FIGURE 1 - uploaded by Xingyu Zhang
Content may be subject to copyright.
| Racial/Ethnic-Specific ED health outcome and medical resource utilization rate from 2005 to 2016: NHAMCS 2005-2016. *Predicted rate were derived from a model using data over the time period, modeling time as a linear trend. Age, gender, and health insurance type were adjusted.

| Racial/Ethnic-Specific ED health outcome and medical resource utilization rate from 2005 to 2016: NHAMCS 2005-2016. *Predicted rate were derived from a model using data over the time period, modeling time as a linear trend. Age, gender, and health insurance type were adjusted.

Source publication
Article
Full-text available
Importance: While the literature documenting health disparities has advanced in recent decades, less is known about the pattern of racial/ethnic disparities in emergency care in the United States. Objective: To describe the trends and differences of health outcomes and resource utilization among racial/ethnic groups in US emergency care for adult p...

Contexts in source publication

Context 1
... adjusting for other covariates, waiting times in the ED were significantly longer for all minorities (p < 0.001) as compared to white patients ( Table 4). Figure 1 displays trends of different health outcome and resource utilization variables over time (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016) by racial/ethnic group. Table 5 includes the estimated health outcome and resource utilization rates and changes over time. ...
Context 2
... adjusting for other covariates, waiting times in the ED were significantly longer for all minorities (p < 0.001) as compared to white patients ( Table 4). Figure 1 displays trends of different health outcome and resource utilization variables over time (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016) by racial/ethnic group. Table 5 includes the estimated health outcome and resource utilization rates and changes over time. ...

Citations

... 32 In this light, racial inequities in wait times for obstetric ED care are of serious concern, given the existing evidence linking extended wait times/delays in care with increased odds of morbidity and mortality. 25,34 Not only do prolonged wait times increase the risk that Black women's health needs are not addressed in a timely and equitable manner, but they also increase the risk that women will leave the ED prior to receiving care. 27 When women do not receive care related to their presenting complaints, women's perinatal health issues may go undetected and unaddressed. ...
Article
Full-text available
Objective Emergency department care is common among US pregnant women. Given the increased likelihood of serious and life-threatening pregnancy-related health conditions among Black mothers, timeliness of emergency department care is vital. The objective of this study was to evaluate racial/ethnic variations in emergency department wait times for receiving obstetrical care among a nationally representative population. Methods The study used pooled 2016–2018 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of emergency department visits. Regression models were estimated to determine whether emergency department wait time was associated with the race/ethnicity of the perinatal patient. Adjusted models controlled for age, obesity status, insurance type, whether the patient arrived by ambulance, triage status, presence of a patient dashboard, and region. Results There were a total of 821 reported pregnancy-related visits in the National Hospital Ambulatory Medical Care Survey sample of emergency department visits. Of those 821 visits, 40.6% were among White women, 27.7% among Black women, and 27.5% among Hispanic women. Mean wait times differed substantially by race/ethnicity. After adjusting for potential confounders, Black women waited 46% longer than White women with emergency department visits for pregnancy problems (p < .05). Those reporting another race waited 95% longer for pregnancy problems in the emergency department than White women (p < .05). Conclusion Findings from this study document significant racial/ethnic differences in wait times for perinatal emergency department care. Although inequities in wait times may emerge across the spectrum of care, documenting the factors influencing racial disparities in wait times are critical to promoting equitable perinatal health outcomes.
... There were no statistically significant differences between Black and White PEH in regard to achieving post-program outcomes (Table 5). (Zhang et al., 2020), less likely to be admitted to the hospital (Zhang et al., 2020), less likely to have diagnostic imaging ordered in EDs (Ross et al., 2020), and more likely to die in the ED or hospital (Ross et al., 2020 (Spector et al., 2020). Additionally, residence in permanent housing may reduce the perception of being discriminated against due to being homeless and poor (Wenzel et al., 2019) in addition to being a Black person. ...
... There were no statistically significant differences between Black and White PEH in regard to achieving post-program outcomes (Table 5). (Zhang et al., 2020), less likely to be admitted to the hospital (Zhang et al., 2020), less likely to have diagnostic imaging ordered in EDs (Ross et al., 2020), and more likely to die in the ED or hospital (Ross et al., 2020 (Spector et al., 2020). Additionally, residence in permanent housing may reduce the perception of being discriminated against due to being homeless and poor (Wenzel et al., 2019) in addition to being a Black person. ...
Article
Full-text available
Objective: This study explored race-based differences in disease burden, health care utilization, and mortality for Black and White persons experiencing homelessness (PEH) who were referred to a transitional care program, and health care utilization and program outcomes for program participants. Design: This was a quantitative program evaluation. Sample: Black and White PEH referred to a transitional care program (n = 450). We also analyzed data from the subgroup of program participants (N = 122). Of the 450 referrals, 122 participants enrolled in the program. Measures: We included chronic disease burden, mental illness, substance use, health care utilization, and mortality rates for all PEH referred. For program participants, we added 6-month pre/post health care utilization and program outcomes. All results were dichotomized by race. Results: Black PEH who were referred to the program had higher rates of hypertension, diabetes, renal failure, and HIV and similar post-referral mortality rates compared to White PEH. Black and White PEH exhibited similar program outcomes; however, Black PEH revisited the emergency department (ED) less frequently than White PEH at 30 and 90 days after participating in the program. Conclusions: Health care utilization may be a misleading indicator of medical complexity and morbidity among Black PEH. Interventions that rely on health care utilization as an outcome measure may unintentionally contribute to racial disparities.
... For example, Black and low SES patients are more likely to visit the Emergency Department (ED) for routine care and non-urgent reasons. 79 The difference in number and severity of ED visits may affect a model's analysis of risk across groups. Moreover, each model relies on diagnoses, clinical severity, and comorbidities. ...
Article
Full-text available
Objective Health care providers increasingly rely upon predictive algorithms when making important treatment decisions, however, evidence indicates that these tools can lead to inequitable outcomes across racial and socio-economic groups. In this study, we introduce a bias evaluation checklist that allows model developers and health care providers a means to systematically appraise a model’s potential to introduce bias. Materials and Methods Our methods include developing a bias evaluation checklist, a scoping literature review to identify 30-day hospital readmission prediction models, and assessing the selected models using the checklist. Results We selected 4 models for evaluation: LACE, HOSPITAL, Johns Hopkins ACG, and HATRIX. Our assessment identified critical ways in which these algorithms can perpetuate health care inequalities. We found that LACE and HOSPITAL have the greatest potential for introducing bias, Johns Hopkins ACG has the most areas of uncertainty, and HATRIX has the fewest causes for concern. Discussion Our approach gives model developers and health care providers a practical and systematic method for evaluating bias in predictive models. Traditional bias identification methods do not elucidate sources of bias and are thus insufficient for mitigation efforts. With our checklist, bias can be addressed and eliminated before a model is fully developed or deployed. Conclusion The potential for algorithms to perpetuate biased outcomes is not isolated to readmission prediction models; rather, we believe our results have implications for predictive models across health care. We offer a systematic method for evaluating potential bias with sufficient flexibility to be utilized across models and applications.
... It is well-documented that Black individuals are more likely to visit the ED for nonurgent reasons and to rely on the ED for routine care compared to White individuals. [16][17][18][19] A study examining ED use before COVID-19 using data from the National Hospital Ambulatory Medical Care Survey 16 found that Black patients were more likely than White patients to visit the ED for nonemergent conditions whereas Hispanic patients were more likely than White patients to have emergent conditions. Black patients were less likely than White patients to be admitted to the hospital from the ED, whereas there was no difference in hospital admission or in ICU admission between Hispanic and White patients seen in the ED. ...
... The majority of the patients presenting to the ED were Black (40.1%) or Hispanic (43.8%) and16.1% of the patients were White(Table 1). White patients were older: 46.3% were ≥ 65 compared with 18.5% of Hispanic and 22.7% of Black patients. ...
Article
Background: Several studies have found that among patients testing positive for COVID-19 within a health care system, non-Hispanic Black and Hispanic patients are more likely than non-Hispanic White patients to be hospitalized. However, previous studies have looked at odds of being admitted using all positive tests in the system and not only those seeking care in the emergency department (ED). Objective: This study examined racial/ethnic differences in COVID-19 hospitalizations and intensive care unit (ICU) admissions among patients seeking care for COVID-19 in the ED. Research design: Electronic health records (n=7549) were collected from COVID-19 confirmed patients that visited an ED of an urban health care system in the Chicago area between March 2020 and February 2021. Results: After adjusting for possible confounders, White patients had 2.2 times the odds of being admitted to the hospital and 1.5 times the odds of being admitted to the ICU than Black patients. There were no observed differences between White and Hispanic patients. Conclusions: White patients were more likely than Black patients to be hospitalized after presenting to the ED with COVID-19 and more likely to be admitted directly to the ICU. This finding may be due to racial/ethnic differences in severity of disease upon ED presentation, racial and ethnic differences in access to COVID-19 primary care and/or implicit bias impacting clinical decision-making.
... 20,21 Lack of insurance can drive patients, notably ethnic minorities, to be treated in emergency rooms rather than private offices. 22 Further exacerbating the lack of access, Hispanic patients often face language barriers, low education rates, and a lack of providers with similar cultural and ethnic backgrounds. 23 In addition, cancer screening is more deficient in minority patients, possibly due to insurance as even Medicaid screening coverage varies by state and does not guarantee lung cancer screening. ...
... Medicaid does not guarantee lung cancer screenings, 20 and patients with Medicaid are often barred from primary care physician offices because of decreased reimbursement, moving patients towards emergency rooms and hospitals for treatment. 22,24,25 The lack of screening has been implied in our study as most patients had higher severity of illness, demonstrating a lack of early screening and prevention. The increased cost for Hispanic patients seen in the current study may reflect increased emergency room visits, ICU stays, inpatient treatment, and aggressive chemotherapy treatmenttrends more commonly seen in minority patients. ...
... The increased cost for Hispanic patients seen in the current study may reflect increased emergency room visits, ICU stays, inpatient treatment, and aggressive chemotherapy treatmenttrends more commonly seen in minority patients. 8,9,22 Length of stay between Hispanic and non-Hispanic lung cancer patients had a minor variation; however, Hispanic patients across the study period did have a greater length of stay in hospitals. Furthermore, increased length of stay may also be connected to increased hospital use. ...
Article
Full-text available
Purpose: There is a lack of research focused on understanding the differences in the healthcare utilization of lung cancer patients between ethnic groups. This study aims to characterize disparities in healthcare utilization for Hispanic lung cancer patients compared to non-Hispanic patients. Methods: National Inpatient Sample was used to identify nationwide lung cancer patients (n=141,675, weighted n=702,878) from 2010 to 2014. We examined the characteristics of the study sample by race (Hispanic vs non-Hispanic) and its association with healthcare utilization, measured by discounted hospital charges and length of stay. Multivariate survey regression models were used to identify predictors by racial groups. Results: Among 702,878 lung cancer patients, 5.1% were Hispanic. Descriptive statistics showed that Hispanics have higher hospital charges and length of stay. Survey regression results also suggested that Hispanic lung cancer patients were associated with higher hospital charges (26.6%) and length of stay (3.5%) than non-Hispanic lung cancer patients. Subgroup analysis displayed a similar trend to the full model. Conclusion: Healthcare utilization disparities may exist for lung cancer Hispanic patients due to insurance status and early detection. Thus, our findings support providing financial assistance and targeted programs for minority patients. Future health policy consideration should be given to those vulnerable populations where limited healthcare resources are available.
... Pertinent research evidence has confirmed the differences in primary care physician (PCP) referrals, emergency department (ED) care, and hypertension medication adherence across race and ethnic groups. [14][15][16] A current knowledge gap exists regarding how health maintenance and socioeconomic factors affect the presentation and short-term outcomes of TBAD. ...
Article
Objective Racial disparities in cardiovascular risk factors and disease outcomes are well documented. A knowledge gap exists on the role health maintenance plays in the development and outcomes of type B aortic dissection (TBAD). This study aims to evaluate the comparative presentation and short-term outcomes of patients with TBAD across race. Methods In this single center retrospective study, TBAD patients admitted to the intensive care unit (ICU) were identified from 2015 to 2020. Patients self-identified as Black (N= 57) and White (N=123) were included. Groups were compared on variables including demographics, socioeconomic, pre-event health maintenance. Socioeconomic disadvantage was quantified based on The Area Deprivation Index (ADI). Management strategies included nonoperative and surgical repair. Outcomes were 30-day mortality, length of stay (LOS), and Acute Physiology and Chronic Health Evaluation (APACHE II) score. Results The study included 180 consecutive patients with TBAD. TBAD included complicated (n= 42) and uncomplicated (n=138), of which (n=79) had high risk features. Blacks were younger than Whites (58.9 vs 67.6; p< 0.01), more likely to have end stage renal disease (ESRD) (8.8% vs 0.8%; p= 0.01) and to present with anemia (10.5% vs 2.4%; p=0.03). TBAD anatomic features and management were similar in both groups. Surgical intervention during hospitalization was 40% and 46% in Blacks and Whites, respectively (p= 0.4). Black patients were more likely to be on 3 or more hypertension agents, (42.2% vs 16.4%; p= 0.005) and less likely to be adherent to prescribed agents (27.1% vs 6.7%; p<0.001). Black patients had fewer primary care physician (PCP) visits prior to TBAD event (p= 0.03) and more Emergency Department (ED) utilization prior to TBAD, (57.9% vs 26.9% ;p < 0.001). Black patients had higher ADI scores, 86.0 ± 14.6 vs 64.4 ± 21.3 (p < 0.001). Median [IQR] APACHE II score was the same in both Blacks and Whites, 9[6, 12] and 9[7, 13] respectively (p=0.7). Hospital median LOS (days) was identical in both groups 7 [5, 13]. Readmission was 24.5% in Blacks vs 15.5% in Whites (p=0.16) with a 30-day mortality similar in Blacks 7.0% vs 5.7% Whites (p= 0.7). Conclusion Black patients present younger with similar dissection morphology, rate of anatomic high risk features and APACHE II scores. Fewer PCP visits, greater ED utilization, and higher ADI suggest lower health maintenance in Black patients. White patients with TBAD were also highly deprived of health maintenance compared to the national percentile, indicating that TBAD is a disease that affects vulnerable populations regardless of race.
... This may be attributed to racial and ethnic minority groups managing more chronic health conditions than non-Latino adults. Specifically, national data shows that African American patients received lower triage scores and higher mortality rates [25]. Another study focused on structural and geographic determinants of ED use in California showed that high rates of ED visits are associated with less access to primary health care [26]. ...
Article
Full-text available
Objectives This study uses a theoretical model to explore (a) emergency department (ED) utilization, (b) hospital admissions, and (c) office-based physician visits among sample of under-resourced African American and Latino older adults. Methods Nine hundred five African American and Latino older adults from an under-resourced urban community of South Los Angeles participated in this study. Data was collected using face-to-face interviews. Poisson and logistic regression analysis were used to estimate the parameters specified in the Andersen behavioral model. Predictors included predisposing factors, defined as demographic and other personal characteristics that influence the likelihood of obtaining care, and enabling factors defined as personal, family, and community resources that support or encourage efforts to access health services. Results African American older adults have a greater frequency of hospital admissions, ED, and physician visits than their Latino counterparts. About 25%, 45%, and 59% of the variance of the hospital admissions, ED utilization, and physician visits could be explained by predisposing and enabling characteristics. Lower health-related quality of life was associated with a higher number of hospital admissions, ED, and physician visits. Financial strain and difficulty accessing medical care were associated with a higher number of hospital admissions. Being covered by Medicare and particularly Medi-Cal were positively associated with higher hospital admissions, ED, and physician visits. Discussion Compared to African American older adults, Latino older adults show higher utilization of (a) emergency department (ED) utilization, (b) hospital admissions, and (c) office-based physician visits. A wide range of predisposing and enabling factors such as insurance and financial difficulties correlate with some but not other types of health care use. Multi-disciplinary, culturally sensitive, clinic- and community-based interventions are needed to address enabling and predisposing factors that influence ED utilization and hospital admission among African American and Latino older adults in under-resourced communities.
... The aforementioned lower access to health care due to multiple factors such as household income, health insurance, and distance from emergency services, may have contributed to the underutilization of emergency care for asthma exacerbations. Racial/ ethnic minorities were also found to receive lower triage scores in the ED, which may have resulted in underreporting of asthma as the primary diagnosis (Baker et al. 1996;Hong et al. 2007;Zook et al. 2016;Zhang et al. 2020). There may also be cultural reasons for the differences noted in this study, particularly for Hispanic and Asian populations. ...
Article
Full-text available
Gentrification is associated with factors that negatively impact health outcomes among low-income households, but few studies have explored its correlation with disease rates. In this study, we assess the relationship between increased levels of gentrification and the rate ratio of asthma exacerbations in nine counties within the San Francisco Bay Area. We conducted an ecological study of gentrification levels and asthma exacerbations in nine San Francisco Bay Area counties. Measures of gentrification were calculated with the Freeman, et al. method, using data from the 2006–2015 American Community Survey to classify median income and educational attainment per census tract. The census tract-level population-level age-adjusted rate of emergency department (ED) visits for asthma was obtained from the CalEnvironScreen 3.0. The association between gentrification levels and asthma exacerbations was modeled with population weighted log-linear regression. An adjusted model with potential confounding variables from the CalEnviroScreen 3.0 were added to the adjusted model, including the percentage of adults with less than high school education (labeled as educational attainment), traffic emissions, particulate matter (PM 2.5), toxic factory emissions, diesel exhaust emissions, and pollution burden. The unadjusted rate ratio of ED visits for asthma when comparing gentrifying to stable neighborhoods was 1.29 (95% CI 1.27–1.31, p < 0.001) for the aggregate of all nine San Francisco Bay Area counties. After adjustment for educational attainment and five pollution measures, the rate ratio was 1.15 (95% CI 1.13–1.17, p < 0.001). Tests for effect modification between percentage racial composition and levels of gentrification found that gentrifying census tracts with higher racial segregation for Blacks, Hispanics, and Asians had lower adjusted rate ratios of ED visits for asthma (Blacks: 0.97, 95% CI 0.83–1.13, p = 0.7, Hispanics: 0.84, 95% CI 0.81–0.88, p < 0.001, Asians: 0.86, 95% CI 0.81–0.9, p < 0.001). Living in a gentrifying neighborhood was associated with an increased rate ratio of asthma in the nine county San Francisco Bay Area. Our results were consistent with prior studies suggesting a differential effect of gentrification on health outcomes by racial composition in the neighborhood. However, it is unclear whether this is a reflection of an increased risk of asthma at the population level, increased asthma diagnosis due to the availability of resources in a gentrifying area, or an unmeasured factor in the population.
... 11 Disparities in health care access and outcomes based on race and ethnicity, sex, and socioeconomic status exist within the US health care system. 12,13 In a nationally representative study, Zhang et al 14 found that patients who were Black were 10% less likely to be admitted to the hospital from the ED compared with patients who were White. The extent to which differences in care reflect individually mediated clinician bias, whether conscious or not, is challenging to quantify and is often considered as a residual explanation after controlling for observable clinical factors and other patient differences attributable to structural factors, such as differences in health insurance. ...
Article
Full-text available
Importance Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups. Objective To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment. Design, Setting, and Participants This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities. Main Outcomes and Measures Admission from the ED. Results The analysis included 4 567 760 ED visits involving 2 334 361 beneficiaries and 15 767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2 700 661 visits (59.1%) were by women, and most patients (3 839 055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98). Conclusions and Relevance This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician’s propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients.
... 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.