Black and Hispanic patients with chest pain often downgraded in ER

Lopez L. Acad Emerg Med. doi:10.1542/peds.2009-2675 doi: 10.1111/j.1553-2712.2010.00823.x

Issue: November 2010

Triage units are less likely to prioritize black and Hispanic patients with chest pain when compared to white patients with similar symptoms, according to a study.

“In this first nationally representative sample of emergency room patients, we found persistent racial, gender and insurance-coverage based differences in triage categorization and cardiac testing,” Lenny Lopez, MD, of Massachusetts General Hospital, said in a press release. “Emergency room triage is the critical step that determines the whole cascade of clinical decisions and testing that happens next, so if patients are misclassified on arrival, they won't receive the care they need when they need it.”

The researchers studied data from the National Hospital Ambulatory Health Care Survey of Emergency Departments. Any patient entering an ED with chest pain was counted and examined for age, gender, race/ethnicity and insurance status. The data included 235,000 visits by almost 22,000 patients over a 10-year period. A patient was categorized as “emergent” if they were seen immediately or waited up to 60 minutes.

Among patients with MI, initial symptoms were similar across racial or ethnic groups. An emergent classification was less likely for patients who were black (OR=0.70; 99% CI, 0.53-0.92), Hispanic (OR=0.74; 99% CI, 0.51-0.99) on Medicaid (OR=0.72; 99% CI, 0.54-0.94) or uninsured (OR=0.65; 99% CI, 0.51 to 0.84).

ECGs were less likely in blacks (OR=0.86; 99% CI, 0.70-0.99), Medicaid patients (OR=0.70; 99% CI, 0.55-0.88) and uninsured patients (OR=0.70; 99% CI, 0.55-0.89). This directly violates American College of Cardiology and American Heart Association guidelines calling for an ECG for any patient with chest pain, the authors noted.

Cardiac enzyme studies were also less likely to be ordered in blacks (OR=0.69; 99% CI, 0.49-0.97), Medicaid patients (OR=0.67; 99% CI, 0.47-0.95), and uninsured patients (OR=0.66; 99% CI, 0.44-0.96). Blacks and Hispanics were less likely than white patients to have a cardiac monitor and pulse oximetry ordered. The uninsured and those on Medicare were less likely to have a monitor ordered, according to the study.

"These differences in ED triage may be important drivers of disparities in testing, procedures and eventual outcomes," Lopez said in the release. "If you are misclassified at this first step, you're less likely to get the ECG because your condition is not considered urgent. In the long term, you may have an even more severe heart attack that could have been prevented if intervention had occurred earlier. This is not an area of medicine where there is a lack of clarity about what we are supposed to do, so quality improvement strategies need to focus on guideline-driven triage management for every single patient."

Follow CardiologyToday.com on Twitter.