EQUIP emergency: can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

Colleen Varcoe, Annette J Browne, Nancy Perrin, Erin Wilson, Vicky Bungay, David Byres, Nadine Wathen, Cheyanne Stones, Catherine Liao, Elder Roberta Price, Colleen Varcoe, Annette J Browne, Nancy Perrin, Erin Wilson, Vicky Bungay, David Byres, Nadine Wathen, Cheyanne Stones, Catherine Liao, Elder Roberta Price

Abstract

Background: Despite a publicly funded system, health care in Canada has been shown to be deeply inequitable, particularly toward Indigenous people. Based on research identifying key dimensions of equity-oriented health care as being cultural safety, harm reduction and trauma- and violence-informed care, an intervention to promote equity at the organizational level was tested in primary health care, refined and adapted, and tested in Emergency Departments (EDs).

Methods: In partnership with clinical, community and Indigenous leaders in three diverse EDs in one Canadian province, we supported direct care staff to tailor and implement the intervention. Intervention activities varied in type and intensity at each site. Survey data were collected pre- and post-intervention from every consecutive patient over age 18 presenting to the EDs (n = 4771) with 3315 completing post-visit questions in 4 waves at two sites and 3 waves (due to pandemic constraints) at the third. Administrative data were collected for 12 months pre- and 12 months post-intervention.

Results: Throughout the study period, the participating EDs were dealing with a worsening epidemic of overdoses and deaths related to a toxic drug supply, and the COVID 19 pandemic curtailed both intervention activities and data collection. Despite these constraints, staff at two of the EDs mounted equity-oriented intervention strategies; the other site was experiencing continued, significant staff shortages and leadership changeover. Longitudinal analysis using multiple regression showed non-significant but encouraging trends in patient perceptions of quality of care and patient experiences of discrimination in the ED. Subgroup analysis showed that specific groups of patients experienced care in significantly different ways at each site. An interrupted time series of administrative data showed no significant change in staff sick time, but showed a significant decrease in the percentage of patients who left without care being completed at the site with the most robust intervention activities.

Conclusions: The trends in patient perceptions and the significant decrease in the percentage of patients who left without care being completed suggest potential for impact. Realization of this potential will depend on readiness, commitment and resources at the organizational and systems levels.

Trial registration: Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

Keywords: Discrimination; Emergency; Emergency departments; Health disparities; Health equity; Health inequity; Indigenous; Intervention research; Racism; Stigma.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Patient and staff survey data collection and intervention timeline
Fig. 2
Fig. 2
ITS analysis for LWCC for all three sites

References

    1. Kim PJ. Social determinants of health inequities in indigenous Canadians through a life course approach to colonialism and the residential school system. Health Equity. 2019;3(1):378–381. doi: 10.1089/heq.2019.0041.
    1. Phillips-Beck W, Eni R, Lavoie JG, Avery Kinew K, Kyoon Achan G, Katz A. Confronting racism within the Canadian healthcare system: systemic exclusion of first nations from quality and consistent care. Int J Environ Res Public Health. 2020;17(22):8343. doi: 10.3390/ijerph17228343.
    1. National Collaborating Centre for indigenous health . Access to health services as a social determinant of first nations, Inuit and Métis health Prince George, BC: National Collaborating Centre for Aboriginal Health. 2019.
    1. McLane P, Bill L, Barnabe C. First nations members’ emergency department experiences in Alberta: a qualitative study. CJEM. 2021;23(1):63–74. doi: 10.1007/s43678-020-00009-3.
    1. Schultz A, Nguyen T, Sinclaire M, Fransoo R, McGibbon E. Historical and continued colonial impacts on heart health of indigenous peoples in Canada: What's reconciliation got to do with it? CJC Open. 2021;3(12):S149–SS64. doi: 10.1016/j.cjco.2021.09.010.
    1. Tang S, Browne AJ, Mussell B, Smye V, Rodney P. 'Underclassism' and access to healthcare in urban centres. Sociol Health Illn. 2015;37(5):698–714. doi: 10.1111/1467-9566.12236.
    1. Browne AJ, Smye VL, Rodney P, Tang SY, Mussell W, O’Neil J. Access to primary care from the perspective of Aboriginal patients at an urban emergency department. Qual Health Res. 2011;21(3):333–348. doi: 10.1177/1049732310385824.
    1. Gilmer C, Buccieri K. Homeless patients associate clinician bias with suboptimal care for mental illness, addictions, and chronic pain. J Prim Care Community Health. 2020;11:2150132720910289. doi: 10.1177/2150132720910289.
    1. Purkey E, MacKenzie M. Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care. Int J Equity Health. 2019;18(1):101. doi: 10.1186/s12939-019-1004-4.
    1. Shah TI, Clark AF, Seabrook JA, Sibbald S, Gilliland JA. Geographic accessibility to primary care providers: comparing rural and urban areas in southwestern Ontario. Can Geogr. 2020;64(1):65–78. doi: 10.1111/cag.12557.
    1. Jones E. Surviving influenza: lived experiences of health inequity and pandemic disease in Canada. Can Med Assoc J. 2020;192(25):E688–E6E9. doi: 10.1503/cmaj.201074.
    1. World Health Organization . Social determinants of health to advance equity. 2020.
    1. Mate K, Wyatt R. Health equity must be a strategic priority. NEJMCatalyst. 2017. .
    1. Browne AJ, Lavoie J, McCallum MJL, Big CC. Addressing anti-indigenous racism in Canadian health systems: multi-tiered approaches are required. Can J Pub Health. 2022;113:222–226. doi: 10.17269/s41997-021-00598-1.
    1. Almutairi AF, Rodney P. Critical cultural competence for culturally diverse workforces: toward equitable and peaceful health care. ANS Adv Nurs Sci. 2013;36(3):200–212. doi: 10.1097/ANS.0b013e31829edd51.
    1. Baum F, Legge DG, Freeman T, Lawless A, Labonté R, Jolley G. The potential for multi-disciplinary primary healthcare services to take action on the social determinants of health: actions and constraints. BMC Public Health. 2013;13:460. doi: 10.1186/1471-2458-13-460.
    1. Baum FE, Bégin M, Houweling TAJ, Taylor S. Changes not for the fainthearted: reorienting health care systems toward health equity through action on the social determinants of health. Am J Public Health. 2009;99(11):1967–1974. doi: 10.2105/AJPH.2008.154856.
    1. Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care. 2005;43(4):356–373. doi: 10.1097/01.mlr.0000156861.58905.96.
    1. Hall A, McKenna B, Dearie V, Maguire T, Charleston R, Furness T. Educating emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study. BMC Nurs. 2016;15:1–8. doi: 10.1186/s12912-016-0141-y.
    1. Gagné T, Veenstra G. Inequalities in hypertension and diabetes in Canada: intersections between racial identity, gender, and income. Ethn Dis. 2017;27(4):371–378. doi: 10.18865/ed.27.4.371.
    1. Bufalino VJ, Bleser WK, Singletary EA, Granger BB, O'Brien EC, Elkind MSV, et al. Frontiers of upstream stroke prevention and reduced stroke inequity through predicting, preventing, and managing hypertension and atrial fibrillation: a call to action from the value in healthcare initiative's predict & prevent learning collaborative. Circ Cardiovasc Qual Outcomes. 2020;13(7):e006780–e00678e. doi: 10.1161/CIRCOUTCOMES.120.006780.
    1. Sayani A. Health equity in national cancer control plans: an analysis of the Ontario cancer plan. Int J Health Policy Manag. 2019;8(9):550–556. doi: 10.15171/ijhpm.2019.40.
    1. Park C, Jones M-M, Kaplan S, Koller FL, Wilder JM, Boulware LE, et al. A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health. 2022;21:1–20. doi: 10.1186/s12939-021-01616-x.
    1. Browne AJ, Varcoe C, Lavoie J, Smye VL, Wong S, Krause M, et al. Enhancing health care equity with indigenous populations: evidence-based strategies from an ethnographic study. BMC Health Serv Res. 2016;16(544):1–17.
    1. Browne AJ, Varcoe C, Ford-Gilboe M, Wathen N, EQUIP Team EQUIP healthcare: an overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. Int J Equity Health. 2015;14:152. doi: 10.1186/s12939-015-0271-y.
    1. Browne AJ, Varcoe C, Wong S, Littlejohn D, Smye VL, Lavoie J, et al. Closing the health equity gap: evidence-based strategies for primary healthcare organizations. Int J Equity Health. 2012;11(15).
    1. Wong ST, Browne AJ, Varcoe C, Lavoie J, Smye VL, Fridkin A, et al. Development of health equity indicators in primary health care organizations using a modified Delphi. PLoS One. 2014;9(12):e114563. doi: 10.1371/journal.pone.0114563.
    1. Ford-Gilboe M, Wathen CN, Varcoe C, Herbert C, Jackson BE, Lavoie JG, et al. How equity-oriented health care affects health: key mechanisms and implications for primary health care practice and policy. Milbank Q. 2018;96(4):635–671. doi: 10.1111/1468-0009.12349.
    1. Browne AJ, Varcoe C, Ford-Gilboe M, Wathen CN, Smye V, Jackson BE, et al. Disruption as opportunity: impacts of an organizational-level health equity intervention in primary care clinics. Int J Equity Health. 2018;17:154. doi: 10.1186/s12939-018-0820-2.
    1. Levine S, Varcoe C, Browne AJ. 'We went as a team closer to the truth': impacts of interprofessional education on trauma- and violence- informed care for staff in primary care settings. J Interprof Care. 2020;35:1–9.
    1. Wallace B, Browne AJ, Varcoe C, Ford-Gilboe M, Wathen CN. Self-reported oral health among a community sample of people experiencing social and health inequities: implications for the primary health care sector. BMJ Open. 2015;5:1–10. doi: 10.1136/bmjopen-2015-009519.
    1. Lavoie JG, Varcoe C, Wathen CN, Ford-Gilboe M, Browne A.J. On behalf of the EQUIP research team. Sentinels of inequity: examining policy requirements for equity-oriented primary healthcare. BMC Health Serv Res 2018;18(1):705.
    1. McLane P, Barnabe C, Mackey L, Bill L, Rittenbach K, Holroyd BR, et al. First nations status and emergency department triage scores in Alberta: a retrospective cohort study. Can Med Assoc J. 2022;17(194):E37–E45. doi: 10.1503/cmaj.210779.
    1. McLane P, Barnabe C, Holroyd BR, Colquhoun A, Bill L, Fitzpatrick KM, et al. First nations emergency care in Alberta: descriptive results of a retrospective cohort study. BMC Health Serv Res. 2021;21(1):1–13. doi: 10.1186/s12913-021-06415-2.
    1. Varcoe C. Abuse obscured: an ethnographic account of emergency nursing in relation to violence against women. Can J Nurs Res. 2001;32(4):95–115.
    1. Walsh K, Gilmore AK, Barr SC, Frazier P, Ledray L, Acierno R, et al. The role of discrimination experiences in postrape adjustment among racial and ethnic minority women. J Interpers Violence. 2021;1:8862605211028006.
    1. Sukhera J, Miller K, Milne A, Scerbo C, Lim R, Cooper A, et al. Labelling of mental illness in a paediatric emergency department and its implications for stigma reduction education. Perspect Med Educ. 2017;6(3):165–172. doi: 10.1007/s40037-017-0333-5.
    1. Wright P. The intersection of stigma and inequity : the impact of structural violence on people with lived and living experience of substance use and homelessness in the emergency department. Vancouver: University of British Columbia; 2020.
    1. Reddy NG, Jacka B, Ziobrowski HN, Wilson T, Lawrence A, Beaudoin FL, et al. Race, ethnicity, and emergency department post-overdose care. J Subst Abus Treat. 2021;131:108588. doi: 10.1016/j.jsat.2021.108588.
    1. McCallum MJL, Perry A. Structures of indifference: an indigenous life and death in a Canadian city. Winnipeg: University of Manitoba Press; 2018.
    1. Dell EM, Firestone M, Smylie J, Vaillancourt S. Cultural safety and providing care to Aboriginal patients in the emergency department. CJEM. 2015;18(4):301–305. doi: 10.1017/cem.2015.100.
    1. Varcoe C, Bungay V, Browne AJ, Wilson E, Wathen N, Kolar K, et al. EQUIP emergency: study protocol for an organizational intervention to promote equity in health care. BMC Health Serv Res. 2019;19(1).
    1. Varcoe C, Browne AJ, Bungay V, Perrin N, Wilson E, Wathen CN, et al. Through an equity lens: illuminating the relationships among social inequities, stigma and discrimination, and patient experiences of emergency health care. Int J Health Serv. 2022;52(2):246–260. doi: 10.1177/00207314221075515.
    1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6).
    1. Mate K. On the quintuple aim: Why expand beyond the triple aim? 2022.
    1. Nundy S, Cooper LA, Mate KS. The quintuple aim for health care improvement: a new imperative to advance health equity. JAMA. 2022;327(6):521–522. doi: 10.1001/jama.2021.25181.
    1. Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. Br Med J. 2008;336(7656):1281–1283. doi: 10.1136/.
    1. Hawe P. Minimal, negligible and negligent interventions. Soc Sci Med. 2015;138:265–268. doi: 10.1016/j.socscimed.2015.05.025.
    1. Hawe P. Lessons from complex interventions to improve health. Annu Rev Public Health. 2015;36(1):307–323. doi: 10.1146/annurev-publhealth-031912-114421.
    1. Kaufman AJ, McCready J, Powess J. Impact of a multifaceted antimicrobial stewardship program: a front-line ownership driven quality improvement project in a large urban emergency department. CJEM. 2017;19(6):441. doi: 10.1017/cem.2017.11.
    1. Zimmerman B, Reason P, Rykert L, Gitterman L, Christian J, Gardam M. Front-line ownership: generating a cure mindset for patient safety. Healthc Pap. 2013;13(1):7–22.
    1. Bellringer C. An independent audit of the recruitment and retention of rural and remote nurses in northern B.C. 2018.
    1. Rainbow health Ontario . Designing surveys and questionnaires Toronto, ON. 2012.
    1. Statistics Canada . Canadian Community Health Survey (CCHS) annual component - 2012 questionnaire Ottawa, ON. 2012.
    1. Ail J, Avison W. Employment transitions and psychological distress: the contrasting experiences of single and married mothers. J Health Soc Behav. 1997;38(4):345–362. doi: 10.2307/2955430.
    1. Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socioeconomic status, stress, and discrimination. J Health Psychol. 1997;2(3):335–351. doi: 10.1177/135910539700200305.
    1. Peek ME, Nunez-Smith M, Drum M, Lewis TT. Adapting the everyday discrimination scale to medical settings: reliability and validity testing in a sample of African American patients. Ethn Dis. 2011;21(4):502–509.
    1. Weinick RM, Becker K, Parast L, Stucky BD, Elliot MN, Mathews M, et al. Emergency department patient experience of care survey: development and field test. Santa Monica: RAND Corporation; 2014.
    1. Population Data BC . Patient centered measurement data - the emergency department 2018 survey. 2019.
    1. Bullard MJ, Musgrave E, Warren D, Unger B, Skeldon T, Grierson R, et al. Revisions to the Canadian emergency department triage and acuity scale (CTAS) guidelines 2016. CJEM. 2017;19(S2):S18–S27. doi: 10.1017/cem.2017.365.
    1. Accreditation Canada. Accreditation Canada’s revised worklife pulse tool: a guide. Ottawa; 2012.
    1. Canadian Institute for Health Information . PHC team effectiveness score. Canadian institute for health Information. Canadian Institute for Health Information; 2006.
    1. Zhang F, Wagner AK, Ross-Degnan D. Simluation-based power calculation for designing interrupted time series analyses of health policy interventions. J Clin Epidemiol. 2011;64:1252–1261. doi: 10.1016/j.jclinepi.2011.02.007.
    1. Statistics Canada . British Columbia [province] and Canada [country] (table) Ottawa: Statistics Canada Catalogue no. 98–316-X2016001; 2017.
    1. Maytree. Social assistance summaries 2019. Toronto; 2020.
    1. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther. 2002;27(4):299–309. doi: 10.1046/j.1365-2710.2002.00430.x.
    1. Biglan A, Ary D, Wagenaar AC. The value of interrupted time-series experiments for community intervention research. Prev Sci. 2000;1(1):31–49. doi: 10.1023/A:1010024016308.
    1. Chiu H, Batara N, Stenstrom R, Carley L, Jones C, Cuthbertson L, et al. Feasibility of using emergency department patient experience surveys as a proxy for equity of care. Patient Exp J. 2014;1(2):78–86. doi: 10.35680/2372-0247.1026.
    1. Kusmaul N, Wilson B, Nochajski T. Infusion of trauma-informed care in organizations: experience of agency staff. Hum Serv Organ Manag Leadersh Gov. 2015;39(1):25–37.
    1. Kulik CT, Roberson L. Diversity initative effectiveness: What organizations can (and cannot) expect from diversity recruitment, diversity training, and formal mentoring programs. Diversity at Work. Cambridge: Cambridge University Press; 2010. pp. 265–317.
    1. Sukhera J, Watling CJ, Gonzalez CM. Implicit bias in health professions: from recognition to transformation. Acad Med. 2020;95(5):717–723. doi: 10.1097/ACM.0000000000003173.
    1. Provost S, MacPhee M, Daniels MA, Naimi M, McLeod C. A realist review of violence prevention education in healthcare. Healthcare (Basel) 2021;9(3):339. doi: 10.3390/healthcare9030339.
    1. Shariff-Marco S, Breen N, Landrine H, Reeve BB, Krieger N, Gee GC, et al. Measuring everyday racial/ethnic discrimination in health surveys. Du Bois Rev. 2011;8(1):159–177. doi: 10.1017/S1742058X11000129.
    1. Browne AJ, Varcoe C, Wong ST, Smye VL, Khan KB. Can ethnicity data collected at an organizational level be useful in addressing health and healthcare inequities? Ethn Health. 2013;19(2):240–254. doi: 10.1080/13557858.2013.814766.
    1. Kirmayer LJ, Jarvis GE. Culturally responsive services as a path to equity in mental healthcare. Healthc Pap. 2019;18(2):11–23. doi: 10.12927/hcpap.2019.25925.
    1. Browne AJ, Varcoe C, Ward C. San’yas indigenous cultural safety training as an educational intervention: promoting anti-racism and equity in health systems, policies and practices. Int Indig Policy J. 2021;12(3).
    1. Ward C, Morton Ninomiya ME, Firestone M. Anti-indigenous racism training and culturally safe learning: theory, practice, and pedagogy. Int J Indig Health. 2021;16(1):304–313.
    1. Palis H, Bélair M-A, Hu K, Tu A, Buxton J, Slaunwhite A. Overdose deaths and the COVID-19 pandemic in British Columbia, Canada. Drug Alcohol Rev; 2021.
    1. BC Coroners Service . Illicit drug toxicity deaths in BC: January 1, 2012 – February 28, 2022. British Columbia; 2022.
    1. Turpel-Lafond MEA-K. In plain sight: addressing indigenous-specific racism and discrimination in B.C health care. Drug Alcohol Rev. 2022;41(4):912-17. 10.1111/dar.13424.
    1. Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, et al. Identifying subgroups and risk among frequent emergency department users in British Columbia. J Am Coll Emerg Physicians Open. 2021;2(1):e12346. .
    1. Doupe MB, Day S, Palatnick W, Chochinov A, Chateau D, Snider C, et al. An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider. Emerg Med J. 2017;34(3):151–156. doi: 10.1136/emermed-2015-205165.
    1. Rowe BH, McRae A, Rosychuk RJ. Temporal trends in emergency department volumes and crowding metrics in a western Canadian province: a population-based, administrative data study. BMC Health Serv Res. 2020;20(1):1–10. doi: 10.1186/s12913-020-05196-4.
    1. Ronksley PE, Liu EY, McKay JA, Kobewka DM, Rothwell DM, Mulpuru S, et al. Variations in resource intensity and cost among high users of the emergency department. Acad Emerg Med. 2016;23(6):722–730. doi: 10.1111/acem.12939.
    1. Geurts J, Palatnick W, Strome TM, Weldon E. Frequent users of an inner-city emergency department. CJEM. 2012;14(5):306–313. doi: 10.2310/8000.2012.120670.
    1. Lavoie JG, Philips-Beck W, Kinew KA, Kyoon-Achan G, Sinclair S, Katz A. The relationship between rates of hospitalization for ambulatory care sensitive conditions and local access to primary healthcare in Manitoba first nations communities. Can J Pub Health. 2021;112(2):219–230. doi: 10.17269/s41997-020-00421-3.
    1. Wilk P, Ali S, Anderson KK, Clark AF, Cooke M, Frisbee SJ, et al. Geographic variation in preventable hospitalisations across Canada: a cross-sectional study. BMJ Open. 2020;10(5):e037195. doi: 10.1136/bmjopen-2020-037195.
    1. Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation research: A synthesis of the literature Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute. 2005.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren