Emergency department (ED) crowding is a major issue with broad implications ―from delays in physician assessment to prolonging pain to decreasing patient satisfaction. But little has been known about the extent to which recent trends in ED crowding influence care for acute GI illnesses.
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Since the 1980s, studies have shown there are disparities for minority populations when they seek medical care. And since GI diseases are a common cause of ED visits and hospitalization, that’s why a team from Cleveland Clinic recently examined a large database of ED visits to identify disparities in hopes of providing useful information to one day help develop healthcare policies and strategies to overcome them.
Consult QD sat down with advanced endoscopist Prabhleen Chahal, MD, and gastroenterology and hepatology fellow C. Roberto Simons-Linares to discover what they found and what implications it holds for the future. Dr. Simons-Linares recently presented the findings at DDW 2018, also co-authored by Dr. Chahal, Carlos Romero-Marrero, MD, Rocio Lopez, MS, and John Vargo, MD, MPH.
Q: What prompted you to conduct this research, and what were your findings?
Dr. Simons-Linares: Our aim was to identify any racial or ethnic, gender and/or geographic disparities when it comes to ED waiting times for GI diseases. We did find disparities in ED waiting times for the five most common acute GI diseases.
In our study, there were 16,999,442 total ED visits for acute GI diseases. That included 2,874,666 for acute pancreatitis, 3,119,061 for appendicitis, 1,837,369 for cholecystitis, 3,604,911 for diverticultis and 5,762,293 for upper GI hemorrhage.
Average waiting time for all acute GI diseases was 52.4 ± 1.7 minutes and 30.5 percent (95% CI: 28.5, 32.5%) of visits had delayed assessment. Average waiting times were: pancreatitis, 60.0 minutes ± 5.9 minutes; cholecystitis, 54.8 minutes ± 6.1 minutes; appendicitis, 52.0 minutes ± 2.5 minutes; diverticulitis, 53.8 minutes ± 2.8 minutes; and upper GI hemorrhage, 48.1 minutes ± 2.3 minutes.
Males had higher delayed assessment compared with females (33% vs. 28%, P = 0.024). In addition, race/ethnicity, hospital ownership and immediacy with which the patient should be seen were found to be associated with delayed assessment.
After adjusting for all factors, males in the Midwest had 90 percent higher odds of having a delayed assessment compared with females in the Midwest (P < 0.001). Hispanic subjects had 30 percent higher likelihood of having a delayed assessment compared with non-Hispanic white subjects (P = 0.032). Female subjects in the Midwest had 45 percent lower odds of having a delayed assessment than female subjects in the Northeast (P = 0.002).
Q: How do your findings differ from ― or perhaps build upon ― previous research in this area?
Dr. Simons-Linares: Racial differences in the ED have been demonstrated with respect to waiting times to see a physician in multiple studies across different specialties. And they have persisted across evaluation and management of multiple illnesses, especially for analgesia/pain management and GI disease.
A study by Young et al found that African-Americans and Hispanics received opioid prescriptions at a much lower rate than Caucasians. Similar findings were reported in another study by Tamayo et al.
However, these studies were done more than a decade ago, and recent quality improvement projects may have affected the most recent outcomes and improved disparities, hence our desire to do our study.
Q: What implications do your findings have for the current screening and/or treatment standard?
Dr. Simons-Linares: There are no current guidelines or protocol to address the racial and gender disparities that exist in ED waiting times.
Our findings reveal that gender, ethnic and geographic disparities exist in the care of acute GI disease in the ED and delay in clinical assessment was found. The top 5 reported acute GI diseases necessitate rapid assessment and timely management in order to improve outcomes and decrease mortality.
Q: What conclusions should clinicians draw from this research?
Dr. Chahal: Our study found Hispanics had a significantly higher likelihood of delayed assessment compared with non-Hispanic whites. Also notably, males in the Midwest had a higher risk of having delayed assessment compared with females. Quality improvement studies and healthcare policy revisions are needed to address the disparities identified in this study.
Q: Are there any conclusions that should not be drawn from your research?
Dr. Chahal: Our study has limitations, as it was a retrospective study. Also, the database used encodes diseases with billing codes, and there are limitations with using this type of data such as potential type II statistical errors, which may have at least been overcome or minimized by the large sample size.
Q: What additional, follow-up research are you planning?
Dr. Simons-Linares: Our current study should encourage physicians to look into this important topic. More studies are needed to substantiate our findings.
Our team is planning follow-up studies to identify in more detail the disparities we recently found and start brainstorming possible ideas or policies to overcome these racial and gender disparities in ED waiting times.