Abstract
Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes. To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles. A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code-level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63 600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital. Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes. The study sample included 63 600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37 550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P < .001), translating to 3.8 minutes longer in the poorest zip codes. The EMS response time to patients in high-income zip codes was more likely to meet 8-minute and 15-minute cutoffs compared with low-income zip codes. Patients with cardiac arrest from the poorest neighborhoods had longer EMS times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time.
Highlights
The Institute of Medicine has documented that unequal access to health care facilities and health care professionals serves as a principal contributor to health care disparities in vulnerable communities.[1]
Patients with cardiac arrest from the poorest neighborhoods had longer emergency medical services (EMS) times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time
Our analysis demonstrated that EMS responding to low-income communities had a lower likelihood of meeting 8-minute and 15-minute national benchmarks compared with EMS responding to highincome communities and showed that the mean EMS response time, on-scene time, and transport time were longer in low-income communities, even after controlling for observable differences
Summary
While the evaluation of EMS care requires the consideration of many different quality measures, access and timeliness of care, as measured by ambulance response times, have long been reported across EMS systems and act as meaningful benchmarks to the public. Few studies have examined disparities in prehospital care; for example, one reported longer response and transport times for suspected patients with stroke from low-income areas, defined by the percentage of residents living below the household income poverty threshold in the United States.[16] Another study showed shorter intervals for out-of-hospital transport in patients with chest pain from higher-income neighborhoods in Canada,[17] and a third study focused solely on a county in California.[18] the association between ambulance response and transport times and zip code–level income for time-sensitive conditions across the United States has not been widely studied
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