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Martin CA, Coats T, Pareek M, Khunti K, Abeyratne R, Brunskill NJ. Ethnicity and outcomes for patients with gastrointestinal disorders attending an emergency department serving a multi-ethnic population. BMC Med 2024; 22:275. [PMID: 38956541 PMCID: PMC11218405 DOI: 10.1186/s12916-024-03490-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Ethnic inequalities in acute health acute care are not well researched. We examined how attendee ethnicity influenced outcomes of emergency care in unselected patients presenting with a gastrointestinal (GI) disorder. METHODS A descriptive, retrospective cohort analysis of anonymised patient level data for University Hospitals of Leicester emergency department attendees, from 1 January 2018 to 31 December 2021, receiving a diagnosis of a GI disorder was performed. The primary exposure of interest was self-reported ethnicity, and the two outcomes studied were admission to hospital and whether patients underwent clinical investigations. Confounding variables including sex and age, deprivation index and illness acuity were adjusted for in the analysis. Chi-squared and Kruskal-Wallis tests were used to examine ethnic differences across outcome measures and covariates. Multivariable logistic regression was used to examine associations between ethnicity and outcome measures. RESULTS Of 34,337 individuals, median age 43 years, identified as attending the ED with a GI disorder, 68.6% were White. Minority ethnic patients were significantly younger than White patients. Multiple emergency department attendance rates were similar for all ethnicities (overall 18.3%). White patients had the highest median number of investigations (6, IQR 3-7), whereas those from mixed ethnic groups had the lowest (2, IQR 0-6). After adjustment for age, sex, year of attendance, index of multiple deprivation and illness acuity, all ethnic minority groups remained significantly less likely to be investigated for their presenting illness compared to White patients (Asian: aOR 0.80, 95% CI 0.74-0.87; Black: 0.67, 95% CI 0.58-0.79; mixed: 0.71, 95% CI 0.59-0.86; other: 0.79, 95% CI 0.67-0.93; p < 0.0001 for all). Similarly, after adjustment, minority ethnic attendees were also significantly less likely to be admitted to hospital (Asian: aOR 0.63, 95% CI 0.60-0.67; Black: 0.60, 95% CI 0.54-0.68; mixed: 0.60, 95% CI 0.51-0.71; other: 0.61, 95% CI 0.54-0.69; p < 0.0001 for all). CONCLUSIONS Significant differences in usage patterns and disparities in acute care outcomes for patients of different ethnicities with GI disorders were observed in this study. These differences persisted after adjustment both for confounders and for measures of deprivation and illness acuity and indicate that minority ethnic individuals are less likely to be investigated or admitted to hospital than White patients.
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Affiliation(s)
- Christopher A Martin
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
- Development Centre for Population Health, University of Leicester, Leicester, UK
| | - Tim Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
- Development Centre for Population Health, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Centre for Ethnic Health Research, University of Leicester, Leicester, UK
| | - Ruw Abeyratne
- Department of Corporate Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nigel J Brunskill
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
- Department of Nephrology, University Hospitals of Leicester NHS Trust, Leicester, UK.
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Chen YH, Handly N, Chang DC, Chen YW. Racial difference in receiving computed tomography for head injury patients in emergency departments. Am J Emerg Med 2024; 83:54-58. [PMID: 38964277 DOI: 10.1016/j.ajem.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/19/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024] Open
Abstract
STUDY OBJECTIVE Prior studies have suggested potential racial differences in receiving imaging tests in emergency departments (EDs), but the results remain inconclusive. In addition, most prior studies may only have limited racial groups for minority patients. This study aimed to investigate racial differences in head computed tomography (CT) administration rates in EDs among patients with head injuries. METHODS Patients with head injuries who visited EDs were examined. The primary outcome was patients receiving head CT during ED visits, and the primary exposure was patient race/ethnicity, including Asian, Hispanic, Non-Hispanic Black (Black), and Non-Hispanic White (White). Multivariable logistic regression analyses were performed using the National Hospital Ambulatory Medical Care Survey database, adjusting for patients and hospital characteristics. RESULTS Among 6130 patients, 51.9% received a head CT scan. Asian head injury patients were more likely to receive head CT than White patients (59.1% versus 54.0%, difference 5.1%, p < 0.001). This difference persisted in adjusted results (odds ratio, 1.52; 95% CI, 1.06-2.16, p = 0.022). In contrast, Black and Hispanic patients have no significant difference in receiving head CT than White patients after the adjustment. CONCLUSIONS Asian head injury patients were more likely to receive head CT than White patients. This difference may be attributed to the limited English proficiency among Asian individuals and the fact that there is a wide variety of different languages spoken by Asian patients. Future studies should examine rates of receiving other diagnostic imaging modalities among different racial groups and possible interventions to address this difference.
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Affiliation(s)
- Yuan-Hsin Chen
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America
| | - Neal Handly
- Department of Emergency Medicine, Contra Costa Regional Medical Center, Martinez, CA, United States of America; Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America.
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3
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Cooper R, Hayes RA, Corcoran M, Sheth KN, Arnold TC, Stein JM, Glahn DC, Jalbrzikowski M. Bridging the gap: improving correspondence between low-field and high-field magnetic resonance images in young people. Front Neurol 2024; 15:1339223. [PMID: 38585353 PMCID: PMC10995930 DOI: 10.3389/fneur.2024.1339223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/19/2024] [Indexed: 04/09/2024] Open
Abstract
Background Portable low-field-strength magnetic resonance imaging (MRI) systems represent a promising alternative to traditional high-field-strength systems with the potential to make MR technology available at scale in low-resource settings. However, lower image quality and resolution may limit the research and clinical potential of these devices. We tested two super-resolution methods to enhance image quality in a low-field MR system and compared their correspondence with images acquired from a high-field system in a sample of young people. Methods T1- and T2-weighted structural MR images were obtained from a low-field (64mT) Hyperfine and high-field (3T) Siemens system in N = 70 individuals (mean age = 20.39 years, range 9-26 years). We tested two super-resolution approaches to improve image correspondence between images acquired at high- and low-field: (1) processing via a convolutional neural network ('SynthSR'), and (2) multi-orientation image averaging. We extracted brain region volumes, cortical thickness, and cortical surface area estimates. We used Pearson correlations to test the correspondence between these measures, and Steiger Z tests to compare the difference in correspondence between standard imaging and super-resolution approaches. Results Single pairs of T1- and T2-weighted images acquired at low field showed high correspondence to high-field-strength images for estimates of total intracranial volume, surface area cortical volume, subcortical volume, and total brain volume (r range = 0.60-0.88). Correspondence was lower for cerebral white matter volume (r = 0.32, p = 0.007, q = 0.009) and non-significant for mean cortical thickness (r = -0.05, p = 0.664, q = 0.664). Processing images with SynthSR yielded significant improvements in correspondence for total brain volume, white matter volume, total surface area, subcortical volume, cortical volume, and total intracranial volume (r range = 0.85-0.97), with the exception of global mean cortical thickness (r = 0.14). An alternative multi-orientation image averaging approach improved correspondence for cerebral white matter and total brain volume. Processing with SynthSR also significantly improved correspondence across widespread regions for estimates of cortical volume, surface area and subcortical volume, as well as within isolated prefrontal and temporal regions for estimates of cortical thickness. Conclusion Applying super-resolution approaches to low-field imaging improves regional brain volume and surface area accuracy in young people. Finer-scale brain measurements, such as cortical thickness, remain challenging with the limited resolution of low-field systems.
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Affiliation(s)
- Rebecca Cooper
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Rebecca A. Hayes
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, United States
| | - Mary Corcoran
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, United States
| | - Kevin N. Sheth
- Center for Brain and Mind Health, Yale School of Medicine, New Haven, CT, United States
| | - Thomas Campbell Arnold
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA, United States
| | - Joel M. Stein
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA, United States
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - David C. Glahn
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
- Olin Neuropsychiatry Research Center, Institute of Living, Hartford, CT, United States
| | - Maria Jalbrzikowski
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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Joseph JW, Kennedy M, Landry AM, Marsh RH, Baymon DE, Im DE, Chen PC, Samuels-Kalow ME, Nentwich LM, Elhadad N, Sánchez LD. Race and Ethnicity and Primary Language in Emergency Department Triage. JAMA Netw Open 2023; 6:e2337557. [PMID: 37824142 PMCID: PMC10570890 DOI: 10.1001/jamanetworkopen.2023.37557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/30/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Emergency department (ED) triage substantially affects how long patients wait for care but triage scoring relies on few objective criteria. Prior studies suggest that Black and Hispanic patients receive unequal triage scores, paralleled by disparities in the depth of physician evaluations. Objectives To examine whether racial disparities in triage scores and physician evaluations are present across a multicenter network of academic and community hospitals and evaluate whether patients who do not speak English face similar disparities. Design, Setting, and Participants This was a cross-sectional, multicenter study examining adults presenting between February 28, 2019, and January 1, 2023, across the Mass General Brigham Integrated Health Care System, encompassing 7 EDs: 2 urban academic hospitals and 5 community hospitals. Analysis included all patients presenting with 1 of 5 common chief symptoms. Exposures Emergency department nurse-led triage and physician evaluation. Main Outcomes and Measures Average Triage Emergency Severity Index [ESI] score and average visit work relative value units [wRVUs] were compared across symptoms and between individual minority racial and ethnic groups and White patients. Results There were 249 829 visits (149 861 female [60%], American Indian or Alaska Native 0.2%, Asian 3.3%, Black 11.8%, Hispanic 18.8%, Native Hawaiian or Other Pacific Islander <0.1%, White 60.8%, and patients identifying as Other race or ethnicity 5.1%). Median age was 48 (IQR, 29-66) years. White patients had more acute ESI scores than Hispanic or Other patients across all symptoms (eg, chest pain: Hispanic, 2.68 [95% CI, 2.67-2.69]; White, 2.55 [95% CI, 2.55-2.56]; Other, 2.66 [95% CI, 2.64-2.68]; P < .001) and Black patients across most symptoms (nausea/vomiting: Black, 2.97 [95% CI, 2.96-2.99]; White: 2.90 [95% CI, 2.89-2.91]; P < .001). These differences were reversed for wRVUs (chest pain: Black, 4.32 [95% CI, 4.25-4.39]; Hispanic, 4.13 [95% CI, 4.08-4.18]; White 3.55 [95% CI, 3.52-3.58]; Other 3.96 [95% CI, 3.84-4.08]; P < .001). Similar patterns were seen for patients whose primary language was not English. Conclusions and Relevance In this cross-sectional study, patients who identified as Black, Hispanic, and Other race and ethnicity were assigned less acute ESI scores than their White peers despite having received more involved physician workups, suggesting some degree of mistriage. Clinical decision support systems might reduce these disparities but would require careful calibration to avoid replicating bias.
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Affiliation(s)
- Joshua W. Joseph
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Maura Kennedy
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Alden M. Landry
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston
| | - Regan H. Marsh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Da’Marcus E. Baymon
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dana E. Im
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Paul C. Chen
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Margaret E. Samuels-Kalow
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Lauren M. Nentwich
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Noémie Elhadad
- Departments of Biomedical Informatics and Computer Science, Columbia University, New York, New York
| | - León D. Sánchez
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Herington J, McCradden MD, Creel K, Boellaard R, Jones EC, Jha AK, Rahmim A, Scott PJH, Sunderland JJ, Wahl RL, Zuehlsdorff S, Saboury B. Ethical Considerations for Artificial Intelligence in Medical Imaging: Deployment and Governance. J Nucl Med 2023; 64:1509-1515. [PMID: 37620051 DOI: 10.2967/jnumed.123.266110] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 07/11/2023] [Indexed: 08/26/2023] Open
Abstract
The deployment of artificial intelligence (AI) has the potential to make nuclear medicine and medical imaging faster, cheaper, and both more effective and more accessible. This is possible, however, only if clinicians and patients feel that these AI medical devices (AIMDs) are trustworthy. Highlighting the need to ensure health justice by fairly distributing benefits and burdens while respecting individual patients' rights, the AI Task Force of the Society of Nuclear Medicine and Molecular Imaging has identified 4 major ethical risks that arise during the deployment of AIMD: autonomy of patients and clinicians, transparency of clinical performance and limitations, fairness toward marginalized populations, and accountability of physicians and developers. We provide preliminary recommendations for governing these ethical risks to realize the promise of AIMD for patients and populations.
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Affiliation(s)
- Jonathan Herington
- Department of Health Humanities and Bioethics and Department of Philosophy, University of Rochester, Rochester, New York
| | - Melissa D McCradden
- Department of Bioethics, Hospital for Sick Children, and Dana Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen Creel
- Department of Philosophy and Religion and Khoury College of Computer Sciences, Northeastern University, Boston, Massachusetts
| | - Ronald Boellaard
- Department of Radiology and Nuclear Medicine, Cancer Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Elizabeth C Jones
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Abhinav K Jha
- Department of Biomedical Engineering and Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Arman Rahmim
- Departments of Radiology and Physics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter J H Scott
- Department of Radiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - John J Sunderland
- Departments of Radiology and Physics, University of Iowa, Iowa City, Iowa
| | - Richard L Wahl
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri; and
| | | | - Babak Saboury
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland;
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Kimberly WT, Sorby-Adams AJ, Webb AG, Wu EX, Beekman R, Bowry R, Schiff SJ, de Havenon A, Shen FX, Sze G, Schaefer P, Iglesias JE, Rosen MS, Sheth KN. Brain imaging with portable low-field MRI. NATURE REVIEWS BIOENGINEERING 2023; 1:617-630. [PMID: 37705717 PMCID: PMC10497072 DOI: 10.1038/s44222-023-00086-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 09/15/2023]
Abstract
The advent of portable, low-field MRI (LF-MRI) heralds new opportunities in neuroimaging. Low power requirements and transportability have enabled scanning outside the controlled environment of a conventional MRI suite, enhancing access to neuroimaging for indications that are not well suited to existing technologies. Maximizing the information extracted from the reduced signal-to-noise ratio of LF-MRI is crucial to developing clinically useful diagnostic images. Progress in electromagnetic noise cancellation and machine learning reconstruction algorithms from sparse k-space data as well as new approaches to image enhancement have now enabled these advancements. Coupling technological innovation with bedside imaging creates new prospects in visualizing the healthy brain and detecting acute and chronic pathological changes. Ongoing development of hardware, improvements in pulse sequences and image reconstruction, and validation of clinical utility will continue to accelerate this field. As further innovation occurs, portable LF-MRI will facilitate the democratization of MRI and create new applications not previously feasible with conventional systems.
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Affiliation(s)
- W Taylor Kimberly
- Department of Neurology and the Center for Genomic Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Annabel J Sorby-Adams
- Department of Neurology and the Center for Genomic Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew G Webb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ed X Wu
- Laboratory of Biomedical Imaging and Signal Processing, Department of Electrical and Electronic Engineering, The University of Hong Kong, Hong Kong SAR, China
| | - Rachel Beekman
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital and Yale School of Medicine, Yale Center for Brain & Mind Health, New Haven, CT, USA
| | - Ritvij Bowry
- Departments of Neurosurgery and Neurology, McGovern Medical School, University of Texas Health Neurosciences, Houston, TX, USA
| | - Steven J Schiff
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Adam de Havenon
- Division of Vascular Neurology, Department of Neurology, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Francis X Shen
- Harvard Medical School Center for Bioethics, Harvard law School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Gordon Sze
- Department of Radiology, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Pamela Schaefer
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Juan Eugenio Iglesias
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Centre for Medical Image Computing, University College London, London, UK
- Computer Science and AI Laboratory, Massachusetts Institute of Technology, Boston, MA, USA
| | - Matthew S Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital and Yale School of Medicine, Yale Center for Brain & Mind Health, New Haven, CT, USA
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Hajibonabi F, Taye M, Ubanwa A, Rowe JS, Sharperson C, Hanna TN, Johnson JO. Time ratio disparities among ED patients undergoing head CT. Emerg Radiol 2023; 30:453-463. [PMID: 37349643 DOI: 10.1007/s10140-023-02152-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE To assess if patients who underwent head computed tomography (CT) experienced disparities in the emergency department (ED) and if the indication for head CT affected disparities. METHODS This study employed a retrospective, IRB-approved cohort design encompassing four hospitals. All ED patients between January 2016 and September 2020 who underwent non-contrast head CTs were included. Furthermore, key time intervals including ED length of stay (LOS), ED assessment time, image acquisition time, and image interpretation time were calculated. Time ratio (TR) was used to compare these time intervals between the groups. RESULTS A total of 45,177 ED visits comprising 4730 trauma cases, 5475 altered mental status cases, 11,925 cases with head pain, and 23,047 cases with other indications were included. Females had significantly longer ED LOS, ED assessment time, and image acquisition time (TR = 1.012, 1.051, 1.018, respectively, P-value < 0.05). This disparity was more pronounced in female patients with head pain complaints compared to their male counterparts (TR = 1.036, 1.059, and 1.047, respectively, P-value < 0.05). Black patients experienced significantly longer ED LOS, image acquisition time, and image assessment time (TR = 1.226, 1.349, and 1.190, respectively, P-value < 0.05). These disparities persisted regardless of head CT indications. Furthermore, patients with Medicare/Medicaid insurance also faced longer wait times in all the time intervals (TR > 1, P-value < 0.001). CONCLUSIONS Wait times for ED head CT completion were longer for Black patients and Medicaid/Medicare insurance holders. Additionally, females experienced extended wait times, particularly when presented with head pain complaints. Our findings underscore the importance of exploring and addressing the contributing factors to ensure equitable and timely access to imaging services in the ED.
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Affiliation(s)
- Farid Hajibonabi
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
| | - Marta Taye
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA
| | - Angela Ubanwa
- Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jean Sebastien Rowe
- Department of Radiology, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ, 08103, USA
| | - Camara Sharperson
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA
| | - Jamlik-Omari Johnson
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Holland WC, Li F, Nath B, Jeffery MM, Stevens M, Melnick ER, Dziura JD, Khidir H, Skains RM, D’Onofrio G, Soares WE. Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems. Acad Emerg Med 2023; 30:709-720. [PMID: 36660800 PMCID: PMC10467357 DOI: 10.1111/acem.14668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood. METHODS This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity. RESULTS Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64). CONCLUSIONS Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.
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Affiliation(s)
| | - Fangyong Li
- Yale Center for Analytical Sciences, New Haven, Connecticut, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Molly M. Jeffery
- Department of Emergency Medicine and Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Stevens
- Department of Emergency Medicine and Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James D. Dziura
- Yale Center for Analytical Sciences, New Haven, Connecticut, USA
| | - Hazar Khidir
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rachel M. Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - William E. Soares
- Department of Emergency Medicine, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts, USA
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de Havenon A, Parasuram NR, Crawford AL, Mazurek MH, Chavva IR, Yadlapalli V, Iglesias JE, Rosen MS, Falcone GJ, Payabvash S, Sze G, Sharma R, Schiff SJ, Safdar B, Wira C, Kimberly WT, Sheth KN. Identification of White Matter Hyperintensities in Routine Emergency Department Visits Using Portable Bedside Magnetic Resonance Imaging. J Am Heart Assoc 2023; 12:e029242. [PMID: 37218590 PMCID: PMC10381997 DOI: 10.1161/jaha.122.029242] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/27/2023] [Indexed: 05/24/2023]
Abstract
Background White matter hyperintensity (WMH) on magnetic resonance imaging (MRI) of the brain is associated with vascular cognitive impairment, cardiovascular disease, and stroke. We hypothesized that portable magnetic resonance imaging (pMRI) could successfully identify WMHs and facilitate doing so in an unconventional setting. Methods and Results In a retrospective cohort of patients with both a conventional 1.5 Tesla MRI and pMRI, we report Cohen's kappa (κ) to measure agreement for detection of moderate to severe WMH (Fazekas ≥2). In a subsequent prospective observational study, we enrolled adult patients with a vascular risk factor being evaluated in the emergency department for a nonstroke complaint and measured WMH using pMRI. In the retrospective cohort, we included 33 patients, identifying 16 (49.5%) with WMH on conventional MRI. Between 2 raters evaluating pMRI, the interrater agreement on WMH was strong (κ=0.81), and between 1 rater for conventional MRI and the 2 raters for pMRI, intermodality agreement was moderate (κ=0.66, 0.60). In the prospective cohort we enrolled 91 individuals (mean age, 62.6 years; 53.9% men; 73.6% with hypertension), of which 58.2% had WMHs on pMRI. Among 37 Black and Hispanic individuals, the Area Deprivation Index was higher (versus White, 51.8±12.9 versus 37.9±11.9; P<0.001). Among 81 individuals who did not have a standard-of-care MRI in the preceding year, we identified WMHs in 43 of 81 (53.1%). Conclusions Portable, low-field imaging could be useful for identifying moderate to severe WMHs. These preliminary results introduce a novel role for pMRI outside of acute care and the potential role for pMRI to reduce disparities in neuroimaging.
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Affiliation(s)
- Adam de Havenon
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
- Center for Brain and Mind HealthYale University School of MedicineNew HavenCTUSA
| | | | - Anna L. Crawford
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
| | - Mercy H. Mazurek
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
| | - Isha R. Chavva
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
| | | | - Juan E. Iglesias
- Department of Neurology, Division of Neurocritical CareMassachusetts General HospitalBostonMAUSA
- Computer Science and Artificial Intelligence LabMassachusetts Institute of TechnologyCambridgeMAUSA
- Center for Biomedical ImagingMassachusetts General Hospital and Harvard Medical SchoolDepartment of Physics, Harvard UniversityBostonMAUSA
| | - Matthew S. Rosen
- Department of Neurology, Division of Neurocritical CareMassachusetts General HospitalBostonMAUSA
| | - Guido J. Falcone
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
| | - Seyedmehdi Payabvash
- Center for Brain and Mind HealthYale University School of MedicineNew HavenCTUSA
- Department of RadiologyYale University School of MedicineNew HavenCOUSA
| | - Gordon Sze
- Department of RadiologyYale University School of MedicineNew HavenCOUSA
| | - Richa Sharma
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
- Center for Brain and Mind HealthYale University School of MedicineNew HavenCTUSA
| | - Steven J. Schiff
- Department of NeurosurgeryYale University School of MedicineNew HavenCOUSA
| | - Basmah Safdar
- Department of Emergency MedicineYale University School of MedicineNew HavenCOUSA
| | - Charles Wira
- Department of Emergency MedicineYale University School of MedicineNew HavenCOUSA
| | - William T. Kimberly
- Department of Neurology, Division of Neurocritical CareMassachusetts General HospitalBostonMAUSA
| | - Kevin N. Sheth
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
- Center for Brain and Mind HealthYale University School of MedicineNew HavenCTUSA
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Hartford EA, Thomas AA, Kerwin O, Usoro E, Yoshida H, Burns B, Rutman LE, Migita R, Bradford M, Akhter S. Toward Improving Patient Equity in a Pediatric Emergency Department: A Framework for Implementation. Ann Emerg Med 2023; 81:385-392. [PMID: 36669917 DOI: 10.1016/j.annemergmed.2022.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 01/20/2023]
Abstract
Disparities in health care delivery and health outcomes for patients in the emergency department (ED) by race, ethnicity, and language for care (REaL) are common and well documented. Addressing inequities from structural racism, implicit bias, and language barriers can be challenging, and there is a lack of data on effective interventions. We describe the implementation of a multifaceted equity improvement strategy in a pediatric ED using Kotter's model for change as a framework to identify the key drivers. The main elements included a data dashboard with quality metrics stratified by patient self-reported REaL to visualize disparities, a staff workshop on implicit bias and microaggressions, and several clinical and operational tools that highlight equity. Our next steps include refining and repeating interventions and tracking important patient outcomes, including timely pain treatment, triage assessment, diagnostic evaluations, and interpreter use, with the overall goal of improving patient equity by REaL over time. This article presents a roadmap for a disparity reduction intervention, which can be part of a multifaceted approach to address health equity in EDs.
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Affiliation(s)
- Emily A Hartford
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA.
| | - Anita A Thomas
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | - Olivia Kerwin
- Seattle Children's Hospital Emergency Department, Seattle, WA, USA
| | - Etiowo Usoro
- Seattle Children's Hospital Emergency Department, Seattle, WA, USA
| | - Hiromi Yoshida
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | - Brian Burns
- Seattle Children's Hospital Emergency Department, Seattle, WA, USA
| | - Lori E Rutman
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | - Russell Migita
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | | | - Sabreen Akhter
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
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11
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Vagal A, Sucharew H, Wang LL, Kissela B, Alwell K, Haverbusch M, Woo D, Ferioli S, Mackey J, De Los Rios La Rosa F, Mistry EA, Demel SL, Coleman E, Jasne AS, Walsh K, Khatri P, Slavin S, Star M, Stephens C, Kleindorfer D. Trends in Disparities in Advanced Neuroimaging Utilization in Acute Stroke: A Population-Based Study. Stroke 2023; 54:1001-1008. [PMID: 36972349 DOI: 10.1161/strokeaha.122.040790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 02/01/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Our primary objective was to evaluate if disparities in race, sex, age, and socioeconomic status (SES) exist in utilization of advanced neuroimaging in year 2015 in a population-based study. Our secondary objective was to identify the disparity trends and overall imaging utilization as compared with years 2005 and 2010. METHODS This was a retrospective, population-based study that utilized the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) data. Patients with stroke and transient ischemic attack were identified in the years 2005, 2010, and 2015 in a metropolitan population of 1.3 million. The proportion of imaging use within 2 days of stroke/transient ischemic attack onset or hospital admission date was computed. SES determined by the percentage below the poverty level within a given respondent's US census tract of residence was dichotomized. Multivariable logistic regression was used to determine the odds of advanced neuroimaging use (computed tomography angiogram/magnetic resonance imaging/magnetic resonance angiogram) for age, race, gender, and SES. RESULTS There was a total of 10 526 stroke/transient ischemic attack events in the combined study year periods of 2005, 2010, and 2015. The utilization of advanced imaging progressively increased (48% in 2005, 63% in 2010, and 75% in 2015 [P<0.001]). In the combined study year multivariable model, advanced imaging was associated with age and SES. Younger patients (≤55 years) were more likely to have advanced imaging compared with older patients (adjusted odds ratio, 1.85 [95% CI, 1.62-2.12]; P<0.01), and low SES patients were less likely to have advanced imaging compared with high SES (adjusted odds ratio, 0.83 [95% CI, 0.75-0.93]; P<0.01). A significant interaction was found between age and race. Stratified by age, the adjusted odds of advanced imaging were higher for Black patients compared with White patients among older patients (>55 years; adjusted odds ratio, 1.34 [95% CI, 1.15-1.57]; P<0.01), but no racial differences among the young. CONCLUSIONS Racial, age, and SES-related disparities exist in the utilization of advanced neuroimaging for patients with acute stroke. There was no evidence of a change in trend of these disparities between the study periods.
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Affiliation(s)
- Achala Vagal
- Department of Radiology (A.V., L.W., C.S.), University of Cincinnati Medical Center, OH
| | - Heidi Sucharew
- Department of Emergency Medicine (H.S.), University of Cincinnati Medical Center, OH
| | - Lily L Wang
- Department of Radiology (A.V., L.W., C.S.), University of Cincinnati Medical Center, OH
| | - Brett Kissela
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Kathleen Alwell
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Mary Haverbusch
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Daniel Woo
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Simona Ferioli
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Jason Mackey
- Indiana University School of Medicine, Indianapolis (J.M.)
| | | | - Eva A Mistry
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Stacie L Demel
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | | | | | - Kyle Walsh
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Pooja Khatri
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | | | | | - Cody Stephens
- Department of Radiology (A.V., L.W., C.S.), University of Cincinnati Medical Center, OH
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12
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Sharperson C, Hajibonabi F, Hanna TN, Gerard RL, Gilyard S, Johnson JO. Are disparities in emergency department imaging exacerbated during high-volume periods? Clin Imaging 2023; 96:9-14. [PMID: 36731373 DOI: 10.1016/j.clinimag.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/17/2023]
Abstract
PURPOSE Evaluate if disparities in the emergency department (ED) imaging timeline exist, and if disparities are altered during high volume periods which may stress resource availability. METHODS This retrospective study was conducted at a four-hospital healthcare system. All patients with at least one ED visit containing imaging from 1/1/2016 to 9/30/2020 were included. Peak hours were defined as ED encounters occurring between 5 pm and midnight, while all other ED encounters were non-peak hours. Patient-flow data points included ED length of stay (LOS), image acquisition time, and diagnostic image assessment time. RESULTS 321,786 total ED visits consisted of 102,560 during peak hours and 219,226 during non-peak hours. Black patients experienced longer image acquisition and image assessment times across both time periods (TR = 1.030; p < 0.001 and TR = 1.112; p < 0.001, respectively); Black patients also had increased length of stay compared to White patients, which was amplified during peak hours. Likewise, patients with primary payer insurance experienced significantly longer image acquisition and image assessment times in both periods (TR > 1.00; p < 0.05 for all). Females had longer image acquisition and image assessment time and the difference was more pronounced in image acquisition time during both peak and non-peak hours (TR = 1.146 and TR = 1.139 respectively with p < 0.001 for both). CONCLUSION When measuring radiology time periods, patient flow throughout the ED was not uniform. There was unequal acceleration and deceleration of patient flow based on racial, gender, age, and insurance status. Segmentation of patient flow time periods may allow identification of causes of inequity such that disparities can be addressed with targeted actions.
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Affiliation(s)
- Camara Sharperson
- Emory University School of Medicine, Atlanta, GA, United States of America
| | - Farid Hajibonabi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America.
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Roger L Gerard
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Shenise Gilyard
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Jamlik-Omari Johnson
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
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13
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Goldberg JE, Prabhu V, Smereka PN, Hindman NM. How We Got Here: The Legacy of Anti-Black Discrimination in Radiology. Radiographics 2023; 43:e220112. [PMID: 36633971 DOI: 10.1148/rg.220112] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Current disparities in the access to diagnostic imaging for Black patients and the underrepresentation of Black physicians in radiology, relative to their representation in the general U.S. population, reflect contemporary consequences of historical anti-Black discrimination. These disparities have existed within the field of radiology and professional medical organizations since their inception. Explicit and implicit racism against Black patients and physicians was institutional policy in the early 20th century when radiology was being developed as a clinical medical field. Early radiology organizations also embraced this structural discrimination, creating strong barriers to professional Black radiologist involvement. Nevertheless, there were numerous pioneering Black radiologists who advanced scholarship, patient care, and diversity within medicine and radiology during the early 20th century. This work remains important in the present day, as race-based health care disparities persist and continue to decrease the quality of radiology-delivered patient care. There are also structural barriers within radiology affecting workforce diversity that negatively impact marginalized groups. Multiple opportunities exist today for antiracism work to improve quality of care and to apply standards of social justice and health equity to the field of radiology. An initial step is to expand education on the disparities in access to imaging and health care among Black patients. Institutional interventions include implementing community-based outreach and applying antibias methodology in artificial intelligence algorithms, while systemic interventions include identifying national race-based quality measures and ensuring imaging guidelines properly address the unique cancer risks in the Black patient population. These approaches reflect some of the strategies that may mutually serve to address health care disparities in radiology. © RSNA, 2023 See the invited commentary by Scott in this issue. Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Julia E Goldberg
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
| | - Vinay Prabhu
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
| | - Paul N Smereka
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
| | - Nicole M Hindman
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
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14
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Khidir H, Salhi R, Sabbatini AK, Franks NM, Green A, Richardson LD, Terry A, Vasquez N, Goyal P, Kocher K, Venkatesh AK, Lin MP. A Quality Framework to Address Racial and Ethnic Disparities in Emergency Department Care. Ann Emerg Med 2023; 81:47-56. [PMID: 36257864 PMCID: PMC9780164 DOI: 10.1016/j.annemergmed.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/25/2022] [Accepted: 08/04/2022] [Indexed: 02/04/2023]
Abstract
The emergency department serves as a vital source of health care for residents in the United States, including as a safety net. However, patients from minoritized racial and ethnic groups have historically experienced disproportionate barriers to accessing health care services and lower quality of services than White patients. Quality measures and their application to quality improvement initiatives represent a critical opportunity to incentivize health care systems to advance health equity and reduce health disparities. Currently, there are no nationally recognized quality measures that track the quality of emergency care delivery by race and ethnicity and no published frameworks to guide the development and prioritization of quality measures to reduce health disparities in emergency care. To address these gaps, the American College of Emergency Physicians (ACEP) convened a working group of experts in quality measurement, health disparities, and health equity to develop guidance on establishing quality measures to address racial and ethnic disparities in the provision of emergency care. Based on iterative discussion over 3 working group meetings, we present a summary of existing emergency medicine quality measures that should be adapted to track racial and ethnic disparities, as well as a framework for developing new measures that focus on disparities in access to emergency care, care delivery, and transitions of care.
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Affiliation(s)
- Hazar Khidir
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Rama Salhi
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Amber K Sabbatini
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA
| | - Nicole M Franks
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | - Andrea Green
- University Medical Center Northeast, El Paso, TX
| | - Lynne D Richardson
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Emergency Medicine and Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aisha Terry
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC; Department of Health Policy, Milken Institute of Public Health, George Washington University, Washington, DC
| | | | - Pawan Goyal
- American College of Emergency Physicians, Irving, TX
| | - Keith Kocher
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Arjun K Venkatesh
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT; Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, CT
| | - Michelle P Lin
- Department of Emergency Medicine at Stanford University School of Medicine, Palo Alto, CA.
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15
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Roberts SE, Rosen CB, Keele LJ, Wirtalla CJ, Syvyk S, Kaufman EJ, Reilly PM, Neuman MD, McHugh MD, Kelz RR. Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients. JAMA Surg 2022; 157:1097-1104. [PMID: 36223108 PMCID: PMC9558057 DOI: 10.1001/jamasurg.2022.4959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
Importance A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department. Objective To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition. Design, Setting, and Participants This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal. Exposures Black vs White race. Main Outcomes and Measures Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition. Results A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46). Conclusions and Relevance In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.
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Affiliation(s)
- Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Claire B. Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Luke J. Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Christopher J. Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Elinore J. Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Patrick M. Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia
| | - Matthew D. McHugh
- Center for Health Outcomes & Policy Research, School of Nursing, University of Pennsylvania, Philadelphia
| | - Rachel R. Kelz
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
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16
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Harding J, Patel S, Davis T, Patzer R, McDonald B, Walker-Williams D, Jagannathan R, Teunis L, Gander J. Study Protocol: A Mixed-Methods Study for Understanding Racial Disparities in COVID-19-Related Complications. JMIR Res Protoc 2022; 11:e38914. [PMID: 36166652 PMCID: PMC9555818 DOI: 10.2196/38914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/02/2022] [Accepted: 09/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background In the United States, the COVID-19 pandemic has magnified the disproportionate and long-standing health disparities experienced by Black communities. Although it is acknowledged that social determinants of health (SDOH) rather than biological factors likely contribute to this disparity, few studies using rigorous analytic approaches in large, information-rich community-based data sets are dedicated to understanding the underlying drivers of these racial disparities. Objective The overall aim of our study is to elucidate the mechanisms by which racial disparities in severe COVID-19 outcomes arise, using both quantitative and qualitative methods. Methods In this protocol, we outline a convergent parallel mixed methods approach to identifying, quantifying, and contextualizing factors that contribute to the dramatic disparity in COVID-19 severity (ie, hospitalization, mortality) in Black versus white COVID-19 patients within the integrated health care system of Kaiser Permanente Georgia (KPGA). Toward this end, we will generate two quantitative cohorts of KPGA members with a confirmed COVID-19 diagnosis between January 1, 2020, and September 30, 2021: (1) an electronic medical record (EMR) cohort including routinely captured data on diagnoses, medications, and laboratory values, and a subset of patients hospitalized at Emory Healthcare to capture additional in-hospital data; and (2) a survey cohort, where participants will answer a range of questions related to demographics (eg, race, education), usual health behaviors (eg, physical activity, smoking), impact of COVID-19 (eg, job loss, caregiving responsibilities), and medical mistrust. Key outcomes of interest for these two cohorts include hospitalization, mortality, intensive care unit admission, hospital readmission, and long COVID-19. Finally, we will conduct qualitative semistructured interviews to capture perceptions of and experiences of being hospitalized with COVID-19 as well as related interactions with KPGA health care providers. We will analyze and interpret the quantitative and qualitative data separately, and then integrate the qualitative and quantitative findings using a triangulation design approach. Results This study has been funded by a Woodruff Health Sciences grant from December 2020 to December 2022. As of August 31, 2022, 31,500 KPGA members diagnosed with COVID-19 have been included in the EMR cohort, including 3028 who were hospitalized at Emory Healthcare, and 482 KPGA members completed the survey. In addition, 20 KPGA members (10 Black and 10 white) have been interviewed about their experiences navigating care with COVID-19. Quantitative and qualitative data cleaning and coding have been completed. Data analysis is underway with results anticipated to be published in December 2022. Conclusions Results from this mixed methods pilot study in a diverse integrated care setting in the southeastern United States will provide insights into the mechanisms underpinning racial disparities in COVID-19 complications. The quantitative and qualitative data will provide important context to generate hypotheses around the mechanisms for racial disparities in COVID-19, and may help to inform the development of multilevel strategies to reduce the burden of racial disparities in COVID-19 and its ongoing sequelae. Incorporating contextual information, elucidated from qualitative interviews, will increase the efficacy, adoption, and sustainability of such strategies. International Registered Report Identifier (IRRID) RR1-10.2196/38914
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Affiliation(s)
- Jessica Harding
- Department of Surgery, Emory University, 101 Woodruff Circle Suite 1019, Atlanta, US
| | - Shivani Patel
- Hubert Department of Global Health, Emory University, Atlanta, US
| | | | - Rachel Patzer
- Department of Surgery, Emory University, 101 Woodruff Circle Suite 1019, Atlanta, US
| | | | | | | | - Larissa Teunis
- Department of Surgery, Emory University, 101 Woodruff Circle Suite 1019, Atlanta, US
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17
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Wu M, Case A, Kim BI, Cochrane NH, Nagy GA, Bolognesi MP, Seyler TM. Racial and Ethnic Disparities in the Imaging Workup and Treatment of Knee and Hip Osteoarthritis. J Arthroplasty 2022; 37:S753-S760.e2. [PMID: 35151805 DOI: 10.1016/j.arth.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is limited evidence on sociodemographic differences in osteoarthritis management, particularly in non-African American (AA) minorities. We sought to identify differences in imaging modalities, administration of intra-articular injections, and total joint arthroplasty (TJA) between racial/ethnic groups. METHODS We retrospectively reviewed patients presenting to outpatient clinics with a diagnosis of hip or knee osteoarthritis from January 2013 to March 2020 at a tertiary center. Univariate analyses compared differences between groups. Multivariate logistic regression analyses determined sociodemographic predictors of imaging workup and treatment. RESULTS In total, 105,873 patients were included. There were 74,769 (70.6%) Caucasian, 27,117 (25.6%) AA, 1,878 (1.8%) Hispanic, 1,479 (1.4%) Asian, and 630 (0.6%) Native American patients. Multivariate analyses demonstrated that AAs had decreased odds of undergoing a knee magnetic resonance imaging (odds ratio [OR] 0.77, P < .001) or injection (OR 0.94, P = .006). Asian patients had lower odds of receiving any hip X-ray (OR 0.72, P = .047) or knee injection (OR 0.83, P = .017). AA (total knee arthroplasty [TKA]: OR 0.51, P < .001; total hip arthroplasty [THA]: OR 0.57, P < .001), Hispanic (TKA: OR 0.69, P = .003; THA: OR 0.60, P = .006), and Asian (TKA: OR 0.73, P = .010; THA: OR 0.56, P = .010) patients had lower odds of undergoing TJA compared to Caucasians. We found that higher income quartiles had greater odds of receiving a magnetic resonance imaging and TJA, males had lower odds of receiving injections and greater odds of undergoing TJA, and Medicaid and self-pay patients had lower odds of undergoing TJA (P < .05). CONCLUSION After adjusting for sociodemographic factors, we found disparities in the imaging, administration of injections, and/or arthroplasty for AA, Asian, and Hispanic patients. Insurance status, income, and gender were also associated with imaging and treatments performed in managing hip and knee osteoarthritis.
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Affiliation(s)
- Mark Wu
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ayden Case
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Billy I Kim
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Niall H Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Gabriela A Nagy
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Adegunsoye A, Vela M, Saunders M. Racial Disparities in Pulmonary Fibrosis and the Impact on the Black Population. Arch Bronconeumol 2022; 58:590-592. [PMID: 35312569 DOI: 10.1016/j.arbres.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Ayodeji Adegunsoye
- Pulmonary/Critical Care, University of Chicago, Chicago, IL, United States.
| | - Monica Vela
- General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Milda Saunders
- General Internal Medicine, University of Chicago, Chicago, IL, United States
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The Accident Environment Resulting in Fragility Fractures: A 20-year National Epidemiologic Study. J Am Acad Orthop Surg 2022; 30:e911-e918. [PMID: 35472060 DOI: 10.5435/jaaos-d-21-01169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/27/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Fragility fractures are an enduring source of morbidity in the elderly with unfortunate frequency and rising costs. Although the predominant cause of fractures is generally understood to be falls, the exact stratification of the causes of fractures presenting to the emergency department has not yet been described in the literature. We sought out to stratify the primary products associated with fractures in the elderly, further describing the anatomic location of the fracture and setting of injury. METHODS We queried the National Electronic Injury Surveillance System database for all fractures in patients older than 65 years from January 1, 2000, to December 31, 2019. We analyzed demographic data, patient disposition, anatomic fracture location, and injury setting for the top 20 causes of fractures. Trends, proportions and distributions were analyzed using descriptive statistics. RESULTS A total of 901,418 visits to the Emergency Department were reviewed. Of these, 216,657 (24%) were found to have fractures. The top 20 causes for fractures accounted for a total of 173,557 (19%) fractures. The average age in our population was 80.1 years (SD 8.7). Women constituted most of the patients (127,753 [74%]). Flooring (58,347 [33.6%]) was the most common product associated with the cause of fractures, with stairs/steps (29,804 [17.2%]) and bed/bed frames (19,004 [10.9%]) being the second and third most common, respectively. Lower extremity fractures (97,195 [56%]) were more common than upper extremity fractures (63,899 [37%]). The lower trunk (pelvis, femoral neck, and lower spine) was the most common anatomic location of fractures reported (64,132 [37.0%]). Most fractures occurred either at home (113,158 [65.2%]) or at a public setting (31,162 [18.0%]). CONCLUSIONS Most products associated with fractures among mature adults were related to flooring, stairs, or bedding. This study offers a detailed understanding on the common products associated with fractures in mature adults and aids in discussing preventive measures for lowering fracture risk with patients, communities, and healthcare systems.
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Samuels-Kalow ME, De Souza HG, Neuman MI, Alpern E, Marin JR, Hoffmann J, Hall M, Aronson PL, Peltz A, Wells J, Gutman CK, Simon HK, Shanahan K, Goyal MK. Analysis of Racial and Ethnic Diversity of Population Served and Imaging Used in US Children's Hospital Emergency Departments. JAMA Netw Open 2022; 5:e2213951. [PMID: 35653156 PMCID: PMC9164005 DOI: 10.1001/jamanetworkopen.2022.13951] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/07/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Lower rates of diagnostic imaging have been observed among Black children compared with White children in pediatric emergency departments. Although the racial composition of the pediatric population served by each hospital differs, it is unclear whether this is associated with overall imaging rates at the hospital level, and in particular how it may be associated with the difference in imaging rates between Black and White children at a given hospital. Objective To examine the association between the diversity of the pediatric population seen at each pediatric ED and variation in diagnostic imaging. Design, Setting, and Participants Cross-sectional analysis of ED visits by patients younger than 18 years at 38 children's hospitals from January 1, 2016, through December 31, 2019, using data from the Pediatric Health Information System. Data were analyzed from April to September 2021. Exposures Proportion of patients from minoritized groups cared for at each hospital. Main Outcomes and Measures The primary outcome was receipt of an imaging test defined as radiography, ultrasonography, computed tomography, or magnetic resonance imaging; adjusted odds ratios (aORs) were calculated to measure differences in imaging by race and ethnicity by hospital, and the correlation between the proportion of patients from minoritized groups cared for at each hospital and the aOR for receipt of diagnostic imaging by race and ethnicity was examined. Results There were 12 310 344 ED visits (3 477 674 [28.3%] among Hispanic patients; 3 212 915 [26.1%] among non-Hispanic Black patients; 4 415 747 [35.9%] among non-Hispanic White patients; 6 487 660 [52.7%] among female patients) by 5 883 664 pediatric patients (mean [SD] age, 5.84 [5.23] years) to the 38 hospitals during the study period, of which 3 527 866 visits (28.7%) involved at least 1 diagnostic imaging test. Diagnostic imaging was performed in 1 508 382 visits (34.2%) for non-Hispanic White children, 790 961 (24.6%) for non-Hispanic Black children, and 907 222 (26.1%) for Hispanic children (P < .001). Non-Hispanic Black patients were consistently less likely to receive diagnostic imaging than non-Hispanic White patients at each hospital, and for all imaging modalities. There was a significant correlation between the proportion of patients from minoritized groups cared for at the hospital and greater imaging difference between non-Hispanic White and non-Hispanic Black patients (correlation coefficient, -0.37; 95% CI, -0.62 to -0.07; P = .02). Conclusions and Relevance In this cross-sectional study, hospitals with a higher percentage of pediatric patients from minoritized groups had larger differences in imaging between non-Hispanic Black and non-Hispanic White patients, with non-Hispanic White patients consistently more likely to receive diagnostic imaging. These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine.
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Affiliation(s)
| | | | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Elizabeth Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jennifer R. Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alon Peltz
- Department of Population Medicine, Harvard Pilgrim Health Care, Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Jordee Wells
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Colleen K. Gutman
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | - Harold K. Simon
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
- Department of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Kristen Shanahan
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Monika K. Goyal
- Department of Pediatrics, Children’s National Hospital, George Washington University, Washington, DC
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Chan KL, Makary MS, Perez-Abreu L, Erdal BS, Prevedello LM, Nguyen XV. Trends and Predictors of Imaging Utilization by Modality within an Academic Health System's Active Patient Population. Curr Probl Diagn Radiol 2022; 51:829-837. [DOI: 10.1067/j.cpradiol.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 03/28/2022] [Accepted: 04/18/2022] [Indexed: 11/22/2022]
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Colwell RL, Narayan AK, Ross AB. Patient Race or Ethnicity and the Use of Diagnostic Imaging: A Systematic Review. J Am Coll Radiol 2022; 19:521-528. [PMID: 35216945 DOI: 10.1016/j.jacr.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To summarize the existing literature evaluating differences in imaging use based on patient race and ethnicity. METHODS The authors performed a structured search of four databases for the dates January 1, 2000, to April 13, 2021, using key words and derivatives focused on imaging and patient race. Retrieved citations were reviewed by abstract and then full text to identify articles that evaluated the likelihood of imaging use by patient race or ethnicity controlling for sociodemographic factors. Data regarding publication characteristics, study population, clinical setting, and results was extracted and summarized. RESULTS The structured search identified 2,938 articles of which 206 met inclusion criteria. Most studies (87%, 179 of 206) were conducted in the United States, and the majority (72%, 149 of 206) found decreased or inappropriate imaging use in minority groups. Breast cancer screening was the most common clinical setting (50%, 104 of 206), followed by cancer care (10%, 21 of 206) and general imaging use (9%, 19 of 206). Government-administered surveys were the most common data source (40%, 82 of 206). Only a small minority of studies (8%, 17 of 206) evaluated strategies to mitigate the unequal use of imaging based on patient race and ethnicity. DISCUSSION The existing literature shows decreased or inappropriate use of diagnostic imaging for minority patients across a wide variety of clinical settings. Although the number of articles on the topic is large, the majority are clustered around specific topics, and few articles evaluate potential strategies to reduce the inequitable use of diagnostic imaging.
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Affiliation(s)
- Rebecca L Colwell
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Anand K Narayan
- JACR editorial board member; Vice Chair of Equity, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andrew B Ross
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Socioeconomic and Psychosocial Predictors of Magnetic Resonance Imaging Following Cervical and Thoracic Spine Trauma in the United States. World Neurosurg 2022; 161:e757-e766. [DOI: 10.1016/j.wneu.2022.02.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 11/23/2022]
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DeBenedectis CM, Spalluto LB, Americo L, Bishop C, Mian A, Sarkany D, Kagetsu NJ, Slanetz PJ. Health Care Disparities in Radiology-A Review of the Current Literature. J Am Coll Radiol 2022; 19:101-111. [PMID: 35033297 DOI: 10.1016/j.jacr.2021.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Health care disparities exist in all medical specialties, including radiology. Raising awareness of established health care disparities is a critical component of radiology's efforts to mitigate disparities. Our primary objective is to perform a comprehensive review of the last 10 years of literature pertaining to disparities in radiology care. Our secondary objective is to raise awareness of disparities in radiology. METHODS We reviewed English-language medicine and health services literature from the past 10 years (2010-2020) for research that described disparities in any aspect of radiologic imaging using radiology search terms and key words for disparities in OVID. Relevant studies were identified with adherence to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS The search yielded a total 1,890 articles. We reviewed the citations and abstracts with the initial search yielding 1,890 articles (without duplicates). Of these, 1,776 were excluded based on the criteria set forth in the methods. The remaining unique 114 articles were included for qualitative synthesis. DISCUSSION We hope this article increases awareness and inspires action to address disparities and encourages research that further investigates previously identified disparities and explores not-yet-identified disparities.
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Affiliation(s)
- Carolynn M DeBenedectis
- Vice-Chair, Education; Director, Radiology Residency Program; Department of Radiology, President-elect, New England Roentgen Ray Society; and Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Lucy B Spalluto
- Vice-Chair, Health Equity; Director, Women in Radiology; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Ingram Cancer Center, Nashville, Tennessee; Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research; and Education and Clinical Center (GRECC), Nashville, Tennessee
| | - Lisa Americo
- Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Casey Bishop
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Asim Mian
- Director, Radiology Residency Program; Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - David Sarkany
- Director, Radiology Residency Program; Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Nolan J Kagetsu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Priscilla J Slanetz
- Vice-Chair, Academic Affairs; Associate Program Director, Radiology Residency Program, Boston Medical Center; President-elect Massachusetts Radiologic Society; Secretary, Association of University Radiologists; Chair, Breast Imaging Panel 2, ACR Appropriateness Guidelines Committee; and Department of Radiology, Boston Medical Center, Boston, Massachusetts
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Dubey P, Saxena A, Jordan JE, Xian Z, Javed Z, Jindal G, Vahidy F, Sostman DH, Nasir K. Contemporary national trends and disparities for head CT use in emergency department settings: Insights from National Hospital Ambulatory Medical Care Survey (NHAMCS) 2007-2017. J Natl Med Assoc 2022; 114:69-77. [PMID: 34986985 DOI: 10.1016/j.jnma.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/07/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The exponential growth in CT utilization in emergency department (ED) until 2008 raised concerns regarding cost and radiation exposure. Head CT was one of the commonest studies. This led to mitigating efforts such as appropriate use guidelines, policy and payment reforms. The impact of these efforts is not fully understood. In addition, disparities in outcomes of acute conditions presenting to the ED is well known however recent trends in imaging utilization patterns and disparities are not well understood. In this study, we describe nationwide trends and disparities associated with head CT in ED settings between 2007 and 2014. METHODS We analyzed 2007-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) with the primary goal to assess the rate and patterns of head CT imaging in ED. RESULTS There were an estimated 117 million in 2007 and 139 million ED visits in 2017. There was a 4% increase in the any CT use in 2017 compared to 2007. No significant change in head CT utilization rate was seen. The 2007 head CT rate was 6.7% (95% CI: 6.1-7.3) compared to 7.7% (95% CI: 6.8-8.6) in 2017. Trauma, Headache and Dizziness are the top three indications for head CT use in the ED respectively. On adjusted analyses, significantly higher head CT utilization was seen in elderly, (age>65 yrs) and significantly lower utilization rate was seen in Non-Hispanic Black and Medicaid patients, and patients in rural locations. CONCLUSIONS Previously reported exponential growth of CT use in ED is no longer seen. In particular, there was no significant change in ED head CT use between 2007 and 2017. Headache and Dizziness remain commonly used indications despite limited utility in most clinical scenarios, indicating continued need for appropriate use of imaging. There is significantly lower CT utilization in Non-Hispanic Black, Medicaid patients and those in rural locations, suggesting disparities in diagnostic work-up in marginalized and rural populations. This underscores the need for standardizing care regardless of race, insurance status and location.
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Affiliation(s)
- Prachi Dubey
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA.
| | | | - John E Jordan
- Providence Little Company of Mary Medical Center, Torrance, California, USA; Stanford University School of Medicine, Stanford, CA, USA
| | - Zhaoying Xian
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Zulqarnain Javed
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Gaurav Jindal
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Farhaan Vahidy
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Dirk H Sostman
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Khurram Nasir
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
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Delgado C, Powe NR. Resolving the Debate: The Future of Using Race in Estimating Kidney Function. Adv Chronic Kidney Dis 2022; 29:5-16. [PMID: 35690404 DOI: 10.1053/j.ackd.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 11/11/2022]
Abstract
Racial and social unrest witnessed during 2020 ignited a national conversation about the appropriateness of the use of race in health care algorithms and in the estimation of kidney function in particular. The growing concerns over the use of race in kidney function-estimating equations prompted the National Kidney Foundation (NKF) and American Society of Nephrology to launch an effort for change by establishing a task force on reassessing the use of race in diagnosing kidney disease. After nearly a year examining the evidence and obtaining testimony from experts and stakeholders, the task force recommended the immediate implementation of the 2020 Chronic Kidney Disease-Epidemiology creatinine equation refit without race in all US laboratories; increased routine use of cystatin C for confirmation of estimated glomerular filtration rate in clinical decision-making and a call for research on glomerular filtration rate estimation with new endogenous filtration markers and on addressing disparities in health and health care. The NKF and American Society of Nephrology strongly encouraged rapid adoption of these new recommendations. Leadership efforts of the NKF have begun to lay the foundation for national implementation through laboratory engagement, clinician awareness, and patient education.
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Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco VA Medical Center, San Francisco, CA; Department of Medicine, University of California, San Francisco, San Francisco, CA.
| | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Department of Medicine, University of California, San Francisco, San Francisco, CA
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Kioh SH, Pooke TG, Chong SV. Use of Radiography for New Patients Presenting to a Chiropractic Teaching Clinic: A Cross-sectional Analysis. JOURNAL OF CHIROPRACTIC HUMANITIES 2021; 28:9-14. [PMID: 35002573 PMCID: PMC8720650 DOI: 10.1016/j.echu.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The aim of this study was to identify the number and type of indications for radiographs ordered in a chiropractic teaching clinic in Malaysia. METHODS A cross-sectional retrospective analysis was conducted using the medical health records of new patients who presented to the International Medical University Bukit Jalil teaching clinic for chiropractic care between August 2018 and July 2019. Data about sociodemographic characteristics, region of presenting complaint, radiography ordering rates, and referral indications were collected. We compared indications reported in the patient records with those listed in the International Medical University Chiropractic Clinical Manual. We conducted χ2 and logistic regression analysis to identify the association between radiography indications and the number of radiographs ordered. RESULTS Data were collected for 1451 patients (741 [51.1%] women and 700 [48.9%] men). The most common body region for the presenting complaint was the lumbar/pelvic region (39.0%), and the overall radiograph use rate was 2.7%, with the highest number of radiographs for the lumbar spine. CONCLUSION For the patient files sampled in this study, the overall radiograph order rate in the International Medical University Bukit Jalil Chiropractic teaching clinic was 2.7%.
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Affiliation(s)
- Sheng Hui Kioh
- Corresponding author: Sheng Hui Kioh, Department of Chiropractic, International Medical University, 126, Jln Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Federal Territory of Kuala Lumpur, Kuala Lumpur, Malaysia
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Al-Dulaimi R, Duong PA, Chan BY, Fuller MJ, Ross AB, Dunn DP. Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009-2018 data from the NHAMCS. Emerg Radiol 2021; 29:125-132. [PMID: 34713355 DOI: 10.1007/s10140-021-01991-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. MATERIALS AND METHODS Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. RESULTS Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. CONCLUSION Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.
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Affiliation(s)
- Ragheed Al-Dulaimi
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Phuong-Anh Duong
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Brian Y Chan
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Matthew J Fuller
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew B Ross
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Dell P Dunn
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.
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Brown C, Brown K, Brown I, Daniel R. Dear White People in Emergency Medicine. Ann Emerg Med 2021; 78:587-592. [PMID: 34598829 DOI: 10.1016/j.annemergmed.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Indexed: 11/26/2022]
Abstract
We, emergency physicians of color, are not okay. We are living and working through a pandemic that has disproportionately affected our communities and a year in which we cannot escape our lived experiences of police brutality. We see you, dear White people in emergency medicine, and are glad you want to support us. However, let us guide you in supporting our cause.
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Affiliation(s)
- Cortlyn Brown
- Department of Emergency Medicine, Atrium Health Carolinas, Charlotte, NC.
| | | | - Italo Brown
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Rosny Daniel
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
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Bunch PM, Loevner LA, Bhala R, Hepp MB, Hirsch JA, Johnson MH, Lyp KL, Quigley EP, Salamon N, Jordan JE, Schwartz ES. The American Society of Neuroradiology: Cultivating a Diverse and Inclusive Culture to Build a Stronger Organization. AJNR Am J Neuroradiol 2021; 42:2127-2129. [PMID: 34593384 DOI: 10.3174/ajnr.a7310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Delgado C, Baweja M, Burrows NR, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA, Mendu ML, Miller WG, Moxey-Mims MM, Roberts GV, St Peter WL, Warfield C, Powe NR. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report From the NKF-ASN Task Force. Am J Kidney Dis 2021; 78:103-115. [PMID: 33845065 PMCID: PMC8238889 DOI: 10.1053/j.ajkd.2021.03.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For almost 2 decades, equations that use serum creatinine, age, sex, and race to estimate glomerular filtration rate (GFR) have included "race" as Black or non-Black. Given considerable evidence of disparities in health and health care delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non-GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase 1, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.
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Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco Veterans Affairs Medical Center, Division of Nephrology, University of California San Francisco, San Francisco, CA.
| | - Mukta Baweja
- Nephrology Division, Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Crystal A Gadegbeku
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, Temple University, Philadelphia, PA
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Mallika L Mendu
- Division of Renal Medicine and Office of the Chief Medical Officer, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - W Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, VA
| | - Marva M Moxey-Mims
- Division of Nephrology, Children's National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Glenda V Roberts
- External Relations and Patient Engagement, Kidney Research Institute, Center for Dialysis Innovation, University of Washington, Seattle, WA
| | | | | | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA.
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Addressing ethnic disparities in imaging utilization and clinical outcomes for COVID-19. Clin Imaging 2021; 77:276-282. [PMID: 34167069 PMCID: PMC8214936 DOI: 10.1016/j.clinimag.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/23/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022]
Abstract
Purpose Racial and ethnic disparities have exacerbated during the COVID-19 pandemic as the healthcare system is overwhelmed. While Hispanics are disproportionately affected by COVID-19, little is known about ethnic disparities in the hospital settings. This study investigates imaging utilization and clinical outcomes between Hispanic and non-Hispanic COVID-19 patients in the Emergency Department (ED) and during hospitalization. Methods Through retrospective chart review, we included 331 symptomatic COVID-19 patients (mean age 53.2 years) at a metropolitan healthcare system from March to June 2020. Poisson regression was used to compare diagnostic imaging utilization and clinical outcomes between Hispanic and non-Hispanic patients. Results After adjusting for confounders, no statistically significant difference was found between Hispanic and non-Hispanic patients for the number of weekly chest X-rays. Results were categorized into four clinical outcomes: ED management (0.16 ± 0.05 vs. 0.14 ± 0.8, p:0.79); requiring inpatient management (1.31 ± 0.11 vs. 1.46 ± 0.16, p:0.43); ICU admission without invasive ventilation (1.4 ± 0.17 vs. 1.35 ± 0.26, p:0.86); and ICU admission and ventilator support (3.29 ± 0.22 vs. 3.59 ± 0.37, p:0.38). There were no statistically significant relative differences in adjusted prevalence rate between ethnic groups for all clinical outcomes (p > 0.05). There was a statistically significant longer adjusted length of stay (days) in non-Hispanics for two subcohorts: inpatient management (8.16 ± 0.31 vs. 9.72 ± 0.5, p < 0.01) and ICU admission without invasive ventilation (10.39 ± 0.57 vs. 13.45 ± 1.13, p < 0.01). Conclusions For Hispanic and non-Hispanic COVID-19 patients in the ED or hospitalized, there were no statistically significant differences in imaging utilization and clinical outcomes.
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Delgado C, Baweja M, Burrows NR, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA, Mendu ML, Miller WG, Moxey-Mims MM, Roberts GV, St. Peter WL, Warfield C, Powe NR. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report from the NKF-ASN Task Force. J Am Soc Nephrol 2021; 32:1305-1317. [PMID: 33837122 PMCID: PMC8259639 DOI: 10.1681/asn.2021010039] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
For almost two decades, equations that use serum creatinine, age, sex, and race to eGFR have included "race" as Black or non-Black. Given considerable evidence of disparities in health and healthcare delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase one, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.
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Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco Veterans Affairs Medical Center, Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Mukta Baweja
- Nephrology Division, Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nwamaka D. Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Crystal A. Gadegbeku
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, Temple University, Philadelphia, Pennsylvania
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine and Office of the Chief Medical Officer, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - W. Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia
| | - Marva M. Moxey-Mims
- Division of Nephrology, Children’s National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Glenda V. Roberts
- External Relations and Patient Engagement, Kidney Research Institute, Center for Dialysis Innovation, University of Washington, Seattle, Washington
| | | | | | - Neil R. Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California
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Abstract
OBJECTIVE. This article aimed to assess changing use of brain imaging tests among patients with Alzheimer disease and vascular dementia who visited U.S. emergency departments (EDs) between 2006 and 2014. MATERIALS AND METHODS. Using the largest publicly available all-payer ED database, the Nationwide Emergency Department Sample, we identified a weighted cohort of 427,705 individuals with Alzheimer disease and 33,743 individuals with vascular dementia who visited U.S. EDs between 2006 and 2014. Logistic regression analyses were performed to identify factors associated with use. RESULTS. Between 2006 and 2014, ED visits among patients with Alzheimer disease and vascular dementia declined by 24.7% and 20.3%, respectively. However, there was a significant increase in utilization rates of head CT (from 4.4% to 11.1% in patients with Alzheimer disease and from 1.5% to 2.9% in patients with vascular dementia) and brain MRI (from 0.04% to 0.5% in patients with Alzheimer disease and 0.0% to 0.1% in those with vascular dementia) in the same time period. Among patients with Alzheimer disease, age, median income in patient ZIP code, day of the week of the ED visit, hospital teaching status, and hospital geographic region were significant predictors of imaging use. Among patients with vascular dementia, insurance type and hospital classification (urban vs rural) were significant predictors of imaging use. CONCLUSION. Despite declining ED visits, ED brain imaging in patients with Alzheimer disease and vascular dementia has increased. Various patient-specific and hospital-specific factors contribute to differential utilization rates.
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Schmidt IM, Waikar SS. Separate and Unequal: Race-Based Algorithms and Implications for Nephrology. J Am Soc Nephrol 2021; 32:529-533. [PMID: 33510038 PMCID: PMC7920170 DOI: 10.1681/asn.2020081175] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Insa M Schmidt
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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Cho T, Kreatsoulas D, Fritz J, McGregor JM, Hardesty DA. An institutional review of hospital resource utilization and patient radiation exposure in shunted idiopathic intracranial hypertension. Neurosurg Rev 2021; 44:3359-3373. [PMID: 33611722 DOI: 10.1007/s10143-021-01502-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/12/2021] [Accepted: 02/11/2021] [Indexed: 11/28/2022]
Abstract
Patients with idiopathic intracranial hypertension (IIH) frequently utilize healthcare services and undergo radiological studies to assess refractory headache symptoms despite cerebrospinal fluid diversion. To delineate the clinical utility of different imaging modalities and to estimate cumulative patient radiation exposure in shunted patients with IIH, we retrospectively reviewed 100 randomly selected patients with IIH and a prior cerebrospinal fluid diversion procedure treated at our institution between July 2010 and August 2018. Patients had an average of 16.3 office (SD ± 13.8), 12.4 emergency department (± 21.0), and 4.6 inpatient (± 5.1) encounters over an average 4.8 years of follow-up. Patients underwent an average of 9.0 head CTs (± 8.1), 10.3 shunt series x-rays (± 11.2), and 4.3 MRIs (± 3.7). Approximated radiation exposure per patient was 21.4 mSv (± 18.7). Radiological studies performed for acute symptoms usually demonstrated no actionable findings (82.5% CTs, 97.5% shunt series x-rays, and 79.6% MRIs). Shunted IIH patients undergo numerous radiological studies and are subject to considerable levels of radiation, yet imaging shows actionable findings in less than 10% percent of radiographic studies. IIH patients may benefit from radiation-reducing protocols and the use of alternative imaging to assess symptoms.
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Affiliation(s)
- Tyler Cho
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Daniel Kreatsoulas
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Doan Hall, Columbus, OH, 43210, USA
| | - Joel Fritz
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John M McGregor
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Doan Hall, Columbus, OH, 43210, USA
| | - Douglas A Hardesty
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Doan Hall, Columbus, OH, 43210, USA.
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open 2021; 4:e2033710. [PMID: 33512517 PMCID: PMC7846940 DOI: 10.1001/jamanetworkopen.2020.33710] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. OBJECTIVE To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. EXPOSURES Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. RESULTS A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. CONCLUSIONS AND RELEVANCE In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.
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Affiliation(s)
- Jennifer R. Marin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Patient Race/Ethnicity and Diagnostic Imaging Utilization in the Emergency Department: A Systematic Review. J Am Coll Radiol 2020; 18:795-808. [PMID: 33385337 DOI: 10.1016/j.jacr.2020.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE Diagnostic imaging often is a critical contributor to clinical decision making in the emergency department (ED). Racial and ethnic disparities are widely reported in many aspects of health care, and several recent studies have reported a link between patient race/ethnicity and receipt of imaging in the ED. METHODS The authors conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching three databases (PubMed, Embase, and the Cochrane Library) through July 2020 using keywords related to diagnostic imaging, race/ethnicity, and the ED setting, including both adult and pediatric populations and excluding studies that did not control for the important confounders of disease severity and insurance status. RESULTS The search strategy identified 7,313 articles, of which 5,668 underwent title and abstract screening and 238 full-text review, leaving 42 articles meeting the inclusion criteria. Studies were predominately conducted in the United States (41), split between adult (13) and pediatric (17) populations or both (12), and spread across a variety of topics, mostly focusing on specific anatomic regions or disease processes. Most studies (30 of 42 [71.4%]) reported an association between Black, African American, Hispanic, or nonwhite race/ethnicity and decreased receipt of imaging. CONCLUSIONS Despite heterogeneity among studies, patient race/ethnicity is linked with receipt of diagnostic imaging in the ED. The strength and directionality of this association may differ by specific subpopulation and disease process, and more efforts to understand potential underlying factors are needed.
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Disparities in the Use of Emergency Department Advanced Imaging in Medicare Beneficiaries. AJR Am J Roentgenol 2020; 216:519-525. [PMID: 33356434 DOI: 10.2214/ajr.20.23161] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE. The purpose of our study was to assess potential disparities in the utilization of advanced imaging during emergency department (ED) visits. MATERIALS AND METHODS. This retrospective study was conducting using 5% Research Identifiable Files. All CT and MRI (together defined as "advanced imaging") examinations associated with ED visits in 2015 were identified for continuously enrolled Medicare beneficiaries. Individuals with medical claims 30 days before the index ED event were excluded, and encounters that occurred in hospitals without advanced imaging capabilities were also excluded. Patient characteristics were identified using Medicare files and hospital characteristics using the American Hospital Association Annual Survey of Hospitals. Multivariate logistic regression was used for the analysis. RESULTS. Of 86,976 qualifying ED encounters, 52,833 (60.74%) ED encounters were for female patients; 29.03% (n = 25,245) occurred at rural hospitals and 15.81% (n = 13,750) at critical access hospitals. Race distribution was 83.13% White, 11.05% Black, and 5.82% Other. Compared with ED patients at urban hospitals, those at rural and critical access hospitals were 6.9% less likely (odds ratio [OR] = 0.931, p = 0.015) and 18.0% less likely (OR = 0.820, p < 0.0001), respectively, to undergo advanced imaging. Compared with White patients, Black patients were 31.6% less likely (OR = 0.684, p < 0.0001) to undergo advanced imaging. Relative to their urban counterparts, both White (OR = 0.941, p = 0.05) and Black (OR = 0.808, p = 0.047) rural ED patients were less likely to undergo advanced imaging. CONCLUSION. Among Medicare beneficiaries receiving care in U.S. EDs, significant disparities exist in advanced imaging utilization. Although imaging appropriateness was not investigated, these findings suggest inequity. Further research is necessary to understand why consistent health benefits do not translate into consistent imaging access among risk-adjusted ED patients.
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Toy D, Mahmood SS, Rotman J, Weisman SV, Escalon JG, Legasto AC, Cheng EP, McKenney AS, Barbar T, Balkan L, Chen Y, Razavi P, Zainul O, Abedian S, Gruden JF, Truong QA. Imaging Utilization and Outcomes in Vulnerable Populations during COVID-19 in New York City. Radiol Cardiothorac Imaging 2020; 2:e200464. [PMID: 33778647 PMCID: PMC7751279 DOI: 10.1148/ryct.2020200464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) affects vulnerable populations (VP) adversely. Purpose To evaluate overall imaging utilization in vulnerable subgroups (elderly, racial/ethnic minorities, socioeconomic status [SES] disadvantage) and determine if a particular subgroup has worse outcomes from COVID-19. Materials/Methods Of 4110 patients who underwent COVID-19 testing from March 3-April 4, 2020 at NewYork-Presbyterian Hospital (NYP) health system, we included 1121 COVID-19 positive adults (mean age 59±18 years, 59% male) from two academic hospitals and evaluated imaging utilization rates and outcomes, including mortality. Results Of 897 (80%) VP, there were 465 (41%) elderly, 380 (34%) racial/ethnic minorities, and 479 (43%) SES disadvantage patients. Imaging was performed in 88% of patients and mostly portable/bedside studies, with 87% of patients receiving chest radiographs. There were 83% hospital admissions, 25% ICU admissions, 23% intubations, and 13% deaths. Elderly patients had greater imaging utilization, hospitalizations, ICU/intubation requirement, longer hospital stays, and >4-fold increase in mortality compared to non-elderlies (adjusted hazard ratio[aHR] 4.79, p<0.001). Self-reported minorities had fewer ICU admissions (p=0.03) and reduced hazard for mortality (aHR 0.53, p=0.004; complete case analysis: aHR 0.39, p<0.001 excluding "not reported"; sensitivity analysis: aHR 0.61, p=0.005 "not reported" classified as minorities) with similar imaging utilization, compared to non-minorities. SES disadvantage patients had similar imaging utilization and outcomes as compared to their counterparts. Conclusions In a predominantly hospitalized New York City cohort, elderly patients are at highest mortality risk. Racial/ethnic minorities and SES disadvantage patients fare better or similarly to their counterparts, highlighting the critical role of access to inpatient medical care during the COVID-19 pandemic.
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Affiliation(s)
- Dennis Toy
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Syed S Mahmood
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Jessica Rotman
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Stacey Verzosa Weisman
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Joanna G Escalon
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Alan C Legasto
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Edward P Cheng
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Anna Sophia McKenney
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Tarek Barbar
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Lauren Balkan
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Yunchan Chen
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Peyman Razavi
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Omar Zainul
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Sajjad Abedian
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - James F Gruden
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
| | - Quynh A Truong
- Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A)
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Trofimova AV, Duszak R, Kadom N, Sadigh G. Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement. Headache 2020; 61:179-189. [PMID: 33316103 DOI: 10.1111/head.14020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. OBJECTIVE To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. METHODS Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346.xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. RESULTS In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. CONCLUSION Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, at urban hospitals, in certain geographic regions, and on weekdays, raising concerns regarding disparate imaging use.
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Affiliation(s)
- Anna V Trofimova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Imaging Utilization During the COVID-19 Pandemic Highlights Socioeconomic Health Disparities. J Am Coll Radiol 2020; 18:554-565. [PMID: 33220184 PMCID: PMC7598682 DOI: 10.1016/j.jacr.2020.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/27/2022]
Abstract
Objective The devastating impact from the coronavirus disease 2019 (COVID-19) pandemic highlights long-standing socioeconomic health disparities in the United States. The purpose of this study was to evaluate socioeconomic factors related to imaging utilization during the pandemic. Methods Retrospective review of consecutive imaging examinations was performed from January 1, 2019, to May 31, 2020, across all service locations (inpatient, emergency, outpatient). Patient level data were provided for socioeconomic factors (age, sex, race, insurance status, residential zip code). Residential zip code was used to assign median income level. The weekly total imaging volumes in 2020 and 2019 were plotted from January 1 to May 31 stratified by socioeconomic factors to demonstrate the trends during the pre-COVID-19 (January 1 to February 28) and post-COVID-19 (March 1 to May 31) periods. Independent-samples t tests were used to statistically compare the 2020 and 2019 socioeconomic groups. Results Compared with 2019, the 2020 total imaging volume in the post-COVID-19 period revealed statistically significant increased imaging utilization in patients who are aged 60 to 79 years (P = .0025), are male (P < .0001), are non-White (Black, Asian, other, unknown; P < .05), are covered by Medicaid or uninsured (P < .05), and have income below $80,000 (P < .05). However, there was a significant decrease in imaging utilization among patients who are younger (<18 years old; P < .0001), are female (P < .0001), are White (P = .0003), are commercially insured (P < .0001), and have income ≥$80,000 (P < .05). Discussion During the pandemic, there was a significant change in imaging utilization varying by socioeconomic factors, consistent with the known health disparities observed in the prevalence of COVID-19. These findings could have significant implications in directing utilization of resources during the pandemic and subsequent recovery.
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Ross AB, Kalia V, Chan BY, Li G. The influence of patient race on the use of diagnostic imaging in United States emergency departments: data from the National Hospital Ambulatory Medical Care survey. BMC Health Serv Res 2020; 20:840. [PMID: 32894129 PMCID: PMC7487740 DOI: 10.1186/s12913-020-05698-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/31/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND An established body of literature has shown evidence of implicit bias in the health care system on the basis of patient race and ethnicity that contributes to well documented disparities in outcomes. However, little is known about the influence of patient race and ethnicity on the decision to order diagnostic radiology exams in the acute care setting. This study examines the role of patient race and ethnicity on the likelihood of diagnostic imaging exams being ordered during United States emergency department encounters. METHODS Publicly available data from the National Hospital Ambulatory Medical Care Survey Emergency Department sample for the years 2006-2016 was compiled. The proportion of patient encounters where diagnostic imaging was ordered was tabulated by race/ethnicity, sub-divided by imaging modality. A multivariable logistic regression model was used to evaluate the influence of patient race/ethnicity on the ordering of diagnostic imaging controlling for other patient and hospital characteristics. Survey weighting variables were used to formulate national-level estimates. RESULTS Using the weighted data, an average of 131,558,553 patient encounters were included each year for the 11-year study period. Imaging was used at 46% of all visits although this varied significantly by patient race and ethnicity with white patients receiving medical imaging at 49% of visits and non-white patients at 41% of visits (p < 0.001). This effect persisted in the controlled regression model and across all imaging modalities with the exception of ultrasound. Other factors with a significant influence on imaging use included patient age, gender, insurance status, number of co-morbidities, hospital setting (urban vs non-urban) and hospital region. There was no evidence to suggest that the disparate use of imaging by patient race and ethnicity changed over the 11-year study time period. CONCLUSION The likelihood that a diagnostic imaging exam will be ordered during United States emergency department encounters differs significantly by patient race and ethnicity even when controlling for other patient and hospital characteristics. Further work must be done to understand and mitigate what may represent systematic bias and ensure equitable use of health care resources.
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Affiliation(s)
- Andrew B Ross
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Vivek Kalia
- Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Brian Y Chan
- Department of Radiology, School of Medicine, University of Utah, 30 N. 1900 E., Salt Lake City, UT, 84132, USA
| | - Geng Li
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
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Mwinyogle AA, Bhatt A, Ogbuagu OU, Dhillon N, Sill A, Kowdley GC. Use of CT Scans for Abdominal Pain in the ED: Factors in Choice. Am Surg 2020. [DOI: 10.1177/000313482008600428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Overutilization of healthcare resources is a threat to long-term healthcare sustainability and patient outcomes. CTis a costly but efficient means of assessing abdominal pain; however, 97 per cent of ED physicians acknowledge its overutilization. This study sought to understand factors that influence ED providers’ decision regarding CT use in the evaluation of abdominal pain. After evaluating a patient for acute abdominal pain, ED providers filled in a form in which the primary diagnosis and index of suspicion were recorded. Bivariate and multivariate analyses were used to identify predictors of outcomes. The CT scan utilization rate was 54.82 per cent. Whereas 34.11 per cent of CT scans were normal, 30 per cent yielded an acute abdominal pathology. Tenderness and rebound tenderness were positive predictors of high index of suspicion [odds ratio (OR) 2.09 and 2.54, respectively]. These variables were also predictive of obtaining a CT scan [OR 2.64 and 3.41, respectively]. Compared with whites, the index of suspicion was 26 per cent and 56 per cent less likely to be high when patients were black [OR 0.73] or Hispanic [OR 0.44] respectively. Blacks and Hispanics were less likely to have CT scans performed than whites [OR 0.58 and 0.48, respectively]. Leukocytosis significantly affected the index of suspicion for acute abdominal pathology, obtaining a CTscan and the acuity of CTscan diagnosis on multivariate analysis. Patients aged ≥60 years had 2.03 odds of acute CT finding compared with those aged <60 years. There is a need for committed efforts to optimize CT scan utilization and eliminate socioeconomic disparities in health care.
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Affiliation(s)
| | | | | | - Neer Dhillon
- St. Matthew's University School of Medicine, Orlando, Florida
| | - Anne Sill
- Saint Agnes Hospital, Baltimore, Maryland
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