Journal Watch: COVID’s Impact on EMS Refusals

Reviewed This Month

Factors Associated With Voluntary Refusal of Emergency Medical System Transport for Emergency Care in Detroit During the Early Phase of the COVID-19 Pandemic

Authors: Harrison NE, Ehrman RR, Curtin A, et al. 

Published in: JAMA Netw Open, 2021; 4(8) 

The reduction in emergency department visits in 2020 was well documented. While COVID-19 itself certainly played a role, it is difficult to determine the impact of associated factors such as decreased motor vehicle crashes from fewer cars on the road (while we all worked from home), public health restrictions, and voluntary care avoidance. 

The study we review this month had two objectives: The authors sought to “directly quantify refusals in a large EMS system as a proportion of emergency care avoidance after accounting for public health restrictions, changes in prehospital death, preexisting rates of refusal, and other factors not directly unique to 2020 or involving a clear voluntary choice.” They also examined factors associated with EMS refusals in 2020 including geographic, demographic, and temporal factors. 

Study Parameters

The study compared EMS responses from March 1–June 30, 2020 to those from the same period in 2019. Data came from the Detroit East Medical Control Authority, which consists of 12 agencies with a catchment area of 334 U.S. Census tracts. Census tracts are small, relatively permanent subdivisions within counties, uniquely numbered and widely used when analyzing small geographic regions as part of a study. 

The authors indicated they chose this time period because it allowed for the analysis of COVID-19 temporal trends. They noted that when they drafted their manuscript in Detroit, COVID-19 peaked in mid-March and reached its lowest level in mid-June 2020. In addition to evaluating temporal trends, this period allowed direct comparisons of public health measures, which were more restrictive during the mid-March peak, then more relaxed during reopening. 

Refusals were defined as responses in which a patient voluntarily refused transport against medical advice. Prehospital deaths were defined as deaths declared before patient transport with or without resuscitation. EMS-to-hospital transports included total responses (excluding interhospital transports) minus prehospital deaths and refusals. 

The authors used census tracts to link patient data with data from the CDC to evaluate social determinants of health. The CDC’s Social Vulnerability Index consists of 15 risk factors for negative public health outcomes following a natural disaster or disease outbreak. There are four domains within the index: socioeconomic status, household composition, race/ethnicity/language, and housing/transportation. Overall scores range from 0–15, with higher scores indicating greater vulnerability. 

The analysis of 2020 vs. 2019 included evaluations of daily responses, completed transports, prehospital deaths, and refusals when adjusting for age, sex, Social Vulnerability Index score, and COVID-19 high and low points. The authors compared high-refusal census tracts in 2020 to low-refusal tracts. High-refusal tracts were those at or above the median, and low-refusal tracts were those below the median population refusal rates. 

There were 40,984 EMS responses in 2020 and 39,503 in 2019. In 2020 there were 1,299 prehospital deaths, compared to 760 in 2019. There were 9,601 voluntary refusals in 2020 and 6,463 in 2019. The study population was 48% female with an average age of 49 years. The average Social Vulnerability Index score was 9.6. Patients in 2020 were older (average age 49.8) than those in 2019 (47.7). There was also a smaller percentage of female patients in 2020 (47%) vs. 2019 (50%). 

Results

There was a statistically significant increase in daily responses, prehospital deaths, and refusals when comparing 2020 to 2019 (p<0.01). The average difference in daily responses was 10.1 (95% CI: 2.4–18.8). The average difference in prehospital deaths was 4.4 (95% CI: 3.4–5.5) and for refusals was 25.2 (95% CI: 20.4–30.1). Completed hospital transports decreased, with an average difference of -19.5 (95% CI: [-26.6]–[-12.5]) when comparing 2020 to 2019. 

Patients in high-refusal census tracts had higher Social Vulnerability scores (9.8 vs. 9.0), as well as a larger percentage who were unemployed (88.4% vs.78.2%), living below the poverty line (88.2% vs. 77.0%), older than age 65 (41.1% vs. 33.8%), living with a disability (80.7% vs. 58.6%), in single-parent households (80.9% vs. 71.7%), minority race/ethnicity (94.3% vs. 85.8%), in a multi-unit household (62.8% vs. 47.2%,  and without a vehicle (91.2% vs. 78.2%). 

Overall, from March 1 to June 30, the probability of refusal of transport was 25% in 2020 and 15% in 2019. At the peak of COVID-19 incidents and public health restrictions (March), there were 23.9 more responses per day in 2020 compared to 2019. After excluding refusals and prehospital deaths, there were 48.4 fewer completed hospital transports per day. The odds of death (aOR 1.60, 95% CI: 1.20–2.12) and for refusals (aOR 2.33, 95% CI: 2.09–2.60) were greater in 2020 at the peak of COVID-19 incidents and public health restrictions. 

During the low point of COVID-19 incidents and reopening (June), there was no statistically significant difference in total responses or the odds of death. However, daily hospital transports remained significantly decreased, with 18.6 fewer transports per day in 2020 compared to 2019. The odds of refusal were also increased during the low point in COVID-19 incidents and reopening with an adjusted odds ratio of 1.27 (95% CI: 1.14–1.40). 

Conclusion

All studies have limitations, and there were a few worth noting in this one. The baseline year of 2019 was used for comparison; however, the authors cannot be sure 2019 was not also an unusual year. This study was limited to the Detroit East Medical Control Authority and may not be generalizable outside this region. Finally, comparing March 1 to June 30 may have missed important trends outside this time period. 

This was an interesting and valuable study to help us understand prehospital emergency responses during the pandemic and factors related to refusal. I congratulate the authors on their important work, and I look forward to additional peer-reviewed studies in this area that will help us better understand prehospital care during the COVID-19 pandemic.  

Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and serves on the board of advisors of the Prehospital Care Research Forum at UCLA.