Inequities Exist in ED Triage of Heart Failure Patients—With Repercussions

Patients who present to the emergency department (ED) and receive a diagnosis of heart failure are more likely to be admitted to the cardiology service if they are white, male, and age 75 or younger, a retrospective look at data from an academic medical center shows. Black and Latinx patients, in contrast, are more likely to be admitted to the general medicine service (GMS).

Clinician researchers at Brigham and Women’s Hospital in Boston, MA, say their center’s experience, documented here over a 9-year period, “demonstrates the presence of structural racism in admission service for heart failure patients, as well as important inequities based on sex and age.”

What’s more, they found that—irrespective of race—individuals routed through cardiology were less likely to be readmitted to the hospital within 30 days.

One of the senior authors, Michelle Morse, MD, told TCTMD that the impetus for the investigation came from residents who observed certain triage patterns at Brigham and Women’s and sought to determine whether there were data that backed up their impressions of disparity, which also had been noticed by faculty and others. Around the same time, she said, the Black Lives Matter movement inspired “news, media attention, and focus on disparities, racism, and inequality in healthcare . . . . Our team of residents and faculty really said, ‘This is a window of opportunity for us to do something that’s hard to do.’”

Also important, Morse added, is that their department chair, Joseph Loscalzo, MD, PhD, supported the study itself and the idea of funding work to correct disparities that might be identified.

Harlan Krumholz, MD (Yale New Haven Hospital, CT), commenting for TCTMD, said the findings capture “a pattern that many of us are familiar with, where people are being shuttled in different directions based on factors that are independent of their condition. There are many places where, for example, people without insurance may be sent to fellows clinics or to venues away from attending clinics. I think we all are aware of these things happening. They’re a form of structural racism within our medical care system.”

You can’t simply say, ‘Well, that would never happen at my place.’ Harlan Krumholz

Inequality is, at best, “disquieting” to identify, he said. “It’s uncomfortable and there’s no reason for it—people should have equal access to the same kind of care.”

Krumholz said he appreciates how the new study expresses this concept in clear terms and emphasized that Brigham and Women’s isn’t alone in seeing these patterns. “Probably every institution should be doing an audit to see whether or not they’re also acting in the same way,” he suggested, adding, “It’s important to make sure we’re aware and really addressing these issues.” Institutions should publicly report not only what they uncover but also their efforts to reduce any disparities, Krumholz urged.

The results, with Lauren A. Eberly, MD, and Aaron Richterman, MD, as lead authors, were published online October 29, 2019, ahead of print in Circulation: Heart Failure.

Intersectionality in Healthcare

For their retrospective cohort study, Eberly et al analyzed data from September 2008 to November 2017 on patients who self-referred to Brigham and Women’s ED and had received a principal diagnosis of heart failure. Among 1,967 patients (n = 3,133 admissions), 66.7% identified as white, 23.6% as black, and 9.7% as Latinx. During their first admission, 67% of white patients were sent to cardiology, compared with 53% of black and 53% of Latinx patients during the time period (P < 0.0001).

After adjustment for year of admission, place of residence, comorbidities, and other potential confounders, both black and Latinx individuals were less apt to be admitted to the cardiology service than were white patients. So too were women and patients older than 75 years.

Likelihood of Admission to Cardiology Service Among HF Patients

Additionally, chronic pulmonary disease, end-stage renal disease, and being seen by a primary care physician at Brigham and Women’s within the past year were associated with admission to GMS, whereas cardiac valvular disease, arrhythmia, and being seen in a Brigham and Women’s cardiology clinic in the year prior were associated with admission to the cardiology service.

Admission to cardiology was independently linked to a relative 16% lower risk of readmission within 30 days, but there was no difference in 30-day mortality between the two groups.

Patients first admitted to GMS were less likely to receive follow-up at a cardiology clinic within 30 days than those first admitted to the cardiology service (25% vs 46%; P < 0.0001). After their initial admission, white patients were more likely to receive cardiology follow-up (38%) than were black or Latinx patients (34% and 45%, respectively; P = 0.04).

Difference ‘Precipitates a Cycle’

“Taken together, our findings suggest that racial inequities in admission patterns may contribute, in part, to the well-documented racial inequities in HF readmissions in the United States,” the researchers conclude, adding that the difference in care “precipitates a cycle in which inequities are compounded.”

They also make a strong case for change: “Because patients with HF tend to be admitted repeatedly, improving rates of cardiology referral and designing programs to reduce barriers for patients to see a cardiologist after discharge from GMS may both improve care for these patients and reduce inequities in subsequent admission service assignment for HF.”

Cardiologists themselves, said Krumholz, need to call on their institutions to systematically look for patterns in how patients are being treated, because it may be hard for individuals to recognize their own biases and to see the big picture.

“The extreme, explicit episodes of bias are rare, but what are even more insidious are the implicit biases” and the racism that’s embedded on a structural level, he explained. “You can’t simply say, ‘Well, that would never happen at my place.’ It’s precisely those sorts of blinders that make it difficult to appreciate that these things exist and people are being treated differentially on the basis of characteristics that should in no way affect how they get triaged.”

Our team of residents and faculty really said, ‘This is a window of opportunity for us to do something that’s hard to do.’ Michelle Morse

Morse said that, based on their study, the health equity committee within the Department of Medicine at Brigham and Women’s has funding for two different interventions: one will examine bias among doctors in all of the involved departments and the other, already begun, is an effort to standardize triage and to improve heart failure care in GMS. “Even at our best intentions, we can’t snap our fingers and build more cardiology beds,” so ensuring quality HF care in GMS is another avenue to address disparities, Morse explained.

She agreed that recognizing one’s own biases “is nearly impossible” and stressed that physicians should not have to face these issues alone.

“From our perspective, the only way we were able to really build broad support for this was by being inclusive” and encouraging collaboration among residents, faculty, and administrators across internal medicine, cardiology, and emergency medicine as well as the hospitalist service, Morse said. Not only did this interdisciplinary approach enable the research itself, it also “importantly sets you up to be able to do something about inequities in a way that’s more realistic,” she noted. “Because there’s almost nothing at academic medical centers anymore that only involves physicians.”

It’s worth remembering, Morse added, that inequities are “pervasive and structural, not specific to Brigham. For [others] who do want to do this, I would encourage them to build a broad coalition inside their institution as much as possible.”

Another lesson here is that, in contrast to what’s hinted at in much of the literature, healthcare disparities do not have a biological basis, she emphasized. “We feel strongly that this study helps to highlight the fact that race is a social construct and is not a biological driver of inequities en masse, and that our research needs to be more consistent and rigorous about understanding race as a marker—which is what it is, a risk marker—not a risk factor. That is something that we get wrong in medical research all the time.”

That there also were differences based on age and sex is a “common phenomenon,” Morse added. “It’s a great example of intersectionality in healthcare” and a reminder to be on the lookout for all sorts of unequal treatment that can be addressed.