Racial and Ethnic Disparities in EMS System Activation from 2019 – 2021

Abstract

In order to optimize the quality of care provided and patient care outcome, it is essential to understand the demographic composition of patients served by the emergency medical services (EMS) system. By identifying which patient populations are proportionally overrepresented and underrepresented in EMS, we can identify potential population-specific health problems, institutional barriers to accessing healthcare, and shortcomings in the medical field’s ability to adequately care for more at-risk populations. As such, in this study, we specifically investigate the racial and ethnic composition of EMS patients and identify potential racial disparities in EMS system activation in an attempt to better cater population-specific healthcare and improve overall population health.

Key Words

Emergency Medical Services, Racial Disparities, Ethnic Disparities, Access to Healthcare, COVID-19

Methods

Racial and ethnic composition data from the 2019 – 2021 National Emergency Medical Services Information System (NEMSIS), a national database that collects EMS data from 46 states in the United States and its territories, was used. This data was compared with the 2019 – 2021 United States census data from the United States Census Bureau. Statistical analysis was performed using a Z-Test: One Population Proportion test. Additionally, comparative analysis was performed between different years (from 2019 – 2021) for a given racial group to observe the effects of COVID-19 on EMS activations.

Results

From 2019 – 2021, Black patients are proportionally over-represented in the EMS system, with Black patients activating EMS 1.7 – 2 times more than expected. In contrast, from 2019 – 2021, Hispanic/Latino patients are proportionally underrepresented in the EMS system, with Hispanic/Latino patients activating EMS 0.44 – 0.52 times compared to the expected. Asian patients are also proportionally underrepresented in the EMS system from 2019 – 2021, activating the system 0.23 – 0.25 times the number of expected activations. There were no statistically significant differences in expected vs observed EMS activations from 2019 – 2021 for American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and white populations. From 2019 – 2021, there were no statistically significant differences found over the years for the given racial populations.

Conclusion

While the data collected here does not elucidate the causational factors that are contributing to these trends, we have found that our data correlates with the data collected from the in-hospital setting. We hypothesize that, similar to the in-hospital setting, socioeconomic barriers, mismanaged healthcare, and biases against people of color are contributing to the EMS activation trends observed here.

Additionally, while no statistically significant differences are observed from 2019 – 2021 within the given racial populations, future studies must consider the effects of the COVID-19 pandemic on observed disparities in EMS activation. While the correlations and trends observed here corroborate trends observed in the in-hospital setting, future studies must aim to determine the causes behind these observed trends in order to ensure in-hospital and EMS providers can work towards addressing these systemic issues and providing adequate healthcare for all patients.

Introduction

With the improvement in medical diagnosis, treatment, and research, national data has shown that over the past 50 years there has been a steady improvement in the overall health and life expectancy of the American population. Even still, the quality of health and the life expectancy of certain racial and ethnic minorities (i.e. African Americans, Latinx/Hispanics, Indigenous peoples, etc.) remain worse than that of other races (i.e. white). Studies conducted in the

in-hospital setting have shown that in everything from primary care to quaternary care, racial and ethnic minorities are consistently receiving worse quality care and inadequate treatment, likely contributing to worsened health outcomes. While race and ethnicity are often correlated with other demographic variables that may impede access to quality health care, including economics, geographic access, etc., the fact remains that a patient’s race and ethnicity is still a determinant of their healthcare outcomes in the in-hospital setting.

While many racial and ethnic disparity studies have been conducted in the in-hospital setting, research in the out-hospital, emergent setting remains relatively limited. Such study is essential, as we must determine if, similar to the in-hospital setting, mismanaged healthcare, racial biases, and other system barriers are impeding racial and ethnic minority access to out-hospital, emergent care. If such barriers are present, such study is essential to elucidating how we can address them. Furthermore, we must consider if the disparities observed in the in-hospital setting have a trickle-down effect into the out-hospital, emergent setting.

As such, the present study investigates the racial and ethnic composition of EMS patients to observe if certain populations are overrepresented or underrepresented in the out-hospital, emergent setting. In doing so, we can identify potential social, economic, etc. causes of the observed disparities and word toward providing adequate medical care for all patients, in-hospital and out-of-hospital, regardless of race or ethnicity.

Methods

The author used patient demographic racial and ethnic composition data from the 2019-2021 National Emergency Medical Services Information System (NEMSIS), a national database that collects EMS data from 46 states in the United States and its territories. This database is managed by the NEMSIS Technical Assistance Center in the University of Utah School of Medicine in Salt Lake City, Utah, and it is supported by the Office of Emergency Medical Services and the National Highway Traffic Safety Administration. Local EMS agencies from various states and territories submit their data to NEMSIS, and a random subset of approximately 26 million EMS activations annually were added to the database. The requirements for NEMSIS data reporting vary by state.

Additionally, the author used United States census data from the United States Census Bureau to determine the racial and ethnic composition of United States residents living in the United States from 2019-2021. Comparative analyses between NEMSIS and United States census data were conducted to determine which racial and ethnic populations, if any, are overrepresented and underrepresented as patients in EMS.

Statistical analyses between racial groups for a given year were performed using a Z-Test: One Population Proportion test. Results were considered statistically significant if p < 0.05.

Finally, the author trended the ratio of observed to expected EMS activations for each racial group over the 2019 – 2021 year period. Statistical significance for these trends was performed using a paired t-test. Results were considered statistically significant if p < 0.05.

Results

Discussion

This study sought to characterize the patient demographic composition of the EMS system. While many race-based studies regarding patient demographics, patient treatment, patient outcome, etc., have been conducted in the in-hospital setting, such race-based demographic studies in the EMS, out-of-hospital setting are still limited. Such studies in the EMS setting are necessary to determine which patient populations are overrepresented and underrepresented. This will help EMS professionals identify potential population-specific health care problems and systemic issues in the healthcare system to provide better care for all patients.

Of the data studied here, statistically significant differences between the observed and expected EMS activations were found for the Black, Hispanic/Latino, and Asian populations. From

2019-2021, Black populations were found to proportionally over-activate the EMS system, while the Hispanic/Latino and Asian populations were found to proportionally under-activate the EMS system (Figures 1-3). In contrast, no statistically significant differences were observed in expected vs. observed EMS activations from 2019 – 2021 for American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and white populations. While the data collected here does not elucidate the causational factors that are contributing to these trends, we have found that our data correlates with the data collected from the in-hospital setting. We hypothesize that, similar to the in-hospital setting, socioeconomic barriers, mismanaged healthcare, and biases against people of color are contributing to the EMS activation trends observed here.

First, when considering Black patients, they are consistently proportionally over-represented in the EMS system from 2019 – 2021, activating EMS 1.7 – 2 times more than expected (Figures 1-3). This statistically significant proportional overrepresentation of Black patients in EMS reveals there is likely a systemic cause for this observed trend. We hypothesize the economic and social barriers that have led to inadequate healthcare for Black patients in the in-hospital setting are contributing to increased out-of-hospital healthcare emergencies and resulting overactivation of the EMS system by Black Americans.

One potential economic factor contributing to this trend is observed disparities in healthcare coverage and insurance, which have led to inadequate in-hospital care for Black patients and downstream overactivation of the EMS system. Previous studies in the in-hospital setting have found Black patients are 1.83 times more likely to be uninsured than their white counterparts, and for those Black patients that do have healthcare, they are more likely to have public, rather than private, health insurance.^1-3 These inadequacies in healthcare coverage have posed significant economic barriers for Black Americans seeking healthcare, contributing to decreased continuity in care. Without regular visits with a consistent provider, diagnoses, preventative care, and treatments are less likely to be provided for Black patients in-hospital, making Black patients more susceptible to healthcare emergencies. Therefore, inadequacies in the in-hospital setting due to economic barriers may lead to Black patients having an increased need for emergent health care and transport, likely contributing to the observed proportional over-activation of the EMS system.

One potential social factor contributing to this trend are providers’ conscious and unconscious biases against Black patients, which manifest as discrimination and inadequate care in the

in-hospital setting. It has been well-documented that healthcare providers stereotype minority patients – van Ryn and Burke, for example, found that physicians viewed Black patients as less kind, less educated, less likely to adhere to medical advice, and more likely to abuse drugs and alcohol.⁴ Such biases and stereotypes have contributed to the disparities in treatment and care provided to Black patients in-hospital – for example, Black patients are less likely to receive preventative screenings, including rectal examinations, Pap smears, and mental health advising.^5,6

Such overt and covert discrimination has also contributed to general distrust between Black patients and healthcare providers – Black patients are 2.60 times more likely to distrust their provider, leading to Black patients delaying medical consultation and treatment, even if they are able to address the economic barriers to accessing healthcare.^7,8 Thus, systemic social biases have contributed to inadequate treatment and care for Black patients in-hospital, leading to Black patients having a likely increased need for EMS, resulting in the observed overactivation.

Second, when considering the Hispanic/Latino population, we find that in contrast to the Black population, the Hispanic/Latino population is proportionally under-represented in the EMS system, only activating EMS 0.44 – 0.52 times compared to the expected (Figures 1-3). Black and Hispanic/Latino populations face a lot of the same economic and social barriers to healthcare. For example, in 2001, 35% of the Hispanic/Latino population was uninsured – as such, Black and Hispanic/Latino populations face a similar in-hospital economic barrier, which leads to less diagnosis, preventative care, and treatment, contributing to increased downstream healthcare emergencies.

Similarly, Hispanic/Latino populations face provider discrimination. Implicit Association Tests performed on primary care providers show strong implicit bias against Hispanics/Latinos compared to whites, which has manifested itself as lower screening rates for cervical, breast, and colorectal cancers for Hispanic/Latino populations.^9,10 Such perceived bias has also led to 1 in 5 Hispanics/Latinos reporting they avoid medical care due to concerns of being discriminated against.¹¹

Given Hispanic/Latino Americans receive inadequate in-hospital healthcare, it would be expected that, similar to Black Americans, Hispanics/Latinos would be more vulnerable to out-of-hospital healthcare emergencies, and thus, be overrepresented in EMS activations.

However, it is interesting to note that despite facing the same socioeconomic barriers to healthcare as Black Americans, Hispanic/Latino Americans under-activate the EMS system from 2019 – 2021 (Figures 1-3). It is possible that other social barriers that are more specific to the Hispanic/Latino population, such as language barriers, may further discourage Hispanics/Latinos

from activating EMS, even when experiencing health-related emergencies.¹² However, more importantly, such polarized, opposite effects between Black and Hispanic/Latino EMS activations – despite facing many of the same socioeconomic barriers in-hospitals – reveals how complex the issues and manifestation of racial disparities in healthcare can be. Such data also shows the need for future study on further elucidating the causation behind such observed disparities in EMS activation.

Third, when considering the Asian population, similar to the Hispanic population, the Asian population proportionally under-activates the EMS system, activating the system 0.23 – 0.25 times the number of expected activations from 2019 – 2021 (Figures 1-3). However, previous in-hospital studies have shown that the Asian population do not face significant socioeconomic barriers to in-hospital care. In 2021, only 5.8% of the Asian population did not have healthcare insurance, second only to non-Hispanic white Americans, of which only 5.7% are uninsured.¹³

Moreover, in 2020, 74.6% of the insured Asian population had private healthcare insurance.¹⁴ As such, the Asian population faces less economic barriers to in-hospital care, resulting in more adequate preventative care, diagnoses, and treatments in-hospital. As such, Asian patients are less vulnerable to out-of-hospital healthcare emergencies, likely contributing to the proportional underrepresentation in the EMS patient population.

Moreover, Asian populations are less likely to face the social barriers and discrimination that Black and Hispanic/Latino patients face. According to data collected in 2021, the health system performance scores, a multidimensional measure based on quality, cost, access, equity, patient experience, and patient safety, were comparable for Asian Americans and white Americans in the supermajority of states in America.¹⁵ In contrast, Black and Hispanic/Latino Americans consistently scored below the all-group median health system performance score. As such, the Asian patient population does not face as significant of socioeconomic barriers to in-hospital care – with adequate in-hospital care, Asian populations are less likely to have out-of-hospital healthcare emergencies, resulting in the observed proportional underrepresentation of the EMS system.

Parenthetically, it is important to note the data collected for this study was from 2019 – 2021, encompassing both the immediate pre-COVID 19 pandemic, mid-COVID 19 pandemic, and post-COVID 19 pandemic era. As the pandemic continues to play out, studies in the in-hospital setting are still being conducted to determine the short and long-term effects of COVID-19 on minority access to and equity in healthcare. However, healthcare providers and health equity researchers generally hypothesize that the aforementioned economic and social barriers will portend to worse COVID-19 outcomes.¹⁶ As such, EMS activations must be studied from 2019 – 2021, as the pandemic is taxing a healthcare system that is already providing inadequate care for racial minorities. As such, vulnerable populations may be even more overrepresented or underrepresented due to the aforementioned economic and social barriers. This data is shown in

Figure S1 as relative EMS activations, over the 2019 – 2021 year time span. While slight fluctuations are observed in the relative ratios of EMS activations, these are overall not statistically significant. Future studies must consider the effects of the COVID-19 pandemic on observed disparities in EMS activation.

Limitations and Further Studies

One primary limitation of this study is that while relative overactivation and underactivation of EMS could be quantified, causation behind such trends could only be hypothesized, not confirmed. Future studies must aim to determine the causes behind these observed trends in order to ensure in-hospital and EMS providers can work towards addressing these systemic issues and providing adequate healthcare for all patients.

Acknowledgments

The author of this paper would like to thank the National Emergency Medical Services Information System (NEMSIS) for providing the necessary data to perform this analysis.

Declaration of Interest Statement

The author declares they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplemental

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