Background: Racial and ethnic healthcare disparities contribute to significant morbidity, mortality, and healthcare costs in cardiovascular disease. As one of the primary reasons for emergency department (ED) presentation, rapid assessment of patients with chest pain is necessary to guide further intervention and disposition. However, even with continued efforts to achieve health equity and eliminate disparities, Hispanics continue to face significant barriers to healthcare. Our goal was to assess the characteristics, and disposition, of Hispanic patients presenting to the ED with chest pain to identify potential targets for intervention to improve healthcare delivery. Methods: Data was obtained from the electronic medical record warehouse of a large, safety-net, academic hospital from January to December 2020. Patients who presented to the emergency department with a chief complaint of “chest pain” were identified and medical records were reviewed. Bivariate analyses were performed to identify the relationship between Hispanic ethnicity and ED disposition. Results: Hispanic patients who presented with chest pain represented only 4.78% (530 of 11095). Hispanics were of younger age (43.4 vs 48.5) and had lower BP (128.8/77.8 vs 134.5/81.5), but were 2.93 times more likely to be uninsured (2.44-3.51, 95% CI, p<0.05). Hispanic females were 1.58 more likely to present with chest pain (1.32-1.88, 95% CI, p<0.05). Although Hispanics were admitted more often (17.74 vs 16.79%), overall disposition from the ED (admit to inpatient, observation, discharge) was 1.39 times longer for this ethnic group (99.0 vs 71.0 min, p<0.05). Disposition for admitted Hispanics took 1.98 times longer, (86.0 vs 43.5 min, p<0.05). Discussion: Our study suggests that Hispanics with chest pain may experience delays in triage and disposition from the ED. Contributing factors may be due to higher prevalence of undocumented status, lack of insurance, language barriers, and a lack of Hispanic providers who promote healthcare equity. Our next steps are to begin a focused educational program for residents to demonstrate that physician driven interventions are an effective way to promote the elimination of racial and ethnic healthcare disparities.
Introduction: Non-adherence to guideline directed medical therapies (GDMT) is responsible for significant health care costs, morbidity, and mortality in heart failure (HF) patients. Assessing and improving medication adherence (MA) is challenging in this patient population given its multifactorial nature. We aimed to evaluate trainee assessment of MA in HF patients while identifying potential barriers to addressing MA during patient encounters. Methods: This was a single-institution study performed at a large safety net hospital in Atlanta. An anonymous questionnaire was used to assess MA strategies of interns, residents, and medical students for HF patients. This data was compiled and analyzed to identify the most commonly perceived barriers to medication non-adherence. Results: 100 surveys were returned. 99% (99/100) noted that addressing MA is important in HF patients. However, only 83% (83/100) reported that they discussed the specific reasons for non-adherence with their HF patients, with 9%, 12%, and 78% addressing MA in the outpatient, inpatient, and both settings, respectively; the lack of time was reported as the most common contributor in all settings. The most common reasons reported by trainees for patient non-adherence include misunderstanding of their regimen (71%), cost (62%), and polypharmacy (57%). Although, 40% (40/100) of survey responders believed that ≥50% of their HF patients were nonadherent, strikingly, only 12% (12/100) discussed these MA barriers at all HF patient visits. Conclusion: Improving outcomes in HF patients is multifactorial. Medicine teaching teams can play a crucial role in this process by recognizing and addressing the specific barriers to MA in HF patients while promoting GDMT adherence. Our study demonstrates that although trainees recognize the importance of MA, the unique patient characteristics that contribute to non-adherence are under appreciated. Our long-term goal is to not only identify these barriers, but to implement educational interventions, then re-assess trainee comfort level with discussing MA, to demonstrate that trainee driven interventions can improve MA in HF patients while simultaneously reducing HF related re-admissions and hospital costs.
Introduction:Cocaine is a widely abused substance globally. It effects on the pulmonary system can range from bronchospasm to pulmonary vasoconstriction. We present a case of cocaine induced pulmonary vasoconstriction mimicking pulmonary embolism on ventilation-perfusion scan. Case summary:A 65 male with a past medical history of hypertension, diabetes, renal call carcinoma status-post nephrectomy and chronic kidney disease stage IV presents to the emergency department with sudden chest pain and shortness of breath. Denies any fever, chills or prior episodes. Social history was significant 20-year pack smoking history, intravenous drug abuse. Vitals were blood pressure 160/95 mmhg, pulse 90 beats per minutes, respiratory rate 18 breaths per minute and temperature 37.8 C. Physical exam was significant for a non-obese male in acute distress and chest wall tenderness on palpation. A 12 lead electrocardiogram obtained revealed no ischemic findings. Laboratory findings revealed creatinine of 4.3 mg/dL with baseline 3.0-4.5. Other labs including troponin, brain natriuretic peptide were normal. Ventilationperfusion (V/Q) scan obtained to revealed a filing defects in the inferior lingual, posterior inferior upper lobe and posterior inferior lower lobe characteristic for pulmonary embolism (PE). Follow up transthoracic echocardiogram revealed no evidence of ventricular strain. The patient was started on heparin drip and admitted for further management. He remained stable throughout admission, was successfully bridged to warfarin and home in stable condition, international normalized ratio (INR) at that time was 2.3. Two weeks later, he presented to the emergency department with similar complains. Vitals were unremarkable and physical examination was unchanged from prior. Significant laboratory findings were INR 1.12. Patient reports non adherence to warfarin. Due to concern for recurrent PE V/Q scan was ordered, however it revealed no filling defects and lower extremity doppler ultrasound revealed no clot. D-dimers was also normal. Urine drug screen obtained was positive for cocaine. With the help of the radiologist we compared both V/Q scans, it was deemed that the filling defect initially identified was due to vasospasm of the pulmonary vessels, likely secondary to cocaine. Warfarin was discontinued, cocaine cessation was advised and his chest pain was managed as a musculoskeletal pain. He was later discharged home in stable condition. Discussion:While ventilation-perfusion scan is a safe screening tool to evaluated for pulmonary embolism, it lacks specificity. Other causes of ventilation or perfusion defects should be considered. In this case it was due to cocaine inhalation.
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