What Drives Racial Disparities in Emergency Room Treatment of Agitation?

Hospitals Serving More Black Patients Use Sedatives More Often

April 22, 2022

By:

Ari B. Friedman, MD, PhD
and Utsha Khatri, MD, MSHP

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When patients arrive at emergency rooms in an agitated state, clinicians must act quickly. The agitation can be a sign of a serious medical problem, drug ingestion, or mental health crisis, and administering treatment in a timely fashion can be critical. To diagnose and treat medical problems more rapidly and also protect the patient and staff from harm, agitated patients are sometimes physically restrained and chemically sedated.

But while chemical sedation—defined as a first- or second-generation antipsychotic or ketamine—can be useful, it can cause physical and psychological harm that warrants caution. Additionally, the lack of formal criteria for agitation opens the door to provider bias in how patients are treated.

In a new national study in Annals of Epidemiology, we examined the association of race and/or ethnicity with the use of chemical sedation among patients in emergency rooms with psychiatric complaints, and we found that Black patients were 63% more likely to receive chemical sedation than white patients. In all, 5.7% of Black patients presenting with “symptoms referable to psychological and mental disorders” were chemically sedated compared to 3.6% of white patients presenting with the same conditions, according to our evaluation of 2008-2018 data on emergency department visits from a national hospital database.

While our study reveals racial disparity, we found that the difference hinged largely on where patients received care. Hospitals that treated a higher proportion of Black patients tended to use more sedation overall, including among white patients.

The challenge for the U.S. health care system is not just to describe such disparities, but to eliminate them. Our study shows that combatting the forces of racism requires focusing not just on provider bias but also on the underlying structural issues that lead to Black patients receiving worse care based on where they live. Low access to mental health services, compounded by greater use of chemical sedation in Black-serving hospitals, contributes to these harmful disparities.

While our study does not point to immediate solutions, it does suggest that resources and interventions to improve quality should be targeted at the hospital level, particularly at under-resourced hospitals serving a high number of Black patients. Because patients go to nearby hospitals in emergencies, remedying gaps in quality between hospitals can be an important part of the solution to health disparities.

The study, Racial Disparities in the Management of Emergency Department Patients Presenting With Psychiatric Disorders, was published in Annals of Epidemiology in May 2022. Authors include Utsha G. Khatri, Kit Delgado, Eugenia South, and Ari B. Friedman.