The association between ethnicity and delay in seeking medical care for chest pain: a systematic review

Sex and ethnic differences in unrecognized myocardial infarctions: Observations on recognition and preventive therapies from the multiethnic population-based HELIUS cohort

Background

Epidemiological studies suggest sex differences in the prevalence and characteristics of unrecognized and recognized myocardial infarction (uMI, rMI). Despite increasingly diverse populations, observations are limited in multiethnic contexts. Gaining better understanding may inform policy makers and healthcare professionals on populations at risk of uMI who could benefit from preventive measures.

Methods

We used baseline data from the multiethnic population-based HELIUS cohort (2011-2015; Amsterdam, the Netherlands). Using logistic regressions, we studied sex differences in the prevalence and proportion of uMIs across ethnic groups. Next, we studied whether symptoms, clinical parameters, and sociocultural factors were associated with uMIs. Finally, we compared secondary preventive therapies in women and men with a uMI or rMI. We relied on pathological Q-waves on a resting electrocardiogram as the electrocardiographic signature for (past) MI.

Results

Overall, and in Turkish and Moroccan subgroups, the prevalence of uMIs was higher in men than women. The proportion of uMIs was similar in women (21.0%) and men (18.4%), yet varied by ethnicity. In women and men, symptoms (chest pain, dyspnea) and clinical parameters (hypertension, hypercholesterolemia), and in women also lower educational level and diabetes were associated with lower odds of uMIs. Women (0.0%) and men (3.6%) with uMI were unlikely to receive secondary preventive therapies compared to those with rMI (28.1-40.9%).

Conclusions

The prevalence of uMIs was higher in men than women, and sex differences in the proportion of uMIs varied somewhat across ethnic groups. People with uMIs did not receive adequate preventative medications, posing a risk for recurrent events.

The prevalence of frailty and its relationship with sociodemographic factors, regional healthcare disparities, and healthcare utilization in the aging population across India

Objective

To estimate frailty prevalence and its relationship with the socio-economic and regional factors and health care outcomes.

Methods

In this study, participants from the harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) were included. The frailty index (FI) was calculated using a 32-variable deficit model, with a value of ≥ 25% considered as frail. Data on demographic (including caste and religion) and socioeconomic profiles and health care utilization were obtained. The state-wise health index maintained by the government based on various health-related parameters was used to group the participants' residential states into high-, intermediate-, and low-performing states. Multivariable and zero-inflated negative binomial regression was used to assess the relationship of frailty index with sociodemographic characteristics, health index, and health care expenditure or hospitalization.

Results

Among the 3953 eligible participants, the prevalence of frailty was 42.34% (men = 34.99% and women = 49.35%). Compared to high-performing states, intermediate- and low-performing states had a higher proportion of frail individuals (49.7% vs. 46.8% vs. 34.5%, P < 0.001). In the adjusted analysis, frailty was positively associated with age, female sex, rural locality, lower education level, and caste (scheduled caste and other backward classes). After adjusting for the socio-economic profile, FI was inversely associated with the composite health index of a state (P < 0.001). FI was also significantly correlated with total 1-year health care expenditure and hospitalization (P < 0.001 and 0.020, respectively).

Conclusion

There is a high prevalence of frailty among older Indian adults that is associated with sociodemographic factors and regional health care performance. Furthermore, frailty is associated with increased health care utilization and expenditure.

Anesthetic Effect of 2% Amitriptyline Versus 2% Lidocaine: A Comparative Evaluation

Introduction A common dental problem is the fear of pain during needle prick for giving local anesthesia (LA). The needle prick pain during dental procedures often varies with sex and age. Perception of pain depends on various factors, which can be psychological and biological. This perception of pain may change the behavior of patients toward dental treatments. Traditionally, lidocaine gel formulation was utilized before the parenteral dosage form. The lidocaine gel formulation is considered the drug of choice for LA in dental surgery. Currently, amitriptyline has been utilized in dental practice because of its beneficial pharmacology. Hence, the present study has been undertaken to compare the anesthetic ability of amitriptyline as an intraoral topical anesthetic agent with lidocaine gel. Methods This study was a comparative clinical study between two medications' anesthetic properties. This study included 120 patients indicated for bilateral orthodontics (the subdivision of dentistry that emphasizes identifying necessary interventions for the malocclusion of teeth) procedures. All the subjects were divided into amitriptyline and lidocaine groups. Both anesthetic gels were applied at separate sites before the injection of LA. The time of the onset of anesthesia was noted and analyzed. Patients were selected on the basis of inclusion and exclusion criteria. Individuals aged 18 to 30 years who were systemically healthy and orthodontically indicated for bilateral premolar extraction were included in this study. Again, patients with a history of neurological disorders and allergies to amitriptyline and lidocaine were excluded from the current study. Results Significant differences emerged between groups at five and 10 minutes, with amitriptyline-induced partial numbness (36.7% and 6.7%). At 40 and 45 minutes, both groups showed varied partial and complete numbness, with amitriptyline leading to partial recovery (23.3% and 73.3% complete numbness, 23.3% partial recovery) and lidocaine resulting in partial recovery (81.7%). When comparing the visual analog scale (VAS) scores, both groups exhibited a similar simultaneous effect at 15 minutes. Nonetheless, amitriptyline displayed significantly lower scores at 25 and 35 minutes (p < 0.001) in comparison to lidocaine. Similar observations were made when controlling for pain intensity. Conclusion It was concluded that amitriptyline holds both anesthetic and analgesic properties. Nevertheless, this study was unable to generalize the study findings because of the small sample size and being a single-center study. However, the VAS scores of anesthetic and analgesic pharmacodynamics properties of amitriptyline were statistically significantly lower than lidocaine, particularly at 25 and 35 minutes. Additionally, amitriptyline-induced anesthetic and analgesic pharmacology, especially pharmacokinetics properties, depends on the location and pattern of pain.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

BACKGROUND

We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics.

METHODS

The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant.

RESULTS

We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7 days in 2007 to 6 days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014.

CONCLUSION

Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Predicting Patient Length of Stay in Australian Emergency Departments Using Data Mining

Length of Stay (LOS) is an important performance metric in Australian Emergency Departments (EDs). Recent evidence suggests that an LOS in excess of 4 h may be associated with increased mortality, but despite this, the average LOS continues to remain greater than 4 h in many EDs. Previous studies have found that Data Mining (DM) can be used to help hospitals to manage this metric and there is continued research into identifying factors that cause delays in ED LOS. Despite this, there is still a lack of specific research into how DM could use these factors to manage ED LOS. This study adds to the emerging literature and offers evidence that it is possible to predict delays in ED LOS to offer Clinical Decision Support (CDS) by using DM. Sixteen potentially relevant factors that impact ED LOS were identified through a literature survey and subsequently used as predictors to create six Data Mining Models (DMMs). An extract based on the Victorian Emergency Minimum Dataset (VEMD) was used to obtain relevant patient details and the DMMs were implemented using the Weka Software. The DMMs implemented in this study were successful in identifying the factors that were most likely to cause ED LOS > 4 h and also identify their correlation. These DMMs can be used by hospitals, not only to identify risk factors in their EDs that could lead to ED LOS > 4 h, but also to monitor these factors over time.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries

BACKGROUND

Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups.

METHODS

Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed.

RESULTS

Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping.

CONCLUSIONS

There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns.

TRIAL REGISTRATION

PROSPERO- CRD42020167890 .

Variation in Seeking Care for Cardiovascular Disease and Ambulance Utilization among Migrants in Australia: Time, Ethnicity, and Delay (TED) Study III

Insight into differences in seeking medical care for chest pain among migrant populations is limited. This study aimed to determine ethnic differences in seeking care behaviors and using ambulances among migrants compared to an Australian-born group. A total of 607 patients presenting with chest pain to a tertiary hospital between 1 July 2012 and 30 June 2014 were randomly selected. Data from the emergency department dataset and medical record reviews were collected and linked for analysis. The migrant group was stratified into nine ethnic groups for analysis based on the Australian Standard Classification of Cultural and Ethnic Groups. The overall median prehospital delay time was 3.7 (1.5, 10.7) h, which ranged from 2.5 (1.0, 10.7) (Southern and Eastern European group) to 6.0 (2.3, 20.6) (Sub-Saharan African group). The median decision time was 2.0 (0.8, 7.9) h, which ranged from 1.5 (Australian-born group) to 4.5 h (Sub-Saharan African group). Five ethnic groups had significantly longer decision times compared to the Australian-born group. Decision time accounted for 58.4% of pre-hospital delay time. Migrant patients were 60% less likely to seek care for chest pain within one hour (odds ratio 0.40, (0.23–0.68), p = 0.001). There was no significant difference in ambulance utilization between migrant and Australian-born groups. In conclusion, ethnic differences in seeking care for chest pain do exist, and ethnicity plays a vital role in a longer delay in seeking care. To reduce the delays and improve patient outcomes, appropriate health campaigns focusing on ethnic differences among migrant populations and normalizing cultural competency into practice are recommended.

Barriers to seeking health care among returning travellers with malaria: A systematic review

OBJECTIVE

To identify barriers to seeking health care among returning travellers with malaria with the aim of developing targeted interventions that improve early health care-seeking behaviour, diagnosis and treatment.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review of published medical literature, selecting studies that investigated and reported barriers to seeking health care among returning travellers and migrants with malaria. In total, 633 articles were screened, of which four studies met the inclusion criteria after a full-text review.

RESULTS

The four studies reported barriers to seeking healthcare among returning travellers in China, the United States, Thailand and the Dominican Republic. Three studies had an observational design. The identified barriers were summarised based on the appraisal delay, illness delay and utilisation delay stages. During appraisal delays, low awareness of malaria was the most significant factor. Once the patient assessed that he or she was ill, belonging to a specific minority ethnicity, being infected with P. vivax and receiving a low level of social support were predictors of delayed health care-seeking. Finally, the most significant factor associated with utilisation delays was the monetary cost.

CONCLUSION

The health care-seeking behaviour of returning travellers with malaria should be further investigated and improved. Addressing the identified barriers and gaps in health care-seeking behaviour among returning travellers with malaria, particularly among groups at high risk of travel-associated infections, is important to prevent severe disease and deaths as well as secondary transmission and epidemics.

Multicultural presentation of chest pain at an emergency department in Australia

OBJECTIVE

To investigate differences in presenting patient characteristics, investigation, management and related outcomes between culturally and linguistically diverse (CALD) and non-CALD chest pain (CP) patients presenting to the ED.

METHODS

A cohort study of 258 patients was enrolled on presentation to Liverpool Hospital ED with a complaint of CP over a 2-week period. Main outcomes included frequency and timeliness of diagnostic and radiological investigations, medication administered and ED length of stay. Administrative and clinical data were extracted and linked from Cerner EMR FirstNet®, PowerChart® and paper records.

RESULTS

There were 155 (60%) CALD and 103 (40%) non-CALD patients. CALD patients were older by 10 years (95% CI 4, 15; P < 0.0001). There were no significant differences in the number of pathology and imaging investigations carried out in each group, and similarly there were no significant differences in the number of patients administered analgesia or cardiac-specific medications. Neither group differed in their ED length of stay (median 280 vs 259.5 min; P = 0.79) or hospital admission rate (median 56% vs 55%, P = 0.8).

CONCLUSION

Both CALD and non-CALD ED CP patients had similar test ordering, medication administration and clinical outcomes, but this was in the context of CALD patients being 10 years older together with a small study sample size. A larger cohort, matched for age, would provide further insights into potentially important differences.

Ethnicity and outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort study

OBJECTIVE

To describe outcomes within different ethnic groups of a cohort of hospitalised patients with confirmed COVID-19 infection. To quantify and describe the impact of a number of prognostic factors, including frailty and inflammatory markers.

SETTING

Five acute National Health Service Hospitals in east London.

DESIGN

Prospectively defined observational study using registry data.

PARTICIPANTS

1737 patients aged 16 years or over admitted to hospital with confirmed COVID-19 infection between 1 January and 13 May 2020.

MAIN OUTCOME MEASURES

The primary outcome was 30-day mortality from time of first hospital admission with COVID-19 diagnosis during or prior to admission. Secondary outcomes were 90-day mortality, intensive care unit (ICU) admission, ICU and hospital length of stay and type and duration of organ support. Multivariable survival analyses were adjusted for potential confounders.

RESULTS

1737 were included in our analysis of whom 511 had died by day 30 (29%). 538 (31%) were from Asian, 340 (20%) black and 707 (40%) white backgrounds. Compared with white patients, those from minority ethnic backgrounds were younger, with differing comorbidity profiles and less frailty. Asian and black patients were more likely to be admitted to ICU and to receive invasive ventilation (OR 1.54, (95% CI 1.06 to 2.23); p=0.023 and OR 1.80 (95% CI 1.20 to 2.71); p=0.005, respectively). After adjustment for age and sex, patients from Asian (HR 1.49 (95% CI 1.19 to 1.86); p<0.001) and black (HR 1.30 (95% CI 1.02 to 1.65); p=0.036) backgrounds were more likely to die. These findings persisted across a range of risk factor-adjusted analyses accounting for major comorbidities, obesity, smoking, frailty and ABO blood group.

CONCLUSIONS

Patients from Asian and black backgrounds had higher mortality from COVID-19 infection despite controlling for all previously identified confounders and frailty. Higher rates of invasive ventilation indicate greater acute disease severity. Our analyses suggest that patients of Asian and black backgrounds suffered disproportionate rates of premature death from COVID-19.

Assessment of Racial/Ethnic Disparities in Hospitalization and Mortality in Patients With COVID-19 in New York City

IMPORTANCE

Black and Hispanic populations have higher rates of coronavirus disease 2019 (COVID-19) hospitalization and mortality than White populations but lower in-hospital case-fatality rates. The extent to which neighborhood characteristics and comorbidity explain these disparities is unclear. Outcomes in Asian American populations have not been explored.

OBJECTIVE

To compare COVID-19 outcomes based on race and ethnicity and assess the association of any disparities with comorbidity and neighborhood characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted within the New York University Langone Health system, which includes over 260 outpatient practices and 4 acute care hospitals. All patients within the system's integrated health record who were tested for severe acute respiratory syndrome coronavirus 2 between March 1, 2020, and April 8, 2020, were identified and followed up through May 13, 2020. Data were analyzed in June 2020. Among 11 547 patients tested, outcomes were compared by race and ethnicity and examined against differences by age, sex, body mass index, comorbidity, insurance type, and neighborhood socioeconomic status.

EXPOSURES

Race and ethnicity categorized using self-reported electronic health record data (ie, non-Hispanic White, non-Hispanic Black, Hispanic, Asian, and multiracial/other patients).

MAIN OUTCOMES AND MEASURES

The likelihood of receiving a positive test, hospitalization, and critical illness (defined as a composite of care in the intensive care unit, use of mechanical ventilation, discharge to hospice, or death).

RESULTS

Among 9722 patients (mean [SD] age, 50.7 [17.5] years; 58.8% women), 4843 (49.8%) were positive for COVID-19; 2623 (54.2%) of those were admitted for hospitalization (1047 [39.9%] White, 375 [14.3%] Black, 715 [27.3%] Hispanic, 180 [6.9%] Asian, 207 [7.9%] multiracial/other). In fully adjusted models, Black patients (odds ratio [OR], 1.3; 95% CI, 1.2-1.6) and Hispanic patients (OR, 1.5; 95% CI, 1.3-1.7) were more likely than White patients to test positive. Among those who tested positive, odds of hospitalization were similar among White, Hispanic, and Black patients, but higher among Asian (OR, 1.6, 95% CI, 1.1-2.3) and multiracial patients (OR, 1.4; 95% CI, 1.0-1.9) compared with White patients. Among those hospitalized, Black patients were less likely than White patients to have severe illness (OR, 0.6; 95% CI, 0.4-0.8) and to die or be discharged to hospice (hazard ratio, 0.7; 95% CI, 0.6-0.9).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients in a large health system in New York City, Black and Hispanic patients were more likely, and Asian patients less likely, than White patients to test positive; once hospitalized, Black patients were less likely than White patients to have critical illness or die after adjustment for comorbidity and neighborhood characteristics. This supports the assertion that existing structural determinants pervasive in Black and Hispanic communities may explain the disproportionately higher out-of-hospital deaths due to COVID-19 infections in these populations.

The Effect of Migration Duration on Treatment Delay Among Rural-to-Urban Migrants After the Integration of Urban and Rural Health Insurance in China: A Cross-Sectional Study

Few researches have been focused on the treatment delay of rural-to-urban migrants in China. Our study aimed to investigate the effect of migration duration on treatment delay among rural-to-urban migrants in tertiary hospitals. A cross-sectional study was conducted based on a sample of 727 patients and surveyed factors including sociodemographics, medical costs, migration, treatment delay, and health cost-coping strategies. Totally, 727 patients were included, of which 61 delayed their treatment and 666 had no treatment delay. Statistically significant differences were found between different migration duration groups in marital status, education, insurance, family annual income, residency, payment before treatment, reported disease, and migration duration (P < .05). The results from multiple logistic regression showed that migration between 1 and 5 years (adjusted odds ratio [OR] = 7.24; 95% confidence interval [CI] = 1.59-32.87; P < .05) was considered the significant contributing risk factor for treatment delay after adjusting for age, sex, and other variables. To cope with their health expenditure, patients with treatment delay tended to use less savings and borrow more money than those without. Rural-to-urban migrants with 1 to 5 years of migration were the most vulnerable group of having treatment delay. Migrants were more likely to borrow money to cope with the health expenditure. Targeted services should be provided to meet different needs of migrants according to migration duration.

Community-based health promotion about alcohol and other drugs in a multicultural Australia-what works? A review of evidence

Refugee and migrant communities from culturally and linguistically diverse backgrounds in Australia experience dependency, stigma, isolation, mental health issues, family issues and other problems associated with alcohol and other drugs. Yet, refugee and migrant communities also face major linguistic, cultural and technological barriers to health promotion about drug-related problems. The aim of this review is to identify effective techniques and approaches for health promotion that reduces the risk of problems with drugs in culturally and linguistically inclusive ways. To identify what is effective, the Medline/PubMed database was systematically searched for health promotion literature published between 2008 and 2018. Grey literature from relevant agencies was also searched. The review considered both quantitative and qualitative outcome measures, and assessed studies using the Critical Appraisal Skills Programme quality assessment tool. Three studies met inclusion criteria, with weak evaluations. The studies demonstrated effective community engagement, but do not provide conclusive evidence of what is effective drug-related health promotion. The review's findings point to an important knowledge gap. More rigorous research and evaluation are required to identify effective health promotion for reducing drug-related issues with a larger, more diverse range of refugee and migrant communities.

A cross-sectional study of ethnicity-based differences in treatment seeking for symptoms of acute coronary syndrome

BACKGROUND

Patient-related delays in acquiring medical care for symptoms of acute coronary syndrome remain unacceptably long. Many clinical and sociodemographic characteristics associated with treatment-seeking delay are known; however, ethnicity has not been extensively evaluated.

OBJECTIVE

The purpose of this study was to examine ethnicity-based differences in the time-to-treatment-seeking intervals of patients experiencing symptoms of acute coronary syndrome.

METHOD

Data for this descriptive study were collected for the larger Acute Coronary Syndrome Care in Emergency Departments (ASCEND) study. The larger study is a prospective, observational study in which patients presenting to hospital emergency departments and triaged as having symptoms suggestive of acute coronary syndrome are identified. The primary outcome of this study, the time-to-treatment-seeking interval, was defined as the time between symptom onset and treatment seeking. The predictor variable, ethnicity, was measured with self-reported data and categorised as Chinese, South Asian, or 'Other' ethnic group. Participants in the 'Other' ethnic group were predominantly of European ancestry. Univariate and multivariate analyses were undertaken, along with nonparametric testing.

RESULTS

The study sample consisted of 419 participants: 36 Chinese, 126 South Asian, and 257 'Other' participants. The median time-to-treatment-seeking interval, for the total sample, was 180 minutes. A Kruskal-Wallis test demonstrated no statistically significant differences in the time-to-treatment-seeking intervals by ethnicity.

CONCLUSION

No ethnicity-based differences in the time-to-treatment-seeking intervals for symptoms of acute coronary syndrome were found. It is possible that Chinese and South Asian patients living in western countries are more aware of the potential signs and symptoms of acute coronary syndrome or feel more confident to access healthcare services than they have been previously.