Date of Award

January 2024

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Ambrose Wong

Abstract

AbstractImportance: Black patients were more likely than White patients to be brought to the hospital by police, and they were also more likely to be restrained and sedated during behavioral crises in emergency departments (EDs). Although the perils of policing mental health conditions for Black individuals are recognized, it is unclear whether or to what extent police transport mediates the relationship between Black race and physical restraint use in emergency departments. Hispanic/Latino patients were less likely than White patients to be restrained in Emergency departments but more likely to be brought to the hospital by police. They were also less likely to have a psychiatric diagnosis associated with their visit and more likely to have a medical one. Objective: To evaluate the degree to which police transportation mediated the relationship between Black race and restraint in EDs. To evaluate other associations in restraint and sedation rates for minority groups. Design and Setting: This retrospective, cross-sectional study used electronic health record data from ED visits. Data were analyzed from September 1, 2022 to May 30, 2023. Data were collected from three Southeastern and ten Northeastern hospitals for all visits between January 1, 2015, to December 31, 2022. Participants: All adult (aged 18+) ED visits. Exposure: The exposures of interest were race, ethnicity and police transport to the hospital. Main Outcomes and Measures: The outcome variables were police custody and the presence of an order for restraints during an ED visit. In supplemental analyses, sedation and diagnoses were also studied as outcomes. Results: A total of 4,263,437 ED visits by 1,257,339 patients were included in the study; White patients accounted for 50.3% of visits, while Black patients accounted for 27.5% of visits. Hispanic/Latino patients accounted for 17.6% of visits. In models adjusted for age, sex, site, previous behavioral or psychiatric history, and visit diagnoses, Black patients were at increased odds of restraint compared to White patients with an adjusted odds ratio (AOR) of 1.33 (95% CI 1.28 - 1.37) whereas Hispanic/Latino were at a decreased odds of restraints compared to White patients with an AOR of 0.93 (95% CI 0.89-0.96). Within the mediation analysis, Black patients had higher odds of being brought to the hospital by police compared to all other patients with an AOR of 1.38 (1.34 - 1.42). Patients brought to the ED under police transport had increased odds of restraint compared to all other modes of transport with an AOR of 5.51 (5.21 – 5.82). The proportion of restraints for Black patients mediated by police transport was 10.70% (95% CI 9.26% - 12.53%). Supplemental analyses revealed that sedation patterns mirrored restraint patterns, that disparities persisted in the group of patients brought to the hospital by polices, and that there were further disparities related to diagnosis type in the ED. Conclusions and Relevance: In this cross-sectional study of ED visits across 13 hospitals, police transportation may have mediated the relationship between Black race and physical restraint. These findings suggest a need for more equitable transportation methods for patients experiencing behavioral emergencies.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 04/30/2026

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