Race and Ethnicity and Primary Language in Emergency Department Triage.

Importance: Emergency department (ED) triage substantially affects how long patients wait for care but triage scoring relies on few objective criteria. Prior studies suggest that Black and Hispanic patients receive unequal triage scores, paralleled by disparities in the depth of physician evaluations. Objectives: To examine whether racial disparities in triage scores and physician evaluations are present across a multicenter network of academic and community hospitals and evaluate whether patients who do not speak English face similar disparities. Design, Setting, and Participants: This was a cross-sectional, multicenter study examining adults presenting between February 28, 2019, and January 1, 2023, across the Mass General Brigham Integrated Health Care System, encompassing 7 EDs: 2 urban academic hospitals and 5 community hospitals. Analysis included all patients presenting with 1 of 5 common chief symptoms. Exposures: Emergency department nurse-led triage and physician evaluation. Main Outcomes and Measures: Average Triage Emergency Severity Index [ESI] score and average visit work relative value units [wRVUs] were compared across symptoms and between individual minority racial and ethnic groups and White patients. Results: There were 249 829 visits (149 861 female [60%], American Indian or Alaska Native 0.2%, Asian 3.3%, Black 11.8%, Hispanic 18.8%, Native Hawaiian or Other Pacific Islander <0.1%, White 60.8%, and patients identifying as Other race or ethnicity 5.1%). Median age was 48 (IQR, 29-66) years. White patients had more acute ESI scores than Hispanic or Other patients across all symptoms (eg, chest pain: Hispanic, 2.68 [95% CI, 2.67-2.69]; White, 2.55 [95% CI, 2.55-2.56]; Other, 2.66 [95% CI, 2.64-2.68]; P < .001) and Black patients across most symptoms (nausea/vomiting: Black, 2.97 [95% CI, 2.96-2.99]; White: 2.90 [95% CI, 2.89-2.91]; P < .001). These differences were reversed for wRVUs (chest pain: Black, 4.32 [95% CI, 4.25-4.39]; Hispanic, 4.13 [95% CI, 4.08-4.18]; White 3.55 [95% CI, 3.52-3.58]; Other 3.96 [95% CI, 3.84-4.08]; P < .001). Similar patterns were seen for patients whose primary language was not English. Conclusions and Relevance: In this cross-sectional study, patients who identified as Black, Hispanic, and Other race and ethnicity were assigned less acute ESI scores than their White peers despite having received more involved physician workups, suggesting some degree of mistriage. Clinical decision support systems might reduce these disparities but would require careful calibration to avoid replicating bias.

Impact of Urgent Care Openings on Emergency Department Visits to Two Academic Medical Centers Within an Integrated Health Care System.

STUDY OBJECTIVE: The effect of urgent cares on local emergency department (ED) patient volumes is presently unknown. In this paper, we aimed to assess the change in low-acuity ED utilization at 2 academic medical centers in relation to patient proximity to an affiliated urgent care. METHODS: We created a geospatial database of ED visits occurring between April 2016 and March 2018 to 2 academic medical centers in an integrated health care system, geocoded by patient home address. We used logistic regression to characterize the relationship between the likelihood of patients visiting the ED for a low-acuity condition, based on ED discharge diagnosis, and urgent care center proximity, defined as living within 1 mile of an open urgent care center, for each of the academic medical centers in the system, adjusting for spatial, temporal, and patient factors. RESULTS: We identified a statistically significant reduction in the likelihood of ED visits for low-acuity conditions by patients living within 1 mile of an urgent care center at 1 of the 2 academic medical centers, with an adjusted odds ratio of 0.87 (95% confidence interval 0.78 to 0.98). There was, however, no statistically significant reduction at the other affiliated academic medical center. Further analysis showed a statistically significant temporal relationship between time since urgent care center opening and likelihood of a low-acuity ED visit, with approximately a 1% decrease in the odds of a low-acuity visit for every month that the proximal urgent care center was open (odds ratio 0.99; 95% confidence interval 0.985 to 0.997). CONCLUSION: Although further research is needed to assess the factors driving urgent care centers' variable influence on low-acuity ED use, these findings suggest that in similar settings urgent care center development may be an effective strategy for health systems hoping to decrease ED utilization for low-acuity conditions at academic medical centers.

Testing and Treatment After Adolescent Sexual Assault in Pediatric Emergency Departments.

OBJECTIVE: To examine rates of recommended of testing and prophylaxis for chlamydia, gonorrhea, and pregnancy in adolescents diagnosed with sexual assault across pediatric emergency departments (EDs) and to determine whether specialized sexual assault pathways and teams are associated with performance of recommended testing and prophylaxis. METHODS: In this retrospective study of 12- to 18-year-old adolescents diagnosed with sexual assault at 38 EDs in the Pediatric Hospital Information System database from 2004 to 2013, information regarding routine practice for sexual assault evaluations and presence and year of initiation of specialized ED sexual assault pathways and teams was collected via survey. We examined across-hospital variation and identified patient- and hospital-level factors associated with testing and prophylaxis using logistic regression models, accounting for clustering by hospital. RESULTS: Among 12,687 included cases, 93% were female, 79% were <16 years old, 34% were non-Hispanic white, 38% were non-Hispanic black, 21% were Hispanic, and 52% had public insurance. Overall, 44% of adolescents received recommended testing (chlamydia, gonorrhea, pregnancy) and 35% received recommended prophylaxis (chlamydia, gonorrhea, emergency contraception). Across EDs, unadjusted rates of testing ranged from 6% to 89%, and prophylaxis ranged from 0% to 57%. Presence of a specialized sexual assault pathway was associated with increased rates of prophylaxis even after adjusting for case-mix and temporal trends (odds ratio 1.46, 95% confidence interval 1.15 to 1.86). CONCLUSIONS: Evaluation and treatment of adolescent sexual assault victims varied widely across pediatric EDs. Adolescents cared for in EDs with specialized sexual assault pathways were more likely to receive recommended prophylaxis.