Key result
Simulated Black and female chest pain patients are assigned high-priority triage at ~11% lower rates.
Why the study?
It was unknown whether gender and ethnic differences in acute coronary syndrome management stem from less severe initial severity assessments or less intensive management despite identical assessments.
Does the gender and ethnic appearance of simulated patients change the prioritization decision for chest pain in the emergency triage area?
RCT (n=1,563)
randomized among eight standardized images
Does the gender and ethnic appearance of simulated patients change the prioritization decision for chest pain in the emergency triage area?
Effect estimate: difference -11% (95% CI -18% to -4%)
Absolute Event Rate: 47% vs 58%
Emergency healthcare workers assigned lower triage priority to women and Black simulated patients presenting with chest pain compared to men and White patients, highlighting potential implicit bias in early acute coronary syndrome management.
Suggests implicit bias in ED chest pain triage; leaves open effects on real-world ACS outcomes.
BACKGROUND AND IMPORTANCE: There seems to be evidence of gender and ethnic bias in the early management of acute coronary syndrome. However, whether these differences are related to less severe severity assessment or to less intensive management despite the same severity assessment has not yet been established. OBJECTIVE: To show whether viewing an image with characters of different gender appearance or ethnic background changes the prioritization decision in the emergency triage area. METHODS: The responders were offered a standardized clinical case in an emergency triage area. The associated image was randomized among eight standardized images of people presenting with chest pain and differing in gender and ethnic appearance (White, Black, North African and southeast Asian appearance). OUTCOME MEASURES AND ANALYSIS: Each person was asked to respond to a single clinical case, in which the priority level [from 1 (requiring immediate treatment) to 5 (able to wait up to 2 h)] was assessed visually. Priority classes 1 and 2 for vital emergencies and classes 3-5 for nonvital emergencies were grouped together for analysis. RESULTS: Among the 1563 respondents [mean age, 36 ± 10 years; 867 (55%) women], 777 (50%) were emergency physicians, 180 (11%) emergency medicine residents and 606 (39%) nurses. The priority levels for all responses were 1-5 : 180 (11%), 686 (44%), 539 (34%), 131 (9%) and 27 (2%). There was a higher reported priority in male compared to female [62% vs. 49%, difference 13% (95% confidence interval; CI 8-18%)]. Compared to White people, there was a lower reported priority for Black simulated patients [47% vs. 58%, difference -11% (95% CI -18% to -4%)] but not people of southeast Asian [55% vs. 58%, difference -3% (95% CI -10-5%)] and North African [61% vs. 58%, difference 3% (95% CI -4-10%)] appearance. CONCLUSION: In this study, the visualization of simulated patients with different characteristics modified the prioritization decision. Compared to White patients, Black patients were less likely to receive emergency treatment. The same was true for women compared with men.
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Coisy et al. (2023) conducted an RCT in Chest pain (simulated acute coronary syndrome) (n=1,563). Simulated patient images of Black ethnic appearance vs. Simulated patient images of White ethnic appearance was evaluated on Assignment to priority classes 1 and 2 (vital emergencies) (difference -11%, 95% CI -18% to -4%). Simulated Black patients and female patients presenting with chest pain were less likely to be assigned high-priority emergency triage compared to White patients (47% vs 58%) and men (49% vs 62%).
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