Do Sickle Cell Patients Wait Longer to See Physicians in the Emergency Department?

Patients with sickle cell disease (SCD) often complain of long wait times in the emergency department (ED) when they present for treatment of pain. It is known that African-Americans in general often have longer ED wait times than other patients. Because patients with SCD in the US are much more likely to be African-Americans, it can be difficult to separate the effects of disease vs. race on SCD patient wait times. We attempted to disentangle these effects by examining a national sample of ED visits in the US.

We examined data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), which is conducted annually by the National Center for Health Statistics. Weights are provided to allow for the estimation of national level statistics. We examined NHAMCS data from 2003 through 2008. Our outcome variable was waiting time (in minutes) from ED arrival to being seen by a physician. Our primary independent variable was disease status, comparing patients with SCD to those with long bone fracture (LBF) and all other patients. We used a two-part approach for our analyses. First, we examined the association of disease status with wait times among all patients in the sample. We then restricted all analyses to the African-American sample of patients. Because of the highly right-skewed nature of the outcome variable, multivariable regressions were conducted using generalized linear models assuming a gamma distribution and a log link function. All analyses accounted for the complex design of the survey.

An estimated 553,943,439 ED visits occurred over the study period, with LBF patients accounting for 1.1% of those visits (n = 5,929,085), and SCD patients accounting for 0.2% of those visits (n = 1,142,078). SCD patients were significantly younger than all non-SCD patients (27.6 vs. 36.9, p < 0.001), and were more likely than LBF patients and all other patients to be male (55% vs. 51% vs. 46%, p < 0.001), and to have Medicaid (55% vs. 16% vs. 24%, p < 0.001). SCD visits were more likely than LBF and all other visits to have severe pain (scores of 7 to 10) at triage (54% vs. 32% vs. 19%, p < 0.001), and more SCD visits (70%) compared to LBF visits (58%) and all other visits (56%) received high priority triage recommendations of level 1 or 2 (<15 minutes to 1 hour) (p = 0.005). Bivariate analyses found that SCD patient wait times were 25 minutes longer than LBF patients, and 13 minutes longer than all other patients (mean wait = 67 minutes vs. 42 minutes vs. 54 minutes, p < 0.0001). Accounting for the skewness in the data, waiting times for SCD patients were found to be 59% longer than LBF patients (p < 0.001), and 25% longer than all other patients (p = 0.03). After adjustment for age, sex, insurance, and race, SCD wait times remained 32% longer than LBF patients (p = 0.007), and 8% longer than all other patients, though the latter result was no longer significant (p = 0.463). SCD wait times were 38% longer than LBF patients after additional adjustment for assigned triage level and presenting level of pain (p = 0.001). After restricting all analyses to the African-American patient sample, SCD patients were still found to wait 51% longer than LBF patients after adjustment for age, sex, insurance, assigned triage level, and presenting level of pain (p = 0.001).

Compared to patients with LBF, and all other patients, SCD patients were consistently found to have longer wait times to see physicians in the ED. The disparity between SCD patients and all other patients appeared to be explained by patient race. Nevertheless, analyses restricted to African-American patients still found a significant disparity between SCD patients and patients with LBF. Our findings suggests that both the black race of SCD patients, and their status as SCD patients, contribute to longer wait times in the ED compared to other patient populations.

No relevant conflicts of interest to declare.