A Thousand Cuts: Racial and Ethnic Disparities in Emergency Medicine No abstract available

Racial/Ethnic Disparities in Pain Treatment: Evidence From Oregon Emergency Medical Services Agencies Background: Despite the critical role that Emergency Medical Services (EMS) provides in the health care system, racial/ethnic treatment disparities in EMS remain relatively unexamined. Objective: To investigate racial/ethnic treatment disparities in pain assessment and pain medication administration in EMS. Research Design: A retrospective analysis was performed on 25,732 EMS encounters from 2015 to 2017 recorded in the Oregon Emergency Medical Services Information System using multivariate logistic regression models to examine the role of patient race/ethnicity in pain assessment and pain medication administration among patients with a traumatic injury. Results: Hispanic and Asian patients were less likely to receive a pain assessment procedure and all racial/ethnic patients were less likely to receive pain medications compared with white patients. In particular, regarding the adjusted likelihood of receiving a pain assessment procedure, Hispanic patients were 21% less likely [95% confidence interval (CI), 10%–30%; P<0.001], Asian patients were 31% less likely (95% CI, 16%–43%; P<0.001) when compared with white patients. Regarding the adjusted likelihood of receiving any pain medications, black patients were 32% less likely (95% CI, 21%–42%; P<0.001), Hispanic patients were 21% less likely (95% CI, 7%–32%; P<0.01), and Asian patients were 24% less likely (95% CI, 1%–41%; P<0.05) when compared with white patients. Conclusions: Racial/ethnic minorities were more likely to experience disadvantages in EMS treatment in Oregon. Hispanic and Asian patients who requested EMS services in Oregon for traumatic injuries were less likely to have their pain assessed and all racial/ethnicity patients were less likely to be treated with pain medications when compared with white patients.

Contributors to Racial Disparities in Minimally Invasive Hysterectomy in the US Department of Veterans Affairs Background: Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women. Objective: To quantify the contributions of patient, facility, temporal and geographic factors to VA black-white disparity in minimally invasive hysterectomy. Research Design: A cross-sectional study. Subjects: Veterans with fibroids and hysterectomy performed in VA between October 1, 2012 and September 30, 2015. Measures: Hysterectomy mode was defined using ICD-9 codes as minimally invasive (laparoscopic, vaginal, or robotic-assisted) versus abdominal. The authors estimated a logistic regression model with minimally invasive hysterectomy modeled as a function of 4 sets of factors: sociodemographic characteristics other than race, health risk factors, facility, and temporal and geographic factors. Using decomposition techniques, systematically substituting each white woman’s characteristics for each black woman’s characteristics, then recalculating the predicted probability of minimally invasive hysterectomy for black women for each possible combination of factors, we quantified the contribution of each set of factors to observed disparities in minimally invasive hysterectomy. Results: Among 1255 veterans with fibroids who had a hysterectomy at a VA, 61% of black women and 39% of white women had an abdominal hysterectomy. Our models indicated there were 99 excess abdominal hysterectomies among black women. The majority (n=77) of excess abdominal hysterectomies were unexplained by measured sociodemographic factors beyond race, health risk factors, facility, and temporal or geographic trends. Conclusion: Closer examination of the equity of VA gynecology care and ways in which the VA can work to ensure equitable care for all women veterans is necessary.

Improving Shared Decision Making For Asian American Pacific Islander Sexual and Gender Minorities Background: Asian American Pacific Islander (AAPI) sexual and gender minorities (SGM) face unique challenges in mental health and accessing high-quality health care. Objective: The objective of this study was to identify barriers and facilitators for shared decision making (SDM) between AAPI SGM and providers, especially surrounding mental health. Research Design: Interviews, focus groups, and surveys. Subjects: AAPI SGM interviewees in Chicago (n=20) and San Francisco (n=20). Two focus groups (n=10) in San Francisco. Measures: Participants were asked open-ended questions about their health care experiences and how their identities impacted these encounters. Follow-up probes explored SDM and mental health. Participants were also surveyed about attitudes towards SGM disclosure and preferences about providers. Transcripts were analyzed for themes and a conceptual model was developed. Results: Our conceptual model elucidates the patient, provider, and encounter-centered factors that feed into SDM for AAPI SGM. Some participants shared the stigma of SGM identities and mental health in their AAPI families. Their AAPI and SGM identities were intertwined in affecting mental health. Some providers inappropriately controlled the visibility of the patient’s identities, ignoring or overemphasizing them. Participants varied on whether they preferred a provider of the same race, and how prominently their AAPI and/or SGM identities affected SDM. Conclusions: Providers should understand identity-specific challenges for AAPI SGM to engage in SDM. Providers should self-educate about AAPI and SGM history and intracommunity heterogeneity before the encounter, create a safe environment conducive to patient disclosure of SGM identity, and ask questions about patient priorities for the visit, pronouns, and mental health.

The Challenges Presented Around Collection of Patient Sexual Orientation and Gender Identity Information For Reduction of Health Disparities No abstract available

Association Between Geographic Measures of Socioeconomic Status and Deprivation and Major Surgical Outcomes Background: There is evidence suggesting higher rates of negative surgical outcomes for patients with lower socioeconomic status. Objective: The objective of this study was to evaluate the effects of different geographic measures of socioeconomic status and deprivation on surgical outcomes in the United States. Research Design: We extracted county-level, zip code-level, census block group-level and census tract-level measures of geographic risk. We evaluated associations between geographic area inequity and surgical outcomes using linear, logistic, and Poisson regression with generalized estimating equations to account for clustering by hospital. Subjects: Hospital discharges (n=1,573,740) after major surgery in Arizona, Florida, Iowa, Michigan, New Jersey, New York, North Carolina, and Vermont as extracted from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database between the years 2010–2012. Measures: Inpatient mortality, length of stay, hospital costs, discharge status, and 30-day all-cause readmission. Results: After adjusting for patient, hospital, and discharge factors, the odds of inpatient mortality significantly increased as geographic distress increased across all measures of geographic risk. Odds of routine discharge increased and the odds of 30-day all-cause readmission decreased with geographic distress for select measures of geographic inequity. The choice of measure generally did not affect the findings; the results did not conclusively support the use of measures from larger or smaller geographic units. Conclusions: There is a consistent, strong association between geographic indicators for socioeconomic status and distress with important surgical outcomes. Further work is needed to understand the source of these associations and to develop interventions and effective policies to address them.

Is Perceived Stigma in Clinical Settings Associated With Poor Health Status Among New York City’s Residents of Color? Objectives: Our objectives were to assess rates of perceived stigma in health care (clinical) settings reported by racially diverse New York City residents and to examine if this perceived stigma is associated with poorer physical and mental health outcomes. Methods: We analyzed data from the 2016 New York City Community Health Survey. We applied bivariable and multivariable methods to assess rates of perceived stigma, and perceived stigma’s statistical relationship with health care access, physical health status, and mental health status controlling for sociodemographics and health insurance status. Results: Perceived stigma was associated with poorer health care access [odds ratio (OR)=7.07, confidence interval (CI)=5.32–9.41), depression (OR=3.80, CI=2.66–5.43), diabetes (OR=1.86, CI=1.36–2.54), and poor overall general health (OR=0.43, CI=0.33–0.57). Hispanic respondents reported the highest rate of perceived stigma among racial and ethnic minority groups (mean=0.07, CI=0.05–0.08). Conclusions: We found that perceived stigma in health care settings was a potential barrier to good health. Prior studies have illustrated that negative health outcomes are common for patients who avoid or delay care; thus, the unfortunate conclusion is that even in a diverse, heterogeneous community, stigma persists and may negatively affect well-being. Therefore, eliminating stigma in clinical settings should be a top priority for health care providers and public health professionals seeking to improve health equity.

Relative Effects of the Hospital Readmissions Reduction Program on Hospitals That Serve Poorer Patients Importance: Hospitals that serve poorer populations have higher readmission rates. It is unknown whether these hospitals effectively lowered readmission rates in response to the Hospital Readmissions Reduction Program (HRRP). Objective: To compare pre-post differences in readmission rates among hospitals with different proportion of dual-eligible patients both generally and among the most highly penalized (ie, low performing) hospitals. Design: Retrospective cohort study using piecewise linear model with estimated hospital-level risk-standardized readmission rates (RSRRs) as the dependent variable and a change point at HRRP passage (2010). Economic burden was assessed by proportion of dual-eligibles served. Setting: Acute care hospitals within the United States. Participants: Medicare fee-for-service beneficiaries aged 65 years or older discharged alive from January 1, 2003 to November 30, 2014 with a principal discharge diagnosis of acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Main Outcome and Measure: Decrease in hospital-level RSRRs in the post-law period, after controlling for the pre-law trend. Results: For AMI, the pre-post difference between hospitals that service high and low proportion of dual-eligibles was not significant (−65 vs. −64 risk-standardized readmissions per 10000 discharges per year, P=0.0678). For CHF, RSRRs declined more at high than low dual-eligible hospitals (−79 vs. −75 risk-standardized readmissions per 10000 discharges per year, P=0.0006). For pneumonia, RSRRs declined less at high than low dual-eligible hospitals (−44 vs. −47 risk-standardized readmissions per 10000 discharges per year, P=0.0003). Among the 742 highest penalized hospitals and all conditions, the pre-post decline in rate of change of RSRRs was less for high dual-eligible hospitals than low dual-eligible hospitals (−68 vs. −74 risk-standardized readmissions per 10000 discharges per year for AMI, −88 vs. −97 for CHF, and −47 vs. −56 for pneumonia, P<0.0001 for all). Conclusions and Relevance: For all hospitals, differences in pre-post trends in RSRRs varied with disease conditions. However, for the highest-penalized hospitals, the pre-post decline in RSRRs was greater for low than high dual-eligible hospitals for all penalized conditions. These results suggest that high penalty, high dual-eligible hospitals may be less able to improve performance on readmission metrics.

Drivers of Hospital Length of Stay in Medicaid and Commercially Insured Mother-Infant Pairs With a Diagnosis of Neonatal Abstinence Syndrome Background: The occurrence of neonatal abstinence syndrome (NAS) mirrors the growing opioid epidemic in the United States. As Medicaid covers a majority of cases, the commercially insured population has largely been ignored for NAS risk. Objective: The objective of this study was to examine Medicaid and commercially insured mother-infant pairs to determine demographic and clinical characteristics associated with NAS length of stay (LOS). Research Design: This observational, descriptive case-series study utilized administrative claims from HealthCore Integrated Research Database to measure maternal characteristics for 6 months before delivery, and neonatal characteristics and health care service utilization for 3 months after NAS diagnosis. Bootstrapped regressions were used to model LOS. Results: The sample included 1807 mother-infant pairs. Most infants (79%) had Medicaid coverage (Medicaid: N=1419; Commercial: N=388). Although all infants had NAS, Medicaid-insured mothers had more prevalent drug abuse (70.8% vs. 41.0%; P<0.0001), but fewer used prescription opioids (45.3% vs. 60.8%; P<0.0001) compared with commercially insured mothers. Commercially insured infants were sicker, with a higher prevalence of complex chronic conditions, and yet Medicaid-insured infants were admitted to neonatal intensive care unit at a much higher rate (91.1% vs. 78.9%; P<0.0001). After adjustment, neonatal intensive care unit admission (+6.7 d, 95% confidence interval: 4.5–9.3) and chronic complex conditions (+5.2 d, 95% confidence interval: 3.8–6.6) contributed most to LOS. Conclusion: A re-evaluation of obstetrical management towards a focus on the history of possible opioid and substance use regardless of insurance type and demographic background might inform efforts to reduce LOS.

Persistent Disparities in Medicare’s Annual Wellness Visit Utilization Introduction: The Medicare Annual Wellness Visit (AWV) is a preventive care visit introduced in 2011 as part of the Affordable Care Act provided without cost to beneficiaries. The AWV is associated with higher preventive services utilization. Although AWV utilization increased during 2011–2013, utilization was lower among ethnoracial minority beneficiaries who may benefit the most. Objectives: To determine if AWV utilization disparities have persisted using the most recent data available. Research Design: The authors analyzed AWV utilization in 2011–2013 and 2015–2016 by beneficiary-reported race and ethnicity, adjusting for potential confounders. Subjects: Weighted sample of 78,639,501 fee-for-service Medicare beneficiaries aged 66 years and older who participated in the Medicare Current Beneficiary Survey 2011–2013 or 2015–2016. Measures: AWV utilization was identified using Medicare claims. Results: AWV utilization increased from 8.1% to 23.0% of all beneficiaries between 2011 and 2016. Compared with non-Hispanic white beneficiaries, utilization was significantly lower among non-Hispanic Black and non-Hispanic other race beneficiaries in both the minimally and fully-adjusted models. Hispanic/Latino beneficiaries had lower utilization in the minimally adjusted model, but not in the fully-adjusted model. In 2016, compared with non-Hispanic white beneficiaries, AWV utilization was 10.2 points lower for non-Hispanic black, 11.6 points lower for Hispanic/Latino, and 8.6 points lower for non-Hispanic other race beneficiaries, and these differences were attenuated after adjusting for all covariates to 6.8 points lower, 9.4 points lower, and 7.2 points lower, respectively. Conclusions: The AWV has the potential to increase the use of preventive care, improve health, and reduce ethnoracial disparities among Medicare beneficiaries, but realizing these goals will require increasing utilization by minority groups. If ethnoracial minority beneficiaries had used the AWV at the same rate as non-Hispanic white beneficiaries during the study period, then ~1.6 million additional AWVs would have been used.