Equity in U.S. Emergency Medical Services (EMS): A Case Study in California

Overview

Emergency medical services (EMS) systems provide critical prehospital care that improves survival rates and promotes optimal recovery for patients who experience time-sensitive emergencies such as stroke, myocardial infarction, and cardiac arrest. EMS in the United States are administered and funded primarily at the local level. Local EMS systems are complex entities that researchers have struggled to study and describe in a uniform manner. This overview and two primers were developed to fill that gap.

CDC's Division for Heart Disease and Stroke Prevention's EMS project team developed an overview of the two EMS primers:

• Emergency Medical Services (EMS): Local Authority, EMS Funding, Organization, and Management
• Emergency Medical Services (EMS): A Look at Disparities in Funding and Outcomes

Both primers examine EMS literature and then analyze data from five local EMS agencies (LEMSAs) in California. The primers highlight potential inequities in EMS funding and quality, and they may help public health decision makers better understand EMS systems and equity concerns. This page also provides an overview of the study methodology and a glossary.

Cardiovascular disease and EMS

Timely, appropriate emergency care is one of many factors that contribute to desirable cardiovascular disease (CVD) outcomes. For example, one frequently cited study found that for each minute that stroke treatment is delayed, the patient may lose an estimated 1.9 million neurons, which can cause damage to the brain tissue as well as long term disability and death.123 Another frequently cited study that examined 1,832 patients who had been treated for STEMI (ST-elevated myocardial infarction) in Quebec found that patients who did not receive timely STEMI treatments (within accepted 30-minute and 90-minute treatment guidelines) had a higher 30-day mortality rate.45

There is also evidence that EMS response times are longer for patients with lower incomes. Additionally, patients who have lower incomes or who are members of racial/ethnic minority groups use EMS services more frequently, whether because of a lack of medical insurance, no primary care option, or another form of economic deprivation.6789

Unlike the studies described above, the EMS primers do not explore connections between EMS and CVD. Instead, they focus on examining EMS systems by exploring their organization, funding sources, related laws, and quality indicators. They also describe disparities based on geography (urbanicity), race, ethnicity, and sex. However, because delays in EMS treatment have been shown to affect short- and long-term outcomes in stroke and STEMI patients, health policymakers may consider improved timely EMS care as a strategy to improve these CVD outcomes in traditionally underserved areas.

EMS: local authority, EMS funding, organization, and management

There are variations in the cost, management, organization, and quality of EMS, and how local government authority or autonomy may be related is unclear. The first primer, entitled Emergency Medical Services (EMS): Local Authority, EMS Funding, Organization, and Management, highlights the differences in how EMS systems are managed and governed in states and localities. The management and organizational approach for EMS systems may include a public health department, county health service agency, public safety (particularly fire department personnel), and oversight from a medical director and/or an EMS advisory committee. The absence of a uniform management and organizational structure may affect service delivery and access, especially for rural EMS systems.10

California case study

The varied nature of EMS makes it exceedingly difficult to study in any detail at the national level. However, we can gain insight through a limited case study of five LEMSAs in California, where LEMSAs may encompass a single county or multiple counties: This study includes three single-county and two multicounty LEMSAs that encompass a total of 11 counties. Two of the single-county LEMSAs are in counties that have drafted their own governing charters, giving them some flexibility in governance. We conclude with a discussion of EMS organization and management within California, including details on funding sources and related laws within the five LEMSAs.

EMS: a look at disparities in funding and outcomes

The second primer, entitled Emergency Medical Services (EMS): A Look at Disparities in Funding and Outcomes, illustrates that the provision of EMS is frequently hindered by a lack of available resources. Service-related challenges include difficulties in staff retention because of low salaries, insufficient operations support, and poor training opportunities, which may be related to EMS disparities. This primer examines disparities in EMS in the United State based on income, race, sex, and geography (rurality/urbanicity). These include:

• Longer EMS response times in low-income neighborhoods.9
• Longer EMS response times and fewer available resources in rural areas.10
• Less accurate recognition of stroke in women and patients from racial and ethnic minority group.11
• Less frequent assessment and treatment for pain in patients from racial and ethnic minority groups.12

California case study

A nationwide study of disparities in funding and outcomes of EMS systems is extremely challenging for several reasons, including:

• Difficulties calculating demographic disparities due to limited nationwide EMS data.
• Disparities in state-level funding of EMS offices, ranging from $0 to $144 million.
• Disparities in local-level funding of EMS due to differences in available resources.

For these reasons, this primer also includes a case study of EMS within California to facilitate a detailed analysis of these disparities. This limited case study examines the same five LEMSAs as the first primer. A discussion of selection criteria is included in the next section.

Methods and data sources

We have adopted a multipronged methodology to compile and analyze the data used for both primers. This includes:

• A detailed literature review of EMS nationally and within California.
• A detailed review of state and local government websites in California.
• A detailed review of publicly available EMS documents in California.
• Legal coding of California laws related to funding EMS.
• Compilation and analysis of economic data from local EMS agency (LEMSA) reports, including:
  • Local government revenues and funding sources for EMS.
  • Local EMS expenditures.
• Compilation and analysis of California EMS core quality indicators data related to CVD.
• Analysis of economic and epidemiological data from WONDER database and Census Bureau.

California was selected for the case study because of its economic, geographic, and demographic diversity and the availability of extensive EMS data. Detailed data from California are useful to public health practitioners both within and outside of the state. This document may help decision-makers identify benefits and drawbacks in different policies.

In California, 33 LEMSAs provide EMS to 58 counties. Most LEMSAs provide services to a single county. The study included three single-county LEMSAs and two multicounty LEMSAs that provide EMS to a total of 11 counties.A Selection criteria for LEMSAs included the following social and economic factors that were used to maximize diversity across localities:

• Industries, including one LEMSA with a sizable agricultural sector.
• Urban and rural counties.
• Average county incomes.
• Racial and ethnic diversity.
• Reasonable statewide geographic span.

Conclusion and implications

EMS in the United States

U.S. EMS are primarily provided and funded by local governments, which leads to wide variation in funding levels, service costs, and quality.10 Although EMS systems must comply with state regulations, they are run by local governments and thus management and governance differ across localities. Typically, EMS systems are integrated into the greater healthcare system and include collaboration across public health, healthcare, and public safety (they are often run by fire departments).10 EMS structures also vary (e.g., private versus public providers, required protocols).10 These variances may contribute to documented nationwide disparities in EMS care based upon rurality, race/ethnicity, sex, and income.

California case study

Local governments are often challenged by limited resources, and little is known about how local government autonomy and access to funding sources may affect disparities in EMS outcomes. We conducted a case study to answer these questions, and we chose to conduct the case study in California both because it allowed for diversity in local EMS agencies selected and because unlike many states, California publishes local level EMS data through its annual LEMSA reports and Core Quality Indicators projects. We lay out our findings in detail within the two primers. We were unable to examine race, ethnicity, sex, or income level disparities because the available local data was not disaggregated in this way. Improved data availability in California and elsewhere would facilitate additional studies.

Within our case study, the urban LEMSAs had access to more per capita funding for EMS than rural ones. These urban LEMSAs also had governing charters, which gave them increased governing flexibility that may facilitate issuance of special taxes and assessments to fund EMS. In addition, they had better cardiovascular quality indicators. However, when comparing the urban LEMSAs to each other, we found that the better-resourced urban LEMSA had worse quality indicators than one with fewer resources (though both had more resources and better outcomes than the rural LEMSAs we examined). This suggests that while increased funding may help pro optimal EMS care, it is not independently sufficient. It may be useful for local EMS agencies to share success stories and lessons learned to improve EMS care, particularly in areas with limited resources.

Glossary

Charter: As used here, it is a governing document, created by a local government, that sets forth rules related to government administration.

Core quality indicators: These measurements, from the California EMS Authority's Core Quality Measurement Project, are designed to measure an EMS system's ability to arrive at the scene quickly, accurately assess patients, deliver time-sensitive pre-hospital care, and transport the patient to a hospital capable of providing the needed care.13

Emergency medical services (EMS):

• The treatment and transport of people in crisis health situations that may be life-threatening.
• A system of coordinated response and emergency medical care, involving multiple people and agencies.14

Health disparities: a health disparity is a health difference that adversely affects disadvantaged populations, based on one or more of the following health outcomes:

• i. Higher incidence and/or prevalence and earlier onset of disease
• ii. Higher prevalence of risk factors, unhealthy behaviors, or clinical measures in the causal pathway of a disease outcome
• iii. Higher rates of condition-specific symptoms, reduced global daily functioning, or self-reported health-related quality of life using standardized measures
• iv. Premature and/or excessive mortality from diseases where population rates differ
• v. Greater global burden of disease using a standardized metric15

Health inequities: "Particular types of health disparities that stem from unfair and unjust systems, policies, and practices and limit access to the opportunities and resources needed to live the healthiest life possible."

Local autonomy: The extent to which states constitutionally or legislatively grant local jurisdictions the power to enact their own laws to address issues of local concern. This encompasses concepts such as fiscal discretion, decentralization, and home rule.16

Local EMS agency (LEMSA): This is one of 33 local EMS systems that provide EMS for the 58 counties in California. Seven LEMSAs include multiple counties, and all other LEMSAs include a single county. Each LEMSA is required to submit an annual report that includes details about EMS funding and other EMS metrics.17

Acknowledgements

CDC's Division for Heart Disease and Stroke Prevention's EMS project team that worked on these primers includes Moriah Bailey, Stephanie Bernard, Amanda Brown, Bruce Donald, Adam Johnson, Andrea Kennon, Kara Macleod, Teg Uppal, and Zachary Wright.

Disclaimer

The primers presented here, Emergency Medical Services (EMS): Local Authority, EMS Funding, Organization, and Management and Emergency Medical Services (EMS): A Look at Disparities in Funding and Outcomes, are not intended to promote any legislative, regulatory, or other action.