Review Suggests Racial Disparities in Receipt of ER Diagnostic Imaging

By Linda Carroll

January 06, 2021

(Reuters Health) - Racial and ethnic minorities are less likely than white patients to receive diagnostic imagining in the emergency room, a new systematic review finds.

In the analysis of 42 earlier studies, minorities were less likely than white patients to receive MRI, CT, ultrasound or radiography in more than two thirds of the included papers, the study team writes in the Journal of the American College of Radiology.

"The overall take-home from our study is that there is a large-scale association between nonwhite race and a decreased likelihood of receiving imaging," said the review's lead author, Alan Shan, a medical student at Johns Hopkins School of Medicine in Baltimore. Shan's coauthors are from the University of Southern California in Los Angeles.

Shan said "the recent social turmoil and pushes for increased awareness and social justice" were an impetus for the study.

"We are aware that there have been decades of research looking at access and worse outcomes," Shan said. "We wanted to look specifically at imaging."

The type of data included in the study can't explain why the disparities exist, Shan said. "But there's always the potential impact of implicit biases," he added. "It's well known that African Americans, for example, are less likely than other groups to have their pain treated."

To see if disparities might exist in ER imaging, Shan and his colleagues searched PubMed, Embase, and the Cochrane Library for studies that examined the issue, eventually locating 42 that met their criteria. Of these, 41 were from the U.S., and one from Canada. The studies, published through July 2020, examined disparities in several types of imaging: radiography, CT, MRI, ultrasound and fluoroscopy.

Most of the studies, 30 out of 42 (71.4%), found Hispanic, Black, and other nonwhite minority patients were less likely to receive diagnostic imaging in the ER. All the included studies either made efforts to adjust for disease severity (defined as acuity level, triage status, severity score, or related measures such as patient symptoms, physical examination findings, or laboratory values) or accounted for insurance status, including having health insurance or payer status (public vs private). The researchers found disparities in both pediatric and adult patients.

Shan and his colleagues did find, however, that there was heterogeneity in the associations depending on the reason for imaging. For example, there was a strong association between nonwhite race/ethnicity and a decreased likelihood of imaging in children with abdominal pain, while there was no association in adults with possible stroke.

Similarly, the analysis found heterogeneity by imaging type, with one study reporting that Hispanic patients had higher odds of undergoing CT and another finding that nonwhite patients were less likely to undergo radiography or CT but more likely to undergo ultrasound or MRI, the review authors note.

"Awareness of the issue is the first step," Shan said. "And then we need more work to be done to examine the individual dynamics."

Dr. Utibe Essien agreed with the need for a more research, particularly studies to look at the causes of the disparities.

It's not possible to tell from a study like this whether patient preferences might be coming in to play or whether there are physician biases contributing to fewer minorities getting imaging or both, said Dr. Essien, an assistant professor of medicine at the University of Pittsburgh School of Medicine who wasn't involved in the review.

Recent events have shown that racism is all around us, Dr. Essien said.

"We've been reminded that we live in a society with biases and discrimination that come out in every format and space despite decades spent trying to reduce inequalities," Dr. Essien said. "Way before I was a physician there was the landmark study on disparities in 2002. But we're still seeing the same kinds of things. I'm hopeful that there will be a new day, but studies like this just remind us there is so much work to do."

SOURCE: Journal of the American College of Radiology, online December 29, 2020.