Joshua H. Tamayo-Sarver

Racial and Ethnic Disparities in Emergency Department Analgesic Prescription

OBJECTIVES We examined racial and ethnic disparities in analgesic prescription among a national sample of emergency department patients. METHODS We analyzed Black, Latino, and White patients in the 1997-1999 National Hospital Ambulatory Medical Care Surveys to compare prescription of any analgesics and opioid analgesics by race/ethnicity. RESULTS For any analgesic, no association was found between race and prescription; opioids, however, were less likely to be prescribed to Blacks than to Whites with migraines and back pain, though race was not significant for patients with long bone fracture. Differences in opioid use between Latinos and Whites with the same conditions were less and nonsignificant. CONCLUSIONS Physicians were less likely to prescribe opioids to Blacks; this disparity appears greatest for conditions with fewer objective findings (e.g., migraine).

Racial and Ethnic Disparities in the Clinical Practice of Emergency Medicine

There is convincing evidence that racial and ethnic disparities exist in the provision of health care, including the provision of emergency care; and that stereotyping, biases, and uncertainty on the part of health care providers all contribute to unequal treatment. Situations, such as the emergency department (ED), that are characterized by time pressure, incomplete information, and high demands on attention and cognitive resources increase the likelihood that stereotypes and bias will affect diagnostic and treatment decisions. It is likely that there are many as-yet-undocumented disparities in clinical emergency practice. Racial and ethnic disparities may arise in decisions made by out-of-hospital personnel regarding ambulance destination, triage assessments made by nursing personnel, diagnostic testing ordered by physicians or physician-extenders, and in disposition decisions. The potential for disparate treatment includes the timing and intensity of ED therapy as well as patterns of referral, prescription choices, and priority for hospital admission and bed assignment. At a national roundtable discussion, strategies suggested to address these disparities included: increased use of evidence-based clinical guidelines; use of continuous quality improvement methods to document individual and institutional disparities in performance; zero tolerance for stereotypical remarks in the workplace; cultural competence training for emergency providers; increased workforce diversity; and increased epidemiologic, clinical, and services research. Careful scrutiny of the clinical practice of emergency medicine and diligent implementation of strategies to prevent disparities will be required to eliminate the individual behaviors and systemic processes that result in the delivery of disparate care in EDs.

Hurt running from police? No chance of (pain) relief: The social construction of deserving patients in emergency departments

Do physician perceptions of patient “deservingness” factor into the decision to prescribe opioid analgesics? Using a data set of 398 physicians randomly selected from the American College of Emergency Physicians (ACEP) membership list, we explore how a range of patient social context variables influence a physicians decision to prescribe opioids for three conditions: ankle fracture, back pain, and migraine headache. Being hurt running from the police, former and current drug or alcohol use, and frequent emergency room (ER) visits reduce the likelihood of opioid prescription. Having a reliable relationship with a primary care provider and being injured in a ladder fall or intramural collegiate basketball game increase the likelihood of opioid prescription. Factor analyses for each of the three conditions reveal two scales: socially stigmatizing characteristics and socially accepted characteristics. Discussion centers on what places people at risk for inadequate pain control. Our work contributes to the expanding literature on social conditions as a fundamental cause of illness.

Rapid Clinical Decisions in Context: A Theoretical Model to Understand Physicians' Decision-Making With an Application to Racial/Ethnic Treatment Disparities

The purpose of this paper is to draw on previous work in multiple disciplines to establish a theoretical framework for clinical decision-making that incorporates non-medical factors, such as race/ethnicity, into the way physicians make decisions in the practice of medicine. The proposed Rapid Clinical Decision in Context (RCDC) model attempts to understand the influence of various contextual elements on physicians’ decision-making process. The RCDC model provides a basis for future studies to move beyond documentation of areas where disparities exist to understand the causes of the disparities and designing interventions to address those causes. The paper concludes with a discussion on possible studies to test the proposed model.