DISCUSSION

Research has demonstrated significant disparities in healthcare access and quality as well as health outcomes for communities that have been historically marginalized or excluded. Diagnostic imaging—and differences in clinical decision-making around which patients undergo imaging and when—is one such area that has been a topic of interest in recent literature. 

A number of major studies in recent years have focused on differences in diagnostic imaging in the ED based on patient factors or identities. In one cross-sectional study evaluating pediatric patient visits in 44 US children’s hospital EDs, Marin et al. found non-Hispanic Black and Hispanic children were less likely to receive any diagnostic imaging [1]. These patterns were seen across most diagnoses and imaging modalities, including ultrasound, radiography, CT, and MRI, and persisted when controlling for insurance status. A similar study by Schrager et al. evaluating over 220,000 adult patient ED visits across a 10-year period demonstrated decreased odds of Black patients receiving imaging in the ED [2]. These studies together indicate that disparities in rates of diagnostic imaging are seen across the lifespan of a patient. And importantly, these differences in care contribute to significant disparities in health outcomes. A 2020 multi-center retrospective cohort study of children diagnosed with appendicitis demonstrated Black children were less likely to undergo any imaging, more likely to have delayed diagnoses, and more likely to suffer appendiceal perforation [3]. 

While an in-depth root cause analysis of these disparities is beyond the scope of this post, it is important to explicitly acknowledge that racism is at the heart of these disparities. 

Racism is evident in individual factors like physician bias as well as structural or institutional factors like language barriers and disparate access to health insurance and financial resources. There is a marked absence of discussion about racism in the aforementioned articles and a pivoting toward questionable postulated etiologies. For example, Marin et al . suggests “higher imaging rates observed in non-Hispanic white patients may, in part, be attributed to greater levels of parental anxiety with an associated increase in requests for imaging.” This assumption that a white parent may have more anxiety about their child’s pain or health than a non-white parent reproduces a problematic racialized narrative about race and parenting. 

So how can we begin to address these differences in care and work towards health equity for our patients in the ED? First, standardized pathways for given clinical presentations can be helpful in ensuring patients all receive the same evidence-based work-up for their given complaint, thus minimizing impact of provider bias. Additionally, attention to characteristics and identities of providers themselves may be helpful. Studies have looked at the impact of provider gender on use of ultrasound in the ED [4,5], but provider race and ethnicity remain under-studied – an interesting gap given where we see disparities in diagnostic imaging demonstrated on the patient side. Finally, researchers need to expand their scope beyond simply identifying existing disparities, which can have the unintended effect of further entrenching those differences. Robust discussion on underlying causes of health disparities is warranted, with explicit attention given to the effect of racism on human health. Without sufficient root cause analysis with a specific health equity lens, interpretation of research showing race-based health disparities can erroneously point to innate biological differences as the underlying cause. 

CONCLUSIONS

Significant differences in diagnostic imaging use in the ED are seen based on patient race and ethnicity. These disparities may contribute to differences in health outcomes, such as delays in diagnosis and higher complication rates associated with late imaging. 

TAKE-AWAYS

• Non-Hispanic Black and Hispanic pediatric patients are less likely to undergo diagnostic imaging in the ED.

• Differences in diagnostic imaging utilization directly contribute to disparities in health outcomes.

• Health equity research should strive to identify underlying root causes when reporting on existing disparities.

AUTHOR: Kelsey Kolbe is a fourth-year medical student at Brown University with an interest in medical education, health equity, and cats. 
FACULTY REVIEWER: Dr. Kristin Dwyer is an Assistant Professor of Emergency Medicine at Warren Alpert Medical School of Brown University and Emergency Ultrasound Fellowship Director

Keywords: ultrasound; POCUS; disparities; race; gender; medical education

REFERENCES

1.   Marin JR, Rodean J, Hall M, et al. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children’s Hospitals, 2016-2019. JAMA Netw Open. 2021;4(1):e2033710. doi:10.1001/jamanetworkopen.2020.33710

2.   Schrager JD, Patzer RE, Kim JJ, et al. Racial and Ethnic Differences in Diagnostic Imaging Utilization During Adult Emergency Department Visits in the United States, 2005 to 2014. J Am Coll Radiol JACR. 2019;16(8):1036-1045. doi:10.1016/j.jacr.2019.03.002

3.   Goyal MK, Chamberlain JM, Webb M, et al. Racial and ethnic disparities in the delayed diagnosis of appendicitis among children. Acad Emerg Med Off J Soc Acad Emerg Med. 2021;28(9):949-956. doi:10.1111/acem.14142

4.   Acuña J, Stolz U, Stolz LA, et al. Evaluation of Gender Differences in Ultrasound Milestone Evaluations During Emergency Medicine Residency Training: A Multicenter Study. AEM Educ Train. 2020;4(2):94-102. doi:10.1002/aet2.10397

5.   Dessie AS, Lewiss RE, Stolz LA, et al. The state of gender inclusion in the point-of-care ultrasound community. Am J Emerg Med. Published online July 21, 2021:S0735-6757(21)00587-8. doi:10.1016/j.ajem.2021.07.021