Cleveland Manchanda Emily C, Marsh Regan H, Osuagwu Chidinma, Decopain Michel Jennifer, Dugas Julianne N, Wilson Michael, Morse Michelle, Lewis Eldrin, Wispelwey Bram P
Department of Emergency Medicine, Boston Medical Center, Boston, USA.
Department of Emergency Medicine, Boston University School of Medicine, Boston, USA.
Cureus. 2021 Feb 16;13(2):e13381. doi: 10.7759/cureus.13381.
Background Racial inequities in mortality and readmission for heart failure (HF) are well documented. Inequitable access to specialized cardiology care during admissions may contribute to inequity, and the drivers of this inequity are poorly understood. Methodology This prospective observational study explored proposed drivers of racial inequities in cardiology admissions among Black, Latinx, and white adults presenting to the emergency department (ED) with symptoms of HF. Surveys of ED providers examined perceptions of patient self-advocacy, outreach to other clinicians (e.g., outpatient cardiologist), diagnostic uncertainty, and other active co-morbid conditions. Service census, bed availability, prior admission service, and other structural factors were explored through the electronic medical record. Results Complete data were available for 61/135 patients admitted with HF during the study period, which halted early due to coronavirus disease 2019. No significant differences emerged in admission to cardiology versus medicine based on age, sex, insurance status, education level, or perceived race/ethnicity. White patients were perceived as advocating for admission to cardiology more frequently (18.9 vs. 5.6%) and more strenuously than Black patients (p = 0.097). ED clinicians more often reported having spoken with the patient's outpatient cardiologist for whites than for Black or Latinx patients (24.3 vs. 16.7%, p = 0.069). Conclusions Theorized drivers of racial inequities in admission service did not reach statistical significance, possibly due to underpowering, the Hawthorne effect, or clinician behavior change based on knowledge of previously identified inequities. The observed trend towards racial differences in coordination of care between ED and outpatient providers, as well as in either actual or perceived self-advocacy by patients, may be as-yet undemonstrated components of structural racism driving HF care inequities.
背景 心力衰竭（HF）死亡率和再入院率方面的种族不平等现象有充分记录。住院期间获得专科心脏病护理的机会不平等可能导致不平等，而这种不平等的驱动因素却知之甚少。方法 这项前瞻性观察性研究探讨了因出现HF症状而前往急诊科（ED）的黑人、拉丁裔和白人成年人在心脏病住院治疗中种族不平等的潜在驱动因素。对ED医护人员的调查考察了对患者自我倡导、与其他临床医生（如门诊心脏病专家）沟通、诊断不确定性以及其他现存合并症的看法。通过电子病历探索了服务普查、床位可用性、既往住院服务及其他结构因素。结果 在研究期间，因2019年冠状病毒病研究提前终止，共有61/135例HF住院患者获得了完整数据。基于年龄、性别、保险状况、教育水平或感知的种族/族裔，在入住心脏病科与内科方面未出现显著差异。白人患者被认为比黑人患者更频繁（18.9%对5.6%）且更强烈地主张入住心脏病科（p = 0.097）。ED临床医生报告称，与黑人或拉丁裔患者相比，与白人患者的门诊心脏病专家沟通的频率更高（24.3%对16.7%，p = 0.069）。结论 入院服务中种族不平等的理论驱动因素未达到统计学意义，可能是由于样本量不足、霍桑效应或临床医生基于先前确定的不平等知识而改变行为。在ED与门诊医护人员之间的护理协调方面以及患者实际或感知的自我倡导方面观察到的种族差异趋势，可能是推动HF护理不平等的结构种族主义尚未得到证实的组成部分。
