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Ethnic and Racial Disparities in Emergency Department Care for Mild Traumatic Brain Injury


Abstract and Figures

To identify racial, ethnic, and gender disparities in the emergency department (ED) care for mild traumatic brain injury (mTBI). A secondary analysis of ED visits in the National Hospital Ambulatory Medical Care Survey for the years 1998 through 2000 was performed. Cases of mTBI were identified using ICD-9 codes 800.0, 800.5, 850.9, 801.5, 803.0, 803.5, 804.0, 804.5, 850.0, 850.1, 850.5, 850.9, 854.0, and 959.01. ED care variables related to imaging, procedures, treatments, and disposition were analyzed along racial, ethnic, and gender categories. The relationship between race, ethnicity, and selected ED care variables was analyzed using multivariate logistic regression with control for associated injuries, geographic region, and insurance type. The incidence of mTBI was highest among men (590/100,000), Native Americans/Alaska Natives (1026.2/100,000), and non-Hispanics (391.1/100,000). After controlling for important confounders, Hispanics were more likely than non-Hispanics to receive a nasogastric tube (OR, 6.36; 95% CI = 1.2 to 33.6); nonwhites were more likely to receive ED care by a resident (OR, 3.09; 95% CI = 1.9 to 5.0) and less likely to be sent back to the referring physician after ED discharge (OR, 0.47; 95% CI = 0.3 to 0.9). Men and women received equivalent ED care. There are significant racial and ethnic but not gender disparities in ED care for mTBI. The causes of these disparities and the relationship between these disparities and post-mTBI outcome need to be examined.
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ACAD EMERG MED dNovember 2003, Vol. 10, No. 11 1209
Ethnic and Racial Disparities in Emergency
Department Care for Mild Traumatic Brain Injury
Yen Ting Cheng, MD, William Flesher, RN, MPH
Objectives: To identify racial, ethnic, and gender disparities
in the emergency department (ED) care for mild traumatic
brain injury (mTBI). Methods: A secondary analysis of ED
visits in the National Hospital Ambulatory Medical Care
Survey for the years 1998 through 2000 was performed.
Cases of mTBI were identified using ICD-9 codes 800.0,
800.5, 850.9, 801.5, 803.0, 803.5, 804.0, 804.5, 850.0, 850.1,
850.5, 850.9, 854.0, and 959.01. ED care variables related
to imaging, procedures, treatments, and disposition were
analyzed along racial, ethnic, and gender categories. The
relationship between race, ethnicity, and selected ED care
variables was analyzed using multivariate logistic regres-
sion with control for associated injuries, geographic region,
and insurance type. Results: The incidence of mTBI
was highest among men (590/100,000), Native Americans/
Alaska Natives (1026.2/100,000), and non-Hispanics (391.1/
100,000). After controlling for important confounders,
Hispanics were more likely than non-Hispanics to receive
a nasogastric tube (OR, 6.36; 95% CI ¼1.2 to 33.6);
nonwhites were more likely to receive ED care by a resident
(OR, 3.09; 95% CI ¼1.9 to 5.0) and less likely to be sent back
to the referring physician after ED discharge (OR, 0.47; 95%
CI ¼0.3 to 0.9). Men and women received equivalent ED
care. Conclusions: There are significant racial and ethnic
but not gender disparities in ED care for mTBI. The causes
of these disparities and the relationship between these
disparities and post-mTBI outcome need to be examined.
Key words: ethnic groups; African Americans; Hispanic
Americans; whites; minority groups; brain injuries; brain
concussion; emergency services. ACADEMIC EMER-
GENCY MEDICINE 2003; 10:1209–1217.
Over 85% of the 1.5 million traumatic brain injuries
(TBIs) that occur in the United States annually are
considered mild, which is defined as a brief loss of
consciousness or amnesia, a Glasgow Coma Scale
(GCS) score of 13–15, no skull fracture on physical
examination, and a nonfocal neurologic examina-
Most mild TBI (mTBI) patients seek initial
care in an emergency department (ED), where they
receive a variety of diagnostic tests and treatments
ranging from a brain computed tomographic (CT)
scan to ibuprofen. One of the goals of the U.S.
government’s Department of Health and Human
Services Healthy People 2010 Initiative is to eliminate
racial and ethnic disparities in health care delivered to
Americans. Although racial and ethnic disparities in
post-mTBI outcome have been reported, disparities in
ED care for this injury have not been explored.
The consequences of mTBI, which include cogni-
tive, physical, psychological, and social dysfunction
resulting in disability and unemployment
1), appear to disproportionately affect certain groups.
Compared with whites, African Americans and
Hispanics have lower levels of social functioning
and higher rates of alcohol abuse after TBI,
racial biases may confound outcome evaluation.
African Americans have a 35% higher TBI incidence
than whites
but are less likely to have appropriate
follow-up after ED discharge.
Women, who have
a lower TBI incidence than men, are more likely to
report post-concussive symptoms, although tenden-
cies toward expressive behavior and symptom report
may confound this relationship.
Despite the magnitude of this public health
problem and the disparities in outcomes, little is
known about the relationship between race/ethnicity
and the ED care mTBI patients receive. However,
racial and ethnic disparities have been reported in the
content, process, and quality of care involving other
diseases and conditions treated outside of the ED.
For example, minorities have been found to be less
likely to receive carotid artery imaging
and other
cardiovascular procedures,
less likely to receive
From the Department of Emergency Medicine, University of
Rochester Medical Center (JJB, JM); the Department of Community
and Preventive Medicine, University of Rochester (CP); the
Department of Community and Preventive Medicine, University
of Rochester, Rochester, NY (WF); and Hospital Max Peralta, San
´, Costa Rica (YTC).
Received June 13, 2003; accepted July 3, 2003.
Dr. Bazarian is supported by a Mentored Patient-Oriented Research
Career Development Award from the National Institute of
Neurological Disorders and Stroke (1K23 NS4195-02).
Presented at the Fifth World Congress on Traumatic Brain Injury,
Stockholm, Sweden, May 2003.
Address for correspondence and reprints: Jeffrey J. Bazarian, MD,
MPH, Department of Emergency Medicine, University of Rochester
Medical Center, Box 655, 601 Elmwood Avenue, Rochester, NY
14642. Fax: 585-473-3516; e-mail:
cancer screening such as mammography,
or later
receive appropriate information
or treatments for
less likely to receive analgesics for
less likely to get dialysis and kidney trans-
plant for end-stage renal disease,
and more likely to
receive extreme treatments such as cesarean delivery
in childbirth
or amputation with diabetes.
ities have also been reported for African Americans
and Hispanics in diagnosis,
unmet needs in some emergency services, as well as
in the underreporting of some forms of trauma
of whites. Consequently, minority pa-
tients report less trust,
less willingness to participate
in visits,
and less satisfaction with care.
The more accurate identification of ED health care
disparities, the better the chance of improving
emergency medical care. For certain pathologies, such
as mTBI, outcome depends on appropriate early
In the current study, we explore the
variations in care for mTBI nationally across racial,
ethnic, and gender lines. We sought to determine any
disparities in the emergency care of patients with
mTBI, in hopes of seeking ways to reduce any
differences and thereby enhance patient outcomes
Study Design. A secondary analysis of ED visits in
the National Hospital Ambulatory Medical Care
Survey (NHAMCS) for the years 1998–2000 was
performed. Patients meeting the administrative case
definition of mTBI for surveillance and research
during these years were analyzed. A study exemption
for human subjects under ‘‘Secondary Use of Pre-
existing Data’’ was granted by the Research Subject’s
Review Board of the University of Rochester.
Study Setting and Population. NHAMCS is a mul-
tistage probability sample of approximately 25,000 ED
visits collected each year by the Centers for Disease
Control and Prevention and the National Center for
Health Statistics. Hospitals and clinics are randomly
selected within geographically defined areas (Primary
Sampling Units), after adjustment for size, to repre-
sent the U.S. population. The NHAMCS dataset is
available to the public via the Internet.
Measurements. NHAMCS coders retrospectively re-
view selected records and abstract data in several
categories, including patient demographics, chief
complaint, insurance type, provider type, medical
evaluation/workup, diagnosis, treatment, and dispo-
sition. The origin of the race and ethnicity data in
each abstracted ED chart (i.e., the patient, a family
member, a surrogate, or the health care provider) is
not captured. However, when abstracting these data,
NHAMCS coders use the United States Census Office
of Management and Budget (OMB) two-tier categori-
zation of race and ethnicity. In this scheme, race is
categorized as ‘‘white,’’ ‘‘black/African American,’’
‘‘Asian and/or Native Hawaiian/Other Pacific Is-
lander,’’ ‘‘American Indian/Alaska Native,’’ and
‘‘more than one race reported.’’ To facilitate multivar-
iate analysis, ‘‘black/African Americans,’’ ‘‘Native
Hawaiian/Other Pacific Islanders,’’ and ‘‘American
Indian/Alaska Natives’’ were grouped into ‘‘non-
whites.’’ Ethnicity is categorized as ‘‘Hispanic or
Latino,’’ ‘‘not Hispanic or Latino,’’ and ‘‘blank.’’
The NHAMCS dataset does not contain information
on amnesia or loss of consciousness, which is part of
the clinical definition of mTBI.
Cases of mTBI were
identified using ICD-9 codes 800.0, 800.5, 801.0, 801.5,
803.0, 803.5, 804.0, 804.5, 850.0, 850.1, 850.5, 850.9,
854.0, and 959.01. These codes were recommended as
TABLE 1. Disability after Mild Traumatic Brain Injury (TBI)
Disability Category Details
Post-concussive syndrome Incidence range of PCS at various time intervals from injury: 1 wk: 40%,
4 wk: 89%,
6 wk: 51%,
3 mo: 60%,
6 mo: 25%,
1 yr: 50%
Cognitive and neurobehavioral deficits Areas of impairment noted at various time intervals from injury:
Attention—abnormal at 6 mo
Memory for new information—abnormal at 4 and 6 wk, near normal at 3 mo
Reduction in information processing speed—abnormal at 1 mo, near normal at
Reaction time—abnormal at 6 wk and 3 mo, normal at 6 mo
Occupational disability 20% unemployed at 1 year
4.7 days of work missed per minor TBI patient, on average;
18% missed [1 wk of work
12% unemployed at 2 mo
Children School absenteeism
Attention deficit–hyperactivity
Reading disturbance
Neurobehavioral deficits
PCS ¼post-concussive syndrome.
the administrative case definition of mTBI for sur-
veillance and research by the Centers for Disease
Control and Prevention Mild Traumatic Brain Injury
Work Group in October 2002.
Variables related to ED imaging, procedures,
treatment, and disposition were analyzed along racial,
ethnic, and gender categories. These variables in-
cluded mode of arrival, ED provider type, wait time
to see provider, diagnostic imaging, procedures (e.g.,
wound care), screening blood tests, physical exami-
nation (mental status examination [GCS not avail-
able]), analgesic medications given, and disposition.
Data Analysis. Sample frequencies were used to
calculate national estimates using the patient weight
variable. Annual averages were calculated from the
pooled 1998–2000 national estimates. The sample size
is limited by the number of patients in the dataset
meeting the administrative case definition of mTBI.
The relationship between ethnicity/race and all ED
care variables was examined in a univariate fashion
using the chi-square test and t-test. ED care variables
for which race/ethnicity were significantly associated
and three important ED care items (described below)
served as dependent variables in a multivariate
logistic regression model that included race, ethnicity,
and three important confounders. These confounders
were recommended in the recent Institute of Medicine
report, Unequal Treatment,
and consisted of ‘‘associ-
ated injuries,’’ ‘‘geographic region,’’ and ‘‘socioeco-
nomic status.’’ NHAMCS divides the United States
into four geographic regions of equivalent population
size; northeast, midwest, south and west. Because
there is no direct measure of socioeconomic status in the
NHAMCS database, ‘‘type of insurance’’ served as
a surrogate measure. Insurance types are coded as
‘‘private pay,’’ ‘‘Medicaid,’’ ‘‘Medicare,’’ ‘‘Workman’s
Compensation,’’ ‘‘self-pay,’’ ‘‘no charge,’’ and ‘‘other.’
To facilitate multivariate analysis, we combined
‘‘Medicaid’’ with ‘‘Medicare,’’ and ‘‘no charge’’ with
‘‘Workman’s Compensation’’ and ‘‘other.’’ Associated
injuries were defined as the presence of any non-TBI
ICD-9 code in diagnosis 1, diagnosis 2, or diagnosis 3
The three important ED care items chosen for
additional analysis were ‘‘no CT scan,’’ ‘‘no analgesics
for pain,’’ and ‘‘admission to the hospital.’’ Analgesic
medications were defined as acetaminophen, aspirin,
opiates, nonsteroidals, and COX-2 (cyclooxygenase
inhibitor-2) inhibitors. Because muscle relaxants and
antiemetics are also used to treat headache, these were
included. Antiemetics included promethazine, pro-
chlorperazine, trimethobenzamide, meclizine, dolase-
tron, and dimenhydrinate. Muscle relaxants included
cyclobenzaprine, carisoprodol, metaxalone, and
methocarbamol. Combination drugs containing
acetaminophen and an opiate (e.g., hydrocodone/
acetaminophen [Vicodin]) were classified as an opiate.
Tramadol (Ultram) was included in a separate anal-
gesic category called ‘‘other.’
Confidence intervals and relative standard errors
were calculated using SUDAAN (Research Triangle
Institute, Research Triangle Park, NC) and, in some
cases, using the generalized variance estimation equa-
tions included in NHAMCS online documentation.
Statistical significance was defined as p #0.05. All
other statistical analyses were performed using the
Statistical Analysis System (SAS, Cary, NC), Version 8.
Of the 70,900 ED visits in the pooled three-year
sample, 878 (1.23%) were for mTBI, representing 4.1
million ED visits nationally. The average number of
ED visits annually for mTBI was 1,367,101 (standard
deviation [SD] 652,390), representing an incidence
rate of 503.1/100,000 population. 57.2% (95% CI ¼
50.0% to 64.4%) of the cohort were male, and the mean
age was 26.4 years (median, 21.0 years; range, 0–99
years). The incidence of mTBI was highest among
men, Native American/Alaska Natives, and non-
Hispanics (Table 2).
Variation by Ethnicity. Compared with non-His-
panics, Hispanics were significantly more likely to
have a received a complete blood count, blood alcohol
level, other blood tests, and other diagnostic testing.
As noted in Figure 1, these patients were also more
likely to receive intravenous fluids and to have
a nasogastric tube placed than non-Hispanics. In
addition, Hispanics waited significantly longer to see
a physician (45 vs. 35 minutes, p ¼0.0015) and were
more likely to leave the ED before being seen by
a physician. However, after controlling for important
confounders, ethnicity was found to be an indepen-
dent predictor only of receiving a nasogastric tube:
Hispanics were over six times more likely than non-
Hispanics to receive one (OR, 6.36; 95% CI ¼1.2 to
33.6) (Table 3). The proportions of Hispanics and non-
Hispanics not receiving a CT scan (63.3% vs. 58.8%),
admitted to the hospital (12.2% vs. 10.3%), and not
receiving analgesics for pain (51.8% vs. 53.1%) were
not statistically different. Furthermore, ethnicity was
not an independent prediction of any of these three
ED care items after controlling for important con-
founders (Table 4).
Variation by Race. Compared with whites, African
Americans were more likely to receive ED care from
a resident and less likely to be cared for by a staff
physician, emergency medical technician, or other
provider, as noted in Figure 2. They were also less
likely to be returned to the referring physician for
post-mTBI follow-up. After controlling for the impor-
tant confounders, nonwhites (the majority of whom
are African Americans) were still significantly more
ACAD EMERG MED dNovember 2003, Vol. 10, No. 11 1211
likely to have been seen by a resident (OR, 3.09; 95%
CI ¼1.9 to 5.0) and less likely to be returned to the
referring physician after ED discharge (OR, 0.47; 95%
CI ¼0.3 to 0.9) (Table 5). The proportions of whites
and African Americans not receiving a brain CT scan
(58.9% vs. 62.6%), admitted to the hospital (9.4% vs.
13.3%), and not receiving analgesics for pain (54.3%
vs. 56.9%) were not statistically different. Further-
more, race was not an independent predictor of any of
these three ED care items after controlling for
important confounders (Table 4).
Variation by Gender. Men and women received
equivalent ED care in the variables examined.
In the current study, we have shown that there are
significant disparities in the ED care for mTBI along
racial and ethnic lines. There are several reasons why
the identification of disparities in ED care for this
injury is important. First, identifying disparities in the
health services delivered to Americans constitutes an
important national goal. The Department of Health
and Human Services’ Healthy People 2010, a program
promoting wellness and disease prevention on a na-
tional scale, calls for the elimination of health
disparities as a primary research goal.
identifying disparities is a necessary first step toward
eliminating them, which has been shown to improve
outcome for all groups.
This is particularly
important for mTBI where the risk of poor outcome
is significant, and there are no effective treatments.
Our analysis showed that Hispanics were over six
times more likely to receive a nasogastric tube as part
of the ED care for mTBI, after controlling for race,
associated injuries, geographic region, and type of
insurance. The placement of a nasogastric tube is not
a treatment for head injury per se but is typically part
of the ED care of a suspected abdominal injury, which
can accompany mTBI. This risk estimate was adjusted
for associated injures but not specifically for sus-
pected abdominal injuries. If suspected abdominal
injuries were more frequent among Hispanics with
TABLE 2. Incidence of Mild Traumatic Brain Injury (TBI) by Gender, Race, and Ethnicity
Characteristic Number per Year (95% CI) Incidence (95% CI)
Overall 1,367,101 (1,210,489; 1,523,713) 503.1 (445.4, 560.7)
Male 781,628 (678,399; 884,857) 590.0 (512.1, 667.9)
Female 585,472 (498,881; 672,063) 420.4 (358.2, 482.5)
White 1,096,255 (951,907; 1,240,605) 491.0 (426.4, 555.7)
African American 219,329 (169,498; 269,160) 624.6 (482.7, 766.5)
Native Hawaiian/other Pacific Islander 26,108 (6,269; 45,948) 239.6 (57.5, 421.7)
Native American/Alaska Native 25,407 (4,918; 45,897) 1026.2 (198.6, 1853.7)
Hispanic/Latino 122,009 (84,671; 159,347) 342.3 (237.6, 447.1)
Not Hispanic/Latino 963,961 (829,305; 1,098,618) 391.1 (336.5, 445.7)
Blank 281,129 (207,615; 354,645) NA NA
CI ¼confidence interval; NA ¼not applicable.
Figure 1. Ethnic disparities in emergency department (ED) care for mild traumatic brain injury (TBI).
mTBI, the observed increase in placement of nasogas-
tric tubes among Hispanics would be explained by
confounding. However, the NHAMCS does not
contain variables that would permit this type of
analysis, and there is no a priori reason to believe this
would be the case.
The reasons why Hispanics are more likely to
receive a nasogastric tube for mTBI are not readily
apparent. One possible avenue for exploration is the
relationship between actual and perceived language
differences between Hispanics and their ED providers.
There is no way of knowing from the NHAMCS what
primary languages patients and providers had or
whether interpreters were involved in these inter-
actions. As another source of explanation, language
barriers may lead to compensatory overtesting or
patient inability to refuse, which has been previously
reported for similar ED diagnostic testing with second-
language speakers by Waxman and Leavitt.
language barrier might also explain our observation
that Hispanics waited longer to see a physician. The
summoning of a Spanish interpreter to facilitate the
interaction between the ED staff and the Hispanic
patient introduces a delay not experienced by English-
speaking patients. This delay might in turn lead to
frustration and could explain why many Hispanic
patients with mTBI left the ED before seeing a physi-
cian, which was noted in our univariate analysis
(Figure 1). Future investigations need to address the
lack of documentation about language status and the
presence of interpreters in drawing conclusions.
There were significant disparities identified among
racial groups as well. African Americans were over
three times more likely to be cared for by a resident
than whites. The reasons for this observation are not
immediately clear, although African Americans in
general medical practices are less likely to view
specialists as more highly trained physicians.
Perhaps residents, who are doctors in training and
predominantly white, feel more comfortable and less
scrutinized working with African American patients
and indulge in ‘‘cherry-picking,’’ or screening charts
for what they perceive as easier assignments that
require less attention. Perhaps the supervising ED
attending is more likely to assign a resident to care for
an African American patient to reduce his or her own
contact with an African American patient. Efforts to
clarify reasons for this observation would benefit from
more multidisciplinary exploratory and descriptive
studies, as van Ryn and Fu suggest.
In addition,
African Americans were less likely to be returned to
the referring physician after discharge, probably
because they did not have a referring physician or
because the ED provider assumed they didn’t have
one. The lack of a private, referring physician may
explain previous reports showing that African Amer-
icans with mTBI were less likely than whites to follow
up after ED discharge.
TABLE 3. Ethnic Disparities in Emergency Department Care for Mild Traumatic Brain Injury (TBI): Results of Logistic Regression
Blood Alcohol Level
OR (95% CI)
Complete Blood
OR (95% CI)
Other Blood
OR (95% CI)
Other Diagnostic
OR (95% CI)
OR (95% CI)
OR (95% CI)
Left before Being Seen
by Physician
OR (95% CI)
Nonwhites 1.67 (0.6, 2.5) 1.21 (0.6, 2.4) 0.76 (0.4, 1.4) 0.40 (0.05, 3.3) 0.72 (0.4, 1.3) 1.03 (0.1, 9.9) 0.001 (\0.001, >999)
Hispanic/Latino 1.93 (0.9, 4.2) 0.59 (0.22, 1.6) 1.80 (0.9, 3.3) 0.62 (0.07, 5.3) 1.39 (0.78, 2.5) 6.36 (1.2, 33.6)* 3.37 (0.3, 40.1)
Associated injuries 4.68 (2.2, 9.9)* 1.11 (0.6, 2.0) 2.19 (1.4, 3.5)* 1.05 (0.3, 3.7) 2.42 (1.5, 3.8)* 2.36 (0.4, 12.9) 2.14 (0.2, 26.3)
Geographic region 0.91 (0.3, 2.6) 1.04 (0.5, 2.3) South 3.07 (1.5, 6.4)* 0.61 (0.05, 6.9) 0.55 (0.3, 1.01) 0.001 (\0.001, >999) 0.001 (\0.001, >999)
Insurance type Other, WC 2.64 (1.2, 6.1)* 0.72 (0.3, 1.7) 1.19 (0.6, 2.3) 2.10 (0.4, 10.0) 1.81 (0.99, 3.3) 2.00 (0.3, 15.0) 0.001 (\0.001, >999)
*p #0.05.
CI ¼confidence interval; OR ¼odds ratio; WC ¼workman’s compensation.
ACAD EMERG MED dNovember 2003, Vol. 10, No. 11 1213
Although the focus of this report is on the
identification of racial and ethnic disparities in ED
care for mTBI, it is important to note that such
disparities were not found for many important
aspects of ED care, such as rate of CT scanning,
hospital admission rate, and receipt of analgesics for
pain. In addition, although women tend to have
poorer outcomes after mTBI than men, we did not
identify any gender-based disparities in ED care to
possibly account for this difference.
Finally, our analysis showed a higher TBI incidence
among African American and American Indian/
Alaska Natives but not Native Hawaiian/Other
Pacific Islanders compared with whites. In fact, the
mTBI incidence among American Indian/Alaska
Natives was over twice that of the general American
population (1,026 vs. 503.1/100,000). The reason for
the high mTBI incidence in this ethnic group is
unclear and deserves further study.
For the purposes of this analysis, the limitations and
inconsistencies inherent in concepts of race/ethnicity
are acknowledged but accepted as study variables
already identified in the NHAMCS. The U.S. Census
Department Office of Management and Budget guide-
lines are applied for consistent race and ethnic
However, missing ethnicity data in
nearly one fifth of the cohort is clearly a limitation
of this study. National efforts to improve the re-
cording and collection of ethnicity and race variables
would be vital for accurately defining the epidemiol-
ogy of this injury and for identifying disparities in
ED care.
Finally, the NHAMCS dataset does not specify the
type of CT scan received by each patient; thus, ‘‘CT
scan’’ does not necessarily mean ‘‘brain CT.’’ Some of
these may be nonbrain CT scans. It is unlikely that this
coding problem would differentially affect one group
to produce bias.
An important next step in the process of eliminat-
ing racial and ethnic disparities in ED care for mTBI
would be to examine the relationship between the
disparities we have identified and long-term neuro-
logic and cognitive outcomes. Significant outcome
differences would underscore the need to standardize
treatment across races/ethnicities and might pro-
vide clues as to how to improve overall post-mTBI
Figure 2. Racial disparities in emergency department (ED) care for mild traumatic brain injury (TBI).
TABLE 4. Ethnic and Racial Disparities in Three Important Emergency Department Care Items: Results of
Logistic Regression
No CT Scan
OR (95% CI)
No Analgesics for Pain
OR (95% CI)
Admitted to Hospital
OR (95% CI)
Nonwhites 1.21 (0.82, 1.8) 1.16 (0.6, 2.1) 1.27 (0.7, 2.3)
Hispanic/Latino 1.33 (0.8, 2.1) 0.98 (0.4, 2.3) 1.14 (0.6, 2.3)
Associated injuries 0.67 (0.5, 0.9)* 0.62 (0.4, 1.0) 1.48 (0.9, 2.4)
Geographic region 1.26 (0.8, 2.0) 0.84 (0.4, 1.8) 0.50 (0.2, 1.2)
Insurance type 0.78 (0.5, 1.2) 0.85 (0.4, 1.7) 2.17 (1.04, 4.5)
*p #0.05.
CI ¼confidence interval; CT ¼computed tomographic; OR ¼odds ratio.
Another future direction would be to understand
how ED patients obtain their race/ethnicity labels.
The self-definition of Hispanic does not indicate
language status, whether an interpreter was present,
birth origin, level of acculturation, skin color, socio-
economic level, or specific ethnic identification such
as sources of status.
Conversely, health providers
may identify someone as Hispanic by surname or
appearance or act on language status or skin color as
sources of bias.
The lack of clarity about Hispanic
identification and the role of language bears further
investigation. The discrepancy in nasogastric tube use
marks a valuable opportunity for a qualitative study
that could investigate the selected perspectives of
emergency physicians who have ordered such inter-
ventions. What would open-ended interviewing of
health providers reveal about the motivations for
ordering such tests? How do providers and patients
identify the significance of Hispanic ethnicity? Re-
corded observations and feedback interviews of
Hispanic patients interacting with physicians whose
race/ethnicity were identified in ED encounters could
be systematically compared using ethnography of
communication methods from the social sciences.
These methods determine the role of ways of
speaking, ethnicity, and differing interpretations on
sources of decision making.
A multidisciplinary
research team could use the model of analyzing social
interaction with playback as described by Erickson
and Shultz.
We identified several areas of racial and ethnic—but
not gender—disparities in ED care for mTBI. His-
panics were over six times more likely to receive
a nasogastric tube than non-Hispanics and had
a longer wait time to see a physician. Nonwhites
were over three times more likely to receive ED care
from a resident and less likely to be returned back to
the referring physician after discharge. Multidisci-
plinary qualitative studies could help identify lan-
guage barriers and provider–patient misperceptions
underlying these disparities, which would be a first
step toward their elimination. National efforts to
improve the accurate capture and recording of self-
identified race and ethnicity in the ED setting will
improve the quality of disparity research. Finally, the
significance of the disparities we observed could be
better understood if future efforts focus on the
relationship between these disparities and post-mTBI
The authors thank Susan Fisher, PhD, and Ollivier Hyrien, PhD, for
their statistical assistance. They also thank Peggy Auinger for
assistance with SUDAAN programming.
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TABLE 5. Racial Disparities in Emergency Department Care for Mild Traumatic Brain Injury (TBI):
Results of Logistic Regression
Cared for by
Staff Physician
OR (95% CI)
Cared for by
OR (95% CI)
Cared for by
Emergency Medical
OR (95% CI)
Cared for by
Other Provider
OR (95% CI)
Referred to Primary Care
Physician after
OR (95% CI)
Nonwhites 0.68 (0.4, 1.3) 3.09 (1.9, 5.0)* 0.89 (0.5, 1.7) 0.64 (0.3, 1.4) 0.47 (0.3, 0.9)*
Hispanic/Latino 0.96 (0.4, 2.2) 1.11 (0.6, 2.2) 1.50 (0.8, 2.8) 0.81 (0.3, 1.9) 0.63 (0.3, 1.2)
Associated injuries 1.17 (0.7, 2.0) 0.81 (0.5, 1.3) 1.82 (1.1, 2.9)* 0.99 (0.6, 1.7) 0.74 (0.5, 1.1)
Geographic region 2.07 (0.9, 5.1) 0.52 (0.3, 1.02) 0.99 (0.5, 2.0) 0.53 (0.2, 1.2) Midwest 2.16 (1.1, 4.1)*
Insurance type 1.92 (0.9, 3.9) 1.28 (0.7, 2.3) 1.24 (0.6, 2.4) 0.95 (0.4, 2.0) 1.12 (0.6, 1.9)
*p #0.05.
CI ¼confidence interval; OR ¼odds ratio.
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... Few studies have examined the association between patient-level socioeconomic factors and outcomes across various diseases that are treated by the specialty of neurosurgery-pediatric hydrocephalus (6)(7)(8), craniosynostosis (9), intracranial tumors (10-13), aneurysmal subarachnoid hemorrhage (14,15) and stroke (16,17), traumatic brain injury (18)(19)(20)(21), spine disorders (22) and spinal cord injury (23,24). Many of these studies describe the more frequently unfavorable outcomes among the inadequately insured and those with lower socioeconomic status. ...
... In an analysis of the largest TBI databasethe International Mission for Prognosis And Clinical Trial (IMPACT) database-Mushkudiani and colleagues concluded that outcome following TBI is also dependent on race and to a lesser extent on the level of education of the patient, even when adjusting for other causes (18). The underlying reason can be traced to limited access to acute and post-acute care (20,21); therefore, prehospital and acute hospital care systems ought to be efficiently responsive to socioeconomically disadvantaged patients with TBI (38). Indonesia and the Philippines have the twin problem of a low neurosurgeon-topopulation ratio −1 per 731,000 and 1 per 807,000, respectively (30)-and a high prevalence of TBI estimated at around 930 per 100,000 population in the Southeast Asia/Western Pacific region (39). ...
Full-text available
Which conditions treated by neurosurgeons cause the worst economic hardship in low middle-income in countries? How can public health financing be responsive to the inequities in the delivery of neurosurgical care? This review article frames the objectives of equity, quality, and efficiency in health financing to the goals of global neurosurgery. In order to glean provider perspectives on the affordability of neurosurgical care in low-resource settings, we did a survey of neurosurgeons from Indonesia and the Philippines and identified that the care of socioeconomically disadvantaged patients with malignant intracranial tumors were found to incur the highest out-of-pocket expenses. Additionally, the surveyed neurosurgeons also observed that treatment of traumatic brain injury may have to require greater financial subsidies. It is therefore imperative to frame health financing alongside the goals of equity, efficiency, and quality of neurosurgical care for the impoverished. Using principles and perspectives from managerial economics and public health, we conceptualize an implementation framework that addresses both the supply and demand sides of healthcare provision as applied to neurosurgery. For the supply side, strategic purchasing enables a systematic and contractual management of payment arrangements that provide performance-based economic incentives for providers. For the demand side, conditional cash transfers similarly leverages on financial incentives on the part of patients to reward certain health-seeking behaviors that significantly influence clinical outcomes. These health financing strategies are formulated in order to ultimately build neurosurgical capacity in LMICs, improve access to care for patients, and ensure financial risk protection.
... Adult minorities in the U.S. are less likely to return to work following traumatic brain injuries than whites [2]. Adult minorities in the U.S. suffering mild traumatic brain injuries may receive disparate emergency department care as compared to whites [3]. Despite such work, less has been done to the look at the influence of ethnicity or race on outcomes following traumatic brain injury in pediatric populations. ...
Background Pediatric traumatic brain injury represents a significant cause of morbidity and mortality. Broadly healthcare disparities exist for ethnic and racial minorities in the United States but it has not previously be evaluated how these disparities might influence outcomes in pediatric traumatic brain injury. Methods We sought all hospital admissions between the years 2006 and 2011 for patients aged 0-17 years admitted with traumatic brain injuries as identified by the International Classification of Diseases, 9th Revision (ICD-9) code, from a statewide database of all civilian hospital admissions. Demographic information including race, ethnicity, insurance status and illness severity as calculated by All Patient Refined-Diagnosis Related Group (APR-DRG) were analysed versus the disposition at discharge. Results 14,087 pediatric traumatic brain injury patients were admitted between 2006 and 2011. Pediatric traumatic brain injury patients of ethnic or racial minority had higher rates of in-hospital mortality as compared to whites (4.2% versus 3.3%, p = 0.009) and were less likely to be discharged to inpatient rehabilitation (2.9% versus 4%, p < 0.001). These disparities persisted even when controlling for insurance status and illness severity. Conclusion Ethnic and racial minority children from the U.S. state of Texas suffer worse short-term outcomes following traumatic brain injury than their white counterparts. Strategies are needed for addressing this disparity.
Background Prior research has demonstrated the widespread presence of racial disparities in emergency department (ED) care and analgesia. We hypothesized that racial disparities continue to exist in ED analgesic prescribing patterns, time to analgesia, and time to provider in the treatment of headache. Methods We performed a retrospective cohort study of patients presenting to a large tertiary academic ED with chief complaint of headache. A structured medical record review was conducted to abstract relevant variables of interest. Patient race was categorized as white or Black, Indigenous, or person of color (BIPOC). Descriptive statistics were used to characterize the cohort and stratified analyses were conducted based on patient race and our key outcome measures of analgesic prescribing patterns, time to analgesia, and time to provider in the treatment of headache. Results White patients were more likely to be assigned an Emergency Severity Index score 2 or 3 and their BIPOC counterparts were more likely to be assigned an ESI score 3 or 4 (p = 0.02). There was no significant difference by race in time to analgesia (p = 0.318), time to provider (p = 0.358), or time to first medication treatment (p = 0.357). However, there were clear differences in prescribing patterns. BIPOC patients were significantly more likely to be treated with acetaminophen (p = 0.042) or ibuprofen (p = 0.015) despite reporting higher pain levels during triage (p < 0.001). White patients were significantly more likely to receive a head CT scan (p < 0.001) or neurology consult (p = 0.003) than their BIPOC counterparts. Conclusion Racial disparities persist in assessment and type of analgesia for patients being treated for headache in a large academic emergency department.
Purpose Emergency medicine is a common access point to health care; disparities in this care by demographic characteristics, including race and ethnicity, may affect outcomes. The Massachusetts Eye and Ear (MEE) Emergency Department (ED) is a subspecialty emergency department; data from this site can be utilized to better understand social determinants of quality ophthalmic care. Design This is a retrospective cross sectional cohort study in the MEE ED examining patient visits from June 1, 2016 to June 30, 2019. Methods Using the electronic medical record system, all unique visits were identified between June 1, 2016 and June 30, 2019 (inclusive); patient demographics (sex, race, ethnicity [Hispanic vs. non-Hispanic], primary care provider [PCP] status, insurance type, zip code, primary language), date of visit, triage category and outcomes (final diagnosis, visit duration, and next visit at MEE within 3 months of the ED visit) were collected. Kaplan-Meier plots were used to visualize likelihood of follow-up visit to MEE for urgent patients based on demographics. Multivariate linear regression was used to examine factors affecting visit durations, as stratified by urgency, and Cox proportional hazards regression was used to establish hazard ratios for next visit to MEE. Results Of the 46,248 ophthalmology ED initial visits, only triage status, season of visit, out-of-state residency, Medicare coverage, and Medicaid coverage led to statistically significant differences in visit durations for urgent visits compared with the respective reference groups. Similar trends persisted within the non-urgent visit cohort for visit durations. Residency, insurance coverage, season of visit, race, PCP status, and sex were identified as statistically significant predictors of the likelihood of a follow-up visit. Conclusion Data from an ophthalmic emergency department suggest that demographic factors do impact patient visit duration and time to follow-up visit. These findings suggest a continued need for attention to social determinants of health and equitable care of patients within ophthalmology.
Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.
Background Emergency department (ED) visits for opioid-related overdoses continue to rise across the United States, particularly among Black, Latinx, and American Indian/Alaskan Native communities. A minority of people with opioid use disorder (OUD) engages in formal addiction treatment and racial disparities in treatment access exist. ED visits for opioid overdose are crucial opportunities to link individuals with OUD to harm reduction and treatment services, including take-home naloxone, behavioral counseling, and referral to treatment. However, we know little about whether racial inequities exist in ED treatment for opioid overdose. Methods This observational, cross-sectional study examined services provided to overdose patients who were discharged from their first visit in two Rhode Island EDs based on patient race-ethnicity. Primary outcomes included take-home naloxone, ED-based behavioral counseling, and linkage to treatment. The research team performed chi-square analyses to compare race-ethnicity differences in post-overdose ED services, and performed multivariable logistic regression analyses to examine associations of race-ethnicity with receiving post-overdose services, controlling for other institutional-, provider-, and patient-level factors. Results From September 2017 to February 2020, 734 patients were discharged from the ED for an opioid-related overdose. Most patients were White non-Latinx (70.0%), 8.9% were Black non-Latinx, 3.3% were Other race non-Latinx, and 18.0% were Latinx. Take-home naloxone was the most frequent intervention provided to patients while behavioral counseling was the lowest across all race-ethnicity categories. No statistically significant differences occurred in proportions of take-home naloxone and treatment referral based on patient race-ethnicity. However, a lower proportion of Black non-Latinx patients who were discharged received behavioral counseling compared to patients of other race-ethnicities, and the odds of receiving behavioral counseling was significantly higher for White non-Latinx (OR: 1.75; 95% CI: 1.00, 3.06); Latinx (OR: 2.06; 95% CI: 1.05, 4.06); and Other race non-Latinx (OR: 3.29; 95% CI: 1.18, 9.15) patients compared to Black non-Latinx patients. Conclusion Black non-Latinx patients discharged from the ED for an opioid-related overdose were less likely to receive behavioral counseling compared to non-Black patients. Possible reasons for this decreased provision of behavioral counseling include provider bias, patient mistrust of the medical and behavioral health care systems, and limited provider training in addiction medicine and motivational interviewing. These inequities add to the known racial disparities in ED patient care. Further research should elucidate barriers to behavioral counseling within ED settings and factors contributing to racial inequities in post-overdose emergency care.
Background Traumatic brain injury (TBI) is one of the leading causes of pediatric trauma morbidity and mortality around the world. However, limited research exists regarding disparities in the incidence of TBI and medical care seeking behaviors and medical expenditures for TBI, particularly using population-based and nationally-representative data. Materials and Methods The present study used the Medical Expenditure Panel Survey (MEPS) Panels 9-19 (2004-2015) to provide nationally-representative estimates for the civilian, non-institutionalized U.S. population. We examined differences in TBI incidence and associated medical care seeking behaviors and expenditures in relation to individual and family sociodemographic characteristics. Results From a total of 50,563 children in the MEPS Panels 9-19, we identified 449 children with TBI. For 82% of these children, medical treatment was sought. The estimated annual total expenditure associated with pediatric TBIs nationally was approximately $667 million, with mean expenditures per TBI being $1,532 and family out of pocket expenditures accounting for 8.3% of total expenditures. Race/ethnicity was the only significant factor associated with both medical care seeking behavior and total expenditures. Conclusions The present study is among the first to compare pediatric TBI-related medical expenditures among different sociodemographic groups in the U.S. Our findings can inform future intervention research and policy-making from the perspectives of both epidemiological and behavioral sciences.
Background: This study aims to describe TBI-related hospitalizations for the whole population and identify factors associated with in-hospital mortality among elderly (≥65 years) patients hospitalized with TBI in Texas. Methods: Using Texas Hospital Discharge Data from 2012 to 2014, TBI-related hospitalizations were identified using International Classification of Diseases – Ninth Revision – Clinical Modification (ICD-9-CM) codes. Rates for age and gender were estimated using U.S. Census data. Univariate and multivariate analyses were used to identify factors associated with in-hospital mortality among those aged at least 65 years. Results: There were 51,419 TBI-related hospitalizations from 2012 to 2014 in Texas. Falls were the leading cause of TBI-related hospitalizations 6235 (36.64%), 6595 (38.40%), and 5412 (37.59%) for 2012, 2013, and 2014, respectively. Males had higher rates of hospitalizations while rates were highest for those above 80 years of age. Compared to Whites, Hispanics had 1.18 higher adjusted odds of in-hospital mortality [OR = 1.18: 95% CI (1.01–1.40)]. Similarly, adjusted odds of in-hospital mortality were higher among males [OR = 1.55: 95% CI (1.36–1.77)]. Conclusion: This study provided evidence of demographic disparities in the burden and outcome of TBI in Texas, findings could serve as a foundation for targeted TBI prevention interventions.
Background There is a growing body of evidence on racial and ethnic disparities within traumatic brain injury (TBI) care. The aim of this paper was to conduct a narrative review of the literature, demonstrating how racial and ethnic disparities manifest across the full spectrum of the TBI experience in civilian populations: injury, acute care and diagnosis, post-TBI recovery and adjustment, and long-term outcomes.Methods We searched five electronic databases (Scopus, APA PsychNet, PubMed/MEDLINE, and Google Scholar) using the search terms traumatic brain injury, head trauma, concussion, health disparities, ethnic minority, racial minority, race ethnicity, racial ethnic, prevalence, incidence, diagnosis, rehabilitation, recovery, and outcomes. Boolean search modifiers AND, NOT, and OR were used to produce relevant results. Additional resources were included by the authors, as deemed relevant to the investigation.ResultsOur narrative review of 39 articles elucidated numerous ways in which racial and ethnic disparities span the TBI continuum of care, including acute care and diagnosis, post-TBI recovery and adjustment, and long-term outcomes.Conclusions Understanding racial and ethnic disparities is a first step in ensuring equitable care for all individuals with TBI, including raising awareness among clinicians and guiding the development of tailored interventions for racial and ethnic minority populations.
Background While significant racial inequities in health outcomes exist in the United States, these inequities may also exist in healthcare processes, including the Emergency Department (ED). Additionally, gender has emerged in assessing racial healthcare disparity research. This study seeks to determine the association between race and the number and type of ED consultations given to patients presenting at a safety-net, academic hospital, which includes a level-one trauma center. Method Retrospective data was collected on the first 2000 patients who arrived at the ED from 1/1/2015–1/7/2015, with 532 patients being excluded. Of the eligible patients, 77% (74.6% adults and 80.7% pediatric patients) were black and 23% (25.4% adults and 19.3% pediatric patients) were white. Results White and black adult patients receive similar numbers of ED consultations and remained after gender stratification. White pediatric males have a 91% higher incidence of receiving an ED consultation in comparison to their white counterparts. No difference was found between black and white adult patients when assessing the risk of receiving consultations. White adult females have a 260% higher risk of receiving both types of consultations than their black counterparts. Black and white pediatric patients had the same risk of receiving consultations, however, white pediatric males have a 194% higher risk of receiving a specialty consultation as compared to their white counterparts. Discussion Future work should focus on both healthcare practice improvements, as well as explanatory and preventive research practices. Healthcare practice improvements can encompass development of appropriate racial bias trainings and institutionalization of conversations about race in medicine.
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Women report greater distress than men, but do women genuinely experience greater distress, suggesting a heavier burden of hardship and constraint? Or do they merely report the feelings in standard indexes more frequently? Perhaps women discuss their emotions more freely. Or perhaps the indexes tap "feminine" emotions such as depression rather than "masculine" ones such as anger. This study analyzes data from a 1990 U.S. sample of 1,282 women and 749 men. Results show that men keep emotions to themselves more than women, and that women express emotions more freely than men. However, these factors do not explain the effect of sex on reported levels of distress--an effect that remains significant with adjustment for these factors. Our results also contradict the idea that the sex difference in distress would diminish if the indexes of distress contained more items that tap anger. Adjusting for emotional reserve and expressiveness, women experience anger more often than men, as they do sadness, anxiety, malaise, and aches. In fact, being female has twice the effect on the frequency of anger that it has on the frequency of sadness. Women report feeling happy as often as men, but adjusting for emotional expressiveness reveals a negative effect of being female on happiness. Overall, women experience distress about 30 percent more often than men. We discuss the possibility that drug abuse and heavy drinking mask male distress, but find little evidence that those behaviors ameliorate distress. We conclude that women genuinely suffer more distress than men.
Coronary artery disease is the leading cause of death in the United States. Blacks are more likely than whites to experience premature disease, and they have poorer prognosis after acute myocardial infarction. Multiple studies have demonstrated that blacks are less likely to be referred for certain invasive cardiac procedures. Few studies have examined the effect of race on physician and patient decision making in referrals for cardiac procedures. The authors present a framework for the complex series of steps involved in obtaining invasive cardiac care. Patient race can affect each of these steps, and differences in physician and patient race may be a particular impediment to effective communication about symptoms and preferences and to the establishment of a therapeutic partnership. The potential role of communication in race-discordant physician-patient relationships suggests a need for more research in physician decision making and for efforts to promote cultural competency as a core component of medical education.
Context Abusive head trauma (AHT) is a dangerous form of child abuse that can be difficult to diagnose in young children.Objectives To determine how frequently AHT was previously missed by physicians in a group of abused children with head injuries and to determine factors associated with the unrecognized diagnosis.Design Retrospective chart review of cases of head trauma presenting between January 1, 1990, and December 31, 1995.Setting Academic children's hospital.Patients One hundred seventy-three children younger than 3 years with head injuries caused by abuse.Main Outcome Measures Characteristics of head-injured children in whom diagnosis of AHT was unrecognized and the consequences of the missed diagnoses.Results Fifty-four (31.2%) of 173 abused children with head injuries had been seen by physicians after AHT and the diagnosis was not recognized. The mean time to correct diagnosis among these children was 7 days (range, 0-189 days). Abusive head trauma was more likely to be unrecognized in very young white children from intact families and in children without respiratory compromise or seizures. In 7 of the children with unrecognized AHT, misinterpretation of radiological studies contributed to the delay in diagnosis. Fifteen children (27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%) experienced medical complications related to the missed diagnosis. Four of 5 deaths in the group with unrecognized AHT might have been prevented by earlier recognition of abuse.Conclusion Although diagnosing head trauma can be difficult in the absence of a history, it is important to consider inflicted head trauma in infants and young children presenting with nonspecific clinical signs.
Describes mild traumatic brain injury (TBI) as a traumatically induced physiological disruption of brain function manifested by at least one of the following: (1) any period of loss of consciousness, (2) any loss of memory for events immediately before or after the accident, (3) any alteration in mental state at the time of the accident, and (4) focal neurological deficit(s) that may or may not be transient. Severity of injury in mild TBI does not exceed the following: (1) loss of consciousness of 30 min or less, (2) after 30 min, an initial Glasgow Coma Scale of 13-25, and (3) posttraumatic amnesia not greater than 24 hrs. (PsycINFO Database Record (c) 2006 APA, all rights reserved)
Of 145 patients with concussion from minor head injuries admitted to the Royal Victoria Hospital, Belfast, over one year, 49·0% had no symptoms, 38·9% had between 1 and 6 symptoms, and 2·1% had more than 6 symptoms about six weeks after the accident. There was significant correlation between a high symptom-rate at six weeks and positive neurological signs and symptoms at twenty-four hours. Post-concussion symptoms were more frequent in women, in those injured by falls, and in those who blamed their employers or large impersonal organisations for their accidents. The results suggest that both organic and neurotic factors are involved in the pathogenesis of symptoms at six weeks.
This analysis examines the association between race and satisfaction with physicians among a sample of community-dwelling older adults. It is hypothesized that minority elderly will hold more negative attitudes toward physicians than will their White peers due to the difficulty in establishing rapport in the physician-patient relationship. Using data from the Established Populations for Epidemiologic Studies of the Elderly (Duke), we find that African Americans believe that physicians do not display much compassion for, and respect toward, the elderly. However, African Americans report more positive attitudes about the prudence of physicians. These findings are discussed in the context of improving the physician-patient relationship.