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

Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. To examine the factors associated with EMS refusal in relation to COVI...

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Bibliographic Details
Published in:JAMA network open 2021-08, Vol.4 (8), p.e2120728-e2120728
Main Authors: Harrison, Nicholas E, Ehrman, Robert R, Curtin, Andrea, Gorelick, Damon, Hill, Alex B, Brennan, Erin, Dunne, Robert
Format: Article
Language:English
Subjects:
Adult
Aged
Communicable Disease Control - statistics & numerical data
Coronaviruses
COVID-19
COVID-19 - epidemiology
COVID-19 - prevention & control
Emergency medical care
Emergency Medical Services - statistics & numerical data
Emergency Medicine
Emergency Service, Hospital - statistics & numerical data
Emergency services
Female
Humans
Logistic Models
Male
Michigan - epidemiology
Middle Aged
Odds Ratio
Online Only
Original Investigation
Pandemics
Patient Acceptance of Health Care - statistics & numerical data
Public health
Retrospective Studies
SARS-CoV-2
Shelter in place
Transportation of Patients - statistics & numerical data
Treatment Refusal - statistics & numerical data
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Summary:Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths. A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression. A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions. Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability. A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines,
ISSN:2574-3805
2574-3805
DOI:10.1001/jamanetworkopen.2021.20728