Provider bias and patient selection for emergency department procedural sedation and analgesia

SCOPE OF THE PROBLEM In 1999, the U.S. Congress requested that the Institute of Medicine (IOM) investigate and report on disparities in health-care delivery among racial and ethnic minorities. In its landmark report, Unequal treatment: Confronting racial and ethnic disparities in health care, the IOM documented widespread disparities throughout the health-care delivery system and recommended a number of countermeasures to address these inequities. These findings are summarized in Table 5-1. Specifically, the IOM reported that racial and ethnic disparities wereconsistent across a broad range of clinical conditions, medical specialties, and treatment settings and that health disparities persisted after controlling for multiple potential confounders, including socioeconomic status and access to care. With regard to clinician-level factors, physician bias, stereotyping, and clinical uncertainty were felt to contribute to the observed disparities. Given the subjective nature of pain experience and assessment, particularly in clinical conditions where overt tissue damage is not involved (e.g., migraine, low back pain), it is not surprising that disparities in pain management are prominent in the emerging health disparities literature. Although findings are not uniform, a number of reports from a variety of settings indicate that African Americans and Hispanics are more likely to be undertreated for pain than similarly presenting white patients. Emergency medicine, by virtue of its mission to provide universal and timely access to health care, affords a unique perspective on the problems of health disparities. The emergency department (ED) clinical interaction is characterized by lack of patient-physician continuity, diagnostic uncertainty, and significant demands on time.