healthcare equity analysis findings · treatment equity analysis #2 cardiac chest pain summary •...

Healthcare Equity Analysis Findings

1. Equity Benchmarking

• Pain Management Treatment Equity Analysis

• Chest Pain Treatment Equity Analysis

2. Organizational Review

1. Equity Benchmarking1. Equity Benchmarking

• Pain Management Treatment Equity Analysis

• Chest Pain Treatment Equity Analysis

2. Organizational Review

1. Equity Benchmarking

EMSTreatment

EMSUtilization

CommunityOutreach

Workforce

Assessment & Preparation

TreatmentPerformance

TreatmentOutcome

Equity

1. Equity Benchmarking – Treatment Categories

Treatment Equity Analysis #1Pain Management of Traumatic Injuries and Atraumatic Pain

Pain Treatment Equity Analysis – Data and Methods

• Inclusion• PCRs with a Primary Impression of Traumatic Injury or Atraumatic Pain• 2015-2019• Merged AMR and VFD PCRs into a single encounter PCR

• Exclusion• Pediatric patients (<18)• Scene address outside of Vancouver• Interfacility transfers or scheduled transports• PCRs with clinical contraindications for pain medications (AMS, GCS < 14, respiratory depression

(SI or RR<7), documented pain medication allergies)

• Final Dataset = 18,028 PCRs (14%, 2,513 PCRs with VFD data)


• Predictor Variables• Patient race• Patient gender• Patient insurance status• Patient obesity status

• CDC guidelines for severe obesity using average heights (males >270lbs, females >232lbs)

• Control Variables• Patient age• Primary Impression• First documented pain score (in pain medication and outcome)• All other predictor variables above


• Outcome Variables• Pain assessment performed (binary)

• Documentation of two pain assessment scores (0-10)• IV or IO attempted (binary)• Any pain medication administered (binary)• Reduction in pain

• At least 1 point reduction in pain score from 1st to last pain score


Results

Assessment for Pain for Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)

Adjusts for: patient gender, patient age, patient health insurance, obesity status, and EMS provider’s specific primary impression.

less likelyto have a

pain assessment

23%29%

Hispanic patients are

Asian patients are

Pain AssessmentLikelihood When compared to clinically comparable White patients:

50%

25%

0%

-25%

-50%

-23%-29%

-38%-50%

-25%

0%

25%

50%

Pain Management - Pain Assessment

His

pani

c

Asi

an

Oth

er

38%“Other” patients are

Assessment for Pain for Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)

Pain AssessmentLikelihood When compared to clinically comparable patients with

private insurance:50%

25%

0%

-25%

-50%

-14%

-35%

-16%

-53%

-75%

-50%

-25%

0%

25%

50%

Med

icar

e

Med

icai

d

No

Insu

ranc

e

Unk

now

n

-53%


pain assessment

14%35%

Medicare patients are

Patients without insurance are 16%Patients with unknown insurance are 53%

Medicaid patients are


Pain Management - Pain Assessment

Administration of Medication for Pain for Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)

less likelyto receive pain

medication

35%Hispanic patients are

Pain MedicationLikelihood When compared to clinically comparable White patients:

50%

25%

0%

-25%

-50%-35%

-67%-75%

-50%

-25%

0%

25%

50%

Adjusts for: patient gender, patient age, pain assessment, pain assessment initial score, patient health insurance, and EMS provider’s specific primary impression.

Pain Management - Pain Medication

His

pani

c

“Unk

now

n”

67%“Unknown” patients are

-67%

All pain categories


less likelyto receive pain

medication

35%Hispanic patients are


50%

25%

0%

-25%

-50%Adjusts for: patient gender, patient age, pain assessment, pain assessment initial score, patient health insurance, and EMS provider’s specific primary impression.

His

pani

c

“Unk

now

n”

-35%

-67%-75%

-50%

-25%

0%

25%

50%


-73%

His

pani

c

“Unk

now

n”

Moderate to severe pain



Pain MedicationLikelihood When compared to clinically comparable patients with


25%

0%

-25%

-50%

-25%

-48%

-16%

-57%-75%

-50%

-25%

0%

25%

50%

Med

icar

e

Med

icai

d

No

Insu

ranc

e

Unk

now

n

-57%


less likelyto receive

pain medication

25%48%




All pain categories



Pain MedicationLikelihood When compared to clinically comparable patients with


25%

0%

-25%

-50%

-28%

-56%

-23%

-39%

-75%

-50%

-25%

0%

25%

50%

Med

icar

e

Med

icai

d

No

Insu

ranc

e

Unk

now

n

-56%



pain medication

28%56%






Pain Reduction for Patients with Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)

less likelyto have their pain

reduced


50%

25%

0%

-25%

-50%

Pain Management - Pain Reduction

“Unk

now

n”


Adjusts for: patient gender, patient age, initial pain score, patient health insurance, obesity status, and EMS provider’s specific primary impression.

-49%-56%

-75%

-50%

-25%

0%

25%

50%

56%“Unknown” patients in moderate to severe pain are

-56%

“Unk

now

n”

“Unk

now

n”

Mod

erat

e to

sev

ere


Pain ReductionLikelihood When compared to clinically comparable patients with


25%

0%

-25%

-50%

-15%

-40%

-22%

-43%-50%

-25%

0%

25%

50%

Med

icar

e

Med

icai

d

No

Insu

ranc

e

Unk

now

n



pain reduction

15%40%




All pain categories



Pain ReductionLikelihood When compared to clinically comparable patients with


25%

0%

-25%

-50%

-15%

-49%

-26%

-37%

-75%

-50%

-25%

0%

25%

50%

Med

icar

e

Med

icai

d

No

Insu

ranc

e

Unk

now

n



pain reduction

15%49%







Summary

• EMS treatments and outcomes varied significantly by social categories

• Asian and Hispanic patients were less likely to receive a pain assessment

• Hispanic patients were less likely to receive pain medications overall and when in moderate to severe pain

• Poor and elderly patients were less likely to receive the same EMS treatments in all measures reviewed, including a pain assessment, attempt at an IV or IO, receipt of pain medications, and reported reduction in pain level.

Treatment Equity Analysis #2Cardiac Chest Pain

Cardiac Chest Pain– Data and Methods

• Inclusion• PCRs with a Primary Impression of Cardiac or contained a STEMI flag• 2016-2019• Merged AMR and VFD PCRs into a single encounter PCR

• Exclusion• Scene address outside of Vancouver• Interfacility transfers or scheduled transports• Patient age < 35

• Final Dataset = 5,188 PCRs (32%, 1,660 PCRs with VFD data)

• Predictor Variables• Patient race• Patient gender• Patient insurance status• Patient obesity status

• CDC guidelines for severe obesity using average heights (males >270lbs, females >232lbs)

• Control Variables• Patient age• Primary Impression• All other predictor variables above


• Outcome Variables (all binary measures)

• 12-lead performed

• 12-lead performed within 10 minutes

• IV or IO attempted

• Pain assessment performed

• ASA administration (if no contraindications)

• NTG administration (if in documented pain and no contraindications)

• Fentanyl (if in documented pain post NTG and no contraindications)



Results

Pain Assessment for Cardiac Chest Pain(5,188 charts, 2016-2019)

Adjusts for: patient gender, patient health insurance, obesity status, and EMS provider’s specific primary impression.


pain assessment

58%Asian patients are

Pain AssessmentLikelihood When compared to clinically comparable White patients:

50%

25%

0%

-25%

-50%

Cardiac Chest Pain

-58%

-46%

-75%

-50%

-25%

0%

25%

50%

Asi

an

Oth

er

46%“Other” patients are

-58%

IV/IO attempted and receipt of a 12-lead for Cardiac Chest Pain(5,188 charts, 2016-2019)

Likelihood

50%

25%

0%

-25%

-50%

Cardiac Chest Pain

less likelyto have an IV/IO

56%33%

42%

When compared to clinically comparable White patients:

Adjusts for: patient gender, patient health insurance, obesity status, and EMS provider’s specific primary impression.

-56%

-33%

-75%

-50%

-25%

0%

25%

50%

Black patients are

“Other” patients are

“Other” patients are less likelyto have a 12-lead

-42%-50%

-25%

0%

25%

50%

-56%

-33%-42%

IV/IO 12lead

Administration of 12-lead and Nitroglycerin for Cardiac Chest Pain(5,188 charts, 2016-2019)


29%Female patients

are

When compared to clinically comparable male patients:50%

25%

0%

-25%

-50%Adjusts for: patient race, patient health insurance, obesity status, and EMS provider’s specific primary impression.

Cardiac Chest Pain

27%

Likelihood

-29% -27%-21%

-50%

-25%

0%

25%

50%

Nitro12lead

12Lead

< 10m

21%

12-lead

12-lead within 10 min

Nitroglycerin


Summary

• Many racial minority categories were less likely to receive the same treatments for cardiac chest pain

• Asian and ‘other’ race patients were less likely to have their pain assessed

• Black patients were less likely to have an IV or IO attempted

• ‘Other’ race patients were less likely to receive an IV/IO attempt or a 12-lead

• Female patients were less likely to receive a 12-lead, receive a 12-lead within the 10 min goal, or receive NTG despite being in documented pain

Organizational Review

Organizational Review – Quality Reporting

Challenges

• Predominant use of single chart reviews

• Limited process-of-care reporting vs outcome reporting

• Impact of Training efforts on system improvement is largely unknown

• Outsourcing of quality reporting

• No stratification of existing performance reports by vulnerable

populations

Organizational Review – Quality Reporting

Recommendations

1. Develop aggregate process-of-care reporting to improve visibility to system performance.

2. Disaggregate process-of-care reports by vulnerable patient categories.

3. Establish the capability to consistently report on the impact of training resources on system performance improvements.

4. Increase the robustness of the performance reporting capabilities within VFD and AMR.

Organizational Review - Training

Challenges1. Topic selection

a. Training topics are primarily selected to assist with re-certification needs of EMS providers as opposed to training in the areas where system performance deficiencies exist.

b. Training resources largely overlook individual provider performance variation and apply all training resources to all providers.

2. Inability to determine if training resources are improving system performance.

Organizational Review - Training

Recommendations1. When choosing training topics, prioritize current process-of-care system

performance deficiencies rather than continuing education re-certification requirements.

2. Utilize aggregate process-of-care performance analysis for individual providers to improve effectiveness of training resources instead of assigning all training topics to all providers or selecting topics based on errors identified on single chart reviews.

Organizational Review – Community Education and Outreach

Challenges

• Resources are deployed without community needs assessments to

understand and prioritize efforts to improve community health

• Currently lacking a method to measure the impact of community

education resources

Organizational Review – Community Ed and Outreach

Recommendations1. Encourage a strategic and proactive approach that:

a. objectively identifies the communities most in need,

b. aligns with organizations already working to improve the health/healthcare of the targeted communities,

c. promotes the role EMS plays in helping to reduce health disparities, and

d. develops the capabilities to track the effectiveness (e.g. improved community health, increased appropriate EMS utilization, etc.) of the resources applied to the effort rather than reporting on volume of effort.

Organizational Review - Language and Interpretation Practice

Challenges

1. Currently no policy, practice, or guidelines exists for

a. providing crews with on-scene treatment performance expectations for Limited English Proficiency (LEP) patients

b. charting requirements and expectations for LEP patients

c. appropriate interpreter selection and consent obtainment

2. Current interpreter solution is not being utilized (no use at AMR in two years) and is likely grossly underutilized at VFD (8 uses in 2019).

• LEP patient encounters are estimated conservatively at 1-3% of all calls (300-900 calls a year) based on Portland LEP benchmarking.

3. No current training or quality assurance reporting is currently being conducted on LEP patient interactions.

Organizational Review - Language and Interpretation Practice

Recommendations1. Establish a policy and practice guideline for treating Limited English Proficiency

(LEP) patients that addresses crew on-scene performance expectations, charting requirements, appropriate interpreter selection, and consent obtainment.

2. Evaluate the utilization barriers to the unused interpreter solution currently in place.

3. Conduct specific training and quality assurance reporting on LEP patient interactions as they likely represent some of the most vulnerable populations served.

Organizational Review – Data Collection and Management

Challenges

• Management of Patient Race challenges with VFD and AMR data as

well as between data environments

• Patient Gender and Sex data collection is limited to binary values

• No collection of preferred patient pronouns

• Currently no charting guidelines for patient refusals of individual

treatments

Organizational Review – Data Collection and Management

Recommendations

1. Revise demographic data collection to be consistent between VFD and AMR.

2. Utilize more inclusive variables, values, and charting controls for the collection of race, ethnicity, sex, gender, and pronouns.

- detailed recommendations provided within the written report

Equity Report Summary

• There is evidence that marginalized populations in Vancouver are not receiving the same quality of EMS care.

• Evidence of these treatment disparities were found in both a high provider discretion protocol (pain management) and a relatively low provider discretion protocol (cardiac chest pain emergencies).

• There are several organizational steps that can be taken to improve treatment inequities within the EMS system in Vancouver.

Acknowledgements

Tara Erickson, Operations Analyst

Michelle Bresee, CPA and EMS Analyst

Robb Milano, Division Chief, EMS

Rod Floyd, EMS Captain

Timothy Kays, Division Chief, Training

David Lukacs, MEDS Analyst

John Griffith, Operations Supervisor

Jeff Bissett, Operations Manager

Rocco Roncarati, Regional Director, Northwest Region

Kanessa Thompson, Community Relations Coordinator

Lynn Wittwer, Medical Program Director

Mark Muhr, Assistant Medical Program Director

Questions

healthcare equity analysis findings · treatment equity analysis #2 cardiac chest pain summary •...

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