Association of race/ethnicity with emergency department wait times

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.

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.

Emergency Department Waiting Times in an Israeli Children's Hospital During Times of Military Conflict

Introduction

During military conflicts in southern Israel, many families moved north, and hospitals and primary care clinics under threat of missile attacks referred their patients to hospitals outside the combat zone, causing overcrowding of the emergency departments (ED). The study objective is to examine the effect of military conflicts on ED waiting time in a children's hospital outside the combat zone.

Materials and Methods

A retrospective cohort study of patients admitted between January 2011 and December 2015 was conducted. Multivariable regression was used to examine the effect of age, gender, triage category, arrival time, weekday, and period of admission (peacetime and time of military conflict) on waiting time.

Results

Totally, 79,825 children were admitted in peacetimes and 3,058 in times of military conflict. Factors that most influenced shorter waiting times were triage category 1 (change in waiting time: -25.5%; 95% confidence interval: -29.3 to -21.7) or triage category 2 (change in wait time: -21.8%; 95% confidence interval: -23.7 to -20.05). Arriving during times of military conflict did not influence ED waiting time (p=0.18). ED waiting times during times of peace and times of military conflict were 38 min of interquartile range (21-65) and 38 min of interquartile range (22-65), respectively.

Conclusions

In this report of a large cohort of patients, waiting times were similar during periods of peace and periods of military conflict. The findings suggest that the 2012 and the 2014 military conflicts did not influence ED waiting times in a hospital outside the combat zone, despite the population shift that occurred during these conflicts. This study is the first to examine the association between periods of military conflict and ED waiting time in children.

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.

Care delays in patients with signs and symptoms of acute myocardial infarction

AIM

More than six million patients with signs and symptoms suggestive of a heart attack present to emergency departments (EDs) in the US each year. Of those diagnosed with acute myocardial infarction (AMI), one third die in the acute phase. Rapid ED triage can reduce the mortality rate, yet there are still delays in patient care. The aim of this study is to explore the relationship between patient and nurse characteristics, patient presentations, delays in triage, and delays in obtaining electrocardiograms (ECGs) of patients with signs and symptoms of AMI.

METHODS

A retrospective correlational study drawing on data from the records of 286 patients with signs and symptoms of AMI.

RESULTS

Delays in triage are related significantly to patients' gender and race. Most patients were triaged by nurses with associate degrees in nursing, a mean age of 45 and a mean of 18 years' experience. An increase in nurse years of experience predicted greater delay in triage. Delays in obtaining ECGs were also significantly greater with more experienced nurses and when patients reported no chest pain.

CONCLUSION

The study adds to the literature on delays in triage and ECGs in care of patients with possible AMI, and further research of the effects of ED crowding and availability of resources in emergency cardiac care is warranted. Studies should identify the processes that cause delays in the emergency care of patients with signs and symptoms of AMI to ensure timely treatment and care.

Racial differences in the pain management of children recovering from anesthesia

BACKGROUND

When pain management has been studied in settings such as pediatric emergency departments, racial disparities have been clearly identified. To our knowledge, this has not been studied in the pediatric perioperative setting. We sought to determine whether there are differences based on race in the administration of analgesia to children suffering from pain in the postanesthesia care unit.

METHODS

This is a prospective, observational, study of 771 children aged 4-17 years who underwent elective outpatient surgery. Racial differences in probability of receiving analgesia for pain in the recovery room were assessed using bivariable and multivariable logistic regression analyses.

RESULTS

A total of 294 children (38.2%) received at least one class of analgesia (opioid or nonopioid); while 210 (27.2%) received intravenous (i.v.) opioid analgesia in the recovery room. Overall postanesthesia care unit analgesia utilization was similar between white and minority children (white children 36.8% vs minority children 43.4%, OR 1.3; 95% CI=0.92-1.89; P=.134). We found no significant difference by racial/ethnic group in the likelihood of a child receiving i.v. opioid for severe postoperative pain (white children 76.0% vs 85.7%, OR 1.89; 95% CI=0.37-9.67; P=.437). However, minority children were more likely to receive i.v. opioid analgesia than their white peers (white children 24.5% vs minority children 34.2%, OR 1.5; 95% CI=1.04-2.2; P=.03). On multivariable analysis, minority children had a 63% higher adjusted odds of receiving i.v. opioids in the recovery room (OR=1.63; 95% CI, 1.05-2.62; P=.03).

CONCLUSIONS

Receipt of analgesia for acute postoperative pain was not significantly associated with a child's race. Minority children were more likely to receive i.v. opioids for the management of mild pain.

The Role of Bias by Emergency Department Providers in Care for American Indian Children

BACKGROUND

American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings.

OBJECTIVE

Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care.

RESEARCH DESIGN

We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site.

RESULTS

A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias.

CONCLUSIONS

The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.

Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH

INTRODUCTION

Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits.

METHODS

Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances.

RESULTS

Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions.

CONCLUSION

We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.

Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?

BACKGROUND

Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation.

METHODS

Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only.

RESULTS

For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation.

CONCLUSION

Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of Emergency Department Wait Times in Adults with Sickle Cell Disease Versus Other Painful Etiologies

Sickle cell disease is characterized by intermittent painful crises often requiring treatment in the emergency department (ED). Past examinations of time-to-provider (TTP) in the ED for patients with sickle cell disease demonstrated that these patients may have longer TTP than other patients. Here, we examine TTP for patients presenting for emergency care at a single institution, comparing patients with sickle cell disease to both the general population and to those with other painful conditions, with examination of both institutional and patient factors that might affect wait times. Our data demonstrated that at our institution patients with sickle cell disease have a slightly longer average TTP compared to the general ED population (+16 min.) and to patients with other painful conditions (+4 min.) However, when confounding factors were considered, there was no longer a significant difference between TTP of patients with sickle cell disease and the general population nor between patients with sickle cell disease and those with other painful conditions. Multivariate analyses demonstrated that gender, race, age, high utilizer status, fast track use, time of presentation, acuity and insurance type, were all independently associated with TTP, with acuity, time of presentation and use of fast track having the greatest influence. We concluded that the longer TTP observed in patients with sickle cell disease can at least partially be explained by institutional factors such as the use of fast track protocols. Further work to reduce TTP for sickle cell disease and other patients is needed to optimize care.

Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED

BACKGROUND

Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging (ultrasound ±computed tomography [CT]) and factors associated with isolated CT use.

METHODS

This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007 to 2013. Primary outcome was ultrasound or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging.

RESULTS

Of the 21 152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.4-0.5) and Medicaid (OR, 0.6; 95% CI, 0.5-0.7) had lower odds of advanced imaging compared with white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR, 0.6; 95% CI, 0.5-0.7) compared with the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared with 76% of those to general EDs included an isolated CT (P<.001). Low pediatric volume (OR, 1.8; 95% CI, 1.5-2.2) and rural (OR,1.8; 95% CI, 1.3-2.5) EDs had higher odds of isolated CT use, compared with higher pediatric volumes and nonrural EDs, respectively.

CONCLUSION

There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of "ultrasound first."

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.

Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments

IMPORTANCE

Racial disparities in use of analgesia in emergency departments have been previously documented. Further work to understand the causes of these disparities must be undertaken, which can then help inform the development of interventions to reduce and eradicate racial disparities in health care provision.

OBJECTIVE

To evaluate racial differences in analgesia administration, and particularly opioid administration, among children diagnosed as having appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

Repeated cross-sectional study of patients aged 21 years or younger evaluated in the emergency department who had an International Classification of Diseases, Ninth Revision diagnosis of appendicitis, using the National Hospital Ambulatory Medical Care Survey from 2003 to 2010. We calculated the frequency of both opioid and nonopioid analgesia administration using complex survey weighting. We then performed multivariable logistic regression to examine racial differences in overall administration of analgesia, and specifically opioid analgesia, after adjusting for important demographic and visit covariates, including ethnicity and pain score.

MAIN OUTCOMES AND MEASURES

Receipt of analgesia administration (any and opioid) by race.

RESULTS

An estimated 0.94 (95% CI, 0.78-1.10) million children were diagnosed as having appendicitis. Of those, 56.8% (95% CI, 49.8%-63.9%) received analgesia of any type; 41.3% (95% CI, 33.7%-48.9%) received opioid analgesia (20.7% [95% CI, 5.3%-36.0%] of black patients vs 43.1% [95% CI, 34.6%-51.4%] of white patients). When stratified by pain score and adjusted for ethnicity, black patients with moderate pain were less likely to receive any analgesia than white patients (adjusted odds ratio = 0.1 [95% CI, 0.02-0.8]). Among those with severe pain, black patients were less likely to receive opioids than white patients (adjusted odds ratio = 0.2 [95% CI, 0.06-0.9]). In a multivariable model, there were no significant differences in the overall rate of analgesia administration by race. However, black patients received opioid analgesia significantly less frequently than white patients (12.2% [95% CI, 0.1%-35.2%] vs 33.9% [95% CI, 0.6%-74.9%], respectively; adjusted odds ratio = 0.2 [95% CI, 0.06-0.8]).

CONCLUSIONS AND RELEVANCE

Appendicitis pain is undertreated in pediatrics, and racial disparities with respect to analgesia administration exist. Black children are less likely to receive any pain medication for moderate pain and less likely to receive opioids for severe pain, suggesting a different threshold for treatment.

One Size Does Not Fit All: Pediatric Patient Satisfaction Within an Integrated Health Network

It is unknown how differently a factor influences pediatric patient satisfaction across multiple service areas. The objective of the study was to assess relative impacts of factors across 4 health service areas. In this retrospective study of 27 028 responses from patient satisfaction surveys, the multiple-group structural equation modeling was used to assess factor effects. "Physician care" has the largest impact on overall pediatric patient satisfaction in outpatient specialty care with a 1.4-fold, 1.7-fold, and 3-fold reduction in effect in primary care, emergency department, and inpatient care, respectively. "Nursing care" has the largest impact in inpatient care with a 3-fold effect reduction in emergency care. "Personal concern" is an impacting factor in all areas with the largest effect in emergency care. The influence of factors on pediatric patient satisfaction varies significantly across service areas. These findings help health care leaders design customized patient experience models to achieve optimal outcomes across the health system.

Relationship between racial disparities in ED wait times and illness severity

BACKGROUND

Prolonged emergency department (ED) wait times could potentially lead to increased mortality. Studies have demonstrated that black patients waited significantly longer for ED care than nonblack patients. However, the disparity in wait times need not necessarily manifest across all illness severities. We hypothesize that, on average, black patients wait longer than nonblack patients and that the disparity is more pronounced as illness severity decreases.

METHODS

We studied 34143 patient visits in 353 hospital EDs in the National Hospital Ambulatory Medical Care Survey in 2008. In a 2-model approach, we regressed natural logarithmically transformed wait time on the race variable, other patient-level variables, and hospital-level variables for 5 individually stratified illness severity categories. We reported results as percent difference in wait times, with 95% confidence intervals. We used P < .05 for significance level.

RESULTS

On average, black patients experienced significantly longer mean ED wait times than white patients (69.2 vs 53.3 minutes; P < .001). In the multivariate model, black patients did not experience significant different wait times for the 2 most urgent severity categories; black patients experienced increasingly longer waits vs nonblack patients for the 3 least urgent severity categories (14.7%, P < .05; 15.9%, P < .05; 29.9%, P < .001, respectively).

CONCLUSION

Racial disparity in ED wait times between black and nonblack patients exists, and the size of the disparity is more pronounced as illness severity decreases. We do not find a racial disparity in wait times for critically ill patients.

Health literacy affects likelihood of radiology testing in the pediatric emergency department

OBJECTIVE

To test the hypothesis that the effect of race/ethnicity on decreased radiologic testing in the pediatric emergency department (ED) varies by caregiver health literacy.

STUDY DESIGN

This was a secondary analysis of a cross-sectional study of caregivers accompanying children ≤ 12 years to a pediatric ED. Caregiver health literacy was measured using the Newest Vital Sign. A blinded chart review determined whether radiologic testing was utilized. Bivariate and multivariate analyses, adjusting for ED triage level, child insurance, and chronic illness were used to determine the relationship between race/ethnicity, health literacy, and radiologic testing. Stratified analyses by caregiver health literacy were conducted.

RESULTS

Five hundred four caregivers participated; the median age was 31 years, 47% were white, 37% black, 10% Hispanic, and 49% had low health literacy. Black race and low health literacy were associated with less radiologic testing (P < .01). In stratified analysis, minority race was associated with less radiologic testing only if a caregiver had low health literacy (aOR 0.5; 95% CI 0.3-0.9), and no difference existed in those with adequate health literacy (aOR 0.7; 95% CI 0.4-1.3).

CONCLUSIONS

Caregiver low health literacy modifies whether minority race/ethnicity is associated with decreased radiologic testing, with only children of minority caregivers with low health literacy receiving fewer radiologic studies. Future interventions to eliminate disparities in healthcare resource utilization should consider health literacy as a mutable factor.

Partnering health disparities research with quality improvement science in pediatrics

Disparities in pediatric health care quality are well described in the literature, yet practical approaches to decreasing them remain elusive. Quality improvement (QI) approaches are appealing for addressing disparities because they offer a set of strategies by which to target modifiable aspects of care delivery and a method for tailoring or changing an intervention over time based on data monitoring. However, few examples in the literature exist of QI interventions successfully decreasing disparities, particularly in pediatrics, due to well-described challenges in developing, implementing, and studying QI with vulnerable populations or in underresourced settings. In addition, QI interventions aimed at improving quality overall may not improve disparities, and in some cases, may worsen them if there is greater uptake or effectiveness of the intervention among the population with better outcomes at baseline. In this article, the authors review some of the challenges faced by researchers and frontline clinicians seeking to use QI to address health disparities and propose an agenda for moving the field forward. Specifically, they propose that those designing and implementing disparities-focused QI interventions reconsider comparator groups, use more rigorous evaluation methods, carefully consider the evidence for particular interventions and the context in which they were developed, directly engage the social determinants of health, and leverage community resources to build collaborative networks and engage community members. Ultimately, new partnerships between communities, providers serving vulnerable populations, and QI researchers will be required for QI interventions to achieve their potential related to health care disparity reduction.

Prospective, 10-year evaluation of the impact of Hispanic ethnicity on pain management practices in the ED

INTRODUCTION

Hispanic ethnicity has been reported as an independent risk factor for oligoanalgesia in the emergency department (ED).

OBJECTIVES

The objectives are to compare pain management practices in White and Hispanic patients in the ED to determine whether treatment differences exist.

METHODS

Prospective analysis of a convenience sample of patients presenting to an urban, academic, tertiary-care ED over the 10-year period from 2000 to 2010. We compared patients with pain-related complaints of any nature, who self-identified their race as White or Hispanic, and evaluated initial morphine administration/dosing, arrival/disposition pain scores, and overall ED satisfaction scores (0-10 scale).

RESULTS

Fifteen thousand sixty patients were enrolled. Eighty-one point 2 percent (n, 12 232) of the patients were White and 11.2% (n, 1680), Hispanic. White and Hispanic patients reported similar pain at presentation (6.7 vs 7.3, P < .001) and discharge/admission (4.6 vs 4.8, P = .14). Hispanic patients were not less likely to receive an analgesic during the ED visit (odds ratio, 1.06; confidence interval, 0.96-1.17; P = .62), nor less likely to receive an opioid analgesic (odds ratio, 0.97; confidence interval, 0.88-1.08; P = .70). Hispanic patients, on average, received similar initial doses of morphine (4.1 vs 4.3 mg, P = .29) and had similar wait times from arrival to initial dose of morphine (82 vs 86 minutes). Overall ED satisfaction scores were the same (8.7 vs 8.7, P = .65).

CONCLUSION

White and Hispanic patients were similar in rates of initial morphine administration for pain-related complaints. These findings contrast with previous studies reporting lower rates of initial analgesia administration among Hispanic patients in the ED.

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children

OBJECTIVE

To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain.

STUDY DESIGN

We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models.

RESULTS

Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95).

CONCLUSION

Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Children's Mental Health Visits to the Emergency Department: Factors Affecting Wait Times and Length of Stay

Objective. This study explores the association of patient and emergency department (ED) mental health visit characteristics with wait time and length of stay (LOS). Methods. We examined data from 580 ED mental health visits made to two urban EDs by children aged ≤18 years from April 1, 2004, to March 31, 2006. Logistic regressions identified characteristics associated with wait time and LOS using hazard ratios (HR) with 95% confidence intervals (CIs). Results. Sex (male: HR = 1.48, 95% CI = 1.20-1.84), ED type (pediatric ED: HR = 5.91, 95% CI = 4.16-8.39), and triage level (Canadian Triage and Acuity Scale (CTAS) 2: HR = 3.62, 95% CI = 2.24-5.85) were statistically significant predictors of wait time. ED type (pediatric ED: HR = 1.71, 95% CI = 1.18-2.46), triage level (CTAS 5: HR = 2.00, 95% CI = 1.15-3.48), number of consultations (HR = 0.46, 95% CI = 0.31-0.69), and number of laboratory investigations (HR = 0.75, 95% CI = 0.66-0.85) predicted LOS. Conclusions. Based on our results, quality improvement initiatives to reduce ED waits and LOS for pediatric mental health visits may consider monitoring triage processes and the availability, access, and/or time to receipt of specialty consultations.

Association of race and ethnicity with management of abdominal pain in the emergency department

OBJECTIVE

To determine if race/ethnicity-based differences exist in the management of pediatric abdominal pain in emergency departments (EDs).

METHODS

Secondary analysis of data from the 2006-2009 National Hospital Ambulatory Medical Care Survey regarding 2298 visits by patients ≤ 21 years old who presented to EDs with abdominal pain. Main outcomes were documentation of pain score and receipt of any analgesics, analgesics for severe pain (defined as ≥ 7 on a 10-point scale), and narcotic analgesics. Secondary outcomes included diagnostic tests obtained, length of stay (LOS), 72-hour return visits, and admission.

RESULTS

Of patient visits, 70.1% were female, 52.6% were from non-Hispanic white, 23.5% were from non-Hispanic black, 20.6% were from Hispanic, and 3.3% were from "other" racial/ethnic groups; patients' mean age was 14.5 years. Multivariate logistic regression models adjusting for confounders revealed that non-Hispanic black patients were less likely to receive any analgesic (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.43-0.87) or a narcotic analgesic (OR: 0.38; 95% CI: 0.18-0.81) than non-Hispanic white patients (referent group). This finding was also true for non-Hispanic black and "other" race/ethnicity patients with severe pain (ORs [95% CI]: 0.43 [0.22-0.87] and 0.02 [0.00-0.19], respectively). Non-Hispanic black and Hispanic patients were more likely to have a prolonged LOS than non-Hispanic white patients (ORs [95% CI]: 1.68 [1.13-2.51] and 1.64 [1.09-2.47], respectively). No significant race/ethnicity-based disparities were identified in documentation of pain score, use of diagnostic procedures, 72-hour return visits, or hospital admissions.

CONCLUSIONS

Race/ethnicity-based disparities exist in ED analgesic use and LOS for pediatric abdominal pain. Recognizing these disparities may help investigators eliminate inequalities in care.

Unscheduled return visits to the emergency department: the impact of language

BACKGROUND

Return visits to the emergency department (ED) resulting in admission are an important marker of quality of care. Patients and families with limited English proficiency (LEP) are at risk for suboptimal care related to imprecise communication.

OBJECTIVE

The objective of this study was to compare the rate of return visits resulting in admission in LEP patients to the rate in the English-speaking patients.

METHODS

We assembled a retrospective cohort of patients cared for in a pediatric, tertiary ED. Eligible patients included those who were discharged on the first encounter, and those who returned and were admitted to the hospital within 72 hours of ED discharge were identified. A logistic regression was performed comparing the rate of return visits resulting in admission in the LEP and non-LEP populations adjusting for emergency severity index and time of day at ED visit.

RESULTS

A total of 119,782 patients were discharged from the ED during a 32-month study period. Of these patients, 11.7% (14,053) identified a language other than English as their primary language. The rate of return visits resulting in admission was 1.2% (1279/105,729) among English speakers and 1.6% (220/14,053) in the LEP population. Patients with LEP were more likely to return to the ED for admission (odds ratio, 1.30; 95% confidence interval, 1.12-1.50; P < 0.001) The increased risk of a return visit for LEP patients remained significant after controlling for age, emergency severity index, and time of day (adjusted odds ratio, 1.43; 95% confidence interval, 1.23-1.66; P < 0.001).

CONCLUSION

Patients with LEP are at higher risk of return visit for admission.

Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department

OBJECTIVE

The objective of this study was to examine the association of race and language on laboratory and radiological testing in the pediatric emergency department (ED).

METHODS

This retrospective, case-cohort study examined laboratory and radiological testing among patients discharged home from 2 urban, pediatric EDs between March 2, 2009, and March 31, 2010.

RESULTS

There were 75,254 visits among 49,164 unique patients, of whom 31.0% had laboratory and 30.5% had radiological testing. African American (adjusted odds ratio [aOR], 0.93; confidence interval [CI], 0.89-0.98; P = 0.004) and biracial racial categories (aOR, 0.91; CI, 0.86-0.98; P = 0.007) were associated with decreased odds of laboratory testing compared with non-Hispanic whites. Similarly, Native American (aOR, 0.82; CI, 0.73-0.94), African American (aOR0.81; CI, 0.72-0.81), biracial (aOR, 0.82; CI, 0.77-0.88), Hispanic (aOR.76; CI, 0.72-0.81), and "other" (aOR, 0.84; CI, 0.73-0.97) racial categories were each associated with lower odds of radiological testing compared with non-Hispanic whites. Subgroup analysis of visits with a final diagnosis of fever and upper respiratory tract infection, conditions for which there were few treatment protocols, confirmed the racial differences. Subgroup analysis in visits for head injury, for which there is an established evaluation protocol, did not find a lower odds of laboratory or radiological testing by race compared with non-Hispanic whites.

CONCLUSIONS

Racial disparities in laboratory and radiological testing were present in pediatric ED visits. No racial differences were seen in the radiological and laboratory charges in the head injury subgroup, suggesting that evaluation algorithms can ameliorate racial disparities in pediatric ED care.

Racial disparity in emergency department triage

BACKGROUND

Previous reports of lower triage acuity scores and longer Emergency Department (ED) wait times for African Americans compared to Caucasians had insufficient information to determine if this was due to bias or appropriately based on medical history and clinical presentation.

OBJECTIVE

(1) Determine if African Americans are assigned lower triage acuity scores (TAS) after adjusting for a number of demographic and clinical variables likely to affect triage scores. (2) Determine if lower TAS translate into clinically significant longer wait times to assignment to a treatment area.

METHODS

This was a retrospective matched cohort design analysis of de-identified data extracted from the ED electronic medical record system, which included demographic and clinical information, as well as TAS, and ED process times. Triage scores were assigned using a 5-point scale (ESI), with 1 being most urgent and 5 being least urgent. Mean TAS and wait times to a treatment area for specific chief complaints were compared by race; after adjusting for age, gender, insurance status, time of day, day of week, presence of co-morbidities, and abnormal vital signs using a 1:1 matched case analysis.

RESULTS

The overall mean TAS for African Americans was 2.97 vs. 2.81 for Caucasians (difference of 0.18; p<0.001), translating to a lower acuity rating. African Americans had a significantly longer wait time to a treatment area compared to case-matched Caucasians (10.9min; p<0.001), with much larger differences in wait times noted within certain specific chief complaint categories.

CONCLUSION

Our current study supports the hypothesis that racial bias may influence the triage process.

The complex association of race and leaving the pediatric emergency department without being seen by a physician

OBJECTIVES

This study examined the influence of race and language on leaving the emergency department (ED) without complete evaluation and treatment (LWCET).

METHODS

This retrospective, case-cohort study examined LWCET among patients discharged home from 2 EDs between March 2, 2009, and March 31, 2010. Race and language were obtained by family self-report. We also explored wait time to see a physician as an explanation of racial disparities.

RESULTS

One thousand two hundred eighty-five (1.7%) of 76,931 ED encounters ended in LWCET. Factors increasing LWCET were high ED activity, low acuity, and medical assistance (MA) insurance. American Indian, biracial, African American, and Hispanic races were also associated with higher odds of LWCET among visits by MA insurance patients compared with those of white patients on private insurance. Restricting the analysis to visits by MA insurance patients, only American Indian race was associated with LWCET compared with white race. Visits by patients using an interpreter or speaking a language other than English at home had lower odds of ending in LWCET. Sensitivity analyses in subgroups confirmed these findings. We developed a measure of ED activity that correlated well with wait time to see a physician (correlation coefficient = 0.993; P < 0.001). Among non-LWCET visits, wait time to see a practitioner did not correlate with racial disparities in LWCET.

CONCLUSIONS

Race, language, and insurance status interact to form a complex relationship with LWCET. Medical assistance insurance status appears to account for much of the excessive instances of LWCET seen in nonwhites. After restricting the analysis to MA insurance patients, only visits by American Indian patients had higher odds of LWCET compared with whites on MA insurance. Wait time to see a physician did not explain racial differences in LWCET.

Insurance status and the care of adult patients 19 to 64 years of age visiting the emergency department

OBJECTIVES

The objective was to determine whether insurance status is associated with the care of patients presenting to the emergency department (ED).

METHODS

This was a retrospective cross-sectional analysis of ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS; 1999 through 2008). Patients 19 to 64 years of age were categorized as having private insurance, public insurance, or no insurance as their primary insurance. Six components of ED care were assessed: wait time, left prior to discharge, use of diagnostic testing, treatment, instructions for follow-up, and whether the patient had been seen in the past 72 hours.

RESULTS

Nonprivate insurance status was associated with all six components of ED care, including higher proportions of leaving before discharge of patients with public insurance (4.1%, 95% confidence interval [CI]=3.8% to 4.5%) versus patients with no insurance (4.7%, 95% CI=4.2% to 5.1%) or private insurance (2.2%, 95% CI=2.0% to 2.4%; p<0.001). It was also associated with a higher proportion of return visits with 5.1% (95% CI=4.6% to 5.6%) of patients with public insurance versus 4.7% (95% CI=4.1% to 4.6%) of patients with no insurance versus 3.8% (95% CI=3.5% to 4.2%) of patients with private insurance (p<0.001). Patients with public or no insurance also had decreased odds of ED testing compared to those with private insurance (adjusted odds ratio [AOR] for public=0.84, 95% CI=0.80 to 0.88; and AOR for none=0.82, 95% CI=0.79 to 0.86).

CONCLUSIONS

Nonprivate insurance status is associated with different care patterns in adults aged 19 to 64 years visiting the ED. Further studies are needed to evaluate how these disparate care patterns affect health outcomes.

Emergency department volume and racial and ethnic differences in waiting times in the United States

BACKGROUND

Racial and ethnic differences in emergency department (ED) waiting times have been observed previously.

OBJECTIVES

We explored how adjusting for ED attributes, particularly visit volume, affected racial/ethnic differences in waiting time.

RESEARCH DESIGN

We constructed linear models using generalized estimating equations with 2007-2008 National Hospital Ambulatory Medical Care Survey data.

SUBJECTS

We analyzed data from 54,819 visits to 431 US EDs.

MEASURES

Our dependent variable was waiting time, measured from arrival to time seen by physician, and was log transformed because it was skewed. Primary independent variables were individual race/ethnicity (Hispanic and non-Hispanic white, black, other) and ED race/ethnicity composition (covariates for percentages of Hispanics, blacks, and others). Covariates included patient age, triage assessment, arrival by ambulance, payment source, volume, region, and teaching hospital.

RESULTS

Geometric mean waiting times were 27.3, 37.7, and 32.7 minutes for visits by white, black, and Hispanic patients. Patients waited significantly longer at EDs serving higher percentages of black patients; per 25 point increase in percent black patients served, waiting times increased by 23% (unadjusted) and 13% (adjusted). Within EDs, black patients waited 9% (unadjusted) and 4% (adjusted) longer than whites. The ED attribute most strongly associated with waiting times was visit volume. Waiting times were about half as long at low-volume compared with high-volume EDs (P<0.001). For Hispanic patients, differences were smaller and less robust to model choice.

CONCLUSIONS

Non-Hispanic black patients wait longer for ED care than whites primarily because of where they receive that care. ED volume may explain some across-ED differences.

Factors associated with prolonged emergency department length of stay for admitted children

OBJECTIVE

To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children.

METHODS

Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time >8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS.

RESULTS

Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS.

CONCLUSIONS

We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.

Perceptions of discrimination among Mexican American families of seriously ill children

This paper describes Mexican American family members' descriptions of perceived discrimination by pediatric health care providers (HCPs) and the families' reactions to the HCPs' discriminatory conduct. A retrospective, grounded theory design guided the overall study. Content analysis of interviews with 13 participants from 11 families who were recruited from two children's hospitals in Northern California resulted in numerous codes and revealed that participants perceived discrimination when they were treated differently from other, usually white, families. They believed they were treated differently because they were Mexican, because they were poor, because of language barriers, or because of their physical appearance. Participants reported feeling hurt, saddened, and confused regarding the differential treatment they received from HCPs who parents perceived "should care equally for all people." They struggled to understand and searched for explanations. Few spoke up about unfair treatment or complained about poor quality of care. Most assumed a quiet, passive position, according to their cultural norms of respecting authority figures by being submissive and not questioning them. Participants did not perceive all HCPs as discriminatory; their stories of discrimination derived from encounters with individual nurses or physicians. However, participants were greatly affected by the encounters, which continue to be painful memories. Despite increasing efforts to provide culturally competent palliative care, there is still need for improvement. Providing opportunities for changing HCPs' beliefs and behaviors is essential to developing cultural competence.

Disparities exist in the emergency department evaluation of pediatric chest pain

OBJECTIVES

To identify and describe disparities in the provision of Emergency Department (ED) care in pediatric patients presenting with chest pain (CP).

PATIENTS AND METHODS

Nationally representative data were drawn from the National Hospital Ambulatory Medical Care Survey (NHAMCS). All ED visits with a chief complaint of CP and age <19 years from 2002 to 2006 were analyzed. The primary outcome variable was "Anytest" performed (defined as any combination of complete blood count, electrocardiogram, and/or chest x-ray). Univariable analyses were performed with "Anytest" as the dependent variable and patient characteristics as independent variables. Multivariable analysis was performed using logistic regression with the same independent patient characteristics.

RESULTS

Eight hundred eighteen pediatric CP visits representing 2 552 193 such visits nationwide were analyzed. Gender and metro/non-metro location were not associated with "Anytest." However, Caucasian patients (p = 0.01) and those with private insurance (p < 0.01) were significantly more likely to receive testing despite otherwise similar demographics and severity of illness. Multivariate analysis revealed race (p = 0.03), expected payer (p = 0.003), and triage level (p = 0.009) were significantly and independently associated with the frequency of testing performed.

CONCLUSION

Disparities exist in the ED care of pediatric patients with CP. Identification of such variations is important and provides an opportunity for targeted interventions that ensure delivery of high-quality, cost-effective health care for children.

Neuroimaging for pediatric head trauma: do patient and hospital characteristics influence who gets imaged?

OBJECTIVES

The objective was to identify patient, provider, and hospital characteristics associated with the use of neuroimaging in the evaluation of head trauma in children.

METHODS

This was a cross-sectional study of children (< or =19 years of age) with head injuries from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected by the National Center for Health Statistics. NHAMCS collects data on approximately 25,000 visits annually to 600 randomly selected hospital emergency and outpatient departments. This study examined visits to U.S. emergency departments (EDs) between 2002 and 2006. Multivariable logistic regression was used to analyze characteristics associated with neuroimaging in children with head injuries.

RESULTS

There were 50,835 pediatric visits in the 5-year sample, of which 1,256 (2.5%, 95% confidence interval [CI] = 2.2% to 2.7%) were for head injury. Among these, 39% (95% CI = 34% to 43%) underwent evaluation with neuroimaging. In multivariable analyses, factors associated with neuroimaging included white race (odds ratio [OR] = 1.5, 95% CI = 1.02 to 2.1), older age (OR = 1.3, 95% CI = 1.1 to 1.5), presentation to a general hospital (vs. a pediatric hospital, OR = 2.4, 95% CI = 1.1 to 5.3), more emergent triage status (OR = 1.4, 95% CI = 1.1 to 1.8), admission or transfer (OR = 2.7, 95% CI = 1.4 to 5.3), and treatment by an attending physician (OR = 2.0, 95% CI = 1.1 to 3.7). The effect of race was mitigated at the pediatric hospitals compared to at the general hospitals (p < 0.001).

CONCLUSIONS

In this study, patient race, age, and hospital-specific characteristics were associated with the frequency of neuroimaging in the evaluation of children with closed head injuries. Based on these results, focusing quality improvement initiatives on physicians at general hospitals may be an effective approach to decreasing rates of neuroimaging after pediatric head trauma.

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

OBJECTIVE

To quantify the variation in emergency department (ED) wait times by patient race/ethnicity and payment source, and to divide the overall association into between- and within-hospital components.

DATA SOURCE

2005 and 2006 National Hospital Ambulatory Medical Care Surveys.

STUDY DESIGN

Linear regression was used to analyze the independent associations between race/ethnicity, payment source, and ED wait times in a pooled cross-sectional design. A hybrid fixed effects specification was used to measure the between- and within-hospital components.

DATA EXTRACTION METHODS

Data were limited to children under 16 years presenting at EDs.

PRINCIPAL RESULTS

Unadjusted and adjusted ED wait times were significantly longer for non-Hispanic black and Hispanic children than for non-Hispanic white children. Children in EDs with higher shares of non-Hispanic black and Hispanic children waited longer. Moreover, Hispanic children waited 10.4 percent longer than non-Hispanic white children when treated at the same hospital. ED wait times for children did not vary significantly by payment source.

CONCLUSIONS

There are sizable racial/ethnic differences in children's ED wait times that can be attributed to both the racial/ethnic mix of children in EDs and to differential treatment by race/ethnicity inside the ED.

Factors associated with longer emergency department length of stay for children with bronchiolitis : a prospective multicenter study

OBJECTIVES

Emergency department (ED) length of stay (LOS) is a quality of care measure and, when prolonged, contributes to ED crowding. Bronchiolitis, a common seasonal illness of infants, provides an opportunity to examine factors affecting ED LOS.

METHODS

We analyzed data from a 30-center prospective cohort study of ED patients younger than 2 years with an attending physician diagnosis of bronchiolitis to determine what factors affect LOS. Researchers conducted a structured interview and chart review.

RESULTS

Among 1459 children enrolled, ED LOS was available for 1416 children (97%). The median ED LOS was 3.3 hours (interquartile range, 2.3-4.8 hours). Multivariate analysis demonstrated that factors significantly (P < 0.05) associated with ED LOS were larger annual ED visit volume (reference, lowest tertile [< 44,134 visits], 44,134-62,420 [β = 0.74], and ≥ 62,421 [β = 0.63]), Hispanic race/ethnicity (reference, white race, β = 1.43), lack of primary care provider (β = 1.28), duration of symptoms of 4 to 7 days (reference, < 1 day; β = 0.58), presentation of midnight to 7 AM (reference, 4:00-11:59 PM; β = 1.07), decreasing lowest oxygen saturation in ED (β = 0.07), fewer number of A-agonists during the first hour (β = 0.74), unknown oral intake (reference, adequate; β = 0.69), performance of chest x-ray (β = 0.62), and hospital admission (β = 1.11).

CONCLUSIONS

In this prospective multicenter study of children younger than 2 years with bronchiolitis, multiple factors were associated with longer ED LOS. These factors suggest the following steps to help shorten ED LOS: optimizing translation services, improving primary care provider rates, enhancing overnight patient flow, forgoing chest x-rays, and developing evidence-based admission criteria.

Influence of Ambulance Arrival on Emergency Department Time to Be Seen

OBJECTIVES

For a limited number of presenting complaints, arrival by ambulance has been shown in some emergency departments to decrease time to be seen by a physician. We sought to determine if this time advantage could be demonstrated as a national trend over a variety of presenting complaints.

METHODS

A secondary analysis was performed on the National Hospital Ambulatory Medical Care Survey, a national probability sample of emergency department visits. To compare waiting times between patients arriving by ambulance and those arriving by walk-in, a survival analysis was performed using univariate and multivariate Cox proportional hazards models. Primary variables of interest were mode of arrival, waiting time to see physician, and immediacy to be seen (triage category). The weighted values were utilized to produce national estimates. Patients who left without being seen were treated as right censored data.

RESULTS

A total of 61,130 records, weighted to represent 268.3 million emergency department visits from 1997 to 2000, were included in the analysis. Patients arrived by ambulance in 14.4% of these cases. Median wait time for patients arriving by ambulance was 14.1 minutes (95% confidence interval [CI], 4.3 to 34.2) as compared with 26.0 minutes (95% CI, 11.5 to 55.1) for patients who arrived by walk-in. In the multivariate analysis, arrival by ambulance offered a 25.0% (95% CI, 19.0% to 31.6%) time advantage over walk-in and a 40.8% (95% CI, 23.5% to 58.7%) time advantage over arrival by public service.

CONCLUSIONS

Arrival by ambulance offered a time to be seen advantage for a broad range of presenting complaints in the National Hospital Ambulatory Medical Care Survey across all triage categories.

Disparities in emergency department wait times for acute gastrointestinal illnesses: results from the National Hospital Ambulatory Medical Care Survey, 1997-2006

OBJECTIVES

(i) The aims of this study were to report wait times for visits to US emergency departments (EDs) for acute gastrointestinal illnesses, (ii) to identify whether racial/ethnic disparities exist in wait times, and (iii) to characterize factors associated with delays in physician assessment.

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 to 2006. We studied wait times for acute pancreatitis, appendicitis, cholecystitis, and upper gastrointestinal hemorrhage (UGIH). Diagnosis was based on the International Classification of Diseases, Ninth Revision, Clinical Modification. Racial/ethnic categories were defined as non-Hispanic White (NHW), non-Hispanic Black, and Hispanic White (HW). Wait time was stratified by racial/ethnic group and by study year. We evaluated the association between race/ethnicity and frequency of delay relative to triage assignment. Multivariate logistic regression was used to estimate the impact of age, sex, payment status, and geography on wait time.

RESULTS

There were an estimated 1.6 million ED visits for acute pancreatitis, 2.2 million visits for appendicitis, 1.2 million visits for cholecystitis, and 3.9 million visits for UGIH in the NHAMCS survey during the study period. Average wait time ranged from 48 min (acute pancreatitis) to 61 min (cholecystitis). We identified a delay in clinical assessment in 24% of cases. In multivariate analysis, race/ethnicity was an independent predictor for increased wait time. HW waited longer and had higher frequency of delays compared with NHW for all four disease groups.

CONCLUSIONS

A significant proportion of visits to US EDs for acute gastrointestinal illnesses are associated with a delay in initial clinical assessment. Hispanic patients waited longer and had a higher frequency of delays compared with other racial/ethnic groups. Future policies should be directed at reducing delays in physician assessment and addressing this healthcare disparity.

Contemporary homicide risks among women of reproductive age

CONTEXT

Homicide is a leading cause of death among women of reproductive age. However, little is known about how risk for homicide differs among women from different racial and ethnic groups.

PURPOSE

The purpose of this study was to identify the risk of homicide mortality among Hispanic, Black and White females of reproductive age in the United States, and to describe differences between these groups.

METHODS

A secondary data analysis of deaths certificates collected in the United States from 1999 to 2002 was conducted using descriptive statistics, chi(2) analysis, and logistic regressions.

FINDINGS

When controlled for education level, marital status, and year, the adjusted odds ratio for homicide mortality among Hispanics (2.6) and Blacks (2.1) were significantly greater than for Whites (1.0). Victim and homicide characteristics also differed across these groups.

CONCLUSIONS

Minority women are disproportionately at risk for homicide mortality. Homicide prevention programs and policies need to be developed to target the specific risks and unique characteristics of high risk groups in the United States.

Triage presenting complaint descriptions bias emergency department waiting times

OBJECTIVES

The authors aimed to determine whether certain emergency department (ED) triage "presenting complaint" descriptions are associated with shorter or longer waiting times, when compared with matched controls.

METHODS

This was a retrospective, analytical study in three tertiary referral EDs. Data relating to adult patients with Australasian National Triage Scale (NTS) Category 3-5 complaints, who presented over 1 year, were accessed. A pilot study of 25 emergency physicians (EPs) identified five most liked and five most disliked presenting complaints. For each liked or disliked complaint, "cases" were identified using key words and phrases in the triage presentation description. For each case, the previous presentation at that institution with the same NTS category was used as a "control." Cases and controls were compared for waiting time and proportions seen within the Australasian College for Emergency Medicine (ACEM)-recommended waiting times.

RESULTS

Data on 28,566 case-control pairs were examined. Compared to their controls, three of the five most liked complaints (dislocations, fractures, and palpitations) had significantly shorter waiting times, and significantly more were seen within the recommended waiting times (p < 0.05). In contrast, three of the five most disliked complaints (dizziness, constipation, and back pain) had significantly longer waiting times, and significantly fewer were seen within the recommended waiting times (p < 0.05). Other presenting complaints showed similar, although nonsignificant, trends.

CONCLUSIONS

Waiting times for patients with certain presenting complaints are significantly associated with triage presenting complaint descriptions. It is likely that these descriptions allow EPs to selectively seek or avoid patients with liked or disliked complaints, respectively. The impact of this for patients and ED flow needs investigation.

Association between language proficiency and the quality of primary care among a national sample of insured Latinos

BACKGROUND

Latinos experience substantial barriers to primary care. Limited English language proficiency may be a mechanism for these deficiencies, even for Latinos with health coverage.

OBJECTIVE

To determine the relationship between English language proficiency and the experience of primary care reported by insured Latinos.

DESIGN, SETTING, PARTICIPANTS

Analysis of the National Latino and Asian American Study, a nationally representative household survey, 2002-2003. This analysis was restricted to Latinos who reported current health insurance (n= 1792), and included information on ethnic subgroups.

MAIN OUTCOME MEASURES

Four outcomes addressed different aspects of the quality of primary care: (1) not having a regular source of care or lacking continuity of care, (2) difficulty getting an appointment over the phone, (3) long waits in the waiting room, and (4) difficulty getting information or advice by phone.

RESULTS

English language proficiency was associated with the experience of primary care for 3 of the 4 outcomes. Insured Latinos with poor/fair English language proficiency were more likely than those with good/excellent proficiency to report not having a regular source of care or lacking continuity [odds ratio (OR) 2.20, 95% confidence interval (CI) 1.60-3.02], long waits (OR, 1.88; CI, 1.34-2.64), and difficulty getting information/advice by phone (OR, 1.76; 95% CI, 1.25-2.46).

CONCLUSIONS

Among insured Latinos, low English language proficiency is associated with worse reports of the quality of primary care. These results suggest that interventions to address limited English proficiency may be important to improving the quality of primary care for this rapidly growing population.

Emergency care for children in pediatric and general emergency departments

OBJECTIVE

We examine the pediatric emergency department (ED) population and their clinical course in pediatric versus general EDs and identify potential factors contributing to differences in performance metrics between the 2 ED settings.

METHODS

This was a retrospective analysis of pediatric visits to nationally representative EDs participating in the National Hospital Ambulatory Medical Care Survey from 1995 to 2002. Differences between pediatric and general EDs were examined in terms of patient characteristics and clinical course.

RESULTS

Pediatric EDs treated more children with medical problems than general EDs, which treated more children with injuries. Visits by children to pediatric EDs were associated with longer wait times to see a physician (median, 40 vs. 25 minutes; P < 0.001) and longer stays in the ED (median, 130 vs. 98 minutes; P = 0.006). In multivariate analysis, the type of ED treating a pediatric patient was a significant determinant of wait time (percent change for pediatric EDs, 23.1; 95% confidence interval [CI], 3.4-46.6), length of stay (percent change for pediatric EDs, 23.0; 95% CI, 5.1-43.9), and rate of discharge (odds ratio for pediatric EDs, 0.75; 95% CI 0.61-0.92). Children in pediatric EDs seemed to be sicker than those in general EDs.

CONCLUSIONS

These data provide the first glimpse of health care delivery to children seen in EDs nationally. Our findings indicate that significant differences exist between pediatric visits to pediatric and general EDs. These findings may be useful in establishing performance metrics for the care of ill and injured children in both pediatric and general EDs.