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ACAD EMERG MED dNovember 2003, Vol. 10, No. 11 dwww.aemj.org 1209
Ethnic and Racial Disparities in Emergency
Department Care for Mild Traumatic Brain Injury
JeffreyJ.Bazarian,MD,MPH,CharlenePope,PhD,MPH,JasonMcClung,MD,
Yen Ting Cheng, MD, William Flesher, RN, MPH
Abstract
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-
tion.
1–3
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
4–21
(Table
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,
22
although
racial biases may confound outcome evaluation.
23–27
African Americans have a 35% higher TBI incidence
than whites
1
but are less likely to have appropriate
follow-up after ED discharge.
28
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.
29–31
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.
32
For example, minorities have been found to be less
likely to receive carotid artery imaging
33
and other
cardiovascular procedures,
34,35
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
Jose
´, 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: jeff_bazarian@urmc.rochester.edu.
doi:10.1197/S1069-6563(03)00491-3
cancer screening such as mammography,
36
or later
receive appropriate information
37
or treatments for
cancer,
38,39
less likely to receive analgesics for
pain,
40,41
less likely to get dialysis and kidney trans-
plant for end-stage renal disease,
42
and more likely to
receive extreme treatments such as cesarean delivery
in childbirth
43
or amputation with diabetes.
44
Dispar-
ities have also been reported for African Americans
and Hispanics in diagnosis,
45
interventions,
46
and
unmet needs in some emergency services, as well as
in the underreporting of some forms of trauma
47
and
overtesting
48
of whites. Consequently, minority pa-
tients report less trust,
49
less willingness to participate
in visits,
50
and less satisfaction with care.
51
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
treatment.
52
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
overall.
METHODS
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.
53
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.’’
54
The NHAMCS dataset does not contain information
on amnesia or loss of consciousness, which is part of
the clinical definition of mTBI.
3
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%,
6
4 wk: 89%,
7
6 wk: 51%,
8
3 mo: 60%,
9
6 mo: 25%,
10
1 yr: 50%
11
Cognitive and neurobehavioral deficits Areas of impairment noted at various time intervals from injury:
Attention—abnormal at 6 mo
12
Memory for new information—abnormal at 4 and 6 wk, near normal at 3 mo
13
Reduction in information processing speed—abnormal at 1 mo, near normal at
3mo
7
Reaction time—abnormal at 6 wk and 3 mo, normal at 6 mo
14
Occupational disability 20% unemployed at 1 year
15
4.7 days of work missed per minor TBI patient, on average;
18% missed [1 wk of work
9
12% unemployed at 2 mo
16
Children School absenteeism
17
Attention deficit–hyperactivity
18
Reading disturbance
19
Neurobehavioral deficits
20
PCS
21
PCS ¼post-concussive syndrome.
1210 Bazarian et al. dETHNIC AND RACIAL DISPARITIES IN MILD TBI CARE
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.
55
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,
32
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
fields.
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.
55
Statistical significance was defined as p #0.05. All
other statistical analyses were performed using the
Statistical Analysis System (SAS, Cary, NC), Version 8.
RESULTS
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 dwww.aemj.org 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.
DISCUSSION
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.
56,57
Second,
identifying disparities is a necessary first step toward
eliminating them, which has been shown to improve
outcome for all groups.
58,59
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)
Gender
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)
Race
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)
Ethnicity
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).
1212 Bazarian et al. dETHNIC AND RACIAL DISPARITIES IN MILD TBI CARE
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.
60
A
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.
61
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.
62
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.
28
TABLE 3. Ethnic Disparities in Emergency Department Care for Mild Traumatic Brain Injury (TBI): Results of Logistic Regression
Covariates
Blood Alcohol Level
OR (95% CI)
Complete Blood
Count
OR (95% CI)
Other Blood
Tests
OR (95% CI)
Other Diagnostic
Tests
OR (95% CI)
Intravenous
Fluids
OR (95% CI)
Nasogastric
Tube
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 dwww.aemj.org 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.
LIMITATIONS
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
references.
54
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
outcome.
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
Covariates
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.
1214 Bazarian et al. dETHNIC AND RACIAL DISPARITIES IN MILD TBI CARE
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.
63
Conversely, health providers
may identify someone as Hispanic by surname or
appearance or act on language status or skin color as
sources of bias.
64
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.
65
A multidisciplinary
research team could use the model of analyzing social
interaction with playback as described by Erickson
and Shultz.
66
CONCLUSIONS
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
outcome.
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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