By Jamie Kennel, MS, NRP
In recent years, the conversation about equity in healthcare and the role EMS plays has changed.
In 2017, Multnomah County, Oregon, issued an Emergency Ambulance Services Request for Proposal (RFP) that included a 10-page addendum directing responding EMS organizations to describe how their EMS service would maintain and advance health equity in the community. The addendum described, among other items, the county鈥檚 requirement for the selected agency to ensure equity in the quality of EMS treatments provided.
In doing so, the county EMS office took an impressive leap forward by bringing EMS to the table with other areas of medicine stakeholders that are engaged in understanding and mitigating racial disparities in both health and healthcare, as well as providing an example of how a government regulator can encourage the EMS industry to take active steps to respond to the EMS Agenda 2050 Social Equity guiding principle.
Don鈥檛 we treat all our patients with the same high-quality care?
With very few exceptions, there is a clear and overwhelming evidence base spanning several decades and several spheres of medicine (including emergency departments) which demonstrates that racial minorities, regardless of access to healthcare, receive a lower quality of treatment [1-8]. There is also a small but growing body of research that has found that this discrepancy also occurs in EMS [9-11].
Striking findings highlight racial inequity in pain treatment
Along with my colleagues, I recently published a paper in which we analyzed more than 25,000 EMS charts of patients being treated for traumatic injuries in 2015-2017 from an estimated 70% of all EMS agencies in the state of Oregon. We found that patients charted as Asian and Hispanic were significantly less likely (LL) to receive a pain assessment (21% and 31% respectively) and all racial minority patients studied were significantly less likely to receive any pain medications when compared to Caucasian patients [11]:
- Black patients: 32% LL
- Asian patients: 24% LL
- Hispanic patients: 21% LL
As there are many patient characteristics that may influence a provider鈥檚 decision to assess and treat a patient with a traumatic injury who is in pain, we attempted to control for as many of these characteristics as possible, including:
- Age
- Gender
- Injury location
- The paramedic鈥檚 primary impression
- Pain score
- Insurance status
While there are limitations to the interpretations we can make from these results, these findings are striking and, unfortunately, are in alignment in both the direction and severity of racial treatment disparities found in other areas of medicine.
It is imperative that we recognize that this is not about pain treatment in EMS, but rather, this is about race. In our work with several EMS agencies interested in improving their visibility, understanding and mitigation of disparities, we have found significant racial treatment differences in a wide range of EMS treatments. While this may be surprising and discouraging, we should not let those feelings delay our response to this very real and important part of our commitment to high quality care for all patients.
4 mechanisms contributing to provider-level racial disparities
Naturally, we next ask why. It is important to appreciate, as was pointed out by the Institute of Medicine in the report, 鈥淯nequal Treatment,鈥� that this is a complex issue with contributing elements from multiple levels, including institutions, individual providers and patients [1,12].
Focusing on the areas where the majority of us have the most direct influence 鈥� the provider level 鈥� highlights four mechanisms that are likely involved.
- First, patients who are unable to speak English have been found to receive a lower quality of treatment from medical providers in a number of medical specialties [13]. While there have been very few studies on the impact language barriers have on the quality of EMS treatments, it is not difficult to imagine the disproportional impact limited English proficiency will have for some, but not all, categories of racial minorities [14].
- Second, evidence suggests that medical providers may still misunderstand the concept of race to be a biological construct instead of a social one [15]. While it has been shown conclusively that there are no medically relevant biological differences between individuals of different races, there is evidence that medical providers nevertheless believe race to be a medically relevant factor and may be adjusting their clinical actions accordingly. Professor Dorothy Roberts has a wonderful overview of this topic in her [16].
- Third, medical providers who make decisions under heavy cognitive loads utilize heuristics, or mental shortcuts. While effective, and often considered required for rapid decision making, these heuristics also often rely on the use of stereotypes, which are known to be laden with bias [17,18].
- Fourth, there is evidence that even when individuals explicitly support racial equality, we might still feel uncomfortable (consciously or unconsciously) in mixed-race situations in a way that impacts our behavior [19,20].
I talk to colleagues, front line providers, supervisors, patients and/or students on a daily basis about race and racial disparities in healthcare. I appreciate that this can be a difficult message to hear. I hope you don鈥檛 take my word for it, but are motivated to become more informed.
Given the mechanisms involved, the evidence from other areas of medicine, and the growing evidence of disparities in EMS treatments, we can no longer assume that we are providing high-quality EMS treatment to all of our patients, especially if we have never looked at our own data in this way. Our anecdotal experience as providers as well as the common practice of performing only single chart level quality reviews are insufficient to see these disparities.
Start with the reference list at the end of this article as a foundation, and at minimum, work with your CQI department to explore performing aggregate data analysis that is stratified by patient race within your local EMS agency. As we get comfortable in our seat at the larger healthcare table, we need to acknowledge that our EMS providers are human and are not immune to the same tendencies that are impacting other healthcare providers. Future research will need to review the internal systems, practices, trainings and communication strategies required to start exploring effective interventions.
About the author
Jamie Kennel is an associate professor and program director of the Paramedic Program, a joint program between Oregon Health and Science University, and Oregon Institute of Technology. Jamie is also a co-founder of Healthcare Equity Group, a consultancy that assists EMS organizations in better understanding and improving the equity of their care.
References
1. Smedley B, Stith AY, Nelson AR (Eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.; 2003. doi:10.17226/10260
2. US Department of Health and Human Services A of HR and Q. 2017 National Healthcare Quality and Disparities Report.; 2018. www.ahrq.gov/research/findings/nhqrdr/index.html.
3. Nafiu OO, Chimbira WT, Stewart M, Gibbons K, Porter LK, Reynolds PI. Racial Differences in the Pain Management of Children Recovering from Anesthesia. Paediatr Anaesth. 2017;27(24):760-767. doi:10.1002/cncr.27633.Percutaneous
4. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physician鈥檚 recommendations for cardiac catheterization. New Engl J Med. 1999;340(8):618.
5. Todd KH, Deaton C, D 鈥檃damo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 1999;35(1):11-16. doi:10.1016/S0196-0644(00)70107-7
6. Todd KH. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA J Am Med Assoc. 1993;269(12):1537-1539. doi:10.1001/jama.1993.03500120075029
7. Mills AM, Shofer FS, Boulis AK, Holena DN, Abbuhl SB. Racial disparity in analgesic treatment for ED patients with abdominal or back pain. Am J Emerg Med. 2011;29(7):752-756. doi:10.1016/j.ajem.2010.02.023
8. Tamayo-Sarver JH, Hinze SW, Cydulka RK, Baker DW. Racial and ethnic disparities in emergency department analgesic prescription. Am J Public Health. 2003;93(12):2067-2073. doi:10.2105/AJPH.93.12.2067
9. Young MF, Hern HG, Alter HJ, Barger J, Vahidnia F. Racial differences in receiving morphine among prehospital patients with blunt trauma. J Emerg Med. 2013;45(1):46-52. doi:10.1016/j.jemermed.2012.07.088
10. Hewes HA, Dai M, Mann NC, Baca T, Taillac P. Prehospital pain management: Disparity by age and race. Prehospital Emerg Care. 2017;3127(October):1-9. doi:10.1080/10903127.2017.1367444
11. Kennel J, Withers E, Parsons N, Woo H. Racial/Ethnic Disparities in Pain Treatment: Evidence from Oregon Emergency Medical Services Agencies. Med Care. 2019;(September):1-6.
12. Jones CP. Going public. Am J Public Heal J Public Heal. 2000;9090(8):1212-1215. doi:10.2105/AJPH.90.8.1212
13. Brach C, Fraser I, Paez K. Crossing the language chasm. Health Aff. 2005;24(2):424-434. doi:10.1377/hlthaff.24.2.424
14. Tate R. The Need for More Prehospital Research on Language Barriers: A Narrative Review. West J Emerg Med. 2015;16(7):1094-1105. doi:10.5811/westjem.2015.8.27621
15. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113
16. Roberts D. Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-First Century. 2nd ed. New York: The New Press; 2012.
17. Burgess DJ. Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead to biases in medical decision making. Med Decis Mak. 2010;30(2):246-257. doi:10.1177/0272989X09341751.Are
18. Burgess DJ, Phelan S, Workman M, et al. The effect of cognitive load and patient race on physicians鈥� decisions to prescribe opioids for chronic low back pain: A randomized trial. Pain Med (United States). 2014;15(6):965-974. doi:10.1111/pme.12378
19. Kovel J. White Rascism: A Psychohistory. New York: Columbia University Press; 1970.
20. Bonilla-Silva E. Racism Without Racists: Color-Blind Racism and the Persistence of Racial Inequality in America. 4th ed. Plymouth: Rowman and Littlefield; 2014.