Racial and Sex Differences in Emergency Department Triage Assessment and Test Ordering for Chest Pain, 1997–2006

Authors

  • Lenny López MD, MPH,

    1. From the Mongan Institute for Health Policy (LL, MCC, JRB, ARG), the Department of Medicine (LL), and the Disparities Solutions Center (LL, MCC, JRB, ARG), Massachusetts General Hospital, Boston, MA; Harvard Medical School (LL, JRB, ARG), Boston, MA; The Brigham and Women’s Academic Hospitalist Program, Brigham and Women’s Hospital (LL), Boston, MA; Boise VA Medical Center (APW), Boise, ID; and the Department of Medicine, University of Washington School of Medicine (APW), Seattle, WA.
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  • Andrew P. Wilper MD,

    1. From the Mongan Institute for Health Policy (LL, MCC, JRB, ARG), the Department of Medicine (LL), and the Disparities Solutions Center (LL, MCC, JRB, ARG), Massachusetts General Hospital, Boston, MA; Harvard Medical School (LL, JRB, ARG), Boston, MA; The Brigham and Women’s Academic Hospitalist Program, Brigham and Women’s Hospital (LL), Boston, MA; Boise VA Medical Center (APW), Boise, ID; and the Department of Medicine, University of Washington School of Medicine (APW), Seattle, WA.
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  • Marina C. Cervantes,

    1. From the Mongan Institute for Health Policy (LL, MCC, JRB, ARG), the Department of Medicine (LL), and the Disparities Solutions Center (LL, MCC, JRB, ARG), Massachusetts General Hospital, Boston, MA; Harvard Medical School (LL, JRB, ARG), Boston, MA; The Brigham and Women’s Academic Hospitalist Program, Brigham and Women’s Hospital (LL), Boston, MA; Boise VA Medical Center (APW), Boise, ID; and the Department of Medicine, University of Washington School of Medicine (APW), Seattle, WA.
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  • Joseph R. Betancourt MD, MPH,

    1. From the Mongan Institute for Health Policy (LL, MCC, JRB, ARG), the Department of Medicine (LL), and the Disparities Solutions Center (LL, MCC, JRB, ARG), Massachusetts General Hospital, Boston, MA; Harvard Medical School (LL, JRB, ARG), Boston, MA; The Brigham and Women’s Academic Hospitalist Program, Brigham and Women’s Hospital (LL), Boston, MA; Boise VA Medical Center (APW), Boise, ID; and the Department of Medicine, University of Washington School of Medicine (APW), Seattle, WA.
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  • Alexander R. Green MD, MPH

    1. From the Mongan Institute for Health Policy (LL, MCC, JRB, ARG), the Department of Medicine (LL), and the Disparities Solutions Center (LL, MCC, JRB, ARG), Massachusetts General Hospital, Boston, MA; Harvard Medical School (LL, JRB, ARG), Boston, MA; The Brigham and Women’s Academic Hospitalist Program, Brigham and Women’s Hospital (LL), Boston, MA; Boise VA Medical Center (APW), Boise, ID; and the Department of Medicine, University of Washington School of Medicine (APW), Seattle, WA.
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  • Conflict of interest: the authors report no conflict of interest, financial or other.

  • Presented at the national meeting of the Society of General Internal Medicine, Miami, FL, May 2009.

  • Supervising Editor: Lowell W. Gerson, PhD.

Address for correspondence and reprints: Lenny Lopez, MD, MPH; e-mail: llopez1@partners.org.

Abstract

ACADEMIC EMERGENCY MEDICINE 2010; 17:801–808 © 2010 by the Society for Academic Emergency Medicine

Abstract

Objectives:  This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.

Methods: A nationally representative ED data sample for all adults (≥18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997–2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.

Results:  Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.

Conclusions:  Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect “downstream” clinical care and help eliminate observed disparities in cardiac outcomes.

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