Advocates for Evidence-Based Health Policy Speakers
Is There Systemic Racism in EMS?
Recent research has provided insight into what could prove to be another example of systemic racism in the delivery of health care. Emergency Medical Services (EMS) are more likely to transport a Black or Hispanic patient to a safety net hospital than their White counterparts even when such patients are coming from the same zip code. The authors used data from a nationwide Medicare data bank and then identified zip codes with an adequate amount of diversity as well as transports by EMS services. They also controlled for a multitude of variables including socioeconomic status and location. Ultimately, they assessed whether the patient was transported to a safety net hospital versus a reference hospital based on the patient’s race.
The point is quite clear: there are disparities in the way prehospital medicine is being administered to minority patients. It is not understood whether the disparity found has resulted in a difference in outcomes. However, there is a call for more focused studies on prehospital medicine and the potential for racial disparities.
There is more to be done, and it can be done now. Of the limitations with this paper, I find the most astonishing to be a product of American society: out of the 38,423 zip codes only 5,606 of them had enough diversity to be included in the study. The requirements for diversity in this study meant having at least 10% of White, Black, and Hispanic patients in the same zip code. Only 15% of zip codes in America contain at least 10% of the 3 largest races and ethnicities in this county. These are the real-life ramifications of generations of segregation and redlining. Our generation must still actively and aggressively challenge segregation – a problem, possibly now worse than ever with gentrification.
Nationwide, EMS personnel are 83% White and in the last 10 years there has not been much increase in the 8% of paramedics that are Black. This aspect of health care workforce diversity has not garnished as much attention as the racial disparities amongst physicians. We don’t need a study to tell us that this is unacceptable. We should diversify our EMS personnel, especially given that Blacks are nearly 50% more likely to use the emergency department for health care than their White counterparts.
This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. It is written by Joshua Ellis, MD. He is an emergency medicine medical education fellow at the Beth Israel Deaconess Medical Center.
Abstract
IMPORTANCE: Evidence from national studies indicates systematic differences in hospitals in which racial/ethnic minorities receive care, with most care obtained in a small proportion of hospitals. Little is known about the source of these differences.
OBJECTIVES: To examine the patterns of emergency department (ED) destination of emergency medical services (EMS) transport according to patient race/ethnicity, and to compare the patterns between those transported by EMS and those who did not use EMS.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study of US EMS and EDs used Medicare claims data from January 1, 2006, to December 31, 2012. Enrollees aged 66 years or older with continuous fee-for-service Medicare coverage (N?=?864?750) were selected for the sample. Zip codes with a sizable count (>10) of Hispanic, non-Hispanic black, and non-Hispanic white enrollees were used for comparison of EMS use across racial/ethnic subgroups. Data on all ED visits, with and without EMS use, were obtained. Data analysis was performed from December 18, 2018, to July 7, 2019.
MAIN OUTCOMES AND MEASURES: The main outcome measure was whether an EMS transport destination was the most frequent ED destination among white patients (reference ED). The secondary outcomes were (1) whether the ED destination was a safety-net hospital and (2) the distance of EMS transport from the ED destination.
RESULTS: The study cohort comprised 864?750 Medicare enrollees from 4175 selected zip codes who had 458?701 ED visits using EMS transport. Of these EMS-transported enrollees, 26.1% (127 555) were younger than 75 years, and most were women (302?430 [66.8%]). Overall, the proportion of white patients transported to the reference ED was 61.3% (95% CI, 61.0% to 61.7%); this rate was lower among black enrollees (difference of -5.3%; 95% CI, -6.0% to -4.6%) and Hispanic enrollees (difference of -2.5%; 95% CI, -3.2% to -1.7%). A similar pattern was found among patients with high-risk acute conditions; the proportion transported to the reference ED was 61.5% (95% CI, 60.7% to 62.2%) among white enrollees, whereas this proportion was lower among black enrollees (difference of -6.7%; 95% CI, -8.3% to -5.0%) and Hispanic enrollees (difference of -2.6%; 95% CI, -4.5% to -0.7%). In major US cities, a larger black-white discordance in ED destination was observed (-9.3%; 95% CI, -10.9% to -7.7%). Black and Hispanic patients were more likely to be transported to a safety-net ED compared with their white counterparts; the proportion transported to a safety-net ED among white enrollees (18.5%; 95% CI, 18.1% to 18.7%) was lower compared with that among black enrollees (difference of 2.7%; 95% CI, 2.2% to 3.2%) and Hispanic enrollees (difference of 1.9%; 95% CI, 1.3% to 2.4%). Concordance rates of non-EMS-transported ED visits were statistically significantly lower than for EMS-transported ED visits; the concordance rate among white enrollees of 52.9% (95% CI, 52.1% to 53.6%) was higher compared with that among black enrollees (difference of -4.8%; 95% CI, -6.4% to -3.3%) and Hispanic enrollees (difference of -3.0%; 95% CI, -4.7% to -1.3%).
CONCLUSIONS AND RELEVANCE: This study found race/ethnicity variation in ED destination for patients using EMS transport, with black and Hispanic patients more likely to be transported to a safety-net hospital ED compared with white patients living in the same zip code.
PMID: 31490537
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