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“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

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Martin Luther King, Jr

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The United States of America, which was founded on the promise of liberty and opportunity for all, is growing increasingly diverse (Figure 27-1). These shifting demographics are keenly felt in the emergency department (ED). Even in fairly homogenous communities, the ED must be prepared to care for any patient, regardless of race, ethnicity, religion, country of origin, gender orientation, or socioeconomic status. Providing high-quality emergency care to all patients requires cognizance of the complex interactions between culture and health as well as an awareness of the pervasive, existing disparities in health and healthcare for certain groups.

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Figure 27-1.
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US population race and ethnicity 1970, 2010, and 2050. Source: 1970 data from US Census Bureau, 2002; 2010 and 2050 data from US Census Bureau, 2008. http://www.census.gov/population/projections/data/national/2009.html.

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The Institute of Medicine has included “equitable as one of the 6 components of quality.1 Most physicians and nurses believe that they deliver “equitable” care to their patients but very few have data to substantiate that belief. Whether motivated by professional pride, a commitment to social justice, or a desire to optimize clinical and financial performance, ED directors must be able to demonstrate that their clinicians and staff provide equitable care. Achieving this requires attention to several relevant issues that are discussed in this chapter and are defined in Table 27-1—existing disparities in health and healthcare, cultural competence, workforce diversity, and the need for accurate, group-specific data on race and ethnicity.

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Table 27-1 Definitions
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Racial/ethnic disparities in health have been well described, with data showing that blacks, Latinos, Native Americans, Alaskans, and Hawaiians suffer disproportionately from many conditions, including cardiovascular diseases, stroke, diabetes, asthma, influenza, and pneumonia. Racial and ethnic minorities have excess morbidity and mortality, as well as decreased life expectancy, at every level of socioeconomic status.2,3 The causes of racial/ethnic health disparities are multifactorial, reflecting differences in biological vulnerability to disease as well as differences in social resources, environmental conditions, and healthcare utilization.4-6 Annually since 2002, the Agency for Healthcare Research and Quality has issued the National Healthcare Disparities Report (NHDR) to track core measures ...

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