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Researchers examine racial and ethnic disparities in emergency care

The Institute of Medicine's (IOM's) landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, documents the extent of racial and ethnic disparities in the U.S. health care delivery system and offers recommendations to address them. Several recent studies have described disparities in emergency care. They reveal, for example, poorer pain management among racial and ethnic minorities compared with whites seen in the emergency department (ED). Among children with asthma seen in the ED, African American urban children receive less treatment according to nationally recognized guidelines than white children.

Prompted by the IOM report, the journal Academic Emergency Medicine convened a Consensus Conference on Disparities in Emergency Health Care on May 28, 2003. The Agency for Healthcare Research and Quality provided support for the conference (HS14030). An executive summary and seven papers presented at the conference are included in a special section of the November 2003 issue of Academic Emergency Medicine 10(11). The papers are summarized here.

Biros, M.H., Adams, J.G., and Cone, D.C. "Executive summary: Disparities in emergency health care," pp. 1153-1154.

In this executive summary, the authors describe the conference goal and objectives and explain the various sessions that took place at the conference.

Cohen, J.J. "Disparities in health care: An overview," p. 1155-1160.

The most important predictor of quality of health care across all racial and ethnic groups is access to care, especially insurance status and the ability to pay for health care. Two groups emerge with differing qualities of health care: nonminority and minority populations. When researchers control for the stage of disease at presentation, coexisting illnesses, severity of illness, and other variables, substantial differences in health care based on race and ethnicity can still be found. Raising the consciousness about this issue is an important step toward recognizing and eliminating health care disparities, according to the author.

Connor, R.E., and Haley, L. "Disparities in emergency department health care: Systems and administration," pp. 1193-1198.

This paper summarizes the conference proceedings. The goals of the conference were to examine the presence, causes, and outcomes related to health care disparities as they occur in EDs and determine the degree to which external forces have an impact on ED patients. Participants were asked to describe the means of defining, assessing, measuring, and investigating disparities that occur in emergency care.

Discussions were organized around several major questions, including:

  1. Are only the vulnerable inadequately served by the current system?
  2. Do inequities in care reflect systems limitations?
  3. What would the cost of providing equality in health care be?

Richardson, L.D., Irvin, C.B., and Tamayo-Sarver, J.H., "Racial and ethnic disparities in the clinical practice of emergency medicine," pp. 1184-1188.

The emergency department milieu, which is characterized by time pressure, incomplete information, and high demands on attention and cognitive resources, increases the likelihood that stereotypes and bias will affect diagnostic and treatment decisions, note these authors. The potential for disparate treatment includes the timing and intensity of ED therapy as well as patterns of referral, prescription choices, and priority for hospital admission and bed assignment. Several strategies to address these disparities in ED care emerged from a roundtable discussion during the Academic Emergency Medicine conference.

Increased use of evidence-based guidelines might decrease uncertainty and minimize individual physician discretion. Use of continuous quality improvement programs to monitor adherence to clinical protocols could also be used to track clinical disparities at the individual or institutional level. In addition, zero tolerance for stereotypical remarks in the workplace, cultural competency training for emergency providers, enhanced linguistic services for patients who are not fluent in English, and increased workforce diversity would go a long way toward reducing disparities in the ED, according to these authors.

Cone, D.C., Richardson, L.D., Todd, K.H., and others. "Health care disparities in emergency medicine," pp. 1176-1183.

These authors discuss two strategies that are likely to reduce care disparities in the ED: workforce diversity and cultural competency training.

First, workforce diversity is likely to result in a community of emergency physicians who are better prepared to understand, learn from, and collaborate with individuals from other racial, ethnic, and cultural backgrounds, whether these individuals are patients, fellow clinicians, or the larger medical and scientific community. Given the ethical and practical advantages of a more diverse ED workforce, continued and expanded initiatives to increase diversity within emergency medicine should be undertaken.

Second, emergency medicine educational programs need to equip emergency physicians with the skills and knowledge needed to serve an increasingly diverse population. These cultural competence skills should include an awareness of existing racial and ethnic health disparities, recognition of the risks of stereotyping and biased treatment, and knowledge of the incidence and prevalence of health conditions among diverse populations.

Hamilton, G., and Marco, C.A., "Emergency medicine education and health care disparities," pp. 1189-1192.

One means of improving health care disparities is changing the behavior and understanding of key personnel in academic health centers. These individuals influence policy and procedure, design and evaluate health systems, and define curricular standards for graduate and undergraduate medical education. The broad issue of disparities in emergency health care may be addressed in part by cultural competency education at several levels.

The authors point out several barriers to educating medical providers about disparities in health care. For example, cultural issues are rarely central to decisions about accreditation, certification, or credentialing. They suggest making cultural competency a formal element of curriculum and residency assessment and encouraging emergency medicine faculty to become more involved with the community.

Richards, C.F., and Lowe, R.A., "Researching racial and ethnic disparities in emergency medicine," pp. 1169-1175.

One of the goals of the Consensus Conference was to develop a research agenda for emergency medicine researchers working on disparities in health care. The authors of this article propose such an agenda. They call for more definitive clinical studies involving existing clinical datasets or primary data collection to more rigorously determine the extent of care disparities in emergency medicine.

They suggest that studies of ED health care disparities can be integrated into other research projects that involve large-scale primary data collection. Multicenter clinical trials of medications or other interventions could collect additional ED data that would enable researchers to examine questions about disparities. Different methods will be necessary to investigate the role of stereotypes and bias in clinical decisionmaking, patient preferences, and the differences between stated values and those manifested in the clinical encounter.

Weinick, R.M. "Researching disparities: Strategies for primary data collection," pp. 1161-1168.

Comparatively little disparities research to date has focused on emergency medicine. However, the body of disparities research developed in other areas of health care has identified a number of issues that are directly applicable. To promote research on disparities in emergency medicine, Robin M. Weinick, Ph.D., of AHRQ's Office of Performance, Accountability, Resources, and Technology, addresses several of these issues related to collecting and classifying data on race/ethnicity and socioeconomic status and selected methodologic issues that are particularly important for examining and evaluating disparities.

Reprints (AHRQ Publication No. 04-R013) are available from the AHRQ Publications Clearinghouse.

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