Ethnic differences in seeking medical care for chest pain among culturally and linguistically diverse populations: Time, Ethnicity and Delay (TED) study

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Wechkunanukul, Kannikar, 2016 Ethnic differences in seeking medical care for chest pain among culturally and linguistically diverse populations: Time, Ethnicity and Delay (TED) study, Flinders University, School of Nursing & Midwifery

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Abstract

Background Delay in seeking medical care for chest pain in the general population is well documented and may adversely impact on patient outcomes. To date there has been limited knowledge of differences in seeking medical care for chest pain among culturally and linguistically diverse (CALD) populations. Methodology The Time, Ethnicity, and Delay (TED) study was a triangulation of three distinct research approaches aimed to investigate differences in seeking medical care for chest pain among CALD populations. The process of triangulation in the TED study involved: TED I: a systematic review to determine the association between ethnicity and delay time in seeking medical care for chest pain globally TED II: a cross-sectional analysis of an Emergency Department Information System (EDIS) dataset which focused on the differences in the characteristics and processing times between CALD and Australian-born patients with chest pain TED III: a retrospective medical record review which aimed to determine the differences in care-seeking behaviours during the suspected ACS events among all ethnic groups living in Australia. Results The systematic review (TED I) found global reports of an association between ethnicity and a delay time n seeking medical care for chest pain, with patients from some ethnic groups (e.g. Black, Asian, Hispanic and South Asian) took a longer time than those of the majority population. TED II study revealed that CALD patients were older than the Australian patients (mean ± SD; 62 ± 18.4 years vs 56 ± 19.6 years, p < 0.001). There was no difference in ambulance utilisation (41.7% vs 41.1%, p = 0.679). There was no significant difference in times taken to receive treatment in ED, but CALD patients spent a longer time in ED compare to the Australian-born population (median 5.4 (2.9, 7.7) vs 4.3 (0.5, 7.0) hours, p < 0.001). There was a low rate of concordance with three chest pain related standards (ambulance use, Triage priority 1 or 2 and time to treatment ≤10 minutes) from the guidelines (the Guidelines for the management of acute coronary syndromes 2006 and the Guidelines on the Implementation of the Australasian Triage Scale in Emergency Departments) in both groups, but it did not differ significantly (12.5% vs 13.1%, p = 0.556). CALD status was a significant predictor of the guideline concordance. CALD patients were 22% (95% CI, 0.65, 0.95, p=0.015) less likely to receive the guideline management for chest pain. The ethnic differences in care-seeking behaviour during suspected ACS events were found in TED III. The median decision time (hours) ranged from 1.5 (Australian) to 4.5 (Sub-Saharan African). Five ethnic groups had significantly longer decision times compared to Australian, including Sub-Saharan African (4.5 (1.8, 14.3) vs 1.5 (0.6, 4.5), p=0.001); North African and Middle Eastern (4.1 vs 1.5 (0.6, 4.5), p <0.013); South-East Asian (3.9 vs 1.5 (0.6, 4.5), p =0.001); North-East Asian (3.0 vs 1.5, (0.6, 4.5), p <0.006); and Oceanian (2.4 (1.0, 7.0) vs 1.5 (0.6, 4.5), p = 0.035). The median prehospital delay time (hours) ranged between 2.5 (1.0, 10.7) (Southern and Eastern European) and 6.0 (2.3, 20.6) (Sub-Saharan African). Only two ethnic groups had their delay time differ significantly from Australian; the Sub-Saharan African (6.0 (2.3, 20.6) vs 3.2 (1.4, 8.8) hours, p=0.025) and the South-East Asian (5.3 (3.0, 22.3) vs 3.2 (1.4, 8.8) hours, p=0.012) groups. Decision time accounted for 58.4% of prehospital delay time. There was no difference in ambulance utilization between ethnic and Australian groups. CALD patients were 60% less likely to seek medical care within one hour when experiencing chest pain (95% CI, 0.23, 0.68, p=0.001). CALD patients had a higher readmission rate than Australians at 30 days and 6 months. Conclusions The outcomes of TED study have demonstrated an association between ethnicity and delay in seeking medical care for chest pain globally and in the area studies in Australia. The ethnic differences in responding to chest pain, particularly decision time were found, and ethnicity had a significant impact on patients’ delay. The initial treatment in ED was equally provided to all patients, but CALD patients spent a longer time in ED and had a higher readmission rate than Australian patients reviewed in this study.

Keywords: Ethnicity, CALD, migrant, chest pain, delay, seeking care, ACS
Subject: Nursing thesis

Thesis type: Doctor of Philosophy
Completed: 2016
School: School of Nursing & Midwifery
Supervisor: Robyn Clark