Black patients less likely to receive diagnostic testing for common conditions

Key takeaways:

• Study findings suggest that Black patients may be at risk for undertesting and missed diagnoses.
• Several drivers of these disparities were highlighted by researchers, like racial bias in the ED triage process.

White patients discharged from the ED with a nonspecific diagnosis, like vomiting or chest pain, were more likely to receive related diagnostic testing vs. Black patients, according to a recent analysis in JAMA Network Open.

As a result, white patients may be exposed to overuse of diagnostic testing, whereas Black patients may be at risk for undertesting and missed diagnoses, the researchers noted.

“Much of the research on diagnostic intensity and low-value care has historically focused on measuring this phenomenon at the regional level,” Michael I. Ellenbogen, MD, an assistant professor of medicine at the Johns Hopkins University School of Medicine, told Healio. “However, we felt that many of the drivers of low-value care and diagnostic overuse are the result of incentives at the hospital level. These two indices can be applied to understand hospital-level factors associated with diagnostic intensity, but they can also be used to understand patient-level factors associated with diagnostic intensity.”

In the cross-sectional study, the researchers analyzed ED discharges, hospital observation stays and hospital admissions between 2016 and 2018 using administrative claims among EDs and acute-care hospitals in several states.

They proceeded to use a diagnostic intensity index that paired nonspecific discharge diagnoses — like syncope, nausea and vomiting, chest pain and abdominal pain — with related diagnostic testing to determine the rates of nondiagnostic testing.

The study included 3,683,055 encounters, among which 28.7% included encounters with Black patients and 80.6% were ED discharges. The most common diagnosis was chest pain, whereas patients with nausea and vomiting were least likely to receive related testing.

Black patients discharged from the ED with a diagnosis of interest had an adjusted OR of 0.74 (95% CI, 0.72-0.75) of having related diagnostic testing compared with white patients.

These findings persisted in subanalyses, Ellenbogen and colleagues noted.

Further results showed Black patients as less likely to undergo observation stays compared with white patients (aOR = 0.92; 95% CI, 0.9-0.94), “although the magnitude was smaller,” the researchers wrote.

Ellenbogen offered several possible explanations behind the findings.

“I suspect this is due in part [to] racial bias in ED triage, which a number of studies have identified,” he said. “Additionally, communication difficulty between physicians who are predominantly white and Black patients might lead to Black patients’ symptoms being dismissed more often.”

He added that implicit bias may also be a factor.

“The greater time pressure that ED physicians face — compared with hospitalists — could explain why we observed this trend for patients discharged from the ED but not those admitted to the hospital,” he said.

The researchers identified multiple study limitations.. For example, they did not test study underuse, “limiting our ability to evaluate variation in missed diagnoses across races and ethnicities,” they wrote.

Study investigators also lacked the ability to adjust for factors like education level and income.
disparities in diagnostic intensity among patients discharged from the ED.

“They are the ones who will be seeing these patients after discharge from the ED,” he said. “They should be aware that Black patients may be at higher risk for a missed diagnosis — at least for the discharge diagnoses we looked at — and be sure to perform a thorough evaluation for resolution of these symptoms to decide if further workup is needed.”