The Social Determinants of Disparity
Patients who are discharged from the emergency department come in several varieties.
There are those who fill their prescriptions… and those who don’t. There are those who keep their follow-up appointments… and those who don’t.
And then, there are those patients who want to fill their prescriptions and keep their follow-up appointments… and they can’t.
Can you predict which patients are which?
Photo credit: M. Gisondi.
Disparity is defined as “the quality or state of being different.” And for those in the world who get the short end of the stick – when it comes to a particular disparity – that ‘state of being different’ can really stink.
Disparity isn’t simply difference. Difference is difference. The use of the word disparity acknowledges the inherent injustice in an observed difference.
It always bugs me when scientists use these words incorrectly. Here’s a quick example:
Say, there are 140 jelly beans in a jar. 80 are red and 60 are blue. Is there an observed disparity between the types of jelly beans? No, of course not -- there is simply a difference.
Take instead, life expectancy in two neighboring countries. On the east side of the border, the average life expectancy is 80; on the west side of the border, its 60. Is this simply a difference? Not when it comes to human death. In this case, there is clearly an observed disparity between life expectancy across a border that must be studied, understood, and mitigated.
Visit the emergency department of any US hospital and you will observe disparity. Heartbreaking, unjust, and systemic disparity. Emergency physicians know health disparities all too well; and as a specialty, we are slowly getting better at identifying the etiologies of the disparities we observe.
Social Emergency Medicine, a growing subspecialty of emergency medicine, explores the effects of social, environmental, and behavioral factors on the health of individuals in a community – commonly referred to as, ‘social and behavioral determinants of health.’ In short, Social EM is about fundamentally understanding disparity.
One of my first research publications was a study of parental compliance with prescriptions and follow-up appointments for pediatric patients discharged from the emergency department. Once again, some parents complied with aftercare instructions and others did not. However, we knew that some parents wanted to fill their children’s prescriptions and take their children to follow-up clinic appointments – but they couldn’t. Or they didn’t, even though they wanted to. Couldn’t? Didn’t? It was the cause and effect work of identifying a disparity, determining the cause of the disparity, and describing the impact or meaning behind the disparity.
We considered many potential social factors that might explain a disparity in pediatric aftercare compliance. And as I remember, there was a lot of math and complex statistics involved. Skipping ahead to the punchline, we found that insurance status was the sole predictor of pediatric aftercare compliance. If you had private insurance, you were significantly more likely to fill your child’s prescriptions and take them to their pediatrician for follow-up after an emergency department visit.
The study finding may not have been Earth-shattering: those with more (insurance), get more (aftercare). Yet, I was proud of the work. Our study was among the first investigations of health disparities among pediatric emergency department patients. And for me, a very junior faculty member at the time, it gave me the opportunity to describe one of the many systemic disparities I observed in the emergency department.
“Disparities are not simply benign differences among subjects, but instead represent a meaningful inequality of social class, wealth, power, or privilege. Disparities are differences defined by their social context, which increase the risk of harm or neglect.” (Wang NE, Gisondi MA, et al, AEM, 2003.)
August 1, 2020
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Co-Authors of Original Article: N. Ewen Wang MD – Stanford University, Michael A. Gisondi, MD - Stanford University, Mana Golzari, MD - The Children’s Hospital of Pennsylvania, Theresa van der Vlugt, MD - Fairfax Hospital, Methodius Tuuli, MD, MPH, MBA - Indiana University