Association of Race and Ethnicity With Triage Emergency Severity Index Scores and Total Visit Work Relative Value Units for Emergency Department Patients

This cross-sectional study evaluates the association of race and ethnicity with triage Emergency Severity Index scores and total work relative value units for emergency department (ED) patients.


Introduction
Previous literature on emergency department (ED) patients has suggested that nurses assign loweracuity triage scores to non-White patients and that physicians order fewer diagnostic interventions for them. 1,2A potential cause of this phenomenon is a higher rate of nonurgent symptoms, owing to disparities in socioeconomic status and access to primary care. 3It is less clear whether these discrepancies persist for specific, urgent chief symptoms.

Methods
In this retrospective cross-sectional study examining adult patients at an academic, urban ED in the Northeastern United States with an average of 55 000 visits annually, we investigated the triage Emergency Severity Index (ESI) scores (range, level 1 [most urgent] to level 5 [least urgent]) and work relative value units (wRVUs) associated with patients' visits for the 5 most common acute chief symptoms (abdominal pain, chest pain, dyspnea, nausea or vomiting, and falls).Owing to the association of diagnostic testing and procedures with wRVUs, they served as a proxy for the intensity of a patient's diagnostic workup.All unique patient visits between July 1, 2016, and March 1, 2020, were included in the study.Data collected at triage included self-reported race and ethnicity (American Indian or Alaska Native, Asian, Black, Hispanic, other race or ethnicity [the registration process at the institution allows patients to self-identify race as "other" in cases where they do not feel that the provided categories adequately describe their racial and ethnic identity], and White).
The study was granted an exemption from review and from the use of informed consent by the Beth Israel Deaconess Medical Center institutional review board owing to the use of deidentified, aggregated data.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. 4fferences in ESI scores and wRVUs between self-identified racial and ethnic groups were evaluated using stratified independent t tests, with mean values and 95% CIs as descriptive statistics.
An overall significance level of P < .001was used to correct for 5 sets of comparisons across racial and ethnic groups for 5 chief symptoms.To capture differences in physician evaluation independent of testing typically ordered from nursing triage for patients with acute ESI scores (levels 1 and 2), we conducted a secondary analysis for patients assigned ESI level 3 only.Analysis was performed in Python, version 3.9 (Python Software Foundation) using the SciPy library.).This difference remained when controlling for lower acuity scores assigned from triage.Similar differences were seen across racial and ethnic categories for the wRVUs associated with visits for abdominal pain and in ESI scores for patients self-identifying as Asian or other race or ethnicity with chest or abdominal pain.No differences were seen in insurance status, mode of arrival, or primary language.

Table 1 .
Characteristics of the Study Population

Table 2 .
Emergency Severity Index and Visit Work Relative Value Units Differences Between Racial and Ethnic Groups