease (CVD) is the leading cause of death for people of most racial and ethnic groups in the United States, including African American, American Indian, Alaska Native, Hispanic, and white men. For women from the Pacific Islands and Asian American, American Indian, Alaska Native, and Hispanic women, heart disease is second only to cancer.46 Between 2015 and 2018, 126.9 million U.S. adults had some form of CVD. Between 2016 and 2017, direct and indirect costs of total CVD were $363.4 billion ($216.0 billion in direct costs and $147.4 billion in lost productivity/mortality). In 2015 to 2018, 58.8% of non-Hispanic Black females and 60.1% of non-Hispanic Black males had some form of CVD. In 2018, coronary heart disease was the leading cause (42.1%) of deaths attributable to CVD in the United States, followed by stroke (17.0%), high blood pressure (11.0%), heart failure (9.6%), diseases of the arteries (2.9%), and other CVD (17.4%).47
Investigations into the care of patients presenting to the ED with chest pain, acute coronary syndrome, and acute myocardial infarction (AMI) have demonstrated lower use of diagnostic tests and delays in obtaining these studies for non-white patients.48-50 One study found that, when compared with white patients, Black patients presenting with chest pain were less likely to have an electrocardiogram (ECG) ordered. Patients with Medicare, Medicaid, and no insurance also were less likely to have an ECG ordered compared to patients with private insurance. Those with Medicare and Medicaid were less likely to be triaged emergently, and those with Medicare were less likely to have cardiac enzymes ordered.51
Non-white patients are significantly less likely to undergo cardiac stress testing or receive reperfusion therapies, including cardiac catheterizations. Door-to-therapy times are significantly longer for African American, Hispanic, and Asian patients who do receive thrombolytics or percutaneous coronary intervention (PCI).52-54 A review of non-ST elevation myocardial infarction patients showed that women had higher in-hospital mortality rates, longer ED lengths of stay, and were much less likely to receive an early invasive strategy (defined as diagnostic coronary angiography within 24 hours of arrival) than men.55
A review of AMI patients within the equal-access, government-subsidized Department of Defense healthcare system demonstrated no race-based variability in the rate of immediate revascularization procedures.56 In another study, participants were randomly assigned to receive usual inpatient care, or Accelerated Chest pain Evaluation with Stress imaging (ACES), with the ACES care pathway including placement in observation for serial cardiac markers and an expectation for stress imaging. In usual care, objective testing occurred less frequently among African Americans (71%) than among white (88%) participants, primarily driven by cardiac catheterization (3% vs. 24%). In the ACES pathway, testing rates did not differ by race. The researchers concluded that a care pathway with the expectation for stress imaging eliminates the racial disparity between African American and white participants with chest pain in the acquisition of index-visit cardiovascular testing.57 These studies suggest that a healthcare system that does not have a disparity in access, or that follows defined management guidelines, could help bridge the racial gap in cardiac care.
Pain Management
Pain is one of the main complaints of patients who present to the ED and comprises almost 80% of the causes for referral to the ED.58-60 Pain management has been used as an evaluative marker for ED care because it is one of the quality-of-care indicators.61 Patients whose primary pain is well managed and treated in the ED have a higher overall satisfaction with hospital services.60,62,63 Multiple factors contribute to the choice of analgesia, including sex, age, race, underlying illness, ability to express pain, and physician awareness of the patient’s pain. Pain should be managed while the patient is being evaluated, and pain control should not be delayed while awaiting diagnostic testing and consultation. The pain regimen should be chosen to improve pain while limiting side effects and interactions with other medications.64 Systemic pain management frequently is accomplished with administration of narcotics or nonsteroidal anti-inflammatory drugs.
Multiple studies have documented disparities in the use of analgesia in the ED. A study of patients presenting to the ED with urolithiasis found that Black and Hispanic patients with acute renal colic received less opioid medication than white patients. Black patients also were less likely to receive ketorolac.65 A study of patients diagnosed with long-bone fractures revealed that white patients were more likely to receive opioids for their long-bone fractures compared with non-white patients.37 Another study revealed differences in process and outcome measures by race and ethnicity in the ED management of pain among children with long-bone fractures. Although minority children in the study were more likely to receive analgesics and achieve greater than two-point reduction in pain, they were less likely to receive opioids and achieve optimal pain reduction.66 A systematic review and meta-analysis that included 14 studies from 1990 to 2018 compared racial and ethnic differences in the administration of analgesia for acute pain and found that Black and Hispanic patients were less likely than white patients to receive analgesia for acute pain.67
Disparities in pain control also have been noted in the prehospital setting, with a study showing that Hispanic and Asian patients who requested EMS services for traumatic injuries were less likely to have their pain assessed, and all racial/ethnicity minority patients were less likely to be treated with pain medications when compared to white patients.68
Mental Health
ED use by patients with mental health and SUD has been identified as a contributor to ED overcrowding in both adult and pediatric populations. Mental health-related ED visits among children are increasing overall. However, there is a disproportionate increase among children from minority backgrounds.69
These patients are subject to prolonged ED wait times. Racial disparities in the wait times have been observed, noting that wait times for non-Hispanic Black patients with mental health and SUDs were significantly longer than for non-Hispanic white patients.70 Similarly, increased lengths of stay also have been reported for pediatric mental health ED visits. Similar to Black patients, research suggests that Hispanic children have an increased risk of prolonged ED lengths of stay compared with white non-Hispanic children.71 Increasing telehealth capabilities and expanding community partnerships have been proposed as strategies to address these mental health disparities.
In 2017, Maura et al performed a literature review to examine the evidence surrounding the presence of racial/ethnic disparities in mental healthcare among individuals with severe mental illness. This research indicates that racial and ethnic minorities have less access to regular mental health services, are less likely to receive and use necessary mental healthcare, receive less quality of care, are less satisfied with professional mental health services, and have higher dropout rates from these services when compared to whites.72 This all leads to higher use of urgent and emergent mental health and SUD resources, like the ED.
Common mental diseases, such as depression and anxiety disorders, are prevalent, disabling, and costly, resulting in a decreased quality of life, medical morbidity, and excess mortality. Despite this fact, racial minorities have more mental illness stigma from common mental diseases when compared with racial majorities. The consequences of this disparity can be detrimental to health. Additionally, when one considers the intersection of mental health with social adversities such as migration, poverty, gender, and ethnic and/or sexual minority status, the result can be underuse of mental health services among those who are disproportionately affected.73
COVID-19
During the past year, the COVID-19 pandemic has led to a considerable burden on healthcare systems worldwide. In the United States, the pandemic overwhelmed several metropolitan areas, with data from multiple states demonstrating racial disparities in the rates of COVID-19 cases and COVID-19-related deaths. These disparities have been attributed to underlying marginalization, systemic racism, and lack of access to healthcare. Additionally, language barriers, limited access to housing and healthy food options, and lack of health insurance also contribute to the disproportionate burden of COVID-19 among racial and ethnic minorities.
As the United States was experiencing the first surge of COVID-19 cases in the summer of 2020, Black and Latinx patients accounted for a disparate percentage of morbidity and mortality.74,75 Overall, Black patients had higher rates of hospitalizations and intensive care unit (ICU) admissions. Furthermore, Black patients had a 1.81 times increased risk of requiring ventilator support compared to their white counterparts. Black patients also had a higher risk of mortality compared to white patients.76 EDs and other safety-net systems should be aware of these disparities as they provide information and care to the medically and socially vulnerable.
Vaccine hesitancy, which is the decision to delay vaccination or to refuse it despite its availability and effectiveness, also is shown to disproportionately affect minorities. One study demonstrated statistically significant greater odds of vaccine refusal among Blacks, particularly due to their concerns about safety, effectiveness, lack of insurance, and lack of financial resources.77 An organized effort from both the medical and scientific communities is necessary to provide effective communication about, and increased confidence in, the COVID-19 vaccines. Our colleagues in the United Kingdom have suggested the targeted use of social media to reach demographics of concern to reduce misinformation and vaccine hesitancy.78
Diabetes Mellitus
Diabetes mellitus (DM) is seventh leading cause of death in the United States, with an annual cost of $327 billion. Type 2 DM accounts for 90% to 95% of all cases of diabetes.79 The condition has true epidemic proportions. Just two decades ago, there were 14 million cases in the United States, which accounted for 7% of the U.S. population. The percentages were higher in minority populations: 9% of Hispanics and 11% African Americans, and numbers are also thought to be higher in Native Americans, although data are limited.80,81 The latest Centers for Disease Control and Prevention data now show 34.2 million Americans with DM, or one of 10 people in the United States. The percentages of those with DM also are increasing in minorities: American Indian or Alaska Natives with 14.7% prevalence, Hispanics with 12.5%, non-Hispanic Blacks with 11.7%, non-Hispanic Asian Americans with 9.2%, and non-Hispanic white Americans with 7.5%. DM is more prevalent in women than in men. The incidence of DM is 1.5 million new cases per year (in 2018).79 Many more people are considered to have prediabetes, defined as fasting blood sugar between 100 mg/dL and 125 mg/dL or a glycosylated hemoglobin (Hgb A1c) between 5.7% and 6.4%.
There are many reported reasons for this higher incidence and prevalence of DM in minorities:
- There are genetic differences in glucose metabolism and homeostasis. This results in more incidence of hyperinsulinemia and insulin resistance.
- Higher levels of maternal stress (and higher levels of cortisol) lead to dysregulation of glucose.
- There are higher obesity rates and type of body fat distribution, with the United States ranked fifth highest in male obesity (at 44.2% of the population) and 12th highest in female obesity (at 48.3% of the population). There also is a higher incidence of visceral fat, which is worse than subcutaneous fat.82
Racial and ethnic minorities bear the brunt of the diabetes epidemic: higher prevalence, worse disease control, and more complications.83,84 People living in rural areas also show similar deficiencies.85 Minorities also have more concomitant disease burden, such as dyslipidemias and hypertension.86
Multiple studies show minorities as having more amputations, renal disease, and retinopathy, and an overall higher mortality.87,88 Racial and ethnic minorities also receive less quality of care: They receive less Hgb A1c testing (and have higher Hgb A1c levels), fewer eye exams, less cholesterol screening, and less hypertensive medications.89-92 They also receive fewer foot exams and less screening for microalbuminuria. African Americans are 1.5 times more likely to be hospitalized and 2.3 times more likely to die from DM.
Maternal Mortality
Pregnancy-related deaths in the United States are increasing, with a pregnancy-related mortality ratio (PRMR) higher than that in the best-performing high-resource nations. Medical, social, political, and cultural issues all have been suggested as possible explanations for this disparity. In a study evaluating pregnancy-related mortality in the United States between 2003 and 2016, overall pregnancy-related deaths continued to increase in all types of care delivery settings. However, the PRMR was significantly higher in non-Hispanic Black women. This study also reported that the rate of increase of PRMR was greatest in non-Hispanic white women. Additionally, increases in pregnancy-related mortality among women in the youngest and oldest age groups were noted to be the most dramatic.93,94
Black women experience maternal morbidity and mortality ratios several times higher than other racial groups.95 It is estimated that non-Hispanic Black women are three to almost four times more likely to die while pregnant or within one year postpartum than their non-Hispanic white and Latina counterparts. This disparity in mortality persists at every education level.96
Hypertension
Patients often are referred to the ED for elevated blood pressure. Literature has shown that, in the absence of end-organ damage in the setting of markedly elevated blood pressure, there is a risk of harm associated with rapid blood pressure reduction. However, there is marked variation among emergency medicine physicians regarding the treatment of asymptomatic HTN. Recent literature has noted that, although asymptomatic HTN is not associated with immediate morbidity or mortality, many patients’ only engagement with the healthcare system is through the ED. In light of this, a proposed mechanism includes adjusting or starting antihypertensives through the ED, with the idea that emergency providers’ role in the management of HTN should not be limited to hypertensive emergencies.97 While acute treatment of asymptomatic HTN may not be an emergency, emergency physicians can identify patients with HTN and refer them for appropriate follow-up.
HTN is one of the most prevalent chronic medical conditions in the United States and serves as a classic medical example of disparity. Its prevalence is estimated to be nearly one-third of the U.S. adult population, which is more than 100 million people.98 It is defined as a blood pressure reading that is persistently above 130/80 mmHg.99 According to the US National Health and Nutrition Examination Survey, non-Hispanic Blacks are more likely to be diagnosed with HTN compared to non-Hispanic whites.98
Disparities are present regarding the control of the disease, with non-Hispanic whites having more adequate control and lower associated morbidity and mortality.100 Commonly recognized morbidities include coronary and peripheral artery disease, strokes, and chronic renal disease (including end-stage renal disease).101 Besides HTN, the development of CVD is associated with other modifiable risk factors, such as smoking and DM. However, the single greatest risk factor associated with the development of CVD is HTN.102 Similarly, HTN also is noted to be the greatest risk factor for the development of chronic renal disease.103 In regard to mortality, HTN was noted to be the cause of more than 7 million deaths per year worldwide more than a decade ago, a number that likely has increased since then because of the increased prevalence of this disease.104
Multiple theories for these disparities have been postulated, including decreased access to care, poverty (which has a downstream effect of inability to afford medications), and a host of genetic and environmental factors, including increased nocturnal blood pressure in non-Hispanic Blacks.9,10 Social determinants of health have garnered more attention in recent times.11 By recognizing the impact of these factors on the development and subsequent control of one’s HTN, it is theorized that the associated disparities will decrease, and health equity can be achieved.105
Vulnerable Populations
Pediatric Patients. Nearly 25 million people in the United States have asthma. The annual costs of asthma (in adults and children) are estimated at approximately $82 billion, including medical costs related to 14.2 million office visits, 1.8 million ED visits, and 440,000 hospitalizations.106 Racial/ethnic disparities in ED visits because of childhood asthma have been well documented. Using 2013-2015 National Health Interview Survey (NHIS) data, a study by Urquhart et al revealed that Puerto Rican children had the highest prevalence of current asthma. However, this trend has not been present in every asthma prevalence study. (See Table 3.)
Table 3. Estimates of Selected Chronic Conditions Among Children and Teenagers, by Race/Ethnicity, United States | |
Chronic Condition (Age, y) |
Estimate |
Current asthma (<18)a |
Age-Adjusted Prevalence, % (SE) |
White, non-Hispanic |
5.6 (0.40) |
Black, non-Hispanic |
14.2 (1.52) |
Hispanic |
8.0 (0.85) |
Mexican American |
7.0 (1.01) |
Obesity (2-19)b |
Prevalence, % (SE) |
White, non-Hispanic |
16.1 (1.5) |
Black, non-Hispanic |
24.2 (2.0) |
Hispanic |
25.6 (1.9) |
Mexican American |
26.9 (2.5) |
Asian, non-Hispanic |
8.7 (1.1) |
Type 2 diabetes (10-19)c |
Incidence Rate Per 100,000 |
White, non-Hispanic |
4.5 |
Black, non-Hispanic |
37.8 |
Hispanic |
20.9 |
American Indian |
32.8 |
Asian/Pacific Islander |
11.9 |
Hypertension (12–19)d |
Prevalence, % (95% CI) |
White, non-Hispanic |
2.97 (1.73-4.74) |
Black, non-Hispanic |
6.27 (3.84-9.59) |
Mexican American |
4.94 (3.01-7.59) |
Other |
5.22 (3.65-7.20) |
a 2018 data from the National Health Interview Survey (23). b 2017–2018 data from the National Health and Nutrition Examination Survey (24). c 2014–2015 data from the SEARCH for Diabetes in Youth Study (25). d 2013–2016 data from the National Health and Nutrition Examination Survey (26). Source: Centers for Disease Control and Prevention, Preventing Chronic Disease 2021;18:10.
| |
Racial or ethnic minority children have a higher morbidity and mortality resulting from asthma when compared with white children. Significantly higher odds of asthma-related ED visits were seen among all minority subgroups (except non-Hispanic other) compared to non-Hispanic white children.107 Non-Hispanic African American children have two to three times higher rates of hospitalization and ED visits compared with non-Hispanic white children. African American children face a 4.9-fold higher asthma mortality rate. Hispanic children are 1.5 times more likely to die as a result of asthma when compared with non-Hispanic children.108,109 Factors contributing to asthma disparities include clinician, patient, family, and environmental factors, healthcare policies, and health systems operations.109
Several studies have demonstrated that, for children treated in EDs, wait times are associated with race and ethnicity. Some of the contributing factors may include discrimination, lack of cultural competency, language barriers, social factors, utilization rates of the ED for primary care, and insurance status.110 A study of pediatric ED encounters found that Black and Hispanic pediatric patients were less likely than whites to have their care needs classified as immediate/emergent. (See Table 4.) Black and Hispanic patients also were less likely than white patients to be admitted to the hospital following an ED visit. Black and Hispanic patients also experienced significantly longer wait times and a higher overall number of visits compared to white patients.111
Table 4. Disparities in Health: Vulnerable Populations | |
Population
|
Health Disparity |
Pediatric patients |
A study of pediatric emergency department (ED) encounters found that Black and Hispanic pediatric patients were less likely to have their care needs classified as immediate/emergent, less likely to be admitted to the hospital following an ED visit, and experienced significantly longer wait times and overall visits as compared to whites. |
Homeless patients |
In the United States, age-adjusted mortality is 3.5 times greater for homeless patients compared to those who were not homeless. |
Elderly patients |
Geriatric patients are three times more likely to be undertriaged resulting in a non-trauma activation trauma admission compared to other trauma patients. |
LGBT patients |
LGBT individuals appeared to have more chronic general medical conditions and physical disabilities and tended to use fewer acute services compared with heterosexuals. |
Immigrants
|
Immunization in these patients might be nonexistent and must be assessed when relevant to their ED visit, such as tetanus immunization. |
Rural populations |
Under-triage of patients in the field is higher in the rural setting and is associated with increased mortality. The lack of access to trauma care contributes to outcome disparities for patients in rural settings. |
A study of infants 1 to 28 days old with a diagnosis of fever found that government-funded insurance was associated with a lower likelihood of admission.110,112 Goyal et al studied racial ethnic differences in ED pediatric fracture management. Their study determined that, although minority children are more likely to receive analgesics and achieve two-point or greater reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.66
Appendicitis is the most common surgical diagnosis in pediatric ED patients. A study by Goyal showed that, in comparison to non-Hispanic whites, non-Hispanic Black children had higher likelihood of perforation, were more likely to have delayed diagnoses, and were less likely to undergo any imaging or definitive imaging (e.g., ultrasound/computed tomography/magnetic resonance imaging) during prior ED visits.113
Homeless Patients. There are more than 550,000 homeless individuals in the United States, with 39.8% of homeless persons identified as African Americans. Twenty percent of homeless persons in the United States are children, and 42% of homeless children identify as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ).114 Homeless people often do not have the knowledge and skills that are required to navigate the healthcare system.115 Homelessness is associated with difficulty in accessing primary care, high levels of chronic illness and morbidity, and many unmet basic health needs.116,117 In the United States, age-adjusted mortality is 3.5 times greater for homeless patients compared to those who are not homeless.118 The average life expectancy of a homeless person is just 50 years, almost 30 years less than the average U.S. life expectancy of 79.9 years.114
A study of trauma patients found that trauma activation criteria were met for 84% of all other trauma patients, yet for only 61% of homeless and geriatric patients combined. Injury mechanisms for the homeless included falls (38%), pedestrian/bicycle related (27%), and assaults (24%). These often occur while under the influence of alcohol and drugs. The homeless groups demonstrated increased complications, comorbidities, and higher death rates. Homeless patients often require a higher level of care yet frequently are under-triaged on ED arrival.
Admitted homeless trauma patients have complex case management issues related to preexisting health issues and challenges with discharge planning, both of which can add to longer lengths of stay (LOS) as compared to other trauma patients.119 This applies to non-trauma admissions as well.
The ED presents a window of opportunity where early intervention strategies may be implemented to improve the health status of homeless patients.115 Intensive case management has been shown to reduce ED use and result in better health outcomes by connecting homeless patients with available community resources.120,121 Greater attention must be given to the hospital services that are provided to homeless people so that not only their health needs, but also their behavioral, environmental, and psychosocial needs are addressed effectively and efficiently.115 Integration of healthcare facilities and shelters as overlapping systems of care may improve the quality of transitions of care and improve healthcare outcomes for homeless patients.116,122
Elderly Patients. The geriatric population is the fastest growing age demographic in the United States. Older adults of this generation are more active and independent than those of previous generations. Older adults may experience cognitive and physiological decline, mental health issues, and increased frailty. All of these factors contribute to injuries such as falls and motor vehicle collisions. Geriatric trauma patients often require more resources and increased care coordination than younger trauma patients.
Geriatric patients have consistent delays in trauma evaluations. In 2020, Schaffer et al reported that geriatric patients were three times more likely to be under-triaged even though they met trauma activation criteria, resulting in more non-trauma activation trauma admissions compared to other trauma patients. Additionally, geriatric trauma patients were admitted to the ICU more often compared to all others.119
Violence can have a major impact on older adults. Older adults can be targeted because of their perceived vulnerability and/or lower likelihood of reporting. Although some perpetrators are strangers, many perpetrators who commit physical and sexual elder abuse are persons known to the victim and in a position of trust. Intimate partner violence data among older adults from research in seven U.S. states show that 23% of all women killed by their partners were ages 50 years and older and 31% of homicides among women ages 65 and older were related to intimate partner violence.123
Suicide rates in the United States are much higher than homicide rates among older adults. Older adults are more likely to use firearms compared to younger adults. Dementia also can contribute to episodes of violence and aggression involving older adults. As a result of this, it is estimated that approximately approximately 20% of home-based dementia caregivers experience violence or aggression.124
LGBTQ Patients. In a 2021 poll, 5.6% of Americans identified as LGBT, up from 4.5% in 2017.125 LGBTQ individuals have experienced discrimination, resulting in their being a less visible population that has endured legal barriers, stigmatization, and lack of education on healthcare needs. LBGTQ patients have an increased risk of physical and mental health disorders, SUDs, STIs, eating disorders, and certain cancers. LGBTQ individuals also have less access to insurance and poor access to quality healthcare.126 (See Table 5.) All of these may lead to underutilization of the available care opportunities. A study found that LGB individuals appeared to have more chronic general medical conditions and physical disabilities and tended to use fewer acute services compared with heterosexuals. Gay men and lesbians were significantly less likely than heterosexuals to have used a mental health-related inpatient service or ED service in the past 12 months. Bisexual men and women were more likely than heterosexuals to have shorter SUD-related inpatient stays and to have fewer SUD-related ED visits.127
Table 5. LGB Youth Health |
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Source: Centers for Disease Control and Prevention, National Youth Risk Behavior Survey, 2019. |
Transgender individuals experience negative healthcare outcomes for a variety of reasons. According to the Transgender Discrimination Survey, 19% of transgender individuals were refused medical care because of their transgender status, 28% postponed necessary medical care because of discrimination or inability to pay, 33% delayed or did not seek preventive care, and 50% reported having to teach their providers about transgender care.128
The lifetime suicide attempt rate in the transgender community is 41%, compared to 1.6% in the general population. Anxiety and depression rates are reported as higher than those of the general population.129,130 It has been proposed that discrimination, stigma, lack of social support, and minority stress contribute to anxiety and depression. Minority stress is a concept based on the premise that gay people in a heterosexist society are subjected to chronic stress related to their stigmatization.131
Immigrants and Refugees. Immigrants, or migrants, are people who voluntarily move to another country seeking a better life. Some have a significant incentive for that voluntary move, like a natural disaster, a failed state, or grinding poverty. Refugees are forced to leave the country for a reason, often political persecution, but also because of their religion, race, social group, sexual orientation, or beliefs and opinions. Refugees are seeking asylum, and the legal assessment of this status can take years. In contrast, a displaced person moves to another part of their own country. Today, there are an estimated 7.8 million displaced people worldwide. Half of those are younger than 18 years of age.132
Some specific issues associated with immigrants and refugees include mental health problems, often due to separation and trauma before, during, or after arrival.133 Infectious diseases are common and can include conditions less prevalent in their country of arrival.134 Injuries are common, including rape and sexual abuse, domestic violence, and child abuse. Other sources of illness or injury might result from environmental or other exposures during their migration. These populations often are excluded from research, so there is a lack of information about the most significant and prevalent conditions.
Immunization in these patients might be nonexistent and must be assessed when relevant to their ED visit, such as tetanus immunization.
Finally, women’s health issues, including family planning, gynecologic, and obstetrical care, might bring these patients to the ED.
In the ED, language barriers are an issue.135 Whenever possible, qualified professional interpreters must be used. Often, clinicians lack training on working with interpreters.136
When treating these patient populations, avoid stereotyping, that is, assuming that all members of a group have shared values, beliefs, or attitudes.135
Rural Populations. Patients residing in rural areas of the United States have higher mortality after injury and do not have access to trauma systems as rapidly as their urban counterparts. Various studies have looked at possible etiologies of this disparity. One of the contributing factors in the literature is field under-triage of rural patients. A previous study of the National Field Triage Guidelines reported that just 12.5% of patients living in rural areas were transported to trauma centers, and only 39% of these patients received definitive care at a trauma center. Additionally, transportation to a non-trauma center, despite recognition of significant injuries, also has been reported as contributing to delays in care. In 2020, Deeb et al concluded that under-triage is higher in the rural setting, which was associated with increased mortality. Their findings suggested that lack of rapid access to trauma care contributes to outcome disparities for patients in rural settings. They found that availability of a trauma center in a rural region and the use of air medical transport mitigated the risk of field under-triage.137
Children residing in rural areas of the United States do not have appropriate access to pediatric trauma care, also resulting in increased mortality. Contributing factors to the increased mortality of this pediatric population include the following: 77% of these children lack access to a pediatric trauma center; delayed response times and lengthy transport times contribute to delayed trauma care access; and children involved in motor vehicle collisions in rural areas can have more severe injuries.138
Telehealth may improve care in rural settings by promoting a sustained education of rural care providers and attention to targeted health conditions. For example, a 2019 study assessed outcomes for behavioral health patients in rural EDs after implementation of telehealth-based care delivery. Telehealth consultation in the ED was associated with decreased wait times to be seen by a mental health clinician. However, it also was associated with extended ED lengths of stay. This finding was because of longer ED treatment time if admission was necessary, wait time for bed availability for admitted patients (boarding), and payor-related issues when patients required admission for further care.139
Initiatives to Decrease or Eliminate Disparities
Although it is beyond the scope of emergency medicine to fix a chronic problem of this magnitude, it is clear that emergency medicine providers can contribute to the elimination of some of these disparities. Every opportunity and encounter with a patient can be used to apply quality improvement initiatives, especially when culturally tailored to the population served. These efforts are mostly aimed at improving dietary habits, exercise habits, and self-monitoring. Emergency clinicians also must advocate for DM and HTN walk-in clinics for those who do not have primary care.
Algorithm-based treatments and best practice alerts can serve as reminders to clinicians and can be applied to any clinical setting, including emergency and urgent visits. Provider interventions that are useful include continuing medical education for clinicians, creation of organization-wide practice guidelines, the use of clinical decision support, in-person feedback about practice patterns, and practice-based learning.140
Health system interventions that are useful include the use of case managers and community healthcare workers, pharmacist-led medication management, and the availability of medication assistance programs. Diabetes fairs led by health systems and clinicians also are a way to engage with the community. (See Table 6.)
Table 6. How Emergency Medicine Clinicians Can Help |
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Role of Emergency Medicine in Diminishing Health Disparities
Emergency physicians can take some steps to help decrease health disparities in their work and home communities. The emergency department is the place people come for care, and providing services beyond “just the emergency” can improve the health of the community. These include:
- integrating the principles of shared decision-making into practice.
- bridging communication gaps between healthcare providers and patients. Clinicians should communicate with patients in an open and inclusive manner, using culturally competent and patient-centered terminology while maintaining a nonjudgmental attitude.
- developing and implementing programs to identify patients with social determinants of health-related issues and helping build community partnerships to match patients with local resources.
- providing evidence-based/guideline-based care with clinical decision support whenever possible.
- providing patient education on new and most optimal treatments.
- offering personalized, culturally appropriate action plans using patients’ and caregivers’ language and wording.
- expanding access to specialty care by increasing referrals to specialists’ care or by advocating for the implementation of telehealth platforms.
- providing care coordination and case management in the ED, especially for high-risk, high-prevalence conditions and discharges.
- building broad-based community partnerships with local stakeholders to tailor solutions, increase community member participation, and ensure project sustainability.
Conclusion
Health disparities occur in many ED patients. Overall health is a result of the interactions between a complex set of social, economic, cultural, educational, and healthcare-related variables. To properly care for a wide range of patients, ED clinicians must understand how these variables affect our individual patients, our practices, and the communities we serve.
REFERENCES
The complete list of references is available online: https://bit.ly/3mmYGaI
Overall health is a result of the interactions between a complex set of social, economic, cultural, educational, and healthcare-related variables. To properly care for a wide range of patients, emergency department clinicians must understand how these variables affect our individual patients, our practices, and the communities we serve.
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