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

What explains differences in average wait time in the emergency department among different racial and ethnic populations: A linear decomposition approach

Objective

Non-Hispanic Black (NHB) and Hispanic/Latino (Hispanic) patients wait longer in the emergency department (ED) to see practitioners when compared with non-Hispanic White (NHW) patients. We investigate factors contributing to longer wait times for NHB and Hispanic patients using a linear decomposition approach.

Methods

This retrospective observational study included patients presenting to one tertiary hospital ED from 2019 to 2021. Median wait times among NHW, NHB, and Hispanic were calculated with multivariable linear regressions. The extent to which demographic, clinical, and hospital factors explained the differences in average wait time among the three groups were analyzed with Blinder‒Oaxaca post-linear decomposition model.

Results

There were 310,253 total patients including 34.7% of NHW, 34.7% of NHB, and 30.6% of Hispanic patients. The median wait time in NHW was 9 min (interquartile range [IQR] 4‒47 min), in NHB was 13 min (IQR 4‒59 min), and in Hispanic was 19 min (IQR 5‒78 min, p < 0.001). The top two contributors of average wait time difference were mode of arrival and triage acuity level. Post-linear decomposition analysis showed that 72.96% of the NHB‒NHW and 87.77% of the Hispanic‒NHW average wait time difference were explained by variables analyzed.

Conclusion

Compared to NHW patients, NHB and Hispanic patients typically experience longer ED wait times, primarily influenced by their mode of arrival and triaged acuity levels. Despite these recognized factors, there remains 12%‒27% unexplained factors at work, such as social determinants of health (including implicit bias and systemic racism) and many other unmeasured confounders, yet to be discovered.

Healthcare disparities in pancreatitis: knowledge gaps and next steps

PURPOSE OF REVIEW

This review examines current research on healthcare disparities in pancreatitis, identifies knowledge gaps, and proposes strategies to develop targeted multilevel interventions to address inequities in pancreatitis care.

RECENT FINDINGS

Current literature has identified patient, disease, and healthcare-level factors contributing to disparities in risk factors and health outcomes of pancreatitis. Moreover, social structures, economic systems, social vulnerability, and policy significantly influence the pancreatitis care continuum.

SUMMARY

Understanding the root causes of health inequities is critical to developing effective approaches for the prevention, early detection, and management of pancreatitis.

Diagnosis and Management of Acute Pancreatitis

Acute pancreatitis (AP) is increasing in incidence across the world, and in all age groups. Major changes in management have occurred in the last decade. Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care. Increasing recognition of the risk of recurrence of AP, and progression to chronic pancreatitis, along with the unexpectedly high risk of diabetes and exocrine insufficiency after AP is the subject of large ongoing studies. In this review, we provide an update on important changes in management for this increasingly common disease.

Pre-hospital management and patient-related factors affecting access to the surgical care of appendicitis - a survey study

BACKGROUND AND AIMS

Long pre-hospital delay substantially increases the likelihood of perforated appendicitis. This study aimed to find patient-related factors affecting this delay.

METHODS

A survey was conducted for patients with acute appendicitis after appendectomy. The participants were asked about their path to the surgical center and socioeconomic status. Variables affecting delays and the rate of complicated appendicitis were analyzed.

RESULTS

The study included 510 patients; 157 (31%) had complicated appendicitis with a median prehospital delay of 42 h. In patients with uncomplicated appendicitis, the delay was 21 h, p < .001. Forty-six (29%) patients with complicated appendicitis were not referred to the hospital after the first doctor's visit. The multivariate analysis discovered factors associated with long pre-hospital delay: age 40-64 years (OR 1.63 (95% CI 1.06-2.52); compared to age 18-39), age more than 64 years (OR 2.84 (95% CI 1.18-6.80); compared to age 18-39), loss of appetite (OR 2.86 (95% CI 1.64-4.98)), fever (OR 1.66 (95% CI 1.08-2.57)), non-referral by helpline nurse (OR 2.02 (95% CI 1.15-3.53)) and non-referral at first doctors visit (OR 2.16 (95% CI 1.32-3.53)). Age 40-64 years (OR 2.41 (95% CI 1.50-3.88)), age more than 64 years (OR 8.79 (95% CI 2.19-35.36)), fever (OR 1.83 (95% CI 1.15-2.89)) and non-referral at first doctors visit (OR 1.90 (95% CI 1.14-3.14)) were also risk factors for complicated appendicitis.

CONCLUSIONS

Advanced age, fever and failure to suspect acute appendicitis in primary care are associated with prolonged pre-hospital delay and complicated appendicitis.

Racial and Ethnic Minorities With Acute Pancreatitis Live in Neighborhoods With Higher Social Vulnerability Scores

OBJECTIVES

The primary objective was to determine differences in Social Vulnerability Index (SVI) scores among minorities (African-Americans and Hispanics) with acute pancreatitis (AP) compared with non-Hispanic whites (NHWs) with AP. The secondary objectives were to determine differences in diet, sulfidogenic bacteria gene copy numbers (gcn) and hydrogen sulfide (H2S) levels between the 2 groups.

MATERIALS AND METHODS

Patients with AP were enrolled during hospitalization (n = 54). Patient residential addresses were geocoded, and the Centers for Disease Control and Prevention's SVI scores were appended. Dietary intake and serum H2S levels were determined. Microbial DNAs were isolated from stool, and gcn of sulfidogenic bacteria were determined.

RESULTS

Minorities had higher SVI scores compared with NHWs ( P = 0.006). They also had lower consumption of beneficial nutrients such as omega-3 fatty acids [stearidonic ( P = 0.019), and eicosapentaenoic acid ( P = 0.042)], vitamin D ( P = 0.025), and protein from seafood ( P = 0.031). Lastly, minorities had higher pan-dissimilatory sulfite reductase A ( pan-dsrA ) gcn ( P = 0.033) but no significant differences in H2S levels ( P = 0.226).

CONCLUSION

Minorities with AP have higher SVI compared with NHWs with AP. Higher SVI scores, lower consumption of beneficial nutrients, and increased gcn of pan-dsrA in minorities with AP suggest that neighborhood vulnerability could be contributing to AP inequities.

Disparities in Emergency Department Waiting Times for Acute Gastrointestinal Bleeding: Results From the National Hospital Ambulatory Medical Care Survey, 2009-2018

OBJECTIVE

The primary aim of this study was to assess waiting time (WT) across different racial groups to determine whether racial disparities exist in patients presenting with gastrointestinal bleeding (GIB) to the United States emergency departments (EDs).

METHODS

Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2009 to 2018, we compared WT of patients with GIB across different racial/ethnic groups, including nonhispanic white (NHW), African American (AA), Hispanic White (HW), and Nonhispanic other. Multinomial logistic regression was applied to adjust the outcomes for possible confounders. We also assessed the trend of the WT over the study interval and compared the WT between the first (2009) and last year (2018) of the study interval.

RESULTS

There were an estimated 7.8 million ED visits for GIB between 2009 and 2018. Mean WT ranged from 48 minutes in NHW to 68 minutes in AA. After adjusting for gender, age, geographic regions, payment type, type of GI bleeding, and triage status, multinomial logistic regression showed significantly higher waiting time for AA patients than NHW (OR 1.01, P =0.03). The overall trend showed a significant decrease in the mean WT ( P value<0.001). In 2009, AA waited 69 minutes longer than NHW ( P value<0.001), while in 2018, this gap was erased with no statistically significant difference ( P value=0.26).

CONCLUSION

Racial disparities among patients presenting with GIB are present in the United States EDs. African Americans waited longer for their first visits. Over time, ED wait time has decreased, leading to a decline in the observed racial disparity.

Acute Pancreatitis: Current Clinical Approaches, Molecular Pathophysiology, and Potential Therapeutics

OBJECTIVE

Severe acute pancreatitis (SAP), pancreatic inflammation leading to multiorgan failure, is associated with high morbidity and mortality. There is a critical need to identify novel therapeutic strategies to improve clinical outcomes for SAP patients.

MATERIALS AND METHODS

A comprehensive literature review was performed to identify current clinical strategies, known molecular pathophysiology, and potential therapeutic targets for SAP.

RESULTS

Current clinical approaches focus on determining which patients will likely develop SAP. However, therapeutic options are limited to supportive care and fluid resuscitation. The application of a novel 5-cytokine panel accurately predicting disease outcomes in SAP suggests that molecular approaches will improve impact of future clinical trials in AP.

CONCLUSIONS

Inflammatory outcomes in acute pancreatitis are driven by several unique molecular signals, which compound to promote both local and systemic inflammation. The identification of master cytokine regulators is critical to developing therapeutics, which reduce inflammation through several mechanisms.

Racial and Ethnic Disparities in Emergency Department Wait Times for Children: Analysis of a Nationally Representative Sample

OBJECTIVE

To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED).

METHODS

We performed a cross-sectional study of ED encounters of children (<18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity.

RESULTS

We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76-0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83-1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63-0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64-0.89), and the Midwest region (HR 0.77, 95% CI 0.69-0.87). No differences in wait times were observed for children of Black race or other races.

CONCLUSIONS

Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Racial and Ethnic Differences in Ondansetron Use for Acute Gastroenteritis in Children

OBJECTIVES

There is limited research examining racial/ethnic disparities in antiemetic use for acute gastroenteritis (AGE). We assessed racial/ethnic differences in the care of children with AGE.

METHODS

The Pediatric Health Information System was used to conduct a retrospective cohort study of children 6 months to 6 years old with AGE seen in participating emergency departments from 2016 to 2018. Cases were identified using International Classification of Diseases, Tenth Revision codes. The primary outcome was administration of ondansetron, secondary outcomes were administration of intravenous (IV) fluids and hospitalization, and primary predictor was race/ethnicity. Multivariable logistic regression followed by a mixed model adjusted for sex, age, insurance, and hospital to examine the association of race/ethnicity with each outcome.

RESULTS

There were 78,019 encounters included; 24.8% of patients were non-Hispanic White (NHW), 29.0% non-Hispanic Black (NHB), 37.3% Hispanic, and 8.9% other non-Hispanic (NH) race/ethnicity. Compared with NHW patients, minority children were more likely to receive ondansetron (NHB: adjusted odds ratio, 1.36 [95% confidence interval, 1.2-1.55]; Hispanic: 1.26 [1.1-1.44]; other NH: 1.22 [1.07-1.4]). However, minority children were less likely to receive IV fluids (NHB: 0.38 [0.33-0.43]; Hispanic: 0.44 [0.36-0.53]; other NH: 0.51 [0.44-0.61]) or hospital admission (NHB: 0.37 [0.29-0.48]; Hispanic: 0.41 [0.33-0.5]; other NH: 0.52 [0.41-0.66]). Ondansetron use by hospital ranged from 73% to 95%.

CONCLUSIONS

This large database analysis of emergency departments around the nation found that NHW patients were less likely to receive ondansetron but more likely to receive IV fluids and hospital admission than minority patients. These findings are likely multifactorial and may represent bias, social determinants of health, access to care, or illness severity among other possible causes.

Recruitment and Retention Strategies for the Diabetes RElated to Acute Pancreatitis and Its Mechanisms Study: From the Type 1 Diabetes in Acute Pancreatitis Consortium

ABSTRACT

Recruitment and retention of patients with acute pancreatitis (AP) in clinical studies can be challenging. While some obstacles are similar to other clinical conditions, some are unique to AP. Identifying potential barriers early and developing targeted solutions can help optimize recruitment and retention in AP studies. Such pre-emptive and detailed planning can help prospective, longitudinal studies focus on exocrine and endocrine complications of AP in accurately measuring outcomes. This article highlights the challenges in recruitment and retention strategies in AP studies and reviews available resources to create opportunities to address them. We describe the multifaceted approach used by the Recruitment and Retention Committee of the Type 1 Diabetes in Acute Pancreatitis Consortium, which builds upon earlier experiences to develop a recruitment and retention plan for the DREAM (Diabetes RElated to Acute pancreatitis and its Mechanisms) study.

Effect of language interpretation modality on throughput and mortality for critical care patients: A retrospective observational study

OBJECTIVE

Limited data exist describing possible delays in patient transfer from the emergency department (ED) as a result of language barriers and the effects of interpretation services. We described the differences in ED length of stay (LOS) before intensive care unit (ICU) arrival and mortality based on availability of telephone or in-person interpretation services.

METHODS

Using an ICU database from an urban academic tertiary care hospital, ED patients entering the ICU were divided into groups based on primary language and available interpretation services (in-person vs telephone). Non-parametric tests were used to compare ED LOS and mortality between groups.

RESULTS

Among 22,422 included encounters, English was recorded as the primary language for 51% of patients (11,427), and 9% of patients (2042) had a primary language other than English. Language was not documented for 40% of patients (8953). Among encounters with patients with non-English primary languages, in-person interpretation was available for 63% (1278) and telephone interpretation was available for 37% (764). In the English-language group, median ED LOS was 292 minutes (interquartile range [IQR], 205-412) compared with 309 minutes (IQR, 214-453) for patients speaking languages with in-person interpretation available and 327 minutes (IQR, 225-463) for patients speaking languages with telephone interpretation available. Mortality was higher among patients with telephone (15%) or in-person (11%) interpretation available compared with patients who primarily spoke English (9%).

CONCLUSIONS

Patients with primary languages other than English who were critically ill spent a median of 17 to 35 more minutes in the ED before ICU arrival and experienced higher mortality rates compared with patients who spoke English as a primary language.

Racial/ethnic disparities in emergency department wait times in the United States, 2013-2017

BACKGROUND

Previous research shows that Black and Hispanic patients have longer ED wait times than White patients, but these data do not reflect recent changes such as the Affordable Care Act. In addition, previous research does not account for the non-normal distribution of wait times, wherein a sizable subgroup of patients seen promptly and those not seen promptly experience long wait times.

METHODS

We utilized National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets (2013-2017) to examine mean ED wait time comparing visits by Black, Hispanic, and Asian patients to White patients. Using a two-part regression model, we adjusted for patient, hospital, and health system factors, and estimated differences, for each of five triage levels, in (a) likelihood of waiting at least 5 min and (b) difference in wait time among those not seen promptly.

RESULTS

Our cohort included 38,800 White, 14,838 Black, 10,619 Hispanic, and 1257 Asian patient visits. Black (triage level 3) and Hispanic (triage levels 3 and 4) patients had longer mean wait times than White patients. Adjusted likelihood of not being seen promptly was lower among Blacks (triage levels 3, 4 and 5), Hispanics (triage level 5) and Asians (triage level 5) compared to Whites. Among those waiting at least 5 min, adjusted wait time was longer among Blacks in triage level 3 (5.2 min, 95% CI, 1.3 to 9.0) and level 4 (2.5 min, 95% CI, 0.2 to 4.9), Hispanics in triage level 4 (4.7 min, 95% CI, 1.7 to 7.7) and Asians in triage level 5 (16.3 min, 95% CI, 0.6 to 31.9) compared to Whites.

CONCLUSIONS

Minority patients were less likely to wait to be seen, but waited longer if not seen promptly. These data exhibit that ED wait time disparities persist for African American and Hispanic patients and extend this observation to Asian patients.

Analyzing Main and Interaction Effects of Length of Stay Determinants in Emergency Departments

BACKGROUND

Measuring and understanding main determinants of length of stay (LOS) in emergency departments (EDs) is critical from an operations perspective, since LOS is one of the main performance indicators of ED operations. Therefore, this study analyzes both the main and interaction effects of four widely-used independent determinants of ED-LOS.

METHODS

The analysis was conducted using secondary data from an ED of a large urban hospital in Izmir, Turkey. Between-subject factorial analysis of variance (ANOVA) was used to test the main and interaction effects of the corresponding factors. P values <.05 were considered statistically significant.

RESULTS

While the main effect of gender was insignificant, age, mode of arrival, and clinical acuity had significant effects, whereby ED-LOS was significantly higher for the elderly, those arriving by ambulance, and clinically-categorized high-acuity patients. Additionally, there was an interaction between the age and clinical acuity in that, while ED-LOS increased with age for high acuity patients, the opposite trend occurred for low acuity patients. When ED-LOS was modeled using gender, age, and mode of arrival, there was a significant interaction between age and mode of arrival. However, this interaction was not significant when the model included age, mode of arrival, and clinical acuity.

CONCLUSION

Significant interactions exist between commonly used ED-LOS determinants. Therefore, interaction effects should be considered in analyzing and modelling ED-LOS.

Identifying Nonprovider Factors Affecting Pediatric Emergency Medicine Provider Efficiency

OBJECTIVE

The aim of this study was to create a multivariable model of standardized relative value units per hour by adjusting for nonprovider factors that influence efficiency.

METHODS

We obtained productivity data based on billing records measured in emergency relative value units for (1) both evaluation and management of visits and (2) procedures for 16 pediatric emergency medicine providers with more than 750 hours worked per year. Eligible shifts were in an urban, academic pediatric emergency department (ED) with 2 sites: a tertiary care main campus and a satellite community site. We used multivariable linear regression to adjust for the impact of shift and pediatric ED characteristics on individual-provider efficiency and then removed variables from the model with minimal effect on productivity.

RESULTS

There were 2998 eligible shifts for the 16 providers during a 3-year period. The resulting model included 4 variables when looking at both ED sites combined. These variables include the following: (1) number of procedures billed by provider, (2) season of the year, (3) shift start time, and (4) day of week. Results were improved when we separately modeled each ED location. A 3-variable model using procedures billed by provider, shift start time, and season explained 23% of the variation in provider efficiency at the academic ED site. A 3-variable model using procedures billed by provider, patient arrivals per hour, and shift start time explained 45% of the variation in provider efficiency at the satellite ED site.

CONCLUSIONS

Several nonprovider factors affect provider efficiency. These factors should be considered when designing productivity-based incentives.

Older adults are prioritized in terms of waiting time under the emergency triage system in Guangzhou, China

AIM

To assess whether elderly patients are prioritized under the emergency triage system in Guangzhou, China.

METHODS

This was a cross-sectional survey of clinical data from adult visitors to the emergency department of the Third Affiliated Hospital of Sun Yat-sen University between 1 August 2015 and 31 December 2017. The primary end-point was receiving the first medical service within the target waiting time, which varied according to the triage level of the patient. Multivariate logistic regression was used to determine whether age was an independent predictor of a shorter waiting time.

RESULTS

Data from 262 282 emergency patients were analyzed. The mean age of patients was 35.97 years, and 7.5% were aged ≥65 years. In total, 88.3% of patients received medical service within the target waiting time, and 87.4% of elderly patients received medical service within the target waiting time. Multivariate logistic regression analysis showed that advanced age was independently associated with receiving medical service within the target waiting time (adjusted odds ratio 1.258, 95% confidence interval 1.198-1.321; P < 0.001). The triage level, type of emergency subdivision, availability of outpatient services and time of day were also associated with receiving medical service within the target waiting time.

CONCLUSION

Under the emergency triage system of the hospital, older adults are more likely to receive medical service within the target waiting time than younger patients. Geriatr Gerontol Int 2019; 19: 786-791.

Scope of practice and supervision of orthodontic therapists in the United Kingdom: Part 2: a national cross-sectional survey of orthodontic therapists

BACKGROUND

Orthodontic therapists (OTs) are the most recent addition to the orthodontic clinical team. The General Dental Council (GDC) and the British Orthodontic Society have formulated guidance and guidelines relating to their scope of practice and level of supervision, however there has been no contemporary UK-based research investigating practice and supervision of OTs. The aim of this study was to investigate the scope of practice and level of supervision of OTs working in the UK.

METHOD

Ethical approval was received from the University of Manchester Research Ethics Committee. An anonymous postal questionnaire was dispatched using postal details acquired through the British Orthodontic Societies mailing list. Three mailings of the questionnaire were conducted.

RESULTS

A 74% response rate was achieved. OTs routinely conducted 16 of the 20 procedures from their scope of practice. Uncommon procedures included fitting headgear (24%), lingual appliances (27%), inserting or removing temporary anchorage devices (20%), and taking facebow record (18%). A total of 62% of OTs took patient consent for treatment. 59% were supervised through a written prescription with no direct supervision. OTs were directly supervised for only a quarter of their clinical practice. Orthodontists viewing frequency for OTs varied significantly, and was found to be the following: every 2-4 visits (36%), every other visit (35%), and every visit (26%).

CONCLUSIONS

OTs mostly carried out the scope of practice as permitted by the GDC. Procedures uncommon to routine orthodontic practice were also uncommon to Orthodontic therapist clinical practice. OTs work mostly through written prescription with no direct supervision.

Cherry Picking Patients: Examining the Interval Between Patient Rooming and Resident Self-assignment

OBJECTIVE

We aimed to evaluate the association between patient chief complaint and the time interval between patient rooming and resident physician self-assignment ("pickup time"). We hypothesized that significant variation in pickup time would exist based on chief complaint, thereby uncovering resident preferences in patient presentations.

METHODS

A retrospective medical record review was performed on consecutive patients at a single, academic, university-based emergency department with over 50,000 visits per year. All patients who presented from August 1, 2012, to July 31, 2013, and were initially seen by a resident were included in the analysis. Patients were excluded if not seen primarily by a resident or if registered with a chief complaint associated with trauma team activation. Data were abstracted from the electronic health record (EHR). The outcome measured was "pickup time," defined as the time interval between room assignment and resident self-assignment. We examined all complaints with >100 visits, with the remaining complaints included in the model in an "other" category. A proportional hazards model was created to control for the following prespecified demographic and clinical factors: age, race, sex, arrival mode, admission vital signs, Emergency Severity Index code, waiting room time before rooming, and waiting room census at time of rooming.

RESULTS

Of the 30,382 patients eligible for the study, the median time to pickup was 6 minutes (interquartile range = 2-15 minutes). After controlling for the above factors, we found systematic and significant variation in the pickup time by chief complaint, with the longest times for patients with complaints of abdominal problems, numbness/tingling, and vaginal bleeding and shortest times for patients with ankle injury, allergic reaction, and wrist injury.

CONCLUSIONS

A consistent variation in resident pickup time exists for common chief complaints. We suspect that this reflects residents preferentially choosing patients with simpler workups and less perceived diagnostic ambiguity. This work introduces pickup time as a metric that may be useful in the future to uncover and address potential physician bias. Further work is necessary to establish whether practice patterns in this study are carried beyond residency and persist among attendings in the community and how these patterns are shaped by the information presented via the EHR.

African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients

OBJECTIVES

We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses.

METHODS

Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race.

RESULTS

There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86).

CONCLUSIONS

African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.

Secondary analysis of large databases for hepatology research

Secondary analysis of large datasets involves the utilization of existing data that has typically been collected for other purposes to advance scientific knowledge. This is an established methodology applied in health services research with the unique advantage of efficiently identifying relationships between predictor and outcome variables but which has been underutilized for hepatology research. Our review of 1431 abstracts published in the 2013 European Association for the Study of Liver (EASL) abstract book showed that less than 0.5% of published abstracts utilized secondary analysis of large database methodologies. This review paper describes existing large datasets that can be exploited for secondary analyses in liver disease research. It also suggests potential questions that could be addressed using these data warehouses and highlights the strengths and limitations of each dataset as described by authors that have previously used them. The overall goal is to bring these datasets to the attention of readers and ultimately encourage the consideration of secondary analysis of large database methodologies for the advancement of hepatology.

Relationship between racial disparities in ED wait times and illness severity

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Differences in Presentation and Management of Pediatric Facial Lacerations by Type of Health Insurance

Introduction

Limited data are available regarding differences in presentation and management of pediatric emergency department (PED) patients based on insurance status. The objective of the study was to assess the difference in management of pediatric facial lacerations based on medical insurance status.

Methods

We conducted a retrospective cohort study with universal sampling of patients with facial lacerations who were treated in an urban PED (45K visits/year) over a one-year period. Demographic features and injury characteristics for patients with commercial (private) insurance and those with Medicaid or Medicare (public) insurance were compared.

Results

Of 1235 children included in the study, 667 (54%) had private insurance and 485 (39%) had public insurance. The two groups did not differ in age or gender, arrival by ambulance, location of injury occurrence, mechanism of injury, part of face involved, length or depth of laceration, use of local anesthetic, or method of repair but differed in acuity assigned at triage. Patients with public insurance were found less likely to have subspecialty consultation in bivariable (OR=0.41, 95% CI [0.24–0.68]) and multivariable logistic regression analyses (OR=0.45, 95% CI [0.25–0.78]). Patients with public insurance received procedural sedation significantly less often than those with private insurance (OR=0.48, 95% CI [0.29–0.76]). This difference was not substantiated in multivariable models (OR=0.74, 95% CI [0.40–1.31]).

Conclusion

Patients with public insurance received less subspecialty consultation compared to privately insured patients despite a similarity in the presentation and characteristics of their facial lacerations. The reasons for these disparities require further investigation.

Predictors of severity in childhood pancreatitis: correlation with nutritional status and racial demographics

OBJECTIVE

Acute pancreatitis is one of the leading causes of rising pediatric hospitalizations in North America. The aim of this study was to assess the role of nutritional status and racial influences on the severity of acute pancreatitis in children.

METHODS

The institutional review board approved this retrospective chart review of children with the diagnosis of acute pancreatitis between the ages of 0 and 18 years hospitalized at the Johns Hopkins Hospital between 1998 and 2008. Parameters studied included biochemical markers associated with pancreatitis, review of severity of illness reflected through the length of stay, and pediatric intensive care unit admission.

RESULTS

The length of in-patient hospitalization was longer for children with imaging findings of pseudocyst or pancreatic necrosis (23.1 ± 26.4 days vs 4.4 ± 10.6 days; P = 0.0074) and malnourished children versus normal weight and obese children (16.5 days for malnourished vs 10.6 days for normal weight vs 10.7 days for obese; P = 0.04). There was also a significant difference in the need for pediatric intensive care unit admission across ethnic groups (18% African American vs 7% white) (P = 0.04).

CONCLUSIONS

Ethnicity and nutritional status may influence the severity and duration of hospitalization among children with pancreatitis.

Comparative study between patients with acute appendicitis treated in primary care units and in emergency hospitals

OBJECTIVE

To retrospectively analyze the relationship of time of care, combined with possible post-appendectomy complications, with the promptness of transfer of patients seen in Emergency Care Units (UPA) to the emergency hospital.

METHODS

We analyzed patients with preoperative diagnosis of acute appendicitis undergoing appendectomy from January to July 2012. Patients were divided into two groups according to the site of the first care. Group A included patients who received initial care directly in the emergency department of the Lourenço Jorge County Hospital (HMLJ) and group B consisted of patients seen in the UPA and forwarded to HMLJ to undergo surgical treatment.

RESULTS

the average time between initial treatment and surgery in group A was 29 hours (SD = 21.95) and 54 hours in group B (SD = 54.5). Considering the onset of symptoms, the patients in group A were operated on average 67 hours after (SD = 42.55), while group B, 90 hours (SD = 59.58). After the operation, patients in group A were hospitalized, on average, for 94 hours (SD = 73.53) and group B, 129 hours (SD = 193.42).

CONCLUSION

there was no significant difference in the time elapsed between the onset of symptoms, initial treatment and early surgical treatment, or time elapsed between surgery and discharge.

Racial Disparity in Duration of Patient Visits to the Emergency Department: Teaching Versus Non-teaching Hospitals

Introduction:

The sources of racial disparity in duration of patients’ visits to emergency departments (EDs) have not been documented well enough for policymakers to distinguish patient-related factors from hospital- or area-related factors. This study explores the racial disparity in duration of routine visits to EDs at teaching and non-teaching hospitals.

Methods:

We performed retrospective data analyses and multivariate regression analyses to investigate the racial disparity in duration of routine ED visits at teaching and non-teaching hospitals. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) were used in the analyses. The data include 4.3 million routine ED visits encountered in Arizona, Massachusetts, and Utah during 2008. We computed duration for each visit by taking the difference between admission and discharge times.

Results:

The mean duration for a routine ED visit was 238 minutes at teaching hospitals and 175 minutes at non-teaching hospitals. There were significant variations in duration of routine ED visits across race groups at teaching and non-teaching hospitals. The risk-adjusted results show that the mean duration of routine ED visits for Black/African American and Asian patients when compared to visits for white patients was shorter by 10.0 and 3.4%, respectively, at teaching hospitals; and longer by 3.6 and 13.8%, respectively, at non-teaching hospitals. Hispanic patients, on average, experienced 8.7% longer ED stays when compared to white patients at non-teaching hospitals.

Conclusion:

There is significant racial disparity in the duration of routine ED visits, especially in non-teaching hospitals where non-White patients experience longer ED stays compared to white patients. The variation in duration of routine ED visits at teaching hospitals when compared to non-teaching hospitals was smaller across race groups.

Clinical and economic burden of emergency department visits due to gastrointestinal diseases in the United States

OBJECTIVES

Gastrointestinal (GI) emergencies may cause substantial morbidity. Our aims were to characterize the national clinical and economic burden of GI visits to emergency departments (EDs) in the United States.

METHODS

We performed an observational cross-sectional study using the 2007 Nationwide Emergency Department Sample, the largest US all-payer ED database, to identify the leading causes for ED visits due to GI diseases and their associated charges, stratified by age and sex. Logistic regression was used to analyze predictors of hospitalization after an ED visit.

RESULTS

Of the 122 million ED visits in 2007, 15 million (12%) had a primary GI diagnosis. The leading primary GI diagnoses were abdominal pain (4.7 million visits), nausea and vomiting (1.6 million visits), and functional disorders of the digestive system (0.7 million visits). The leading diagnoses differed by age group. The fraction of ED visits resulting in hospitalization was 21.6% for primary GI diagnoses vs. 14.7% for non-GI visits. Women had more ED visits with a primary GI diagnosis than men (58.5 (95% CI 56.0-60.9) vs. 41.6 (95% CI 39.8-43.3) per 1000 persons), but lower rates of subsequent hospitalization (20.0% (95% CI 19.4-20.7%) vs. 24.0% (95% CI 23.3-24.6%)). There were no differences in hospitalization rates between sexes after adjustment by age, primary GI diagnosis, and Charlson Comorbidity Score. The total charges for ED visits with a primary GI diagnosis in 2007 were $27.9 billion.

CONCLUSIONS

GI illnesses account for substantial clinical and economic burdens on US emergency medical services.

Clinical management of patients with acute pancreatitis

Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. As rates of hospitalization for acute pancreatitis continue to increase, so does demand for effective management. We review approaches to best manage patients with acute pancreatitis, covering diagnosis, risk and prognostic factors, treatment, and complications, considering recommendations from current practice guidelines.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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