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Disparities in Cardiac Care Seen in ED Lisa Nainggolan
Heartwire 2007. © 2007 Medscape
February 2, 2007 (Milwaukee, WI) – A new survey has found further evidence of disparities in cardiac care, this time in the emergency-department (ED) evaluation of chest pain [1]. Dr Liliana E Pezzin (Medical College of Wisconsin, Milwaukee) and colleagues report their findings in the February 2007 issue of Academic Emergency Medicine. They showed that race, gender, and insurance differences affected the likelihood of a person presenting to the ER with chest pain receiving one of four common noninvasive diagnostic tests: ECG, cardiac monitoring (CM), oxygen saturation measurement using pulse oximetry (O2 sat), and chest radiography (CXR). Senior author Dr Gary B Green (Johns Hopkins University, Baltimore, MD) told heartwire: "These four tests are noninvasive and are generally considered to be standard of care for ED chest-pain patients and are often done prior to physician evaluation. Nearly all other cardiac-disparities studies have focused on physician decision making, while the findings here hint at a more pervasive healthcare system bias from the time of arrival at the front door." Study distinctive in three ways Pezzin et al drew on data compiled by the US National Hospital Ambulatory Health Care Survey of Emergency Departments (NHAMCS-ED) from 1995 to 2000 for patients 30 years old or older presenting with chest pain. The retrospective study used a sample of 7068 patients, which corresponded to 32 million visits nationally throughout the six-year period. "Our study differs from related work on disparities in cardiac care in three important respects," they say. First, its focus is on a nationwide population. Second, most previous research has examined disparities in care of hospitalized patients rather than those presenting to the ED, they note. And last, they focused on time trends, which is important, says Green, because the data illustrate that the disparities became significantly greater between 1995 and 2000. "The time trend data show that the disparity seems to be worsening rather than improving. No clear explanation is provided by the study, but we can speculate that as ED overcrowding worsens, fewer tests are being done on those who are perceived (often incorrectly) to be less likely to have 'real' disease," he noted. "Striking" differences by race, gender, and, to a lesser extent, insurance "Our findings reveal striking differences by race and gender and, to a lesser extent, insurance on the probability of ordering an ECG, CM, O2 sat, and CXR testing in the ED," the researchers observe. Overall, African American males were 25% to 30% percent less likely to receive any of the tests than non-African American males. African American women were approximately 5% less likely to have an ECG than non-African American men. And African American women were 17% less likely to undergo cardiac monitoring, 14% less likely to have pulse oximetry, and 6% less likely to have chest X-rays than non-African American men. Similarly, the rate of testing was lower for non-African American women than it was for non-African American men. Patients covered by forms of insurance other than commercial insurance were approximately 13% less likely to undergo ECG, 21% less likely to be placed on cardiac monitoring, 23% less likely to have oxygen saturation measured, and more than 13% less likely to have a chest X-ray than those with commercial insurance. Adjusted probabilities of diagnostic tests for patients aged >30 presenting to EDs with chest pain, by race/gender: US 1995-2000
(p=0.01), and non-African American women CXR (p=0.06) "Inaccurate and sometimes negative stereotypes among physicians and healthcare workers certainly exist and may contribute to the now widely documented existence of healthcare disparities," Pezzin and colleagues state. "Identifying the root causes and their relative contributions to disparities in ED care is arguably a more critical and more difficult task than documenting the existence of these disparities," they conclude.
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