Letter to the Editor
Are there race/ethnicity differences in disposition of older patients in psychiatric emergency service?
- Benjamin K.P. Woo, M.D.
- Olive View–UCLA Medical Center, University of California, Los Angeles, CA
- Received 21 April 2012. Revised 31 May 2012. Accepted 1 June 2012. Available online 6 July 2012.
- To the Editor,
The number of older patients with psychiatric disorders is rapidly increasing nationwide, yet little is known about the outcomes of care for geriatric patients with psychiatric emergencies [1]. This population is also increasing in diversity, and as a result, emergency room clinicians must expand their awareness of ethnicity and its effect on psychiatric emergencies among older patients. Few studies [2] and [3] have examined the utilization patterns of psychiatric emergency service (PES) by older patients, but little is known about the impact of race and ethnicity on PES clinical outcomes. To better understand the mental health needs of diverse, older patients in the PES, it is import to study the associations between ethnicity and PES disposition of this population.
This retrospective study utilized a PES database from a California county of 780,000 people. The PES database was extracted from the Mental Health Management Information System (MIS). Variables included age, gender, legal status, marital status, insurance status, ethnicity, previous psychiatric diagnoses, current psychiatric diagnosis and disposition [4]. There were 2591 PES evaluations in this 10-month study period (August 2005 to May 2006). Data were abstracted from the MIS in 2007. Older patients (aged ≥ 50) accounted for 438 (16.9%) evaluations. All patients who were identified as African Americans, Hispanics or Whites were included in the study. The sample size of older patients of other ethnic backgrounds was less than 11, insufficient for meaningful analyses. Thus, the final sample for this study was reduced to 427 older patients. One-way analysis of variance and χ2 analyses were used to determine racial/ethnic group differences on sociodemographic and clinical factors for continuous variables and categorical variables, respectively.
The sample consisted of 6.8% (29) African Americans, 19.7% (84) Hispanics and 73.5% (314) Whites. The mean age±S.D. was 58.9±9.5, 59.8±10.5 and 57.4±8.0 for African Americans, Hispanics and Whites, respectively (F= 2.69, df=2, P=.07). Comparing among African Americans, Hispanics and Whites, there were 58.6% (17) vs. 45.9% (31) vs. 45.9% (144) males (χ2= 4.49, df=2, P=.11); 10.3% (3) vs. 19.1% (91) vs. 22.9% (72) married (χ2= 2.83, df=2, P=.24); 41.4% (12) vs. 23.8% (20) vs. 29.0% (91) uninsured (χ2= 3.26, df=2, P=.20); 44.8% (13) vs. 32.1% (27) vs. 45.9% (144) without previous psychiatric diagnoses (χ2= 5.12, df=2, P=.08); 58.6% (17) vs. 77.1% (62) vs. 77.1% (242) admitted on involuntary status (χ2= 4.95, df=2,P=.08), respectively. There were no statistically significant differences on any of the sociodemographic and clinical variables. Finally, 22.6% (71) of Whites compared to 24.1% (7) of African Americans and 19.0% (16) of Hispanics were discharged from the PES after evaluations. There were no ethnicity differences on PES dispositions (χ2=.57, df=2, P=.75).
These data present critical information on whether ethnicity plays a role in sociodemographic and clinical factors as well as dispositions of older patients presenting to a PES. Ethnic disparities in medical and mental health treatments have been well documented in numerous studies [5], [6], [7] and [8]. In the adult population, African Americans were overutilizing the PES compared to Whites [5]. Findings from an epidemiological study of a national sample also found ethnic differences in psychiatric treatment among older adults [6]. Clinical findings from the current study, however, demonstrate that among older patients of PES, minority populations have equal disposition rates compared with Whites. Nevertheless, this study is limited by its small sample of African Americans. Thus, multivariable logistic regression was not performed because of the small number of patients. The aggregate data for the PES utilization also did not permit us to infer correlation between race/ethnicity with clinical factors for older PES patients. The PES database also did not include relevant clinical information, such as acuity, comorbidity and severity.
Ethnic disparities in delivery of psychiatric emergency care would contribute to excess mortality among minorities. This study suggests that ethnicity may not play a role in PES disposition rates, despite multiple barriers that may exist for older adults to receive quality PES care. It is likely that, regardless of race, emergency room clinicians adhere to clinical necessity to determine inpatient admission or discharge from PES. Another possibility is that older minority patients presenting to the PES suffer greater acuity and comorbidity, thus restricting the likelihood of being discharged [9] and [10]. As older ethnic minorities are less likely to consult outpatient mental health services [11], PES may have become their last resort during psychiatric crises. Thus, the PES may also be providing care for a significant number of ethnic minorities who contribute a disproportionate share of disease burden. Further investigations should utilize structured interviews to determine whether racial disparities exist in clinical severities among ethnic minorities presenting to PESs. Future studies should investigate the impact of race and ethnicity on PESs nationwide. Given the high prevalence of psychiatric and medical conditions among older PES patients, future studies should also examine the effect of ethnicity on this comorbidity in the acute settings.
