Clinical Context

There is evidence of racial and ethnic bias across the US healthcare system, including the emergency department (ED). But does the emergency medical services transport system contribute to health disparities based on race? A previous study by Hanchate and colleagues, which appeared in the September 4, 2019, issue of JAMA Network Open, explored this issue.^[1]

The study cohort comprised more than 860,000 Medicare enrollees, all older than 66 years, and there were 4,175 ZIP codes represented. The ED most frequently used by White patients in a particular ZIP code was used as the reference ED. White patients were transferred via emergency medical services to the reference ED 61.3% of the time. However, the respective rates of 56.0% and 58.8% among Black and Hispanic patients were significantly lower for transfer to the reference ED. The difference in transfer rates was similar regardless of the acuity of patients' conditions, and Black and Hispanic patients were more likely to be transferred to safety-net hospitals.

On arrival to the ED, people of color still can face differences in care. The current study builds on previous limited evidence that children from racial and ethnic minorities are less likely to receive diagnostic imaging in the ED.

Study Synopsis and Perspective

Non-Hispanic White children were more likely to receive diagnostic imaging at children's hospitals' EDs across the United States than were Hispanic children and non-Hispanic Black children, according to a large study published in JAMA Network Open.^[2]

Researchers found that the more the percentage of children from minority groups cared for by a hospital increased, the wider the imaging gap between those children and non-Hispanic White children.

In the cross-sectional study, led by Margaret E. Samuels-Kalow, MD, MPhil, MSHP, from the Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School in Boston, included 38 children's hospitals and more than 12 million ED visits.

"These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine," the authors write.

Patients included in the study were younger than 18 years and visited an ED from January 2016 through December 2019. Data were pulled from the Pediatric Health Information System.

Of the more than 12 million visits in this study, 3.5 million (28.7%) involved at least 1 diagnostic imaging test.

Diagnostic imaging was performed in 1.5 million visits (34.2%) for non-Hispanic White children, 790,961 (24.6%) for non-Hispanic Black children, and 907,222 (26.1%) for Hispanic children (P<.001).

Non-Hispanic Black children were consistently less likely to get diagnostic imaging than their non-Hispanic White counterparts at every hospital in the study, no matter the imaging modality: radiography, ultrasonography, computed tomography, or magnetic resonance imaging (MRI).

Hispanic patients were generally less likely to receive imaging than non-Hispanic White patients, although results were less consistent for ultrasound and MRI.

In a sensitivity analysis, when looking at imaging from patients' first visit across the study cohort, non-Hispanic Black children were significantly less likely to get imaging than non-Hispanic White children (adjusted odds ratio, 0.77; 95% confidence interval, 0.74-0.79).

"This remained significant even after adjustment for a priori specified confounders including hospital propensity to image," the authors write.

The authors acknowledge that it is possible that some of the differences may be attributable to the patient mix regarding severity of cases or indications for imaging by hospital, but they note that all models were adjusted for diagnosis-related group and other potential confounders.

This study did not assess whether 1 group is being overtested. Researchers also note that higher rates of imaging do not necessarily indicate higher quality of care.

However, the authors note, previous research has suggested overtesting of non-Hispanic White patients for head computed tomography and chest pain, as well as patterns of overtreatment of non-Hispanic White patients who have bronchiolitis or viral upper respiratory tract infections.

Medell Briggs-Malonson, MD, MPH, chief of health equity, diversity and inclusion for the University of California, Los Angeles, Hospital and Clinic System, who was not part of the study, said in an interview, "this all rings true."

"This is not the first study we have had in either the pediatric or adult populations that shows disparate levels of care, as well as health outcomes. Now we are starting to be able to measure it," she said.

This study is further evidence of medical racism, she says, and highlights that it's not the hospital choice or the insurance type affecting the numbers, she said.

"When you control for those factors, it looks to be it's only due to race, and that's because of the very deep levels of implicit bias as well as explicit bias that we still have in our health systems, and even in our providers," said Dr Briggs-Malonson, who is also an associate professor of emergency medicine at the University of California, Los Angeles. "It's incredibly important to identify and immediately address."

Clinical Implications

• A previous study found that EMS was less likely to transfer Medicare patients who were Black or Hispanic to a hospital where the highest number of White patients were seen. Black and Hispanic patients were more likely to be transferred to safety-net hospitals. These differences persisted regardless of acuity of illness.
• The current study demonstrates a lower rate of diagnostic imaging applied to Black and Hispanic patients vs White patients in pediatric EDs. Hospital variables associated with a higher rate of this disparity included a higher proportion of patients from minority backgrounds, a higher proportion of patients with Medicaid, and a higher volume of radiographic studies overall.
• Implications for the healthcare team: The healthcare team should understand its biases in caring for patients. Adherence to evidence-based guidelines for the application of diagnostic imaging can reduce the effect of bias. Healthcare team members must be aware of the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine.

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