Study findings highlight the need to reflect on practices for evaluating and admitting patients for emergent surgical procedures from the emergency department.
The effects of racism on health in marginalized patient groups continue to contribute to disparities in care. About 67.3 million Americans speak a language other than English at home, and 10% of working-age Americans have limited English proficiency (LEP). Studies have shown that patients with LEP have higher rates of postoperative hospital admissions and infections and have more unplanned ED revisits than those without LEP. Patients with LEP also have higher in-hospital mortality rates and more frequent major adverse cardiovascular and cerebrovascular events. However, the combined effects of race and English language proficiency on healthcare outcomes have been relatively understudied.
An Opportunity to Evaluate Racism & LEP on Surgical Care Delivery
Sociocultural factors such as race, English proficiency, and ethnicity are known to impact ED and inpatient quality of care, but the need to undergo emergency surgery is sometimes not clearly or directly influenced by these factors. For a study published in the Western Journal of Emergency Medicine, Marc D. Succi, MD, Grant Rigney, and colleagues assessed the influence of race and English proficiency on admission for emergency surgery from the ED. “Examining urgent surgery procedures give us a unique opportunity to evaluate the impact of racism and language proficiency on the delivery of surgical care,” Dr. Succi says.
For the retrospective observational cohort study, investigators assessed ED patients from all self-reported races who reported preferring to speak a language other than English and required an interpreter (intervention group) or declared English as their preferred language (control group). A multivariable logistic regression was used to assess the associations of LEP status, race, age, sex, method of arrival to the ED, insurance status, and the interaction between LEP status and race with admission for surgery from the ED. The total study sample included 85,899 patients—48.1% of whom were women—and 3.7% of all cases were admitted for emergent surgery.
Several Factors Influence the Likelihood of Urgent Surgical Care
“Regardless of LEP status, our study found that patients identifying as Black or Asian had a significantly lower likelihood of being admitted for surgery from the ED when compared with White patients,” says Dr. Succi (Table). “Women had similarly lower odds for admission as men.” Compared with people on Medicare, those with private insurance were significantly more likely to be admitted for emergent surgery. Patients without insurance were much less likely to be admitted. “This finding suggests that having private insurance often determined the care path for patients,” Dr. Succi says.
Of note, the researchers found no evidence that people with LEP were more or less likely to be admitted for emergent surgery than their English proficient counterparts. A simpler multivariable logistic regression model found that individuals with LEP were more likely to be admitted for surgery than those who were English proficient. However, this association diminished after adjusting for age, sex, method of arrival to the ED, race, and insurance status. “Taken together, the findings suggest ED disparities are complex and might be originating elsewhere in the care process,” says Rigney.
Improving Care in the ED: Time to Reflect on Internal Practices
According to Dr. Succi, the findings highlight the need for institutions to reflect on their practices for evaluating and admitting patients for emergent procedures from the ED. “Improving how racial and ethnic minorities are triaged in the ED might lead to better patient outcomes,” he says. “Institutions should assess their current practices and consider implementing simple, formalized checklists as a part of standard operating procedures to improve how patients are triaged in the ED.”
Dr. Succi notes that additional studies are needed to better understand factors that drive lower admission rates for surgery among minorities and women. “Such research should specifically look at measures of discrimination among patients in the ED,” he says. “Future analyses should also seek to clarify other factors that may influence a patient’s admission for surgery outside of race, gender, and insurance status.”
