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September 16, 2019

Wondering which ED you'd be transported to in an emergency? It may depend on your race.

Daily Briefing

    Black and Hispanic Medicare beneficiaries are less likely to be transported to the same EDs as white Medicare beneficiaries, according to a first-of-its-kind study published recently in JAMA Network Open.

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    Study details

    For the study, researchers examined whether emergency medical services (EMS) providers transport black, Hispanic, and white Medicare beneficiaries who live in the same ZIP codes to the closest EDs, in accordance with national guidelines from the American College of Emergency Physicians (ACEP).


    The researchers analyzed claims data from Jan. 1, 2006, to Dec. 31, 2012, on 864,750 Medicare beneficiaries from 4,175 ZIP codes. The researchers then evaluated whether EMS were as likely to transport black and Hispanic beneficiaries to so-called "reference EDs," which the researchers described as "the most frequent ED destination among white patients." The researchers also looked at how frequently Medicare beneficiaries were taken to "the nearest EDs" in their area and to safety-net hospital EDs, and compared those EMS transport arrivals with Medicare beneficiaries who arrived at EDs on their own.

    The study is the first to explore ambulance transportation patterns at a population level, Modern Healthcare reports.


    The researchers found EMS providers transport Medicare beneficiaries who live in the same ZIP code to "substantially different" ED locations based on the beneficiary's race and ethnicity.

    For example, the researchers found EMS providers transported 61.3% of white Medicare beneficiaries to a reference ED. That rate was 5.3% lower among black Medicare beneficiaries and 2.5% lower among Hispanic Medicare beneficiaries, according to the researchers.

    The researchers identified a similar pattern among Medicare beneficiaries with high-risk acute conditions. According to the researchers, EMS providers transported 61.5% of white Medicare beneficiaries with high-risk acute conditions to a reference ED, but that rate was 6.7% lower among black beneficiaries and 2.6% lower among Hispanic beneficiaries.

    However, the researchers noted that similar patterns were observed when they compared EMS transport ED patients with walk-ins. About 53% of white walk-in Medicare beneficiaries visited the reference ED within their zip codes, but the rates were 4.8% lower among blacks and 3% lower among Hispanics.

    The researchers found the largest racial disparities in reference ED transport occurred in urban areas with multiple EDs in a ZIP code's vicinity.

    In addition, the researchers found EMS providers transported black and Hispanic Medicare beneficiaries to safety-net hospital EDs more often than white beneficiaries who lived in the same ZIP codes. According to the study, EMS providers transported 18.5% of white Medicare beneficiaries to a safety-net hospital ED. That rate was 2.7% higher among black beneficiaries and 1.9% higher among Hispanic beneficiaries, the researchers wrote.

    The researchers also found evidence that "the destination ED is not the nearest ED among patients of all racial/ethnic groups," despite ACEP recommendations that patients "be transported to the nearest appropriate ED in accordance with applicable laws, regulations, and guidelines." For instance, when the researchers looked at mean actual mileage to reach the ED, they determined that reference EDs, which white beneficiaries were brought to more frequently, often were the nearest EDs for patients.


    The researchers concluded, "In all geographic areas, a sizable proportion of black and Hispanic patients were transported to different EDs compared with their white counterparts living in the same zip code." However, they also noted, "Considerable similarity was observed in the pattern of ED destinations between patients transported by EMS and walk-in patients, suggesting that patient choice is a potential determinant."

    Amresh Hanchate, an associate professor of medicine at Boston University School of Medicine and an author on the study, said more research is needed to examine how much patient preference may be at play. "Unfortunately our data does not include information on patient preference or other reasons for determining the destination ED/hospital. So we cannot determine whether racial/ethnic differences in ED destination are due to different patient preferences."

    Meanwhile, Sharon Holman—president of the Sinai Urban Health Institute, which is the research arm of safety-net provider Sinai Health System—noted that there are many factors at play when EMS providers determine where to take a patient, including an ED's capacity, its ability to care for a patient, the part of the neighborhood where a patient lives, and time of day. For instance, Holman explained, "In Chicago our ZIP code areas are pretty big. Sometimes where you're at in the ZIP code puts you closer to Sinai versus Rush [University Medical Center]."

    Feldman said more research is needed to determine whether beneficiaries who were transported to farther EDs had worse outcomes than beneficiaries who were transported to closer facilities. "This is a first step in research that will prompt other investigations that will look critically at the interplay between patient choice, disease severity and acuity, hospital capability, and whether there are other factors that are guiding transportation decision," Feldman said (Renfrow, FierceHealthcare, 9/6; Owens, "Vitals," Axios, 9/9; Ross Johnson, Modern Healthcare, 9/6; Hanchate et al., JAMA, 9/6).

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