Gender Differences in Patients' Experience of Care in the Emergency Department

Rurality and patients' hospital experience: A multisite analysis from a US healthcare system

BACKGROUND

The association between rurality of patients' residence and hospital experience is incompletely described. The objective of the study was to compare hospital experience by rurality of patients' residence.

METHODS

From a US Midwest institution's 17 hospitals, we included 56,685 patients who returned a post-hospital Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. We defined rurality using rural-urban commuting area codes (metropolitan, micropolitan, small town, rural). We evaluated the association of patient characteristics with top-box score (favorable response) for 10 HCAHPS items (six composite, two individual, two global). We obtained adjusted odds ratios (aOR [95% CI]) from logistic regression models including patient characteristics. We used key driver analysis to identify associations between HCAHPS items and global rating (combined overall rating of hospital and recommend hospital).

RESULTS

Of all items, overall rating of hospital had lower odds of favorable response for patients from metropolitan (0.88 [0.81-0.94]), micropolitan (0.86 [0.79-0.94]), and small towns (0.90 [0.82-0.98]) compared with rural areas (global test, P = .003). For five items, lower odds of favorable response was observed for select areas compared with rural; for example, recommend hospital for patients from micropolitan (0.88 [0.81-0.97]) but not metropolitan (0.97 [0.89-1.05]) or small towns (0.93 [0.85-1.02]). For four items, rurality showed no association. In metropolitan, micropolitan, and small towns, men vs. women had higher odds of favorable response to most items, whereas in rural areas, sex-based differences were largely absent. Key driver analysis identified care transition, communication about medicines and environment as drivers of global rating, independent of rurality.

CONCLUSIONS

Rural patients reported similar or modestly more favorable hospital experience. Determinants of favorable experience across rurality categories may inform system-wide and targeted improvement.

Association of Prior Stroke With Health Care Perceptions of Adequate Emergency Care in Women

BACKGROUND

Women with a history of stroke represent a vulnerable patient population due to their extant disability, morbidity, and risk of recurrence. The association between prior stroke with patient experience and perception of emergency medical care is unknown.

METHODS

We utilized data from the Health Care Experiences and Perception cross-sectional, online survey from the American Heart Association Research Goes Red Registry. Ordinal logistic regression models were performed to assess the association between a self-reported history of stroke in the prior 10 years and the perception of not receiving adequate care in an emergency department because of gender or race. Models were adjusted for age at the time of enrollment, race/ethnicity, myocardial infarction within 10 years, and current smoking status.

RESULTS

A total of 3498 women participants met inclusion criteria: 89 participants with a history of stroke in the past 10 years (mean age, 49.4 years; 10.1% Black participants and 5.6% Hispanic participants) and 3409 participants without such history (mean age, 45.8 years; 7.8% Black participants and 7.0% Hispanic participants). In multivariate logistic regression models, stroke history was significantly associated with greater odds of answering "to a great extent" that "I will not receive adequate care in an emergency room based on my gender" (odds ratio, 3.23 [95% CI, 1.69-6.17]) and "…race/ethnicity" (odds ratio, 3.88 [95% CI, 1.45-10.39]). Similar results were seen for secondary outcomes.

CONCLUSIONS

Women patients with a stroke history felt less likely to receive adequate emergency care based on gender and race/ethnicity. Whether these negative health perceptions are associated with delays in presentation for stroke or other time-sensitive conditions should be the focus of future studies, given that these populations are known to less frequently receive advanced therapies for stroke, in part due to delays in presentation.

Shared Decision-Making and Emergency Department Use Among People With High Blood Pressure

INTRODUCTION

Forty-seven percent of all adults in the US have a diagnosis of high blood pressure. Among all US emergency department (ED) users, an estimated 45% have high blood pressure. The success of high blood pressure interventions in reducing ED visits is partially predicated on patients' adherence to treatment plans. One method for promoting adherence to treatment plans is shared decision-making between patients and medical providers.

METHODS

We conducted a cross-sectional observational study using 2015-2019 Medical Expenditure Panel Survey data. We used studies on shared decision-making as a guide to create a predictor variable for shared decision-making. We determined covariates according to the Andersen Behavioral Model of Health Services Use. ED use was the outcome variable. We used cross tabulation to compare covariates of ED use and multivariable logistical regression to assess the association between shared decision-making and ED use. Our sample size was 30,407 adults.

RESULTS

Less than half (39.3%) of respondents reported a high level of shared decision-making; 23.3% had 1 or more ED visits. In the unadjusted model, respondents who reported a high level of shared decision-making were 20% less likely than those with a low level of shared decision-making to report 1 or more ED visits (odds ratio [OR], 0.80; 95% CI, 0.75-0.86; P <.001). After adjusting for covariates, a high level of shared decision-making was still associated with lower odds of ED use (OR, 0.86; 95% CI, 0.76-0.97; P = .01).

CONCLUSION

Shared decision-making may be an effective method for reducing ED use among patients with high blood pressure.

Use of Routine Emergency Department Care Practices with Deaf American Sign Language Users

BACKGROUND

Deaf individuals who communicate using American Sign Language (ASL) seem to experience a range of disparities in health care, but there are few empirical data.

OBJECTIVE

To examine the provision of common care practices in the emergency department (ED) to this population.

METHODS

ED visits in 2018 at a U.S. academic medical center were assessed retrospectively in Deaf adults who primarily use ASL (n = 257) and hearing individuals who primarily use English, selected at random (n = 429). Logistic regression analyses adjusted for confounders compared the groups on the provision or nonprovision of four routine ED care practices (i.e., laboratories ordered, medications ordered, images ordered, placement of peripheral intravenous line [PIV]) and on ED disposition (admitted to hospital or not admitted).

RESULTS

The ED encounters with Deaf ASL users were less likely to include laboratory tests being ordered: adjusted odds ratio 0.68 and 95% confidence interval 0.47-0.97. ED encounters with Deaf individuals were also less likely to include PIV placement, less likely to result in images being ordered in the ED care of ASL users of high acuity compared with English users of high acuity (but not low acuity), and less likely to result in hospital admission.

CONCLUSION

Results suggest disparate provision of several types of routine ED care for adult Deaf ASL users. Limitations include the observational study design at a single site and reliance on the medical record, underscoring the need for further research and potential reasons for disparate ED care with Deaf individuals.

Factors associated with a positive experience at US fertility clinics: the male partner perspective

OBJECTIVE

To determine factors associated with a positive male patient experience (PMPE) at fertility clinics among male patients.

DESIGN

Cross-sectional study Setting: Not applicable Patients: Male respondents to the FertilityIQ questionnaire ( www.fertilityiq.com ) reviewing the first or only US clinic visited between June 2015 and August 2020.

INTERVENTIONS

None Main outcome measures: PMPE was defined as a score of 9 or 10 out of 10 to the question, "Would you recommend this fertility clinic to a best friend?". Examined predictors included demographics, payment details, infertility diagnoses, treatment, and outcomes, physician traits, and clinic operations and resources. Multiple imputation was used for missing variables and logistic regression was used to calculate adjusted odds ratios (aORs) for factors associated with PMPE.

RESULTS

Of the 657 men included, 60.9% reported a PMPE. Men who felt their doctor was trustworthy (aOR 5.01, 95% CI 0.97-25.93), set realistic expectations (aOR 2.73, 95% CI 1.10-6.80), and was responsive to setbacks (aOR 2.43, 95% CI 1.14-5.18) were more likely to report PMPE. Those who achieved pregnancy after treatment were more likely to report PMPE; however, this was no longer significant on multivariate analysis (aOR 1.30, 95% CI 0.68-2.47). Clinic-related factors, including ease of scheduling appointments (aOR 4.03, 95% CI 1.63-9.97) and availability of same-day appointments (aOR 4.93, 95% CI 1.75-13.86), were associated with PMPE on both univariate and multivariate analysis. LGBTQ respondents were more likely to report PMPE, whereas men with a college degree or higher were less likely to report PMPE; however, sexual orientation (aOR 3.09, 95% CI 0.86-11.06) and higher educational level (aOR 0.54, 95% CI 0.30-1.10) were not associated with PMPE on multivariate analysis.

CONCLUSION

Physician characteristics and clinic characteristics indicative of well-run administration were the most highly predictive of PMPE. By identifying factors that are associated with a PMPE, clinics may be able to optimize the patient experience and improve the quality of infertility care that they provide for both men and women.

Documentation Status and Self-Rated Physical Health Among Latinx Young Adult Immigrants: the Mediating Roles of Immigration and Healthcare Stress

Previous research has demonstrated that undocumented Latinx immigrants in the USA report worse physical health outcomes than documented immigrants. Some studies suggest that immigration-related stress and healthcare related-stress may explain this relationship, but none have tested it empirically. The purpose of this study was to determine if immigration-related stress and healthcare-related stress in the USA explain the relationship between documentation status and physical health among Latinx immigrants in North Carolina. The conceptual model was tested utilizing baseline data from a longitudinal, observational, community-engaged research study of young adult (18-44 years) Latinx immigrants residing in North Carolina (N = 391). Structural equation modeling was used to determine relationships among documentation status, healthcare, and immigration stress in the past six months, and self-rated physical health. Goodness-of-fit measures indicated that data fit the model well (RMSEA = .008; CFI = 1.0; TLI = .999; SRMR = .02; CD = .157). Undocumented individuals were more likely to experience immigration stress than their documented counterparts ([Formula: see text] = - 0.37, p < 0.001). Both immigration stress ([Formula: see text] = - 0.22, p < 0.01) and healthcare stress ([Formula: see text] = - 0.14, p < 0.05) were negatively related to physical health. Additionally, immigration stress was positively related to healthcare stress ([Formula: see text] = 0.72, p < 0.001). Results demonstrate that documentation status is an important social determinant of health. Passage of inclusive immigration and healthcare policies may lessen the stress experienced by Latinx immigrants and subsequently improve physical health.

Differential Patterns and Outcomes of 20.6 Million Cardiovascular Emergency Department Encounters for Men and Women in the United States

Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest. In logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage had higher risk of hospitalization and death. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest. Conclusions In this large nationally representative sample of cardiovascular emergency department presentations, we demonstrate significant sex differences in disease distribution, hospitalization, and death.