Many EDs have been collecting race and ethnicity data for quality improvement purposes for decades.
“More frequently, the idea of health equity is coming into center stage. And one of the primary areas of focus often is around racial inequities,” says Rama A. Salhi, MD, MHS, MSc, an assistant professor in the Department of Emergency Medicine at Massachusetts General Hospital.
Salhi and colleagues set out to learn more about the accuracy of the data being documented by EDs.
“When you think about collecting in the ED, which is a chaotic environment, there are a number of reasons why somebody’s chart may not match their self-identified racial ethnicity,” notes Salhi.
The researchers analyzed race and ethnicity data in the ED setting from 42 Michigan hospitals from 2018-2021.1 The researchers included patients with at least two ED visits to the same hospital or health system to determine how often race and ethnicity data were discordant from one visit to the next. In this group of patients, 1.7% of adults and 7% of children had racial and ethnicity data documented that did not match data from a previous ED visit at that same institution. The study’s findings suggest that hospitals are using inconsistent approaches to document patients’ race and ethnicity.
“This does give us a sense that there is a lot of variability in how staff are collecting this data, which suggests we have a lot of work to do,” concludes Salhi.
Prior research has shown that about half of ED staff report that they document race and ethnicity data by looking at the patient and making an assumption as opposed to asking the patient.2 “Some patients could potentially be identified in multiple ways,” says Salhi. The fact that pediatric patients were more likely to have discordant race and ethnicity data could be because children are not reporting their own data, suggest the authors. “Their guardian presents with them. Certainly, people have their own value systems, and that could impact how they report the child’s race and ethnicity,” says Salhi.
For EDs, one important takeaway is the need to support clerical and registration staff who are collecting race and ethnicity data. It is challenging to obtain race and ethnicity data for a patient who comes to the ED in pain or with altered mental status, for instance. Sometimes, staff may get pushback from patients or family who question why the data are needed, or even may react negatively. “We need to give more support to our clerical staff and train them appropriately to field those reactions,” says Salhi. For example, staff can respond with a simple statement such as, “This is administrative data, and we use it for quality improvement.”
“Ultimately, much of the data we collect, including demographic data, are voluntary,” acknowledges Salhi. Thus, the race and ethnicity data often are missing from the chart, or staff simply document “declined to respond.” “Patients need to feel seen and more engaged as partners. Also, we have important lessons to learn on how people identify themselves,” says Salhi.
Also important is to convey the significance of the data to the people tasked with collecting it. “The most powerful messages are ones that come directly from patients,” says Salhi. There has been a lot of work done at the national level, for example, to have Middle Eastern and North African added as a category on the national census. “Some hospitals with large populations of Middle Eastern and North African patients (in Southeast Michigan, for example) had already added the group to their hospital data, partly due to patient feedback,” notes Salhi.
Stories of improvements that resulted from the race and ethnicity data collected by staff also bring home its importance. For instance, ED providers can talk about improvements in ST-elevation myocardial infarction. “The data collected allowed us to identify low rates of timely angiography and an approximately 15% disparity between Black and white patients in receiving timely angiography. Through the implementation of many very effective quality improvement initiatives at the local and national levels, the disparity has narrowed. And care for everyone has improved significantly,” reports Salhi.3
If ED registration staff do not know why the race and ethnicity data are important, it is more likely they will check a box based on the patient’s appearance rather than ask the patient to report their own race and ethnicity and face a potential negative response. “We need to be conveying to the colleagues who do registration work how important their work is and how much depends on it,” recommends Salhi.
ED clinicians can convey the message, “What you do is important, and we appreciate you.” “Very often, clerical staff are doing their best to work around the clinical staff. There may be ways we can facilitate this in our ED workflows as well,” suggests Salhi.
REFERENCES
- Salhi RA, Macy ML, Samuels-Kalow ME, et al. Frequency of discordant documentation of patient race and ethnicity. JAMA Netw Open 2024;7:e240549.
- Pittman MA, Pierce D, Hasnain-Wynia R. Who, when and how: The current state of race, ethnicity, and primary language data collection in hospitals. The Commonwealth Fund. May 1, 2004. https://www.commonwealthfund.org/publications/fund-reports/2004/may/who-when-and-how-current-state-race-ethnicity-and-primary
- Montoy JCC, Shen YC, Hsia RY. Trends in inequities in the treatment of and outcomes for women and minorities with myocardial infarction. Ann Emerg Med 2022;80:108-117.
