Identifying Patient Subpopulations with Significant Race-Sex Differences in Emergency Department Disposition Decisions.

Background/objectives: The race-sex differences in emergency department (ED) disposition decisions have been reported widely. Our objective is to identify demographic and clinical subgroups for which this difference is most pronounced, which will facilitate future targeted research on potential disparities and interventions. Methods: We performed a retrospective analysis of 93 987 White and African-American adults assigned an Emergency Severity Index of 3 at 3 large EDs from January 2019 to February 2020. Using random forests, we identified the Elixhauser comorbidity score, age, and insurance status as important variables to divide data into subpopulations. Logistic regression models were then fitted to test race-sex differences within each subpopulation while controlling for other patient characteristics and ED conditions. Results: In each subpopulation, African-American women were less likely to be admitted than White men with odds ratios as low as 0.304 (95% confidence interval (CI): [0.229, 0.404]). African-American men had smaller admission odds compared to White men in subpopulations of 41+ years of age or with very low/high Elixhauser scores, odds ratios being as low as 0.652 (CI: [0.590, 0.747]). White women were less likely to be admitted than White men in subpopulations of 18 to 40 or 41 to 64 years of age, with low Elixhauser scores, or with Self-Pay or Medicaid insurance status with odds ratios as low as 0.574 (CI: [0.421, 0.784]). Conclusions: While differences in likelihood of admission were lessened by younger age for African-American men, and by older age, higher Elixhauser score, and Medicare or Commercial insurance for White women, they persisted in all subgroups for African-American women. In general, patients of age 64 years or younger, with low comorbidity scores, or with Medicaid or no insurance appeared most prone to potential disparities in admissions.

Patient sex, racial and ethnic disparities in emergency department triage: A multi-site retrospective study.

OBJECTIVES: There is limited evidence on sex, racial, and ethnic disparities in Emergency Department (ED) triage across diverse settings. We evaluated differences in the assignment of Emergency Severity Index (ESI) by patient sex and race/ethnicity, accounting for age, clinical factors, and ED operating conditions. METHODS: We conducted a multi-site retrospective study of adult patients presenting to high-volume EDs from January 2019-February 2020. Patient-level data were obtained and analyzed from three EDs (academic, metropolitan community, and rural community) affiliated with a large health system in the Southeastern United States. For the study outcome, ESI levels were grouped into three categories: 1-2 (highest acuity), 3, and 4-5 (lowest acuity). Multinomial logistic regression was used to compare ESI categories by patient race/ethnicity and sex jointly (referent = White males), adjusted for patient age, insurance status, ED arrival mode, chief complaint category, comorbidity score, time of day, day of week, and average ED wait time. RESULTS: We identified 186,840 eligible ED visits with 56,417 from the academic ED, 69,698 from the metropolitan community ED, and 60,725 from the rural community ED. Patient cohorts between EDs varied by patient age, race/ethnicity, and insurance status. The majority of patients were assigned ESI 3 in the academic and metropolitan community EDs (61% and 62%, respectively) whereas 47% were assigned ESI 3 in the rural community ED. In adjusted analyses, White females were less likely to be assigned ESI 1-2 compared to White males although both groups were roughly comparable in the assignment of ESI 4-5. Non-White and Hispanic females were generally least likely to be assigned ESI 1-2 in all EDs. Interactions between ED wait time and race/ethnicity-sex were not statistically significant. CONCLUSIONS: This retrospective study of adult ED patients revealed sex and race/ethnicity-based differences in ESI assignment, after accounting for age, clinical factors, and ED operating conditions. These disparities persisted across three different large EDs, highlighting the need for ongoing research to address inequities in ED triage decision-making and associated patient-centered outcomes.

Disparities in emergency department prioritization and rooming of patients with similar triage acuity score.

BACKGROUND: We identify patient demographic and emergency department (ED) characteristics associated with rooming prioritization decisions among ED patients who are assigned the same triage acuity score. METHODS: We performed a retrospective analysis of adult ED patients with similar triage acuity, as defined as an Emergency Severity Index (ESI) of 3, at a large academic medical center, during 2019. Violations of a first-come-first-served (FCFS) policy for rooming are identified and used to create weighted multiple logistic regression models and 1:M matched case-control conditional logistic regression models to determine how rooming prioritization is affected by individual patient age, sex, race, and ethnicity after adjusting for patient clinical and time-varying ED operational characteristics. RESULTS: A total of 15,781 ED encounters were analyzed, with 1612 (10.2%) ED encounters having a rooming prioritization in violation of a FCFS policy. Patient age and race were found to be significantly associated with being prioritized in violation of FCFS in both logistic regression models. The 1:M matched model showed a statistically significant relationship between violation of rooming prioritization with increasing age in years (adjusted odds ratio [aOR] 1.009, 95% confidence interval [CI] 1.005-1.013) and among African American patients compared to Caucasians (aOR 0.636, 95% CI 0.545-0.743). CONCLUSIONS: Among ED patients with a similar triage acuity (ESI 3), we identified patient age and patient race as characteristics that were associated with deviation from a FCFS prioritization in ED rooming decisions. These findings suggest that there may be patient demographic disparities in ED rooming decisions after adjusting for clinical and ED operational characteristics.

The effects of emergency department crowding on triage and hospital admission decisions.

BACKGROUND: Emergency department (ED) crowding is a recognized issue and it has been suggested that it can affect clinician decision-making. OBJECTIVES: Our objective was to determine whether ED census was associated with changes in triage or disposition decisions made by ED nurses and physicians. METHODS: We performed a retrospective study using one year of data obtained from a US academic center ED (65,065 patient encounters after cleaning). Using a cumulative logit model, we investigated the association between a patient's acuity group (low, medium, and high) and ED census at triage time. We also used multivariate logistic regression to investigate the association between the disposition decision for a patient (admit or discharge) and the ED census at the disposition decision time. In both studies, control variables included census, age, gender, race, place of treatment, chief complaint, and certain interaction terms. RESULTS: We found statistically significant correlation between ED census and triage/disposition decisions. For each additional patient in the ED, the odds of being assigned a high acuity versus medium or low acuity at triage is 1.011 times higher (95% confidence interval [CI] for Odds Ratio [OR] = [1.009,1.012]), and the odds of being assigned medium or high acuity versus low acuity at triage is 1.009 times higher (95% CI for OR = [1.008,1.010]). Similarly, the odds of being admitted versus discharged increases by 1.007 times (95% CI for OR = [1.006,1.008]) per additional patient in the ED at the time of disposition decision. CONCLUSION: Increased ED occupancy was found to be associated with more patients being classified as higher acuity as well as higher hospital admission rates. As an example, for a commonly observed patient category, our model predicts that as the ED occupancy increases from 25 to 75 patients, the probability of a patient being triaged as high acuity increases by about 50% and the probability of a patient being categorized as admit increases by around 25%.