When Elaine Benes on Seinfeld discovers she was labeled as a “difficult patient” in her medical chart, hilarity ensues when she tries to correct the record—and makes matters worse. But in real life, such labels are no laughing matter, especially because they are often inequitably applied.
A recent study published this month in JAMA Network Open quantified this inequity. Researchers analyzed how often patients in the emergency room were flagged for behavioral issues. Though the analysis found behavioral flags were infrequent, some patients were more likely to have behavioral flags in their records than others.
According to the paper, behavioral flags are meant to help mitigate physical violence against healthcare workers, which the authors report a majority of nurses in the ED have experienced. By flagging patients after patients exhibit threatening or disruptive behavior, ED staff may be better positioned to identify potential safety risks and to take steps to prevent harm. The purpose of the study was to examine how common such flags are, which patients tend to get flagged, and whether these flags have any impact on patient care.
The study included nearly the records of nearly 200,000 patients with nearly 427,000 emergency department (ED) visits to three hospitals in Philadelphia. The visits occurred between 2017 and 2019.
Overall, fewer than 700 patients—just 0.3% of the total—had behavioral flags in their medical records across nearly 7,000 ED visits. Patients whose records contained behavioral flags were more likely to be male, Black, and to have Medicaid for their insurance coverage.
Patients who had flags spent less time in the ED overall (292 minutes compared with 284 minutes for patients without flags). Those visits where flags were present were more likely to end with a patient leaving against medical advice or without being seen by a clinician at all. Patients with flags were less likely to be admitted to the hospital and more likely to have no lab tests or imaging studies ordered.
Black patients were almost twice as likely as white patients to receive flags, at a rate of 4.0 per 1,000 patients compared to 2.4 per 1,000 patients.
And, the disparities in treatment that emerged between patients with and without flags were more pronounced among Black patients whose records contained behavioral flags.
This study adds to a growing body of evidence that healthcare in the United States is full of inequities. A Deloitte analysis estimated that the costs of such inequities could reach $1 trillion by 2040 if left unchecked.
For patients in the ED, being tagged as a potential behavior problem comes with its own costs.
The presence of a behavioral flag was associated with longer wait times to be placed in a room, with Black patients waiting 28 minutes to be moved into a room on average compared to 18 minutes for white patients. Black patients also waited longer to be seen by a clinician than white patients (42 minutes compared to 33 minutes).
Black patients also appear to have gotten “less” care than white patients with behavior flags. Black patients had shorter lengths of stay (274 minutes compared with 305 minutes for white patients). They also had fewer lab tests, with 43% of Black patients with flags received zero lab tests compared to 36% of white patients with flags who got no lab tests. Similarly, nearly 63% of Black patients with behavioral flags got no imaging (eg, x-rays or CT scans) while 56% of white patients with flags had no imaging.