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Emergency Medical Responders Confront Racial Bias

A recent study out of Oregon suggests emergency medical responders — EMTs and paramedics — may be treating minority patients differently from the way they treat white patients.

Specifically, the scientists found that black patients in their study were 40 percent less likely to get pain medication than their white peers.

Jamie Kennel, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was presented in December at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in these cases, unconscious bias may be at work.

A few years ago, Leslie Gregory was one of a very few black female emergency medical technicians working in Lenawee County, Mich. She said the study’s findings ring true based on her experience.

She remembered one particular call — the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that’s when one of her colleagues groaned.

“I think it was something like: ‘Oh, my God. Here we go again,’” Gregory said. She worried — then, as now — that because the patient was black, her colleague assumed he was acting out to get pain medication.

“I am absolutely sure this was unconscious,” added Gregory, who now lives and works in Portland, Ore., where she founded a nonprofit to spread awareness about racial disparities in health care. “At the time, I remember, it increased my stress as we rode up on this person. Because I thought, ‘Now am I going to have to fight my colleague for more pain medication, should that arise?’”

Leslie Gregory, a Portland physician assistant, asks, “How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” She wants the CDC to declare the effects of racism a national health crisis.(Kristian Foden-Vencil/Oregon Public Broadcasting)

Unconscious bias can be subtle — but, as this new report shows, it may be one of the factors behind race-linked health disparities seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients from 2015 to 2017. It found that minority patients were less likely to receive morphine and other pain medication compared with white patients — regardless of socioeconomic factors, such as health insurance status.

During a shift change at American Medical Response headquarters in Portland,  EMTs and paramedics discussed the issue with a reporter as they got their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, was adamant that her work is not affected by race.

“I’ve never treated anybody different — regardless,” said Sanders.

Most of the emergency responders interviewed, including Jason Dahlke, said race doesn’t affect the treatment they give. But Dahlke also said he and some of his co-workers are thinking deeply about unconscious bias.

“Historically it’s the way this country has been,” Dahlke said. “In the beginning, we had slavery and Jim Crow and redlining — and all of that stuff you can get lost in on a large, macro scale. Yeah. It’s there.”

Paramedic Jason Dahlke says he can see how unconscious bias could slip into an emergency responder’s decisions and taint health care. He’s worked hard to be aware of it, in hopes of preventing those disparities in care.(Kristian Foden-Vencil/Oregon Public Broadcasting)

Asked where he thinks unconscious bias could slip in, Dahlke talked about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient’s house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man’s blood sugar level was low.

“So it’s my decision to treat this blood sugar first. Make sure that number comes up,” Dahlke said.

He gave the patient glucose — but no pain medicine.

Dahlke said he did not address the man’s pain in this case because by the time he had stabilized the patient they had arrived at the hospital — where it was the responsibility of the emergency department staff to take over.

“When people are acutely sick or injured, pain medication is important,” Dahlke said. “But it’s not the first thing we’re going to worry about. We’re going to worry about life threats. You’re not necessarily going to die from pain, and we’re going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care.”

Dahlke said he is not sure whether, if the patient had been white, he would have administered pain medicine, though he doesn’t think so.

“Is it something that I think about when I come across a patient that does not look like me? I don’t know that it changes my treatment,” he said

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiled.

“I wonder that — if, in this study, if we’re talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we’re overtreating white people with narcotic medicines.”

Research has found African-Americans more likely to be deeply distrustful of the medical community, and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, said Gregory.

“How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” she asked.

Gregory wrote an open letter to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a threat to public health.

Past declarations of crisis — such as those focusing attention on problems such as smoking or HIV — have had significant results, Gregory noted.

But the CDC told Gregory, in its emailed response, that while it supports government policies to combat racial discrimination and acknowledges the role of racism in health disparities, “racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S.”

Kennel said false stereotypes about race-based differences in physiology that date to slavery also play a role in health care disparities. For example, despite a lack of any supporting science, some medical professionals still think the blood of African-Americans coagulates faster, Kennel said, citing a recent study of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites. “An uncomfortably large percentage of medical students said, ‘Yes, that’s true,’” said Kennel.

On top of that, he said, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. “In these situations, providers are much more likely to default to making decisions [based] on stereotypes,” he said.

Disparities in health care are well-documented. Whites tend to get better care and experience better outcomes, whether they’re in a doctor’s office or the ER. But before Kennel’s study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn’t get to know, because the research required ambulance companies to release highly sensitive data.

“We were prepared to maybe not look that great,” said Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation’s largest ambulance organizations, and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel said he controlled for those variables.

So now that AMR knows about disparities in its care, what can the company do?

“My feeling is we’re probably going to put some education and training out to our folks in the field,” McDonald said.

In addition, he said, AMR is going to hire more people of color.

“We want to see more ethnicities represented in EMS — which has historically been a white, male-dominated workforce,” McDonald said.

AMR’s policies must change, too, he added. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

This story is part of a partnership that includes Oregon Public BroadcastingNPR and Kaiser Health News.

How Helping Patients Get Good Care At Home Helps Rural Hospitals Survive

Rural hospitals close when they don’t have enough paying patients to care for, but they’re also dinged when the same patients show up over and over again. That puts outlying medical facilities in the precarious position of needing to avoid repeat customers.

Charlotte Potts is the type of patient some hospitals try to avoid. She lives in Livingston, Tenn. — a town of 4,000, tucked between rolling hills of the Cumberland Plateau.

“I’ve only had five heart attacks,” Potts said recently with a laugh. “I’ve had carotid artery surgery. Shall we go on? Just a few minor things.” She joked that she’s “a walking stent.”

The heart trouble has affected the way Potts deals with her health problems. She spends much of her day in a recliner in her apartment, tethered to a pulsing oxygen machine, and listening to the radio.

Fortunately, her apartment sits within spitting distance of Livingston Regional Hospital — a 114-bed facility large enough to have a dedicated cardiac unit. But the hospital doesn’t want to see her every time her heart flutters.

So, the last time she landed in the ER, they helped her connect with a few companies that could provide care at home.

“If I’m going to have certain things going on here in my chest, I call for help, and they’re there,” Potts said of the home care team she chose.

Livingston Regional Hospital has cut readmissions by more than four percent in the last five years — more than any other rural hospital in Tennessee.(Shalina Chatlani/WPLN)

A New Era In Hospital Management

There were days when the hospital might have viewed a home health agency as a competitor. Not anymore.

“When I started this almost 40 years ago, the mission was different,” said Tim McGill, CEO of Livingston Regional. “We wanted patients in the hospital. That was the incentive. We were paid for it. Now you’re not.”

Hospitals used to run on a so-called fee-for-service model with virtually no limit to how many times they could see a patient. But, under pressure from private and government insurance programs, that model is transitioning to one in which hospitals are rewarded for safety and efficiency — which often results in a patient spending less time in the hospital.

Under the Affordable Care Act, Medicare began to ding hospitals if too many patients are readmitted to any hospital within 30 days of discharge. The measure is broadly unpopular with the hospital industry, since so much falls outside a hospital’s control. Medicare has even walked back the rules for safety-net facilities, which tend to treat a sicker population.

The penalty is meant to encourage hospitals to get it right the first time. In Livingston, the hospital operates on the thinnest of margins — just 0.2 percent in the most recent figures. And “readmissions” have been a drag on the bottom line.

One in 5 patients with heart failure was back within the month. The hospital has paid the maximum penalty in some years — nearly $200,000. So leaders started asking a basic, unifying question of other providers in town, McGill said: “What can we do together so they’ll stay out of the hospital and stay healthier in their home setting? That’s where the work is.”

Collaborating Instead Of Competing

The work took the form of quarterly lunch meetings at the local library.

Mary Ann Stockton, a nurse at the hospital, invites all the home health agencies as well as hospice providers and the leaders of nursing homes.

At one meeting, she applauded the other providers for increasingly meeting patients inside the hospital before they’re discharged. She said it helps patients and families accept these home health workers.

“We know in our area people don’t like to have a total stranger come into their home,” she said.

The group brainstormed how to generate the same kind of acceptance for hospice care, which — as one doctor in the meeting put it — some families view as “assisted suicide.”

And on this day, the group spent much of its time reviewing the value of flu shots, especially for the staff in nursing homes. Stockton said elderly patients with bad lungs become a hospital emergency room’s “frequent flyers.”

“Flu starts off, goes into pneumonia, COPD exacerbation — and they are a revolving door in our hospital,” Stockton said. “They’re hitting that ER a couple of times a week.”

Advance directives are on the agenda for next time — another way to keep people near the end of life from becoming ER regulars.

Livingston’s parent company, LifePoint Health, is launching this community approach in many of its 80-or-so markets, which are primarily in the Southeast and almost all rural. Cindy Chamness, a LifePoint vice president, helps hospitals find willing partners.

“We were very frustrated for many years,” Chamness said, “because we weren’t able to impact readmissions just working on it by ourselves, as a hospital.”

‘Are We Saving Ourselves Right Out Of Business?’

The solution looks different from one town to another. In Lake Havasu, Ariz., paramedics now visit discharged patients to make sure they’re following doctors’ orders. The house calls also cut down on government-funded ambulance rides.

It’s not just rural hospitals — all hospitals can be penalized for readmissions now. And threatening the bottom line in that way does seem to be effective. Readmissions have been falling across the board, according to the latest research.

But rural hospitals, which already treat fewer patients than urban hospitals, wonder if they’ll have enough patients to survive, said Michael Topchik of the Chartis Center for Rural Health.

“[A] CEO from Montana said to me, ‘The problem is, when we do the right thing, are we saving ourselves right out of business?’” Topchik said.

The focus on cutting readmissions — by definition — cuts overall admissions too, he noted.

“So, this is the real inherent tension and challenge: Hospitals get reimbursed for doing ‘sick care,’” Topchik said. “But more and more they’re being asked to do population health, and really focus on ‘wellness.’”

To make up the volume, the Livingston hospital is expanding its maternity ward and general surgery offerings.

There is also some immediate financial upside to reducing readmissions: Livingston Regional has cut readmissions more than any other rural hospital in Tennessee and even the nation, according to data compiled by Chartis.

As a result, the hospital’s Medicare penalty in the coming year will be reduced to 0.3 percent of its reimbursements — down from the maximum of 3 percent, which was roughly $200,000 a year.

That’s all because patients like Charlotte Potts now can safely stay home.

“I got a real bad tightness in the chest,” Potts recalled about a recent episode. She’d questioned whether to call an ambulance. “I was very uncertain about what was going on.”

But she phoned her home health agency, took a nitroglycerin pill as the agency advised and, instead of going to the ER, was able to get back to sleep.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.