Ambulance crews are generally supposed to take seriously ill patients to the closest hospital that offers the necessary emergency services, such as stroke or trauma care. However, new research shows that patients are sometimes transported somewhere else, and that their race may have something to do with it.
A national study published in JAMA Network Open on Friday found there were differences in the emergency departments where patients were taken by emergency medical services, based on their race or ethnicity. The researchers, from Boston University School of Medicine, found that black and Hispanic patients were more likely to be transported to safety net hospitals compared to white patients living in the same zip code. Safety-net hospitals serve a high proportion of people who are uninsured or on Medicaid, and other vulnerable populations.
The authors said that the study is the first to look for racial differences in where patients are taken by EMS, and that the findings highlight the need for further research into the reasons for the disparity. One possible explanation: Patients or their families may choose to go to a more distant hospital because it’s where they go for routine primary care.
Among the unknowns is whether patients are harmed by going to a more distant emergency department, said Amresh Hanchate, co-lead investigator of the study and associate professor of general internal medicine at B.U. “There is a tradeoff between going to the nearest place vs. going to the familiar place,” he said. “The benefit is not clear and more research is needed.”
The study involved Medicare enrollees over age 66 who were transported by EMS to an emergency department from January 2006 to December 2012. The researchers also looked at instances when patients or families drove to the ED themselves. Overall, there were 864,750 enrollees from 4,175 zip codes.
For each zip code, the most frequent destination among white enrollees was used as a reference ED. White patients were taken by ambulance to the reference ED 61.3% of the time, but for blacks this number was 5.3% lower, and for Hispanics it was 2.5% lower.
The pattern was similar for patients who arrived at the emergency department on their own, a finding that supports the explanation that patient choice is influencing ED destination. Perhaps black and Hispanic patients regularly seek care at safety-net hospitals and other non-reference hospitals, and in times of emergency, the patient or family may request to be taken back to those locations.
“It would make sense that a patient would want to be transported to a hospital where their physicians offer services and where they customarily receive health care,” Dr. Henry Wang, professor and vice chair for research in the department of emergency medicine at University of Texas Health Science Center at Houston, said in an email. “The observed transport patterns may simply reflect EMS personnel appropriately appeasing patient preferences.”
But he added, “The study data sources have inherent limitations and cannot be used to explain the reasons for observed racial disparities.” Instead, the findings “set the stage for more detailed inquiry.”
Across all zip codes, those who were not transported to the reference emergency department traveled an additional 1.67 miles.
The study also found more variation in ED destinations among black and Hispanics compared to white enrollees, and this variation was larger in cities and when there were multiple hospitals in a given zip code.
The data from Medicare claims are not granular enough to capture the decision-making process between emergency response providers and patients or families, but this is the goal of future research. “At a minimum we need much more information to research about where patients are going and about their destination decisions,” said Dr. James Feldman, the other co-lead investigator and professor of emergency medicine at B.U.