Emergency Imaging of At-Risk Patients: General Principles

Introduction

Emergency departments (EDs) comprise a major source of medical care for patients in the United States, accounting for approximately 47.7% of the total number of medical care contacts. In 2018, there were over 143 million ED visits, of which over 123 million ended in release. Patients seek care in the ED for a variety of reasons, including having limited access to other appropriate health care services. The patients most vulnerable to health inequity and the compounding effects of inadequate health care are those who face systemic barriers to care due to a complex network of social, economic, and environmental factors that contribute to social determinants of health.

Structural and systemic racism, discrimination based on sex, gender, and sexual orientation, implicit weight bias against people with obesity, bias against patients with substance use disorder, and ableist language and barriers to accessibility (to name but a few) all create barriers to care. Implicit racial bias among clinicians in particular has been found to be a determining factor in patient access to quality care and has been associated with poorer doctor-patient interactions, treatment decisions, and patient health outcomes. Radiology is not exempt from these issues, as health disparities related to imaging have been widely reported in the literature. For example, many studies have demonstrated significant racial and socioeconomic disparities in cancer screening, diagnostic imaging, and procedures such as mammography, lung cancer, and colorectal cancer screening.

Disparities in diagnostic imaging also exist within the ED both from an ordering standpoint as well as within the department itself, as this chapter will discuss. Radiologists and members of the diagnostic imaging team are not exempt from harboring bias against particular patient populations. For example, in a 2016 Medscape Lifestyle Report survey, 22% of radiologists admitted to being biased against specific types or groups of patients, while 62% of emergency medicine physicians admitted the same biases. Patients presenting for care in the ED are not only medically vulnerable but may also face numerous obstacles to care based on complex socioeconomic and structural conditions that foster health disparity and contribute to worse health outcomes for individuals and communities.

A multitude of factors both within and beyond the health care system drive disparities in population health and access to quality health care. The US federal government’s Healthy People 2030 initiative defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.” Disparities affect groups that “have experienced barriers due to their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” Health disparities disproportionately affect at-risk, vulnerable populations whose health conditions may be exacerbated by a complex network of factors that contribute to social determinants of health and create barriers to health care.

Addressing the social determinants of health is essential to understanding the systemic and structural factors at every level of society that contribute to health disparities. Social determinants of health comprise the material and social conditions in which people are born, grow, live, work, and age, as well as the complex, interrelated economic systems and social structures that fundamentally shape these conditions. According to the Centers for Disease Control and Prevention (CDC), social determinants have been found to influence health outcomes more than lifestyle choices or health care. Studies have found that social determinants of health account for between 30% and 55% of health outcomes, with some estimates showing that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector. To achieve health equity requires addressing obstacles to health such as poverty, discrimination, lack of access to quality education and housing, good jobs with fair pay, and safe environments, as well as access to quality health care. Appropriately addressing social determinants of health is therefore “fundamental for improving health and reducing longstanding inequities in health, which requires action by all sectors and civil society.”

Some of the most vulnerable and at-risk patient populations addressed in this book include geriatric patients, pediatric patients, pregnant patients, patients with obesity, patients with cancer and compromised immune systems, and patients with substance use disorder. Each of these patient populations presents particular challenges to care in the ED while also facing various barriers to care that cut across race, class, gender, and socioeconomic factors that contribute to health disparities. As many of these patients are considered high-risk both medically and socially, it is incumbent upon the entire health care team, including radiology, to work together to address the explicit and implicit biases and structural issues that create barriers to care and lead to worse health outcomes for individuals and communities.

Geriatric Patients

In 2018, approximately 29 million US adults over the age of 65 years, 16 million of whom were over the age of 75 years, sought ED care. Studies have shown that older adults suffer higher rates of morbidity and mortality in the ED despite receiving intensified resource use, including more physician time, more diagnostic testing, longer lengths of stay in the ED, and higher admission rates. In a 2014 study, nearly half (49.8%) of all elderly patients presenting to the ED across the United States underwent diagnostic imaging, 42.8% of whom were evaluated with X-ray and 12.6% with computed tomography (CT). There are many unique challenges to imaging elderly patients, including limited mobility and increased falls risk, potential decreased cognitive abilities, inability to hold still due to voluntary or involuntary motion, and increased anxiety and disorientation in the ED setting. To obtain proper imaging and maintain safety, it may be necessary to use soft immobilization techniques, adjust patient positioning, and assist with transfers.

Elderly patients are also more vulnerable to social isolation, socioeconomic instability, and abuse and neglect, which increase their likelihood of presenting to the ED. For example, seniors with lower incomes or those who rely on Medicaid insurance may have unmet health care needs, prompting them to seek out emergency services to meet these needs. Isolation and lack of social support have also been found to be significant indicators of increased frequency of ED visits by older adults. In particular, individuals with dementia have been shown to have consistently higher rates of ED visits. Dementia is also a well-documented risk factor for elder abuse, which may be overlooked in the fast-paced environment of the ED.

Elder abuse is common, but unfortunately frequently underrecognized and underreported. As many as 10% of older adults in the United States are victims of elder abuse each year, with fewer than 1 in 24 cases identified and reported. Surprisingly, physicians account for only 2% of all reported cases of elder abuse. Because many elderly patients who present to the ED undergo some form of diagnostic imaging, the radiologist is optimally positioned to identify potential signs of abuse and communicate these concerns with the health care team.

Due to an overall increased risk of falls, osteoporosis, and age-related brain atrophy, it can be difficult to distinguish accidental from nonaccidental injury in elderly patients. While there is substantial evidence-based literature regarding radiologic findings of nonaccidental trauma in children, less literature is available on the subject of elder abuse. However, imaging correlates do exist, particularly regarding fracture patterns and “mechanism mismatch,” whereby the fracture pattern is discordant with the mechanism of injury described by the patient or caregiver. Additionally, screening tools such as the Elder Abuse Index and Elder Abuse Suspicion Index that incorporate physical findings and social factors have been developed and validated for use in the community and in busy clinics or EDs to assist in detection of elder abuse.

Elderly patients not only have more comorbidities and complex medical needs but also are more vulnerable to socioeconomic instability, decreased access to care, and abuse and neglect. As many elderly patients in the ED undergo diagnostic imaging, radiologists have the potential to play an important role in the detection of elder physical abuse and advocacy for the health and safety of their patients.