Racial Disparities

AEM Early Acess 15: Predicting High ED Utilization Among Patients With Asthma Exacerbations

Welcome to the fifteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING: (open access through June 30, 2018; click on title to access.)

Comparing Statewide and Single-center Data to Predict High-frequency Emergency Department Utilization Among Patients With Asthma Exacerbation. Margaret E. Samuels-Kalow, MD, MPhil, MSHP, Mohammad K. Faridi, MPH, Janice A. Espinola, MPH, Jean E. Klig, MD, and Carlos A. Camargo, Jr., MD, DrPH. Academic Emergency Medicine, 2018.

 

LISTEN NOW: AUTHOR INTERVIEW WITH DR. SAMUELS-KALOW

Recorded on site at SAEM 2018 in Indianapolis.  Stay tuned to the end for a BONUS about Dr. Samuels-Kalow's winning EXCITE project submission, addressing gender disparities and the 'leaky pipeline' of female leadership in academic emergency medicine. 

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Margaret Samuels-Kalow MD MPhil MSHP

Assistant Professor of Emergency Medicine

Massachusetts General Hospital/Harvard Medical School

ARTICLE SUMMARY:

Background: Previous studies examining high-frequency emergency department (ED) utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single-center data.

Methods: To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single-center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike’s Information Criterion scores, 10-fold cross-validation, and receiver operating characteristic curves.

Results: Among children, high-frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10-fold cross-validation for children was 0.70 (95% confidence interval [CI] = 0.69–0.72), compared to 0.71 (95% CI = 0.69–0.72) in the single-center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76–0.77) and 0.76 (95% CI = 0.75–0.77), respectively.

Conclusion: Data available at the index ED visit can predict subsequent high-frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single-center).

ADDITIONAL READING:

"Looking out for each other": a qualitative study on the role of social network interactions in asthma management among adult Latino patients presenting to an emergency department. Pai S1, Boutin-Foster C, Mancuso CA, Loganathan R, Basir R, Kanna B. 
J Asthma. 2014 Sep;51(7):714-9. doi: 10.3109/02770903.2014.903967. Epub 2014 Apr 7.

"No other choice": reasons for emergency department utilization among urban adults with acute asthma. Lawson CC1, Carroll K, Gonzalez R, Priolo C, Apter AJ, Rhodes KV. Acad Emerg Med 2014 Jan;21(1):1-8. doi: 10.1111/acem.12285.

Duseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after an emergency department encounter: a multistate analysis. Ann Intern Med 2015;162:750-6.

Horrocks D, Kinzer D, Afzal S, Alpern J, Sharfstein JM. The Adequacy of Individual Hospital Data to Identify High Utilizers and Assess Community Health. JAMA Intern Med 2016;176:856-8.    

AEM Early Access 06: Gender and Racial Disparities Among Academic Emergency Medicine Physicians

Welcome to the sixth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

LISTEN NOW: Author INTERVIEW WITH DR. TRACY MADSEN

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Dr. Tracy Madsen

Assistant Professor, Division of Sex and Gender in Emergency Medicine (SGEM)

Department of Emergency Medicine

Alpert Medical School, Brown University

Full text of this month's article (open access through November 1, 2017): Click below

Tracy E. Madsen, et al., “Current Status of Gender and Racial/Ethnic Disparities Among Academic Emergency Medicine Physicians,” A Joint 2015 Report by Academy for Women in Academic Emergency Medicine (AWAEM), Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) and Academy of Administrators in Academic Emergency Medicine (AAAEM).

ARTICLE SUMMARY:

Objective: A 2010 survey identified disparities in salaries by gender and underrepresented minorities.  With an increase in the EM workforce since, the authors aimed to 1) describe the current status of academic EM workforce by gender, race and rank, and 2) evaluate if disparities still exist in salary or rank by gender.

Methods: Information on demographics, rank, clinical commitment, and base and total annual salary for full-time faculty members in U.S. academic EDs was collected in 2015 by the Academy of Administrators in Academic Emergency Medicine (AAAEM) Salary Survey.  Multiple linear regression was used to compare salary by gender while controlling for confounders.

Results:

  • Response rate was 47% for 1371 full-time faculty

  • 33% were women

  • 78% White, 4% Black, 5% Asian, 3% Asian Indian, 4% other, and 7% unknown race

  • White vs nonwhite race:

    • 62% vs 69% instructor/assistant

    • 23% vs 20% associate

    • 15% vs 10% full professors

  • Women vs men (p<0.05):

    • 74% vs 59% instructor/assistant

    • 19% vs 24% associate

    • 7% vs 17% full professors

    • 37% vs 31% fellowship trained

    • 59% vs 64% Core Faculty

    • 47% vs 57% had administrative roles

    • 1069 vs 1051 clinical hours worked

  • 15% of 113 Chair/Vice-Chair positions were women, 18% were nonwhite race

  • Mean salary: $278,631

    • Mean salary of women was $19,418 less (SD +/- $3,736, p<0.001) even after adjusting for race, region, rank, years of experience, clinical hours, core faculty status, administrative roles, board certification, and fellowship training

Conclusions: In 2015, disparities in salary and rank persist among full-time U.S. academic EM faculty, even after controlling for key factors that have been speculated to contribute to salary differences, such as rank, clinical hours, and training.  There were also gender and underrepresented minority disparities in rank and leadership positions.  Future efforts should focus on evaluating salary data by race and developing system-wide practices to eliminate disparities.

Suggestions for further reading:

Jena AB, Olenski AR, Blumenthal DM, A S, P U, R J. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Intern Med. 2016;176(9):1294. 

Heron SL, Lovell EO, Wang E, Bowman SH. Promoting Diversity in Emergency Medicine: Summary Recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup. Acad Emerg Med. 2009;16(5):450-453. 

Choo EK, Kass D, Westergaard M, et al. The Development of Best Practice Recommendations to Support the Hiring, Recruitment and Advancement of Women Physicians in Emergency Medicine. Pines JM, ed. Acad Emerg Med. June 2016. 

Faculty Editor/Reviewer: Dr. Gita Pensa 

Podcast credits: Intro/exit music by Scott Holmes and freemusicarchive.org. Also featuring "Money", Pink Floyd, from The Dark Side of the Moon.