A systematic literature review of Hispanic adults’ experiences with the emergency medical services system in the United States (U.S.) between 2000–2021

Abstract

Objective:

This systematic literature review presents an overview of studies that assess the experiences of Hispanics adults with 1) activation of emergency medical services (EMS); 2) on-scene care provided by EMS personnel; 3) mode of transport (EMS versus non-EMS) to an emergency department (ED); and 4) experiences with EMS before and during the COVID-19 pandemic.

Methods:

A bibliographic database search was conducted to identify relevant studies on Ovid MEDLINE (PubMed), Web of Science, EMBASE, and CINAHL. Quantitative, mixed-methods, and qualitative studies published in English or Spanish were included if they discussed Hispanic adults’ experiences with EMS in the U.S. between January 1, 2000 and December 31, 2021. The Hawker et al. quality assessment instrument was used to evaluate the quality of studies.

Results:

Of the 43 included studies, 13 examined EMS activation, 13 assessed on-scene care, 22 discussed mode of transport to an ED, and 4 described Hispanic adults’ experiences with EMS during the COVID-19 pandemic. Hispanics were less likely to activate EMS (N=7), less likely to receive certain types of on-scene care (N=6), and less likely to use EMS as the mode of transport to an ED (N=13), compared to non-Hispanic Whites. During the early COVID-19 pandemic period (March to May 2020), EMS use decreased by 26.5% compared to the same months during the previous four years.

Conclusions:

The contribution of this study is its attention to Hispanic adults’ experiences with the different phases of the U.S. EMS system.

BACKGROUND:

Emergency medical services (EMS) in the United States (U.S.) are activated with a call to 9–1–1, an action that initiates a series of events, including dispatch of emergency services, on-scene care, and transport to an emergency department (ED). EMS provides critical and time-sensitive care that impacts patients’ trajectories through other sectors of the U.S. healthcare system. For example, the use of EMS, compared to transport by private vehicle, is associated with more rapid ED arrival, earlier medical assessment, and fewer treatment delays in the ED.^1,2

EMS serves as an entry point into the U.S. healthcare system, especially for underserved populations, including Hispanics who often have challenges accessing preventive and diagnostic care.³ Hispanics are the second largest racial and ethnic population in the U.S after non-Hispanic Whites,⁴ with a projected population increase from 62.1 million in 2020 to 111 million by 2060.⁴ Mexicans, Central Americans, and Puerto Ricans comprise the three largest Hispanic subpopulations at 61.6%, 9.3% and 9.6%, respectively.⁴ Over 50% of Hispanics reside in California, Texas and Florida.⁴ Among Hispanics, 71.1% speak a language other than English at home.⁴

Existing literature shows that lower socioeconomic status,⁵ patient-provider language discordance,⁵ limited English proficiency,⁵ provider bias,⁵ and discrimination⁵ are all associated with Hispanics’ receiving lower-quality medical care across many areas in health care, including emergency medicine,⁵ oncology³ and EMS.^6,7 Hispanics also have the lowest rates of health insurance due to employment that does not provide employer-based health insurance, eligibility restrictions associated with immigration status, and fear of being considered a public charge if they apply to government-sponsored health insurance.⁸

Over the past two decades, policy changes have impacted Hispanics’ access to health care.⁸ In 2010, the Patient Protection and Affordable Care Act (ACA) substantially increased rates of health insurance for all racial and ethnic groups, including Hispanics, although this population continued to experience higher uninsured rates, compared to non-Hispanic Whites.⁸ The U.S. Supreme Court’s decision to make Medicaid expansion optional at the state-level and the elimination of the ACA’s individual mandate also disproportionately impacted Hispanics, contributed to increases in the uninsurance rate in this population, limited access to preventive and diagnostic care, and increased the likelihood of EMS use.^7,8

To our knowledge, this is the first systematic literature review to provide an overview of Hispanics’ experiences with the different phases of the EMS system in the U.S. and to identify existing research gaps. Our objective is to present a comprehensive review that assesses Hispanic adults’ experiences with 1) initial activation of EMS; 2) on-scene care provided by EMS personnel; 3) mode of transport (EMS versus non-EMS) to an ED; and 4) experiences with EMS before and during the COVID-19 pandemic.

METHODS:

Data Sources and Search Strategy:

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). The principal investigator developed the search strategy with the assistance of a librarian specialist; the search was conducted on December 27, 2021. Relevant studies were identified on Ovid MEDLINE (PubMed), Web of Science, EMBASE, and CINAHL for January 1, 2000 to December 31, 2021. The search terms included: “emergency medical services” OR “pre-hospital care” OR “prehospital care” AND “Hispanic” OR “Latino” OR “Latina” OR “Latinx.” The protocol for this review was submitted and approved by PROSPERO (CRD42022292926).

Article Selection:

Studies were included in this review if they examined Hispanic adults aged 18 years and olders’ experiences with EMS in the U.S. EMS was defined as emergency services provided by emergency personnel, including emergency medical technicians (EMTs) and/or paramedics, in the prehospital care setting. Prehospital care setting was defined as emergency services provided prior to ED arrival. Quantitative, mixed methods and qualitative studies were included if published in English or Spanish between January 1, 2000 and December 31, 2021.

We excluded studies that did not have a Hispanic category. Further disaggregation by patient ethnicity was not possible in most EMS datasets. Studies were also excluded if they focused on pediatric patients or those under the age of 18, examined medical care exclusively provided in a non-prehospital care setting, or examined health care provided in the prehospital care setting by non-EMS providers, such as general practitioners or civilian bystanders. We also excluded studies that examined air medical services, since these transports are requested by healthcare providers, not patients. We also excluded clinical trials, literature reviews, letters to the editor, editorials, and study protocols.

Data Extraction:

Two researchers independently reviewed titles and abstracts of identified studies using Covidence systematic review software, hereinafter referred to as Covidence. Abstracts that met inclusion criteria were selected for full-text review by two researchers. A third researcher resolved discrepancies that arose from abstract review to study inclusion. The following study characteristics were extracted from included studies: title, author names, publication year, geographic location of study, study design, total sample size, total sample size of Hispanics and key findings (See Supplemental Table 1). The studies were then categorized to align with the review’s objective and four main foci.

Assessment of Study Quality:

The Hawker et al.⁹ quality assessment instrument was used to assess the quality of studies. This instrument was developed to appraise quantitative, mixed methods and qualitative studies.⁹ Two researchers used this quality assessment instrument to examine nine components of each study: title and abstract, introduction and aims, methods and data, sampling, data analysis, ethics and bias, results, transferability or generalizability, and implications and usefulness.⁹ Each of the nine components was independently scored for each study by two researchers using a four-point scale: a. very poor (1-point), b. poor (2-points), c. fair (3-points), and d. good (4-points). After the two researchers individually scored each study, they met and discussed discrepancies in each score. The scores from the nine components were summed to obtain an overall score for each study. The overall possible scores ranged from very poor (a score of 9) to very good (a score of 36). Articles were excluded if the overall score was 18 or less, which is considered very poor to poor quality.⁹ None of the studies scored 18 or less.

RESULTS:

The database search identified 32,627 studies, of which 10,233 were duplicates. The duplicate studies were removed using Covidence. The remaining 22,394 study titles and abstracts were screened against the inclusion criteria by two researchers. Of the 22,394 studies, 21,946 were excluded and 449 continued to full-text review. The 449 studies were independently read by two researchers to determine compliance with the inclusion criteria. Of the 449 studies, 43 studies were included in this review (See Figure 1).

Figure 1:

PRISMA Flow Diagram

Of the 43 included studies, 40^{3,6,7,10–46} were quantitative, 3 were mixed methods^47–49 and none were qualitative (See Table 1). All of the studies assessed Hispanics’ experiences with the EMS system in the U.S, although some studies focused on the national (n=15),^{2,7,10,11,13,16,21–22,24,28,31,35–36,40–41} state (n=11),^{6,14–15,17–18,20,25,39,42,44,46} or local level (n=17). ^{12,19,23,26–27,29–30,32–34,37,38,45,47–49} Hispanic sample size ranged from 1 to 99 (n=4), ^{14,32,40,42,47} 100 to 999 (n= 17),^{12,18–19,27,29–30,33–34,37–39,43–45,47–49} 1000 to 9999 (n=12),^{6,11,15–16,22–24,26,28,31,35,41} and 10,000+ (n=9).^{2,7,10,13,20,21,25,36,46} The majority of the studies assessed Hispanic and non-Hispanic White differences in EMS experiences, except for one study⁴⁷ that described differences among different ethnic subgroups of Hispanics. Of the studies that assessed Hispanic and non-Hispanic White differences, three explicitly focused on differences between Mexican Americans and non-Hispanic Whites.^{26, 37, 49}

Table 1:

Overview of included studies that assess Hispanic adults’ experiences with the emergency medical services (EMS) system in the United States between 2000 and 2021

Study characteristic	Number of studies	Percent
Initial EMS activation (N=13)
Hispanics and non-Hispanic White differences in EMS activation	9	69.2
Hispanic (Mexican Americans specifically) and non-Hispanic White differences in EMS activation	3	23.1
Hispanic and Haitian, West Indian and African American differences in EMS activation	1	7.7
On-scene care (N=13)
Prehospital symptom recognition	1	7.7
EMS response time	3	23.1
Out-of-hospital intervention	3	23.1
Time spent on scene	1	7.7
Pain medication administration and assessment	5	38.4
Modes of transportation (N=22)
EMS vs non-EMS transport to the ED	20	90.9
ED bypassing, transportation to a reference ED and transportation to a safety-net ED	2	9.1
Use of EMS during COVID-19 (N=4)
Respiratory distress	1	25.0
Cardiac arrest	1	25.0
Overdose-associated cardiac arrests	1	25.0
Non-transports	1	25.0
Publication year
2000–2009	6	14.0
2010–2019	24	55.8
2020–2021	13	30.2
Geographic Granularity
National	15	34.9
State	11	25.6
Local	17	39.5
Methods
Quantitative	40	93.0
Mixed methods	3	7.0
Qualitative	0	0.0
Sample size used in the study
1–99	4	9.3
100–999	17	39.5
1000–9,999	12	27.9
10,000+	9	20.9
No sample size reported	1	2.3
Number of Studies Published Before and After the Implementation of the ACA
Before the year ACA was signed into law (2000–2009)	6	14.0
ACA signed into law and implemented (2010–2021)	37	86.0
Final score for bias assessment 1
Very Poor (1–9)	0
Poor (10–18)	0
Fair (19–27)	2	4.7
Good (28–36)	41	95.3

¹The final score for bias assessment is given to each study using the Hawker et al. quality assessment instrument.

Six studies were published between 2000 and 2009,^{11,12,27,36,42,49} 24 studies were published between 2010 and 2019^{2,6,7,13,15,17–19,21–22.24,26,29–30,35,37–41,43,45–47} (a four-fold increase from the previous decade), and 13 studies were published during the COVID-19 pandemic, between 2020 and 2021.^{10,14,16,20,23,25,28,31–34,44,48} Six studies were published before the ACA was signed into law (2000–2009),^{11–12,27,36,42,49,} while 37 studies were published the year the ACA was signed into law or later (2010–2021).^{2,6–7,10,13–26,28–35,37–41,43–48} Of the 43 studies included in this review, 13 examined EMS activation,^{11,12,17,18,26,28,30,35,38,44,47–49} 13 assessed types of on-scene care,^{2,6,12,18,19,22,27,31,33,39,41,43,45} 22 discussed modes of transport to an ED,^{2,7,10–15,18,20–21,24,26,29,32,36–38,40,42,46–47} and 4 described Hispanic adults’ experiences with EMS before and during the COVID-19 pandemic.^16,23,25,34 The quality assessment scores ranged from 24 to 36, with a mean of 32.6, across the 43 studies.

Racial/Ethnic Disparities in Activation of EMS

Thirteen studies examined activation of EMS via a 9–1–1 call.^{11,12,17,18,26,28,30,35,38,44,47,48,49} Most studies (n=7) ^{11,17,26,28,35,47,49} found that Hispanics were less likely to activate EMS, especially for time-sensitive health conditions, such as stroke ^{17,26,28,35,49} and heart attack.^11,47 Hispanics were less likely than non-Hispanic Whites to recognize stroke symptoms,²⁸ acknowledge the time-sensitive window for stroke treatment,⁴⁹ intend to call 9–1–1 for stroke symptoms,^17,35,49 and call 9–1–1 for stroke or heart attack.^11,26.28 Among Hispanics experiencing a heart attack, women were more likely than men to call 9–1–1.³⁰

Hispanics were more likely to adopt a passive response (drinking tea, laying down, or praying) rather than an active response (calling 9–1–1), compared to Haitians, West Indians, and African Americans.⁴⁷ Hispanics in this study were mostly Mexican and Puerto Rican.⁴⁷ From cardiac symptom onset to ED arrival, Hispanics had the shortest time to arrival of 6.00 hours, compared to 6.62 hours for African Americans, 7.83 hours for West Indians, and 8.24 hours for Haitians.⁴⁷ The emergency care sought by all four groups, however, extended beyond the recommended time period of 3 hours from cardiac symptom onset to ED arrival.⁴⁷

Of the 13 studies that examined EMS activation, the remaining six studies found statistically non-significant differences or reported that Hispanics were more likely to use EMS compared to non-Hispanic Whites.^{12,18,30,38,44,48} One study found statistically non-significant differences in cardiac symptom onset to hospital arrival between non-English preferring and English-preferring patients, where most of the non-English preferring patients were Hispanic.⁴⁴ Another study reported that EMS activation among undocumented Hispanic immigrants was the least difficult sector to access in the U.S. healthcare system, although the overall percentage who reported challenges with EMS was high at 50.8%.⁴⁸ Another study found that Hispanics were more likely to call 9–1–1 if they experienced chest pain or a heart attack, compared to non-Hispanic Whites, although the overall percentage of 9–1–1 calls in both groups was low.³⁰

Racial/Ethnic Disparities in Types of On-Scene Care Provided

Thirteen studies assessed types of on-scene care.^{2,6,12,18,19,22,27,31,33,39,41,43,46} Among these, eight examined EMS response time,^2,12,18,33 time spent on scene,³⁹ prehospital recognition of symptoms¹⁹ and administration of out-of-hospital interventions ^22,33,46 between Hispanic and non-Hispanic Whites. EMS response time and return of spontaneous circulation following resuscitation were comparable between Hispanic and non-Hispanic Whites experiencing sudden cardiac arrests.^12,33 EMS personnel spent less time on scene with Hispanics compared to non-Hispanic Whites experiencing chest pain.³⁹ Among Hispanics, EMS personnel spent less time on scene when a language incongruence was noted compared to no language incongruence.³⁹ Less time on scene may be an appropriate action since chest pain is a time-sensitive symptom. On the contrary, less time on scene may also be indicative of suboptimal prehospital care. In another study, Hispanic patients were less likely to have a correct prehospital recognition of stroke, another time-sensitive health condition, compared to non-Hispanic Whites.¹⁹ Hispanics were also less likely to receive an electrocardiogram and more likely to receive mechanical cardiopulmonary resuscitation, compared to non-Hispanic Whites.^22,46

Among the 13 studies, five studies focused on pain assessment⁶ and pain medication administration.^{6,27,31,41,43} Hispanics were less likely to receive a pain assessment compared to non-Hispanic Whites.⁶ Among patients who received a pain assessment, Hispanics reported a higher average pain score compared to non-Hispanic Whites.⁶ The findings for pain medication administration were mixed. Two studies found that Hispanics were less likely to receive pain medication,^6,43 two studies reported statistically non-significant differences in morphine²⁷ or nitroglycerin³¹ administration, and one study found that Hispanics were more likely to receive aspirin,⁴¹ compared to non-Hispanic Whites.

Mode of Transportation to an ED

Twenty-two studies assessed mode of transportation to the ED among Hispanics and non-Hispanic Whites.^{2,7,10–15,18,20,21,24,26,29,32,36–38,40,42,45,47} Of the 22 studies, 13 studies found that Hispanics, including those with time-sensitive health conditions, such as stroke ^{2,7,10,14,26,29,37,38} and heart attack,^11,24,45 were less likely to use EMS versus non-EMS forms of transport to the ED, compared to non-Hispanic Whites.^{2,7,10,11,14,15,24,26,29,36–38,45} Hispanic males and females were less likely to use EMS for transport to an ED compared to non-Hispanic Whites of the same gender.⁷ Among Hispanics experiencing a stroke, males were less likely than females to use EMS as the mode of transport to an ED.⁷ EMS use as the mode of transport was associated with earlier ED arrival,²⁴ faster triage,^2,14 and more rapid treatment.^2,14

Among the 22 studies, two studies assessed Hispanics’ experiences with ED bypassing, transportation to a reference ED, and transportation to a safety-net ED.^20,21 Hispanics were more likely to experience ED bypassing (i.e. be transported to an ED other than the one most proximate to them).²⁰ Hispanics were less likely to be transported to the reference ED (i.e. most frequent ED destination) compared to non-Hispanic Whites from the same ZIP code.²¹ Hispanics were more likely to be transported to a safety-net ED (i.e. ED that is legally obligated to provide health care regardless of a patient’s insurance status) compared to non-Hispanic Whites from the same ZIP code.²¹

Of the 22 studies, six studies found statistically non-significant findings between Hispanics and non-Hispanic Whites for EMS and non-EMS modes of transport to the ED.^{12,13,40,42,47} One study found statistically significant differences in EMS time intervals (e.g. time from 9–1–1 call to EMS arrival on scene, time on scene, and time of on scene departure to hospital arrival) between Hispanics and non-Hispanic Whites, although these differences were small and not clinically significant.¹⁸

Hispanic Adults’ Experiences with EMS During the COVID-19 Pandemic

Four studies examined Hispanic adults’ experiences with EMS during the early COVID-19 pandemic period.^16,23,25,34 EMS calls decreased by 26.5% during the early pandemic period (March to May 2020), compared to the same months in the previous four years (2016–2019).³⁴ Non-transports (e.g. EMS calls that do not result in an ambulance transport) increased by 46.6% during the early pandemic period.³⁴ The increase in non-transports may be explained by EMS recommended non-transports, caller-generated refusals due to fear of COVID-19 infection, and individuals not wanting to burden the healthcare system.³⁴ The early pandemic period was also characterized by an increase in the proportion of EMS calls attributed to respiratory distress,²⁵ cardiac arrest²³ and overdose-associated cardiac arrests,¹⁶ especially among Hispanics. The higher likelihood of these health conditions may be partially explained by the disproportionate impact of COVID-19 on Hispanics.^16,23,25,34

DISCUSSION

This systematic review found disparities in EMS activation, on-scene care and EMS transports among Hispanic adults, compared to non-Hispanic Whites. These disparities in EMS may be attributed to multiple factors, including delayed symptom recognition, underestimation of symptom severity, and lack of knowledge regarding time-sensitive windows, particularly for cardiovascular health outcomes (i.e. heart attack and stroke) among Hispanic adults. The underrepresentation of Hispanics in EMS professions may increase fear of discrimination among Hispanic adults experiencing an emergency. Lack of racial, ethnic and linguistic representation in the EMS workforce may also increase patient-provider language discordance, which contributes to language barriers that impact access and provision of EMS. Lack or inadequate health insurance coverage may deter Hispanic adults’ from using EMS due to perceived costs.

The findings from this review are consistent with disparities identified in the ED between Hispanics and non-Hispanic Whites.⁵ Hispanics are less likely to receive electrocardiograms and chest x-rays in the ED, compared to non-Hispanic Whites.⁵ In this review, the findings for pain medication administration were mixed when comparing Hispanics to non-Hispanic Whites. The ED literature, however, has found that Hispanics are less likely to receive pain medication for long-bone fractures, headaches and back pain, compared to non-Hispanic Whites.⁵ A study also found that Hispanics require more ED visits for asthma, compared to non-Hispanic Whites, which may be indicative of a lack of or limited access to preventive and diagnostic services.⁵

Future EMS research should consider the heterogeneity within the Hispanic population by considering other socio-demographic characteristics including, national heritage, country of origin, primary language, immigration status, and place of residence. Future EMS studies should aim to use representative samples that result in generalizable findings. Most of the current EMS datasets use convenience samples that are not representative of the populations served. To achieve representative samples, EMS agencies need to reassess how prehospital data is recorded and reported at the local, state and national levels. Qualitative and mixed methods studies are needed to study Hispanics’ use of EMS as these methods provide breadth and depth to expand on findings from quantitative studies. In this review, we did not find any qualitative study that met all of our inclusion criteria. Some challenges that may arise when conducting qualitative studies in the EMS context, especially when trying to understand past EMS experiences, include severely ill or deceased patients, privacy concerns that make it difficult for researchers to contact patients, incomplete patient information, and trying to locate hard-to-reach populations. Future research on Hispanics’ experiences with EMS should also consider the changing policy environments. In this review, we focused on understanding changes in EMS use before and during the COVID-19 pandemic, although other potential avenues for in-depth research may assess EMS use before and after the ACA, state Medicaid expansions, before and after Medicare eligibility, different types of Medicare enrollment (Traditional vs. Medicare Advantage) or before and after different presidential administrations.

Limitations:

This review highlights important limitations in EMS research. First, most of the studies rely on non-probability samples,^{6,16,18,22,24–25,27,29–31–34,38–39,41–49} which hinder the generalizability of the findings. Even the National Emergency Medical Services Information System (NEMSIS), the only national EMS database in the U.S., uses a large convenience sample, not a representative sample.⁵⁰ Second, most of the studies use cross-sectional study designs,^{7,11,13,17,19,22–23,28,35–36–37,39,41–42,45,47–49,} which make it difficult to infer causality and assess changes over time. Third, a few studies use small sample sizes of Hispanics,^14,32,40,42 which may contribute to statistically non-significant results in those studies. Fourth, local, state, and national EMS datasets often represent activations, not patients.⁵⁰ This limitation, however, is consistent over time and should not impact analyses of EMS activations.

CONCLUSION

Health equity cannot be achieved in the U.S. healthcare system without identifying and addressing health care disparities in the prehospital setting. The contribution of this review is its attention to Hispanic adults’ experiences with the different phases of the EMS system in the U.S. This review suggests Hispanic versus non-Hispanic White disparities in EMS activation,¹⁷ types of on-scene care provided,⁶ and EMS versus non-EMS modes of transport to the ED.³² EMS use patterns among Hispanic adults also changed during the early COVID-19 pandemic period, compared to the pre-pandemic period.^16,23,25

Supplementary Material

Supplemental Data File (.doc, .tif, pdf, etc.)

Supplemental Table 1: Specific characteristics of the included individual studies that assess Hispanic adults’ experiences with the emergency medical services (EMS) system in the United States between 2000 and 2021