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African American Patients Bear the Brunt of California ED Diversion

SAN FRANCISCO – Who suffers the most when your hospital emergency department has to go on diversion?

A study in the journal BMJ Open suggests the answer could be African American patients suffering heart conditions. A study from the University of California San Francisco reports that those patients are more likely than white patients to have their ambulance diverted to another hospital due to overcrowding in their nearest ED.

The report also emphasizes that, when the nearest hospital had significant ambulance diversion, black patients had a lower chance of receiving specialized cardiac care and lower one-year survival rates. That’s in line with previous research about ambulance diversion and its association with worse long-term mortality, study authors point out.

“The take-home findings from this study are two-fold,” said co-author Renee Hsia, MD, professor of emergency medicine and health policy at UCSF. “First, we now better understand the mechanisms behind emergency department crowding and how it affects patients. Not only are crowded hospitals less able to deliver high-quality care, but even sick patients get diverted to hospitals with less technology. On top of that, they are less likely to receive appropriate treatment.

“Secondly, we have definitive evidence that minority-serving hospitals, or hospitals that serve a high proportion of black patients, tend to experience higher levels of emergency department crowding,” Hsia said.

For the study, researchers linked daily ambulance diversion logs from 26 California counties to Medicare patient records with acute myocardial infarction between 2001 and 2011. Differences in access, treatment, and outcomes between black and white patients at different stages of ambulance diversion were documented.

Of the 30,000 patients in the sample, half experienced no diversion, 25% experienced six hours or less of diversion, 15% had 6-12 hours of diversion, and 10% had more than 12 hours of diversion.

“Hospitals serving high volume of black patients spent more hours in diversion status compared with other hospitals,” according to the report. It also notes that patients facing the most ED diversion had the lowest probability of being admitted to hospitals with cardiac technology compared with those facing no diversion, by 4.4% for cardiac care intensive unit, and 3.4% for catheterization laboratory and coronary artery bypass graft facilities. In addition, those patients experiencing increased diversion had a 4.3% decreased likelihood of receiving catheterization and 9.6% higher one-year mortality.

“Our hope is that we can take this evidence and translate it into change at the systems level,” Hsia said. “While focusing efforts to decrease emergency department crowding is necessary in all hospitals, it might be more ‘bang for the buck’ if we want to make a dent in decreasing disparities by targeting efforts in minority-serving hospitals.”

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