healthcare equity analysis findings · treatment equity analysis #2 cardiac chest pain summary •...
TRANSCRIPT
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)
Pain Treatment Equity Analysis – Data and Methods
• 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
Pain Treatment Equity Analysis – Data and Methods
• 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
Treatment Equity Analysis #1Pain Management of Traumatic Injuries and Atraumatic Pain
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%
less likelyto have a
pain assessment
14%35%
Medicare patients are
Patients without insurance are 16%Patients with unknown insurance are 53%
Medicaid patients are
Adjusts for: patient gender, patient age, patient health insurance, obesity status, and EMS provider’s specific primary impression.
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
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%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%“Unknown” patients are
-73%
His
pani
c
“Unk
now
n”
Moderate to severe pain
Pain Management - Pain Medication
Administration of Medication for Pain for Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)
Pain MedicationLikelihood When compared to clinically comparable patients with
private insurance:50%
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%
Adjusts for: patient gender, patient age, patient health insurance, obesity status, and EMS provider’s specific primary impression.
less likelyto receive
pain medication
25%48%
Medicare patients are
Patients without insurance are 16%Patients with unknown insurance are 57%
Medicaid patients are
All pain categories
Pain Management - Pain Medication
Administration of Medication for Pain for Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)
Pain MedicationLikelihood When compared to clinically comparable patients with
private insurance:50%
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%
Adjusts for: patient gender, patient age, patient health insurance, obesity status, and EMS provider’s specific primary impression.
less likelyto receive
pain medication
28%56%
Medicare patients are
Patients without insurance are 23%Patients with unknown insurance are 39%
Medicaid patients are
Moderate to severe pain
Pain Management - Pain Medication
Pain Reduction for Patients with Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)
less likelyto have their pain
reduced
Pain MedicationLikelihood When compared to clinically comparable White patients:
50%
25%
0%
-25%
-50%
Pain Management - Pain Reduction
“Unk
now
n”
49%“Unknown” patients are
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 Reduction for Patients with Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)
Pain ReductionLikelihood When compared to clinically comparable patients with
private insurance:50%
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
Adjusts for: patient gender, patient age, initial pain score, patient health insurance, obesity status, and EMS provider’s specific primary impression.
less likelyto have a
pain reduction
15%40%
Medicare patients are
Patients without insurance are 22%Patients with unknown insurance are 43%
Medicaid patients are
All pain categories
Pain Management - Pain Reduction
Pain Reduction for Patients with Traumatic Injuries and Atraumatic Pain(18,028 charts, 2015-2019)
Pain ReductionLikelihood When compared to clinically comparable patients with
private insurance:50%
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
Adjusts for: patient gender, patient age, initial pain score, patient health insurance, obesity status, and EMS provider’s specific primary impression.
less likelyto have a
pain reduction
15%49%
Medicare patients are
Patients without insurance are 26%Patients with unknown insurance are 37%
Medicaid patients are
Moderate to severe pain
Pain Management - Pain Reduction
Treatment Equity Analysis #1Pain Management of Traumatic Injuries and Atraumatic Pain
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
Cardiac Chest Pain– Data and Methods
• 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)
Cardiac Chest Pain– Data and Methods
Treatment Equity Analysis #2Cardiac Chest Pain
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.
less likelyto have a
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)
less likelyto receive
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
Treatment Equity Analysis #2Cardiac Chest Pain
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