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Health Policy Journal Club, Health Policy

Health Policy Journal Club: Is There Systemic Racism in EMS?

There are clear disparities in prehospital medicine across communities

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, the most astonishing is a product of American society: Out of the 38,423 zip codes in the United States, 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 country. These are the real-life ramifications of generations of segregation and redlining. We 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 past 10 years there has not been much increase in the 8% of paramedics who are black. This aspect of health care workforce diversity has not garnered as much attention as the racial disparities amongst physicians. We don't need a study to tell us 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.

Abstract: Hanchate AD, Paasche-Orlow MK, Baker WE, Lin MY, Banerjee S, Feldman J. Association of Race/Ethnicity with Emergency Department Destination of Emergency Medical Services TransportJAMA Netw Open. 2019;2(9):e1910816.

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 4,175 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 U.S. 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

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.