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Background: There is an incomplete understanding of disparities in emergency care for children across racial and ethnic groups in the United States. In this project, we sought to investigate patterns in emergency care utilization, disposition, and resource use in children by race and ethnicity after adjusting for demographic, socioeconomic, and cli...

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... These percentages are predicted to change by 2050 to reflect an increasing percentage of children who are Hispanic, Black, Asian, and other non-Hispanic races [24]. Investigating and addressing racial and ethnic health disparities is crucial to continue providing the highest quality of pediatric care to all patients [25]. This analysis of the association between race and outcomes following open treatment of femoral shaft fractures found that pediatric patients from the URM cohort had an increased length of hospital stay but did not have any significant differences in 30-day postoperative complications when compared to patients who were White. ...
Article
Introduction Femoral shaft fractures are a common pediatric injury that can require non-operative or operative management. Several studies have shown that race impacts pain management and a number of emergency department visits in the pediatric femur fracture population. This study aimed to investigate any association between pediatric patient race and number of comorbidities, 30-day postoperative outcomes, and length of stay following open surgical treatment of femoral shaft fractures. Methods Pediatric patients who underwent open treatment of femoral shaft fracture were identified in the National Surgical Quality Improvement Program-Pediatric database from 2012-2019. Patients were categorized into two cohorts: White and underrepresented minority (URM). URM groups included Black or African American, Hispanic, Native American or Alaskan, and Native Hawaiian or Pacific Islander. Demographics, comorbidities, and postoperative complications were compared using bivariate and multivariable regression analyses. Results Of the 5,284 pediatric patients who underwent open treatment of femoral shaft fracture, 3,650 (69.1%) were White, and 1,634 (30.9%) were URM. Compared to White patients, URM patients were more likely to have a higher American Society of Anesthesiologists score (p=0.012), more likely to have pulmonary comorbidities (p=0.005), require preoperative blood transfusion (p=0.006), and have an increased risk of prolonged hospital stay (OR 2.36; p=0.007). Conclusion Pediatric URM patients undergoing open treatment of femoral shaft fractures have an increased risk of extended hospital stay postoperatively compared to White patients. As the racial and ethnic constitution of the pediatric population changes, understanding racial and ethnic health disparities will be crucial to providing equitable care to all patients.
... Optimal disposition of ED visits and referral for follow-up medical care are shared interests of patients, government officials, and health insurance companies because of population growth, hospital readmissions, maximizing clinical care, racial/ethnic disparities in care and outcomes, and ED overcrowding. 16,[18][19][20][21] We describe characteristics of patients and ED visits that result in referral for follow-up medical care in a nationally representative sample of ED visits by age group, sex, race/ethnicity, US geographic region, insurance payment type, and diagnosis, and we highlight inequalities by population group. ...
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Objective To describe characteristics of a nationally representative sample of patient visits that ended with a referral for follow-up medical care after discharge from hospital emergency department (ED) visits. Methods We used 2018 National Hospital Ambulatory Medical Care Survey data to identify patient characteristics associated with higher rates of visits with referrals for follow-up medical care after ED discharge from nonfederal short-stay and general hospitals throughout the United States. Referral included categories of all disposition variables that indicated referral to a source of care consistent with the patient’s clinical condition at ED discharge. Results Approximately 97 million of 130 million visits (29 700/100 000 US resident population) were referred for follow-up medical care during 2018. Visit referral rates were higher among females (33 100) than among males (26 300/100 000 population); higher among Black patients (61 700) than among White patients (25 600/100 000 population); highest in the South (33 200/100 000 population); and similar rates in Nonmetropolitan (29 900/100 000 population) and Metropolitan Statistical Areas (30 200/100 000 population). Visit referral rates were higher for patients with Medicaid/Children's Health Insurance Program (CHIP) (66 900) than those with Medicare (31 500) or private insurance (14 000/100 000 population). Abnormal clinical findings and injuries were the discharge diagnoses most often referred for follow-up medical care. Conclusion Higher visit referral rates were observed among female sex, non-Hispanic Black race, Medicaid/CHIP, abnormal clinical findings, and injuries. Future studies might reveal reasons that prompted higher referral rates among various patients’ characteristics.
... Previous research has also found that Asian/Native Hawaiian/Pacific Islander children did not appear to experience racial disparities in emergency care or health conditions. In a study of US children receiving ED care, Black and Hispanic children were found to experience multiple emergency care disparities when compared with White children but Asian children were not (Zhang et al., 2019). In a large study of racial/ethnic disparities of child health, Asian children reported rates of autism similar to other race/ethnic groups, but reported the least number of adverse health conditions in contrast to Black children who reported the highest prevalence (Mehta et al., 2013). ...
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Using the 2008–2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58–0.66]) and IDD waivers (0.65; [0.64–0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.
... The evidence over an extended period suggests that Black and Hispanic patients waited significantly longer than their White counterparts before having access to the emergency practitioner. [2][3][4][5][6][7][8][9][10][11][12][13] One study estimated that the time from arrival to first treatment of clogged arteries using balloon therapy was significantly longer for Black and Hispanic patients compared with White patients. The difference was evident even after controlling for several variables known to impact patient wait time. 2 Lopez et al 3 also previously found that Black and Hispanic patients presenting to the emergency department (ED) with chest pain were less likely to receive more basic cardiac testing and be offered treatment promptly compared with Whites. ...
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Background: Previous data over an extended period indicated that Black and Hispanic patients waited significantly longer than their White counterparts to see a qualified practitioner in US emergency departments (EDs). Objective: The objective of this study was to assess recent trends and sources of racial and ethnic disparities in patient wait time to see a qualified practitioner in US EDs. Data sources: Publicly available ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2003-2017. Research design: A retrospective cross-sectional analysis of a nationally representative sample of visits to US EDs from 2003 to 2017. Joinpoint statistical analysis and survey-weighted regression were used to assess changes in ED wait time by race/ethnic group over time. Principal findings: For non-Hispanic White patients, median ED wait time increased annually by 1.3 minutes from 2003 through 2008, decreased by 3.0 minutes from 2008 through 2012, and decreased by 1.7 minutes from 2012 to 2017. For non-Hispanic Black patients, median wait time increased annually by 2.0 minutes from 2003 through 2008, decreased by 3.8 minutes from 2008 through 2015, and remained fairly unchanged from 2015 through 2017. For Hispanic patients, the trend in median wait time remained statistically unchanged from 2003 through 2009. It decreased by annually by 4.7 minutes from 2009 to 2012 and by 1.5 minutes from 2012 through 2017. By the end of 2017, median ED wait time decreased to under 20 minutes across all 3 groups. Conclusions: Over time, ED wait times decreased to under 20 minutes across all racial and ethnic groups between 2003 and 2017. Observed disparities were largely the result of where minority populations accessed care and disappeared over time.
... [7][8][9][24][25][26] Studies are underway to identify potentially modifiable factors associated with the disproportionate impact of SARS-CoV-2 on these populations, such as biologic drivers of illness or markers of health disparity in disadvantaged populations like poverty, chronic stress, nutritional status, obesity, chronic conditions, decreased access to health care, and household crowding. [27][28][29][30][31][32][33] Our results showing disproportionate COVID-19 infection in children highlight the need for efforts to increase diagnostic testing that addresses diverse and often community-specific logistical, cultural, and language barriers to testing experienced by members of communities at the greatest risk. 34,35 Our study is strengthened by its large number of children across a wide range of age groups and racial/ethnic groups and the fact that it includes data from a long period of time in a heavily impacted state. ...
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The novel coronavirus SARS-CoV-2 (COVID-19) has infected people across the world, including an increasing number of children in the United States (U.S.). The epidemiology of pediatric infection in the U.S. and how it influences clinical outcomes is still being characterized. In this study, we describe a cohort of 989 children with laboratory-confirmed SARS-CoV-2 infection. Children under age 20 in a statewide health system with SARS-CoV-2 infection, defined by positive PCR testing, between February 1 and August 30, 2020 were included in this observational cohort study. Data extracted from the medical record included age, demographic information, clinical illness severity, hospital stay, and comorbidities. Analysis included descriptive statistics and Chi-square as appropriate. Nine hundred and eighty-children met inclusion criteria for this study, ranging from 1 month to 20 years in age. Most children (62.4%) were asymptomatic at the time of diagnosis and children over the age of 2 were significantly more likely to be asymptomatic at diagnosis than younger children ( P < .05). Hispanic children were significantly more likely to be symptomatic at the time of diagnosis (56.3% asymptomatic; P < .05). The high proportion of children with asymptomatic infection emphasizes the importance of understanding the unique role of children in the pandemic. Older children are more likely to be asymptomatic, but also more likely to experience severe or critical illness when symptoms do develop. Hispanic children were more likely to be symptomatic at diagnosis, highlighting the importance of culturally specific outreach to vulnerable communities.
... 6 These groups historically experience decreased access to healthcare overall, even prior to the impact of COVID-19. [21][22][23] We demonstrate that initially Hispanics did not present to the ED for care at the same rate as White populations. We conjecture that this could have been due to a range of factors, including language barriers, lack of insurance, and misinformation about disease course. ...
Article
Introduction: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. Methods: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. Results: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. Conclusion: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.
... Moreover, modern day experiences of discrimination and institutionalized racism continue to cause and perpetuate experiences of medical mistrust among communities of color [21][22][23][24]. Prior research has shown patients of color are less likely to be admitted to the hospital after an emergency department visit [25,26], classified as an immediate/ urgent case [25,26], and treated for pain [27,28]. Additionally, studies have demonstrated that physician implicit bias impacts clinic decision-making [29,30]. ...
... Moreover, modern day experiences of discrimination and institutionalized racism continue to cause and perpetuate experiences of medical mistrust among communities of color [21][22][23][24]. Prior research has shown patients of color are less likely to be admitted to the hospital after an emergency department visit [25,26], classified as an immediate/ urgent case [25,26], and treated for pain [27,28]. Additionally, studies have demonstrated that physician implicit bias impacts clinic decision-making [29,30]. ...
Article
The COVID-19 pandemic has disproportionately impacted communities of color and highlighted longstanding racial health inequities. Communities of color also report higher rates of medical mistrust driven by histories of medical mistreatment and continued experiences of discrimination and systemic racism. Medical mistrust may exacerbate COVID-19 disparities. This study utilizes the Behavior Model for Vulnerable Populations to investigate predictors of medical mistrust during the COVID-19 pandemic among urban youth of color. Minority youth (N = 105) were recruited from community organizations in Kansas City, Missouri to complete an online survey between May and June 2020. Multiple linear regressions were performed to estimate the effect of personal characteristics, family and community resources, and COVID-19 need-based factors on medical mistrust. Results indicated that loneliness, financial insecurity (e.g., job loss, loss of income) due to the COVID-19 pandemic, and eligibility for free or reduced lunch predicted medical mistrust. Insurance status, neighborhood median household income, social support, and perceived COVID-19 risk were not significantly associated with medical mistrust. Future research and policies are necessary to address systemic factors that perpetuate medical mistrust among youth of color.
... (Tables 1 to 3). The link between nonwhite race/ethnicity and lower imaging 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 utilization is not uniform, with one study reporting that Hispanic patients had higher odds of undergoing CT and another finding that nonwhite patients were less likely to undergo radiography or CT but more likely to undergo ultrasound or MRI [32,35]. Effect sizes varied greatly among studies reporting associations, with adjusted odds ratios of minority patients' undergoing imaging ranging from 0.21 to as high as 0.92, with single-institution and smaller sample studies reporting the largest differences [35,36]. ...
... The link between nonwhite race/ethnicity and lower imaging 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 utilization is not uniform, with one study reporting that Hispanic patients had higher odds of undergoing CT and another finding that nonwhite patients were less likely to undergo radiography or CT but more likely to undergo ultrasound or MRI [32,35]. Effect sizes varied greatly among studies reporting associations, with adjusted odds ratios of minority patients' undergoing imaging ranging from 0.21 to as high as 0.92, with single-institution and smaller sample studies reporting the largest differences [35,36]. Among studies reporting significant associations, effect sizes were generally small or medium, most (25 of 30 [83.3%]) studies determining adjusted odds ratios between 0.5 and 0.9, indicating that black, African American, Hispanic, or nonwhite patients were about 10% to 50% less likely to undergo diagnostic imaging. ...
... There are many factors that can explain differences in imaging utilization by anatomy, pathophysiology, or adult versus pediatric populations, including but not restricted to the use of algorithms and standardized protocols for presentations such as stroke and trauma and known differences in physician prescription of imaging by age group [59,60]. There were also potential differences by modality, with several studies reporting lower utilization of radiography and CT, but no difference or opposite associations with ultrasound [22,35,54]. Nonetheless, the overall body of evidence suggests an association between nonwhite race/ethnicity and lower likelihood of undergoing diagnostic imaging, independent of confounders such as measures of disease severity and insurance status. ...
Article
Purpose Diagnostic imaging often is a critical contributor to clinical decision making in the emergency department (ED). Racial and ethnic disparities are widely reported in many aspects of health care, and several recent studies have reported a link between patient race/ethnicity and receipt of imaging in the ED. Methods The authors conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching three databases (PubMed, Embase, and the Cochrane Library) through July 2020 using keywords related to diagnostic imaging, race/ethnicity, and the ED setting, including both adult and pediatric populations and excluding studies that did not control for the important confounders of disease severity and insurance status. Results The search strategy identified 7,313 articles, of which 5,668 underwent title and abstract screening and 238 full-text review, leaving 42 articles meeting the inclusion criteria. Studies were predominately conducted in the United States (41), split between adult (13) and pediatric (17) populations or both (12), and spread across a variety of topics, mostly focusing on specific anatomic regions or disease processes. Most studies (30 of 42 [71.4%]) reported an association between black, African American, Hispanic, or nonwhite race/ethnicity and decreased receipt of imaging. Conclusions Despite heterogeneity among studies, patient race/ethnicity is linked with receipt of diagnostic imaging in the ED. The strength and directionality of this association may differ by specific subpopulation and disease process, and more efforts to understand potential underlying factors are needed.
Article
Background Concussions affect millions of youths in the United States each year, and there is concern about long-term health effects from this injury. Purpose To examine the association between sports- or physical activity–related concussion and health risk behaviors among middle and high school students in 9 states. Study Design Cross-sectional study; Level of evidence, 3. Methods Data from the 2019 middle school and high school Youth Risk Behavior Survey were used for this analysis. Nine states were identified that included the same question on concussion and similar questions on health risk behaviors in their 2019 Youth Risk Behavior Survey. Students were asked to self-report whether they had ≥1 sports- or physical activity–related concussions during the 12 months preceding the survey. Self-reported concussion was the primary outcome of interest. Other variables included sex, race/ethnicity, played on a sports team, were physically active 5 or more days/week, ever tried cigarette smoking, ever used an electronic vapor product, academic grades, drank alcohol, were in a physical fight, seriously considered attempting suicide, made a suicide plan, and attempted suicide. Results Among the 9 states, 18.2% of middle school students and 14.3% of high school students self-reported ≥1 sports- or physical activity–related concussions. Among both middle school and high school students, the prevalence of ≥1 sports- or physical activity–related concussions was higher among students who played on a sports team, were physically active 5 or more days per week, had ever tried cigarette smoking, had ever used an electronic vapor product, had seriously considered attempting suicide, had made a suicide plan, and had attempted suicide compared with those who had not engaged in those behaviors. The prevalence of sports- or physical activity–related concussion was consistently higher among middle school students than high school students across sex, race/ethnicity, and adverse health behaviors. Conclusion Middle school students with a history of concussion warrant attention as an at-risk population for concussions and adverse health behaviors. Health care providers may consider screening students for adverse health behaviors during preparticipation examinations and concussion evaluations.