IS RACISM A FACTOR IN EMERGENCY DEPARTMENT CARE OF PATIENTS WITH SUSPECTED ACUTE CORONARY SYNDROME?

Investigators have identified important racial-identity/ethnicity-based differences in some aspects of acute coronary syndrome (ACS) care (time to presentation, symptoms, receipt of coronary angiography/revascularization). Patient-based differences (e.g. pathophysiology, treatment-seeking behaviour) account only partly for the differences in subsequent outcomes. Understanding the factors that contribute to these differences is important, given the significant ethnic diversity in Canada. It is unknown if there are racial-identity/ethnicity-based variations in the initial emergency department (ED) triage and care of patients with suspected ACS in Canadian hospitals. We prospectively enrolled ED patients with suspected ACS from 3 acute care hospital sites (1 university affiliated/tertiary-care, 2 community). Trained research assistants administered a standardized interview to gather data on symptoms, treatment-seeking patterns, and self-reported racial/ethnic identity. Clinical parameters were obtained through chart review. The primary outcome was door-to-electrocardiogram (D2ECG) time, adjusted for relevant clinical and sociodemographic variables. Self-reported racial identity was categorized as “White”, “South Asian” (SA), “Asian” or “neither White, Asian or SA/Unknown”, though our initial analysis compared White participants to the group comprised of all those who identified differently. ECG times were log-transformed; 2 linear regression models were fit, controlling for important demographic, system and clinical factors. Of 448 participants, 209 (47%) reported White identity; 115 (26%) SA; 57 (13%) Asian, and 67 (15%) were neither White, Asian or SA, or unknown. Asian respondents were younger, more likely to report initial discomfort as “low” and be accompanied by family; respondents identifying as neither White, Asian or SA were more likely to report initial discomfort as “high”. There was no statistically significant difference in D2ECG time between White participants and those who identified differently, but there were statistically significant differences by site, age and sex. Exploring more specific racial identities revealed similar findings: no significant differences between the White, SA, Asian and “neither White, Asian or SA” groups, while site, age and sex (older participants and women endured longer D2ECG times) remained statistically significantly different in the adjusted models (see Figure). Although racial/ethnicity-based differences in other aspects of ACS care have been previously identified, no such differences have been found in the current study of early emergency department care in a Canadian urban setting. However, women and elderly patients experience longer D2ECG times. While it is encouraging to see equity in the care provided among racial identity groups, improvements in the care of women and elderly ACS patients are necessary.