Abstract
Background
Substance use-related morbidity and mortality rates are at an all-time high in the United States, yet there remains significant stigma and discrimination in emergency medicine about patients with this condition.
Objectives
The purpose of this study was to determine whether there are racial and ethnic differences in emergency department (ED) wait times among patients with substance use disorder.
Methods
The study uses pooled data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2018. The dependent variable is length of time the patient with a diagnosis of substance use disorder waited in the ED before being admitted for care. The independent variable is patient race and ethnicity. Adjusted analyses were conducted using a generalized linear model.
Results
There were a total of 3995 reported ED events among patients reporting a substance use disorder in the NHAMCS sample between 2016 and 2018. After adjusting for covariates, Black patients with substance use disorder were significantly more likely to wait longer in the ED (35% longer) than White patients with substance use disorder (p < 0.01).
Conclusions
The findings showed that Black patients with substance use disorder are waiting 35% longer, on average, than White patients with the same condition. This is concerning, given that emergency medicine is a critical frontline of care, and often the only source of care, for these patients. Furthermore, longer wait times can increase the likelihood of leaving the ED without being seen. Programs and policies should address potential stigma and discrimination among providers, and EDs should consider adding people with lived experiences to the staff to serve as peer recovery specialists and bridge the gap for care.
Keywords
Introduction
The United States is facing a crisis pertaining to substance abuse and overdose deaths. Between April 2020 and April 2021, 100,306 Americans died of a drug overdose, an increase of 28.5% from the prior year and currently, one American dies from an overdose every 5 min (
1
).Neurobiological advances have determined that substance use disorder in its most severe and chronic form (addiction) is a function of a brain disease (
2
). Substance use is often a mechanism for coping with stress and trauma, which can lead to significant impairments in one's ability to function with increasing duration and severity (2
).Although it has been established that substance use disorder be treated as a medical condition and not a moral failure, societal stigma, and bias persist. This misperception permeates through the medical field given the significant barriers to care that people with substance use disorder experience. Consequences of stigmatization create barriers, such as accessibility of treatment, diminished quality of care, and discontinuation of treatment (
3
, 4
, 5
, 6
). Stigma may manifest as lower engagement and empathy, poor communication, missed diagnoses, disrupted care, or exclusion from services (3
,5
, 6
, 7
). When the experience of stigma is internalized, it reinforces the belief one is undeserving of care and threatens recovery, as the patient may withdraw from treatment prematurely (5
,8
). Often, patients may delay seeking treatment or avoid treatment altogether due to the anticipation of stigma (4
,5
,8
).There is also a large and growing body of evidence that has documented inequitable emergency care for some racial and ethnic populations within the United States (
9
,10
). Structural biases, such as quality of providers, hospital locations, hospital funding, and administrative policies, result in unjust distribution of resources (11
). Unequal distribution of resources can overburden providers and lead to inappropriate decision making, driven in part by inherent individual biases (12
). For example, research examining emergency care wait times have consistently found inequities in wait times, particularly among patients with lower care acuity scores. Specifically, research has found that Black patients were consistently assigned lower acuity scores compared with White patients (10
).Patients who identify as a member of a racial and ethnic minoritized group and who have a substance use disorder may be particularly at risk of being underserved within emergency departments (EDs). Patients with substance use disorders are often viewed negatively in EDs as “drug seekers” and may have their concerns minimized by health care workers, even when they are experiencing legitimate emergent health care needs. Implicit bias by staff related to race and ethnicity may make it more likely that patients of color are viewed as drug seekers, resulting in less emergent triage assessment and longer wait times. Wait times are likely a critical factor in whether a patients with substance use disorder will pursue care. A recent study found that people who used drugs cited the main reasons they may refuse emergency medical services (EMS) transport after an overdose are that they anticipate inadequate care on arrival at the hospital and stigmatizing treatment by EMS and hospital providers (
13
). Although less is known about ED care for this specific subpopulation, some literature has indicated racial inequities, particularly for Black patients, are sustained within emergency care services for people with substance use disorders (14
). Notably, literature documenting the inequitable emergency substance use care has often been presented alongside inequities in emergency mental health care (14
,15
). Although mental health conditions and substance use disorders are highly comorbid, their reasons for emergency visits are very heterogeneous and should be examined separately to best understand inequities in emergency care.Weinreb J, Gavrilova P, Avery J, Murphy SM, Pathak J. 1A Nationwide analysis of US racial/ethnic disparities in emergency department patients with mental health and substance use disorders [published online ahead of print September 16, 2021]. Res Square doi:10.21203/rs.3.rs-892560/v1.
Despite stigmatization concerns and suboptimal treatment, people with substance use disorders continue to use EDs, as it guarantees access for this population when other community resources and options are absent (
16
,17
). Previous research has consistently established a very high burden of behavioral health conditions among frequent users of the ED (16
, 17
, 18
, 19
, 20
). Hardy et al. found that of high ED users, > 77% had a mental illness diagnosis, 78% had a substance use disorder, and nearly 90% used opioid pain medications chronically (20
).The purpose of this study was to determine whether there are racial and ethnic differences in ED wait times among patients with substance use disorder. This is particularly important, given that this disorder is often accompanied by acute needs related to overdose, withdrawal, mental health, and pain management.
Methods
Data Source
The study used pooled data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2018. NHAMCS is a nationally representative sample of ambulatory care services conducted in hospital EDs by the National Center for Health Statistics. A 3-stage probability sampling design is used to collect a national sample of visits to EDs in noninstitutional general and short-stay hospitals, excluding federal, military, and Veterans Health Administration hospitals. Information was collected about the patient (i.e., age, sex, race, and ethnicity), ED visit (i.e., provider's diagnosis; services ordered and provided; and treatments, including medication), and hospital facility characteristics. This was a de-identified public data set and therefore exempt from Institutional Review Board approval.
Measures
ED wait time
The recorded number of minutes that patients waited in the ED before being seen.
Race and ethnicity.
Patient race and ethnicity recorded as non-Hispanic White, non-Hispanic Black, Hispanic, or “other.”
Substance use disorder.
ED visits for this diagnosis were recorded as the provider marking “substance abuse or dependence” in the diagnosis category.
Control variables
Analyses controlled for sex (male or female), age group (18–24 years, 25–44 years, 45–64 years, or 65 years and older), insurance status (private, Medicaid, Medicare, uninsured, or other), arrival by ambulance (yes or no), use of computer-assisted triage (yes or no), use of a self-check-in kiosk (yes or no), triage level (high, mid, low, missing, or none), and whether the patient was seen in the past 72 h (yes or no).
Statistical Analyses
Differences in wait time by race and ethnicity were assessed using the survey procedures of STATA SE, version 16.1. Using the survey procedures in conjunction with the weights provided in NHAMCS allowed for results to be nationally representative and for SEs to correctly account for the complex sampling strategy of NHAMCS. First, the unadjusted mean wait times by race and ethnicity were assessed. Because the error terms from a simple linear regression model did not meet the assumptions of a normal distribution, a generalized linear model was fitted that assumed the error terms followed a gamma distribution and the equation had a log link.
Results
Characteristics of the Study Sample
There were 3995 reported ED events among patients reporting a substance use disorder in the NHAMCS sample between 2016 and 2018. Of these visits, 2430 (60.8%) were among White patients, 1031 (25.8%) among Black patients, 426 (10.7%) among Hispanic patients, and 108 (4.3%) among patients whose race was reported as “other.” Table 1 reports the demographic characteristics of the sample.
Table 1Characteristics of Patients with Substance Use Disorder in the National Hospital Ambulatory Medical Care Survey Sample of Emergency Department Visits, 2016–2018 (n = 3995).
| Category | n | % |
|---|---|---|
| Race | ||
| White | 2430 | 60.8 |
| Black | 1031 | 25.8 |
| Hispanic | 426 | 10.7 |
| Other | 108 | 2.7 |
| Insurance type | ||
| Private | 714 | 17.9 |
| Medicare | 598 | 15.0 |
| Medicaid | 1759 | 44.0 |
| Uninsured | 389 | 9.7 |
| Other | 535 | 13.4 |
| Ambulance | ||
| Yes | 1122 | 28.1 |
| No | 2873 | 71.9 |
| Triage level | ||
| High | 656 | 16.4 |
| Medium | 1518 | 38.0 |
| Low | 867 | 21.7 |
| Missing | 746 | 18.7 |
| None | 208 | 5.2 |
Table 2 presents the mean time (in minutes) that patients with substance use disorder waited in the ED before being seen. After applying the NHAMCS sample weights, the overall mean wait time for patients with substance use disorder was approximately 38 min. When broken out by race, White patients had the lowest mean wait time of approximately 33 min, followed by patients in the “other” race group (approximately 39 min), Hispanic patients (approximately 40 min), and Black patients (approximately 52 min).
p < 0.01.
Table 2Weighted Percentages of Visit Characteristics for Patients with Substance Use Disorder in the Emergency Department, 2016–2018.
| Characteristic | White Sample (n = 2430) | Black Sample (n = 1031) | Hispanic Sample (n = 426) | Other Sample (n = 108) | Full Sample (n = 3995) |
|---|---|---|---|---|---|
| Wait time, min, mean (95% CI) | 32.9 (26.6–39.1) | 52.4 (30.2–74.5) | 39.7 (25.3–54.1) | 39.1 (20.7–57.5) | 38.3 (29.8–46.7) |
| Sex | |||||
| Female | 49.2 | 48.9 | 31.5 | 28.7 | 46.7 |
| Male | 50.8 | 51.1 | 68.6 | 71.3 | 53.3 |
| Age group | |||||
| 18–24 y | 13.6 | 11.5 | 20.5 | 5.1 | 13.6 |
| 25–44 y | 45.5 | 42.0 | 48.3 | 53.4 | 45.2 |
| 45–64 y | 31.5 | 39.4 | 26.5 | 26.9 | 32.7 |
| 65 y+ | 9.4 | 7.1 | 4.7 | 14.7 | 8.5 |
| Insurance status | |||||
| Private | 19.4 | 15.2 | 20.8 | 14.2 | 18.5 |
| Medicaid | 39.2 | 41.2 | 42.3 | 24.2 | 39.6 |
| Medicare | 16.6 | 17.1 | 6.6 | 21.7 | 15.8 |
| Uninsured | 8.7 | 9.6 | 6.9 | 20.6 | 9.0 |
| Other | 16.1 | 16.9 | 23.5 | 19.4 | 17.1 |
| Arrival by ambulance | |||||
| Yes | 25.5 | 30.4 | 26.7 | 26.0 | 26.8 |
| No | 74.5 | 69.7 | 73.3 | 74.0 | 73.2 |
| Computer-assisted triage | |||||
| Yes | 56.8 | 53.4 | 71.8 | 67.4 | 57.9 |
| No | 43.2 | 46.6 | 28.2 | 32.6 | 42.2 |
| Self-check-in kiosk | |||||
| Yes | 4.6 | 6.7 | 12.5 | 6.7 | 6.0 |
| No | 95.4 | 93.3 | 87.5 | 93.3 | 94.0 |
| Triage level | |||||
| None | 4.0 | 4.5 | 9.1 | 6.7 | 4.7 |
| Missing | 20.4 | 23.0 | 20.8 | 27.2 | 21.2 |
| Low | 19.8 | 22.8 | 19.8 | 5.1 | 20.1 |
| Medium | 36.9 | 35.2 | 32.8 | 45.7 | 36.3 |
| High | 19.0 | 14.5 | 17.5 | 15.3 | 17.7 |
| Seen in past 72 h | |||||
| Yes | 3.0 | 6.3 | 3.8 | 8.2 | 4.0 |
| No | 97.0 | 93.8 | 96.2 | 91.8 | 96.0 |
† p < 0.05.
Table 3 presents the unadjusted and adjusted analyses. The unadjusted analyses found that Black patients waited 47% longer in the ED than White patients (p < 0.05). After adjusting for covariates, Black patients were still significantly more likely to wait longer in the ED (35% longer) than White patients (p < 0.01). There were no other statistically significant differences in mean wait time by race and ethnicity.
p < 0.05.
Table 3Unadjusted and Adjusted Regression on Mean Emergency Department Wait Times for Patients with Substance Use Disorder by Race and Ethnicity.
| Variable | Coefficient (95% CI) | P Value |
|---|---|---|
| Unadjusted | ||
| White | Ref | — |
| Black | 0.47 (0.06 to 0.87) | 0.024 |
| Hispanic | 0.19 (–0.16 to 0.53) | 0.286 |
| Other | 0.17 (–0.26 to 0.61) | 0.432 |
| Adjusted | ||
| White | Ref | — |
| Black | 0.35 (0.11 to 0.60) | 0.005 |
| Hispanic | 0.20 (–0.13 to 0.54) | 0.233 |
| Other | 0.15 (–0.29 to 0.60) | 0.500 |
† Adjusted for patient age, sex, insurance type, arrival by ambulance, triage level, computer assisted triage, self-check-in kiosk, and whether the patient was seen in the past 72 h.
‡ p < 0.01.
Discussion
The purpose of this study was to determine whether racial and ethnic disparities exist in ED wait times among patients with substance use disorder. We found that Black patients are waiting 35% longer, on average, than White patients. This is supported by Nam et al., who reported that Black patients with a mental health or substance use disorder diagnosis had an ED wait time that was 1.26 times longer than White patients with the same diagnosis (
17
). We found an even greater difference in wait times compared with that study when only substance use visits were examined.The literature has consistently demonstrated that Black patients are experiencing longer wait times for ED visits than White patients overall (
9
,21
). Our findings among a vulnerable subgroup of individuals with substance use disorder are particularly concerning, given that the ED is often the front line of care (and only source of care) for these patients due to socioeconomic constraints and lack of insurance (22
). Longer wait times among these patients may jeopardize their trust in the health care system, thus impacting their potential recovery and willingness to seek treatment when in crisis.People with substance use disorder are a clinically complicated population characterized by comorbidities, social vulnerabilities, and high ED utilization. Despite the frequency of encounters, lack of training and stigmatization leaves providers unprepared to adequately treat this patient population (
23
, 24
, 25
). Providing substandard care leads to poor treatment outcomes. Evidence indicates deficits in the quality of care provided to these patients can be mitigated by providing robust patient-centered support after discharge to addiction consultation services (25
). In addition, frequent exposure to patients with substance use disorder is associated with more favorable attitudes, increased preparedness, and higher likelihood of providing evidence-based care (23
). The availability of appropriate services, coupled with relevant medical school addiction curricula and residency programs with clinical rotations in addiction, can increase a physician's confidence in providing care to this population. These factors can lead to better health outcomes and curb high ED utilization in this patient population.Limitations
Several limitations are of note to the current study. First, given that the NHAMCS data use retrospective chart reviews, there may be errors in reporting on the medical record or during chart abstraction. Second, our study was also limited by ED visits among patients who the provider gave a diagnosis of “substance use disorder.” Therefore, it does not capture patients who may have a substance use disorder, but did not disclose that information (or it was not determined by the provider). Third, some subgroup estimates had small sample sizes and results may not be generalizable to the wider population.
Conclusions
Program Implications
Many of the health care needs related to substance use disorder are urgent and should receive proper care and attention. The ED also represents an opportunity to create a medical home for patients to be referred to resources outside of health care, such as housing, transportation, and career development or job placement. Some EDs are attempting to reduce recidivism by placing peer recovery specialists in their units to specifically serve overdose patients. The peer recovery specialist is a hired position for someone who is in recovery for substance use disorder and can be a resource to link the patient to care and serve as an advocate. Preliminary research supports greater likelihood of substance use treatment engagement, opioid abstinence, and outpatient utilization, and a lower likelihood of hospitalization and ED visits when peer recovery specialists are used (
26
). Although the goal of the peer recovery specialist is to encourage the patient to seek treatment, it is also a role in which they can provide support and understanding associated with the difficulties in ending one's addiction. Furthermore, peer recovery specialists often interface with hospital staff and clinicians about their personal experiences with addiction and recovery and may serve as role models for how to interact with patients with substance use disorder. This may result in changes in the hospital culture by reducing bias associated with substance use disorder (and its interaction with race) among clinicians and staff, which could potentially lead to reduced wait-time disparities.Policy Implications
A societal shift in perception of substance use disorder from a moral failure to a medical condition, particularly among Black patients, is imperative. The frustration that health care providers may feel at the reoccurrence of their patients in these units extends beyond the addiction itself and into the environment in which the patient re-enters, meaning that partnerships with community organizations and resource provisions are vital. In addition, the medical community must understand the conscious and unconscious biases they hold that are leading to inequitable treatment. Medical schools should provide training in implicit bias as part of their curriculum so that students learn the skills necessary to treat patients equally and equitably regardless of race, ethnicity, disability, socioeconomic status, gender, or sexual orientation. Moreover, policies surrounding the criminalization of substance use disorder must be considered, as many patients face barriers to overcoming addiction, such as an inability to get a job due to a criminal record, as a result of their condition. It is well documented that criminalization policies disproportionately impact Black patients. For example, Black women are more likely to be criminalized for substance use in pregnancy even as Black and White patients report similar prevalence rates (
27
, 28
, 29
, 30
, 31
). Treatment-focused policies that aim to address substance use disorder as a medical condition should therefore be prioritized.Article Summary
1. Why is this topic important?
Health care needs related to substance use disorder are urgent and should receive prompt care. Emergency department wait times are a critical factor to whether a patient with substance use disorder will pursue care.
2. What does this study attempt to show?
This study examines if racial and ethnic disparities exist in ED wait times among patients with substance use disorder.
3. What are the key findings?
Racial inequities exist in ED wait times among patients with substance use disorder. Black patients with substance use disorder are waiting 34% longer to be seen in EDs compared to White patients.
4. How is patient care impacted?
Longer wait times increase the likelihood of patients leaving the ED without being seen. Therefore, Black patients with substance use disorder are at an increased risk for being underserved within ED settings. Our findings among a vulnerable subgroup of individuals with substance use disorder are particularly concerning given that the ED is often the front line of care for these patients.
References
- Drug Overdose Deaths in the U.S. Top 100,000 Annually.Centers for Disease Control and Prevention. 2023; (November 17, 2021Accessed March 9)
- Neurobiologic advances from the brain disease model of addiction.N Engl J Med. 2016; 374: 363-371
- Mental illness stigma as a quality-of-care problem.Lancet Psychiatry. 2015; 2: 863-864
- The impact of mental illness stigma on seeking and participating in mental health care.Psychol Sci Public Interest. 2014; 15: 37-70
- The impact of stigma on people with opioid use disorder, opioid treatment, and policy.Subst Abuse Rehabil. 2022; 13: 1-12
- The role of stigma in U.S. primary care physicians' treatment of opioid use disorder.Drug Alcohol Depend. 2021; 221108627
- Stigma in health facilities: why it matters and how we can change it.BMC Med. 2019; 17: 25
- Sinning and Sinned Against: The Stigmatisation of Problem Drug Users.University of York, 2010
- Relationship between racial disparities in ED wait times and illness severity.Am J Emerg Med. 2016; 34: 10-15
- Racial disparity in emergency department triage.J Emerg Med. 2013; 44: 511-518
- Improving hospital quality to reduce disparities in severe maternal morbidity and mortality.Semin Perinatol. 2017; 41: 266-272
- The impact of cognitive stressors in the emergency department on physician implicit racial bias.Acad Emerg Med. 2016; 23: 297-305
- Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care.Int J Drug Policy. 2021; 97103296
- Disparities in emergency department wait time among patients with mental health and substance-related disorders.The Journal of Behav Health Serv Res. 2018; 45: 204-218
Weinreb J, Gavrilova P, Avery J, Murphy SM, Pathak J. 1A Nationwide analysis of US racial/ethnic disparities in emergency department patients with mental health and substance use disorders [published online ahead of print September 16, 2021]. Res Square doi:10.21203/rs.3.rs-892560/v1.
- Emergency department from the mental health client's perspective.Int J Ment Health Nurs. 2007; 16: 126-131
- 10-Year trends of emergency department visits, wait time, and length of stay among adults with mental health and substance use disorders in the United States.Psychiatr Q. 2021; 92: 1159-1174
- Frequent emergency department visits are more prevalent in psychiatric, alcohol abuse, and dual diagnosis conditions than in chronic viral illnesses such as hepatitis and human immunodeficiency virus.J Emerg Med. 2013; 45: 520-525
- Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints?.Am J Emerg Med. 2013; 31: 1512-1515
- Understanding frequent emergency department use among primary care patients.Popul Health Manag. 2018; 21: 24-31
- Racial/ethnic disparities in emergency department wait times in the United States, 2013–2017.Am J Emerg Med. 2021; 47: 138-144
- Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care.Health Aff (Millwood). 2013; 32: 1196-1203
- Attitudes, practices, and preparedness to care for patients with substance use disorder: results from a survey of general internists.Subst Abus. 2016; 37: 635-641
- Impact of substance use disorder on quality of inpatient mental health services for people with anxiety and depression.J Dual Diagn. 2021; 17: 80-93
- Preventing hospital readmission for patients with comorbid substance use disorder: a randomized trial.Ann Intern Med. 2021; 174: 899-909
- Peer recovery coaches in general medical settings: changes in utilization, treatment engagement, and opioid use.J Subst Abuse Treat. 2021; 122108248
- Punishing pregnant drug-using women: defying law, medicine, and common sense.J Addict Dis. 2010; 29: 231-244
- Punitive versus public health oriented responses to drug use by pregnant women.Yale J Health Policy Law Ethics. 2001; 1: 217-235
- Prenatal substance use: exploring assumptions of maternal unfitness.Subst Abuse. 2015; 9: 1-4
- Arrests of and forced interventions on pregnant women in the United States, 1973–2005: implications for women's legal status and public health.J Health Polit Policy Law. 2013; 38: 299-343
- The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida.N Engl J Med. 1990; 322: 1202-1206
Article info
Publication history
Published online: March 01, 2023
Accepted:
February 17,
2023
Received in revised form:
February 3,
2023
Received:
September 21,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2023 The Authors. Published by Elsevier Inc.
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