Race and Ethnicity and Primary Language in Emergency Department Triage.

Publisher: American Medical Association Country of Publication: United States NLM ID: 101729235 Publication Model: Electronic Cited Medium: Internet ISSN: 2574-3805 (Electronic) Linking ISSN: 25743805 NLM ISO Abbreviation: JAMA Netw Open Subsets: MEDLINE

Original Publication: Chicago, IL : American Medical Association, [2018]-

Ethnicity* ; Triage*; Adult ; Humans ; Female ; Middle Aged ; Cross-Sectional Studies ; Emergency Service, Hospital ; Chest Pain

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.

Artif Intell Med. 2020 Jan;102:101762. (PMID: 31980099)
Ann Emerg Med. 2009 Jun;53(6):736-45. (PMID: 19157653)
Ann Emerg Med. 2018 May;71(5):565-574.e2. (PMID: 28888332)
Int J Nurs Stud. 2021 Jan;113:103788. (PMID: 33120136)
Clin Orthop Relat Res. 2020 Mar;478(3):455-461. (PMID: 31855593)
Pediatr Qual Saf. 2022 Aug 1;7(4):e581. (PMID: 35928021)
Clin Imaging. 2021 Dec;80:77-82. (PMID: 34274685)
J Am Coll Radiol. 2019 Aug;16(8):1036-1045. (PMID: 31092354)
JAMA Netw Open. 2022 Jun 1;5(6):e2213951. (PMID: 35653156)
J Emerg Nurs. 2019 Mar;45(2):220-222. (PMID: 30846145)
Am J Emerg Med. 2019 Sep;37(9):1770-1777. (PMID: 31186154)
Ann Emerg Med. 2010 Sep;56(3):261-9. (PMID: 20619500)
JAMA Netw Open. 2022 Sep 1;5(9):e2231769. (PMID: 36103184)
J Gen Intern Med. 2022 Jan;37(1):49-56. (PMID: 33821410)
JAMA Pediatr. 2015 Nov;169(11):996-1002. (PMID: 26366984)
Nat Methods. 2020 Mar;17(3):261-272. (PMID: 32015543)
Future Healthc J. 2021 Mar;8(1):40-48. (PMID: 33791459)
Health Serv Res. 2009 Dec;44(6):2093-105. (PMID: 19732170)
J Emerg Med. 2023 Jan;64(1):83-92. (PMID: 36450614)
Behav Med. 2019 Apr-Jun;45(2):86-101. (PMID: 31343961)
JAMA. 2012 Feb 22;307(8):813-22. (PMID: 22357832)
Emerg Med Clin North Am. 2016 May;34(2):363-75. (PMID: 27133249)
Acad Emerg Med. 2022 Nov;29(11):1320-1328. (PMID: 36104028)
Chest. 2022 Jan;161(1):112-120. (PMID: 34186038)
Ann Emerg Med. 2018 Oct;72(4):432-437. (PMID: 30238909)
Ann Emerg Med. 2012 Sep;60(3):317-25.e3. (PMID: 22401951)
Pediatr Emerg Care. 2021 Dec 1;37(12):e1457-e1461. (PMID: 32150002)
Circ Heart Fail. 2019 Nov;12(11):e006214. (PMID: 31658831)
JAMA Netw Open. 2023 Mar 1;6(3):e233404. (PMID: 36930151)
J Gen Intern Med. 2021 Feb;36(2):464-471. (PMID: 33063202)
J Am Coll Radiol. 2021 Jun;18(6):795-808. (PMID: 33385337)
Am J Community Psychol. 2010 Mar;45(1-2):87-106. (PMID: 20077134)
Science. 2019 Oct 25;366(6464):447-453. (PMID: 31649194)
J Gen Intern Med. 2018 Dec;33(12):2113-2119. (PMID: 30187374)
Simul Healthc. 2021 Aug 1;16(4):275-284. (PMID: 34398114)
PLoS One. 2019 Sep 9;14(9):e0222019. (PMID: 31498823)
JAMA Netw Open. 2020 Dec 1;3(12):e2029650. (PMID: 33320264)

Date Created: 20231012 Date Completed: 20231101 Latest Revision: 20231101

20231215

PMC10570890

10.1001/jamanetworkopen.2023.37557

37824142