Emergency medical services (EMS) personnel form the foundation of care for patients in the prehospital setting. However, the level of care they can provide is not uniform. There are significant differences in education and training among EMS personnel and the US National Highway Traffic Safety Administration recognises four distinct levels of training for EMS personnel: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and paramedic (EMS Data Cube, 2019; National Association of State EMS Officials (NEMSIS), 2019).
Traditionally, EMS units comprise two to three EMS personnel in a ground ambulance, which is classified as either advanced life support (ALS) or basic life support (BLS) depending on the level of training of the EMS personnel on board (Ryynänen et al, 2010). EMRs and EMTs provide BLS care, paramedics provide ALS care and AEMTs provide BLS or ALS care depending on local guidelines (NEMSIS, 2019).
In general, BLS providers are restricted to non-invasive procedures such as administering oxygen, splinting and cardiopulmonary resuscitation, while ALS providers can start intravenous processes and perform intubations, and have access to a much wider array of medications than BLS providers (Ryynänen et al, 2010).
Seizures are a common condition in the prehospital setting accounting for 5–8% of all EMS calls/activations in the United States (US) (Silverman et al, 2017). Critically, for patients experiencing seizures, ALS care was found to lead to superior patient outcomes compared with BLS care (Alldredge et al, 1995; Ryynänen et al, 2010).
Previous studies have found evidence of racial disparities within the overall EMS system, including in prehospital analgesic administration and EMS transport decisions (Mochari-Greenberger et al, 2015; Hewes et al, 2018; Hanchate et al, 2019; Kennel et al, 2019). It is therefore important to identify if racial disparities also exist in access to ALS care for patients experiencing seizures. To the best of our knowledge, no study has been conducted to analyse racial disparities in access to ALS care for patients experiencing a seizure.
Material and methods
This study uses EMS data from the 2017–2019 NEMSIS V3.5.0 database to perform a retrospective cross-sectional analysis. NEMSIS is a national database funded by the National Highway Traffic Safety Administration, which includes EMS activation data from 10 062 EMS agencies in 47 states and territories (Mann, 2020). NEMSIS data stem from patient care reports completed by medical personnel from emergency 911 calls (NEMSIS, 2019). Since the NEMSIS database provides anonymised information, this study is exempt from ethical approval and review by the institutional review board (Mann, 2020).
The NEMSIS database has information on a total of 86 105 327 EMS activations. This study analysed EMS activations only for seizures that included data on both the level of care of the responding EMS unit and the race of the patient. These inclusion criteria left a total of 624 011 cases for the population for this study.
EMS activations were filtered by use of the ‘primary symptom ICD name’ field in the NEMSIS database (NEMSIS, 2015). Since EMS reports varied in the terminology used to describe the primary symptom, cases of convulsions, epilepsy and seizure were all used for the dataset of this study.
The level of care of the EMS unit was defined in the NEMSIS database as ‘the level of care (BLS or ALS) the unit is able to provide based on the units' treatment capabilities for this EMS response’ (NEMSIS, 2020). Race was listed in the NEMSIS database using US Office of Management and Budget definitions (NEMSIS, 2019). The racial groups listed in the NEMSIS database were: American Indian or Alaska Native; Asian; black or African American; Hispanic or Latino; Native Hawaiian or other Pacific Islander; and white (National Institutes for Health, 2015).
Chi-squared testing was used to determine if statistically significant associations were present and relative risk (RR) was used to measure effect size. Data analysis was done using Excel (Microsoft, Redmond, WA), R version 3.6.2 (R Foundation for Statistical Computing, Vienna, Austria) and MedCalc (MedCalc Software, Ostend, Belgium). For all analyses, a P value of <0.05 was used to signify statistical significance.
Results
White patients comprised 57.9% of the study population while non-white patients made up 42.1% (Table 1). Further breakdown of the non-white racial groups shows that black patients accounted for 27.9% of the study population, Hispanic or Latino patients for 11.1%, Asian patients for 1.3%, American Indian or Alaska Native patients for 1.3% and Native Hawaiian or other Pacific patients for 0.4% (Table 1).
| Race | ALS units | BLS units | % BLS |
|---|---|---|---|
| American Indian or Alaska Native | 6648 | 1480 | 18.21% |
| Asian | 7157 | 1221 | 14.57% |
| Black | 151 491 | 22 347 | 12.86% |
| Hispanic or Latino | 60 892 | 9 132 | 13.04% |
| Native Hawaiian or other Pacific | 1938 | 406 | 17.32% |
| White | 322 426 | 38 873 | 10.76% |
| Total | 550 552 | 73 459 |
ALS: advanced life support; BLS: basic life support
Chi-squared testing revealed a statistically significant association between race and the level of care provided by EMS units to patients experiencing seizures (p<0.0001) (Table 2). This association was measured using the relative risk (RR) of each racial group encountering BLS care as opposed to ALS care. Overall, non-white racial groups had a combined RR for encountering BLS care of 1.12 (95% CI [1.1050–1.1318]; P<0.0001).
| Race | Relative risk (RR) of receiving basic life support (P<0.0001) |
|---|---|
| American Indian or Alaska Native | 1.57 (95% CI [1.4764–1.6205] |
| Asian | 1.24 (95% CI [1.1749–1.3045] |
| Black | 1.09 (95% CI [1.0768–1.1074] |
| Hispanic | 1.11 (95% CI [1.0856–1.1305] |
| Native Hawaiian or other Pacific | 1.47 (95% CI [1.3464–1.6078] |
| White | 0.91 (95% CI [0.9034–0.9246] |
This indicates that, on average, non-white patients experiencing a seizure had a 21% higher relative risk of receiving BLS care than white patients. The highest disparity between racial groups was between American Indian or Alaska Native patients and white patients; American Indian and Alaska Native patients experiencing a seizure had a 66% higher relative risk of receiving BLS care than white patients.
Discussion
The data suggest there are statistically significant differences in the level of EMS unit care between racial groups in cases of seizures. Minority patients experiencing a seizure as a whole, and especially American Indian and Alaska Native patients, receive BLS care over ALS care more often than white patients experiencing a seizure.
A potential cause of the racial disparity in access to ALS care is likely to be cost. It costs twice as much to equip an ALS ambulance as a BLS unit and, with ALS units costing close to a $500 000 per year to equip and staff. ALS units require a significant greater investment by EMS agencies than BLS units (O'Brien, 2011; St Clair, 2014).
For many EMS agencies, reimbursement by health insurance providers is their primary source of funding (National EMS Advisory Council (NEMSAC), 2016). However, EMS agencies provide a significant amount of uncompensated care to the uninsured and below reimbursement cost care to Medicare and Medicaid patients, and do not receive sufficient state and federal funding to offset these expenses (NEMSAC, 2016).
Importantly, non-white racial groups tend to have higher rates of uninsurance and Medicaid (Borelli et al, 2016; Sohn, 2017). This can lead local EMS agencies in majority non-white neighbourhoods to experience significant funding difficulties, potentially leading to fewer ALS ambulances in service and fewer ALS providers hired.
Staffing and funding are especially problematic issues for EMS agencies that are a part of the Indian Health Service, which many American Indian and Alaska Native patients rely on for prehospital care (Genovesi et al, 2014). It is notable that the majority of EMS providers in the Indian Health Service Emergency Medical Services agency are trained only to the level of EMT and 42% of EMS agencies in the Indian Health Services lack ALS capabilities altogether (Genovesi et al, 2014). This is likely a potential cause of the reduced frequency of ALS care for American Indian and Alaska Native patients experiencing a seizure compared with other racial groups.
As stated before, ALS care results in superior outcomes than BLS care for patients experiencing seizures (Alldredge et al, 1995; Ryynänen et al, 2010). This is likely to be because only ALS providers are permitted to administer benzodiazepines such as diazepam, which act as anticonvulsants (Alldredge et al, 1995). Administration of anticonvulsants is critical in the prehospital setting as the extent of neurological damage and mortality risk for a patient is correlated with the duration of a seizure (Kapur, 2002). As a result, non-white racial groups may face disproportionate neurological damage and mortality from seizures in the prehospital setting because they have less access to ALS care.
ALS care is also critical for seizure cases because prehospital dispatch protocols such as the Medical Priority Dispatch System (MPDS) are unable to accurately predict the need of ALS care for patients experiencing a seizure. Nearly half (46%) of patients experiencing a seizure classified in the lowest acuity category under MPDS criteria later required ALS interventions (Shah et al, 2003). Furthermore, with 19% of patients overall experiencing a seizure requiring time-sensitive medications and prehospital dispatch protocols being unable to accurately predict whether patients experiencing a seizure will require ALS or BLS care, previous studies have concluded that all EMS activations for seizure should receive an ALS response (Shah et al, 2003; Sporer et al, 2007; Michael and O'Connor, 2011).
Beyond scope of practice, ALS providers have significantly more training and experience than BLS providers. This leads to ALS providers possessing critical patient assessment and leadership skills, which are necessary in a chaotic environment such as the prehospital setting (Wang and Kupas, 2015). This is supported by previous studies that found the greater experience of prehospital providers led to better patient outcomes (Gold and Eisenberg, 2009; Wang et al, 2010; Kurz et al, 2018). Thus, even if the expanded scope of practice that ALS providers possess is not necessary for a specific patient, ALS providers still bring critical decision-making skills gained from experience that can lead to better patient outcomes. Consequently, non-white patients experiencing a seizure may experience worse overall prehospital care than white patients because less trained and experienced EMS personnel are treating them.
Limitations of this study include the inability to account for differences in patient circumstances in EMS activations.
Another limitation is that ‘Hispanic or Latino’ is listed as a racial group in the NEMSIS database as opposed to being listed as an ethnicity. This could lead to issues with standardisation of race categories in the NEMSIS database as some racially white Hispanics or Latinos may select only Hispanic or Latino while others may select only white.
Finally, the use of NEMSIS database means it is not possible to identify regional differences regarding the racial disparities in the level of care of EMS units.
Future studies should look at the cause of non-white racial groups receiving less ALS care for seizures and analyse if patient outcomes are affected because of the difference in level of care.
Conclusion
There are statistically significant racial disparities in the level of care provided to patients experiencing a seizure, especially between American Indian and Alaska Native patients and white patients. Overall, non-white patients receive lower rates of ALS than white patients in cases of seizure.
The implication is that non-white patients may have worse patient outcomes than white patients in cases of seizure because they have less access to time-sensitive medications in the prehospital setting and, overall, EMS personnel treating them are less trained and experienced.
This article's findings suggest that more funding may be needed for EMS agencies in non-white majority neighbourhoods and especially in American Indian and Alaska Native neighbourhoods to allow them to increase the number of ALS ambulances in service.