Dataset Information

Disparities in cardiovascular outcomes among emergency department patients with mental illness.

ABSTRACT:

Background

Patients with mental illness have been shown to receive lower quality of care and experience worse cardiovascular (CV) outcomes compared to those without mental illness. This present study examined mental health-related disparities in CV outcomes after an Emergency Department (ED) visit for chest pain.

Methods

This retrospective cohort included adult Medicaid beneficiaries in Washington state discharged from the ED with a primary diagnosis of unspecified chest pain in 2010-2017. Outcomes for patients with any mental illness (any mental health diagnosis or mental-health specific service use within 1 year of an index ED visit) and serious mental illness (at least two claims (on different dates of service) within 1 year of an index ED visit with a diagnosis of schizophrenia, other psychotic disorder, or major mood disorder) were compared to those of patients without mental illness. Our outcomes of interest were the incidence of major adverse cardiac events (MACE) within 30 days and 6 months of discharge of their ED visit, defined as a composite of death, acute myocardial infarction (AMI), CV rehospitalization, or revascularization. Secondary outcomes included cardiovascular diagnostic testing (diagnostic angiography, stress testing, echocardiography, and coronary computed tomography (CT) angiography) rates within 30 days of ED discharge. Only treat-and-release visits were included for outcomes assessment. Hierarchical logistic random effects regression models assessed the association between mental illness and the outcomes of interest, controlling for age, gender, race, ethnicity, Elixhauser comorbidities, and health care use in the past year, as well as fixed year effects.

Results

There were 98,812 treat-and-release ED visits in our dataset. At 30 days, enrollees with any mental illness had no differences in rates of MACE (AOR 0.96; 95% CI, 0.72-1.27) or any of the individual components. At 6 months, enrollees with any mental illness (AOR 1.86; 95% CI, 1.11-3.09) and serious mental illness (AOR 2.60; 95% CI 1.33-5.13) were significantly more likely to be hospitalized for a CV condition compared to those without mental illness. Individuals with any mental illness had higher rates of testing at 30 days (AOR 1.16; 95% CI 1.07-1.27).

Conclusion

Patients with mental illness have similar rates of MACE, but higher rates of certain CV outcomes, such as CV hospitalization and diagnostic testing, after an ED visit for chest pain.

SUBMITTER: Kumar S

PROVIDER: S-EPMC9018581 | biostudies-literature | 2022 May

REPOSITORIES: biostudies-literature

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Publications

Disparities in cardiovascular outcomes among emergency department patients with mental illness.

Kumar Shilpa S Duber Herbert C HC Kreuter William W Sabbatini Amber K AK

The American journal of emergency medicine 20220224

<h4>Background</h4>Patients with mental illness have been shown to receive lower quality of care and experience worse cardiovascular (CV) outcomes compared to those without mental illness. This present study examined mental health-related disparities in CV outcomes after an Emergency Department (ED) visit for chest pain.<h4>Methods</h4>This retrospective cohort included adult Medicaid beneficiaries in Washington state discharged from the ED with a primary diagnosis of unspecified chest pain in 2 ...[more]

PMID: 35279577

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Project description:ImportanceNoninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.ObjectiveTo determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.Design, setting, and participantsThis retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.ExposuresNoninvasive testing or coronary angiography within 2 days or 30 days of presentation.Main outcomes and measuresThe primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.ResultsThe patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.Conclusions and relevanceCardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.

Project description:BACKGROUND:The goal of these analyses was to determine whether there were systematic differences in Emergency Severity Index (ESI) scores, which are intended to determine priority of treatment and anticipate resource needs, across categories of race and ethnicity, after accounting for patient-presenting vital signs and examiner characteristics, and whether these differences varied among male and female Veterans Affairs (VA) ED patients. METHODS AND FINDINGS:We used a large national database of electronic medical records of ED patients from twenty-two U.S. Department of Veterans Affairs ED stations to determine whether ESI assignments differ systematically by race or ethnicity. Multi-level, random effects linear modeling was used to control for demographic characteristics and patient's vital signs (heart rate, respiratory rate, and pain level), as well as age, gender, and experience of triage nurses. The dataset included 129,991 VA patients presenting for emergency care between 2008 and 2012 (91% males; 61% non-Hispanic White, 28% Black, 7% Hispanic, 2% Asian, <1% American Indian/Alaska Native, 1% mixed ethnicity) and 774 nurses for a total of 359,642 patient/examiner encounters. Approximately 13% of the variance in ESI scores was due to patient characteristics and 21% was due to the nurse characteristics. After controlling for characteristics of nurses and patients, Black patients were assigned less urgent ESI scores than White patients, and this effect was more prominent for Black males compared with Black females. A similar interaction was found for Hispanic males. It remains unclear how these results may generalize to EDs and patient populations outside of the U.S. VA Health Care system. CONCLUSIONS:The findings suggest the possibility that subgroups of VA patients receive different ESI ratings in triage, which may have cascading, downstream consequences for patient treatment quality, satisfaction with care, and trust in the health equity of emergency care.

Project description:Importance:An association between frequent use of the emergency department (ED) and mental health diagnoses is frequently documented in the literature, but little has been done to more thoroughly understand why mental illness is associated with increased ED use. Objective:To determine which factors were associated with higher ED use in the near future among patients with and without mental health diagnoses. Design, Setting, and Participants:A retrospective case-control study of all patients presenting to the ED in California in 2013 using past ED data to predict future ED use. Data from January 1, 2012, through December 31, 2014, from California's Office of Statewide Health Planning and Development were analyzed. Main Outcomes and Measures:Factors associated with higher ED use in the year following an index visit for patients with vs without a mental health diagnosis. Results:Among the 3?446?338 individuals in the study (accounting for 7?678?706 ED visits), 44.6% (1?537?067) were male; 31.6% (1?089?043) were between the ages of 18 and 30 years, 40.3% (1?338?874) were between the ages of 31 and 50 years, and 28.1% (968?421) were between the ages of 51 and 64 years. The mean (SD) number of ED visits per patient per year was 1.69 (2.56), and 29.1% of patients (1?002?884) had at least 1 mental health diagnosis. Previous hospitalization and high rates of lagged ED visits were associated with higher future ED use. The severity of the mental health diagnosis (mild, moderate, or severe) was associated with increased ED visits (incidence rate ratio [IRR], 1.029; 95% CI, 1.02-1.04 for mild; IRR, 1.121; 95% CI, 1.11-1.13 for moderate; and IRR, 1.226; 95% CI, 1.22-1.24 for severe). Little evidence was found for interaction effects between mental health diagnoses and other diagnoses in predicting increased future ED use. Conclusions and Relevance:Certain classes of mental health diagnoses were associated with higher ED use. The presence of a mental illness diagnosis did not appear to interact with other patient-level factors in a way that meaningfully altered associations with future ED use.

Project description:ImportanceEmergency department (ED) triage models are intended to queue patients for treatment. In the absence of higher acuity, patients of the same acuity should room in order of arrival.ObjectiveTo characterize disparities in ED care access as unexplained queue jumps (UQJ), or instances in which acuity and first come, first served principles are violated.Design, setting, and participantsRetrospective, cross-sectional study between July 2017 and February 2020. Participants were all ED patient arrivals at 2 EDs within a large Northeast health system. Data were analyzed from July to September 2022.ExposureUQJ was defined as a patient being placed in a treatment space ahead of a patient of higher acuity or of a same acuity patient who arrived earlier.Main outcomes and measuresPrimary outcomes were odds of a UQJ and association with ED outcomes of hallway placement, leaving before treatment complete, escalation to higher level of care while awaiting inpatient bed placement, and 72-hour ED revisitation. Secondary analysis examined UQJs among high acuity ED arrivals. Regression models (zero-inflated Poisson and logistic regression) adjusted for patient demographics and ED operational variables at time of triage.ResultsOf 314 763 included study visits, 170 391 (54.1%) were female, the mean (SD) age was 50.46 (20.5) years, 132 813 (42.2%) patients were non-Hispanic White, 106 401 (33.8%) were non-Hispanic Black, and 66 465 (21.1%) were Hispanic or Latino. Overall, 90 698 (28.8%) patients experienced a queue jump, and 78 127 (24.8%) and 44 551 (14.2%) patients were passed over by a patient of the same acuity or lower acuity, respectively. A total of 52 959 (16.8%) and 23 897 (7.6%) patients received care ahead of a patient of the same acuity or higher acuity, respectively. Patient demographics including Medicaid insurance (incident rate ratio [IRR], 1.11; 95% CI, 1.07-1.14), Black non-Hispanic race (IRR, 1.05; 95% CI, 1.03-1.07), Hispanic or Latino ethnicity (IRR, 1.05; 95% CI, 1.02-1.08), and Spanish as primary language (IRR, 1.06; 95% CI, 1.02-1.10) were independent social factors associated with being passed over. The odds of a patient receiving care ahead of others were lower for ED visits by Medicare insured (odds ratio [OR], 0.92; 95% CI, 0.88-0.96), Medicaid insured (OR, 0.81; 95% CI, 0.77-0.85), Black non-Hispanic (OR, 0.94; 95% CI, 0.91-0.97), and Hispanic or Latino ethnicity (OR, 0.87; 95% CI, 0.83-0.91). Patients who were passed over by someone of the same triage severity level had higher odds of hallway bed placement (OR, 1.01; 95% CI, 1.00-1.02) and leaving before disposition (OR, 1.02; 95% CI, 1.01-1.04).Conclusions and relevanceIn this cross-sectional study of ED patients in triage, there were consistent disparities among marginalized populations being more likely to experience a UQJ, hallway placement, and leaving without receiving treatment despite being assigned the same triage acuity as others. EDs should seek to standardize triage processes to mitigate conscious and unconscious biases that may be associated with timely access to emergency care.

Project description:IntroductionRacial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients' self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States.MethodsThis was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019-December 31, 2020. We collected demographic and clinical information, including patients' race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient's race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival.ResultsWe studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival.ConclusionHispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia.

Dataset Information

Disparities in cardiovascular outcomes among emergency department patients with mental illness.

Background

Methods

Results

Conclusion

Publications

Disparities in cardiovascular outcomes among emergency department patients with mental illness.

Similar Datasets

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