Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

Figures & data

Table 1. Inclusion/exclusion criteria.

Inclusion criteria
Population	Underrepresented groups of interest: race/ethnicity (Black, Latinx, Native American, Alaskan Native, Asian American, Pacific Islander), gender/gender expression (cisgender women, transgender men, transgender women), or sexual orientation (LGBTQ+)
Content	EMS-related encounters (or events) with stated objectives (or had significant results) of examining disparities in care for underrepresented groups
Time period	1960 to present
Study types	Peer-reviewed literature, theses/dissertations, non-journal professional publications, editorials/op-eds, media reports
Exclusion criteria
Language	Non-English
Geographic location	Non-US setting
Content	If a disparity was noted but was not a stated objective or significant finding in the results or discussion

Figure 1. Inclusion/exclusion flowchart.

Table 2. Included full text articles by phase of care.

Phase of care	Number of articles
EMS Access (17, 18, 20, 28–79)	55
Acute coronary syndrome	22
Diabetic problems	1
Falls and trauma	3
Mental health and opioid overdose	1
Out-of-hospital cardiac arrest	1
Stroke	25
Multiple and other	5
Pre-arrival care (29, 78, 80–123)	46
Out-of-hospital cardiac arrest	45
Multiple and other	1
EMS Diagnosis/Treatment (7–20, 81, 82, 84, 89, 90, 100, 105, 109, 111, 112, 120, 122, 124–139)	42
Acute coronary syndrome	10
Falls and trauma	1
Mental health and opioid overdose	2
Out-of-hospital cardiac arrest	17
Pain	8
Stroke	4
Multiple and other	4
EMS Response/Transport (15, 17–19, 21–23, 38, 41, 59, 82, 89, 96, 100, 105, 106, 109, 113, 120, 121, 124, 127, 138–155)	40
Acute coronary syndrome	13
Diabetic problems	1
Falls and trauma	8
Out-of-hospital cardiac arrest	13
Stroke	4
Multiple and others	3

Categories are not mutually exclusive, with multiple articles reporting on multiple phases of care. Three articles reported on acute coronary syndrome and stroke (33, 57, 63) and two articles reported on acute coronary syndrome and out-of-hospital cardiac arrest (19, 152). One article reported on acute coronary syndrome, falls/trauma, out-of-hospital cardiac arrest, and multiple other health conditions (20).

Table 3. Articles reporting sex/gender disparities by phase of care and health condition.

	Acute coronary syndrome		Diabetic problems		Falls and trauma		Mental health and opioid overdose		Out-of-hospital cardiac arrest		Pain		Stroke		Multiple and other
EMS access	14	2	1	0	3	0			0	0			9	5	1	0
Pre-arrival care									9	7					0	0
EMS diagnosis/Treatment	7	6			1	1	2	0	7	3	4	2	1	1	2	1
EMS response/Transport	8	2	1	0	5	0			0	4			1	0

Orange indicates articles that reported disparities, green indicates articles that reported a lack of disparities, and yellow indicates no articles reporting on disparities for that category.

Table 4. Articles reporting race/ethnicity disparities by phase of care and health condition.

	Acute coronary syndrome		Diabetic problems		Falls and trauma		Mental health and opioid overdose		Out-of-hospital cardiac arrest		Pain		Stroke		Multiple and other
EMS access	20	3	1	0	1	0			1	0			25	10	5	0
Pre-arrival care									36	9					1	0
EMS diagnosis/Treatment	3	1					0	1	5	6	7	2	3	1	2	1
EMS response/Transport	4	4	0	0	5	0			7	2			3	1	2	1

Orange indicates articles that reported disparities, green indicates articles that reported a lack of disparities, and yellow indicates no articles reporting on disparities for that category.

Sullivan AL, Beshansky JR, Ruthazer R, Murman DH, Mader TJ, Selker HP. Factors associated with longer time to treatment for patients with suspected acute coronary syndromes: a cohort study. Circ Cardiovasc Qual Outcomes. 2014;7(1):86–94.

 PubMed Web of Science ®Google Scholar

Sullivan A. Factors associated with longer time to treatment in the care of patients transported by emergency medical services for suspected acute coronary syndromes and ST-segment elevation myocardial infarction. Tufts University; 2013.

 Google Scholar

Weiss SJ, Ernst AA, Phillips J, Hill B. Gender differences in state-wide EMS transports. Am J Emerg Med. 2000;18(6):666–70.

 PubMed Web of Science ®Google Scholar

Barnhart JM, Cohen O, Kramer HM, Wilkins CM, Wylie-Rosett J. Awareness of heart attack symptoms and lifesaving actions among New York City area residents. J Urban Health Bull N Y Acad Med. 2005;82(2):207–15.

 PubMed Web of Science ®Google Scholar

Sasson C, Haukoos JS, Ben-Youssef L, Ramirez L, Bull S, Eigel B, et al. Barriers to calling 911 and learning and performing cardiopulmonary resuscitation for residents of primarily Latino, high-risk neighborhoods in Denver, Colorado. Ann Emerg Med. 2015;65(5):545–552.e2.

 PubMed Web of Science ®Google Scholar

Chan PS, McNally B, Vellano K, Tang Y, Spertus JA. Association of neighborhood race and income with survival after out-of-hospital cardiac arrest. J Am Heart Assoc. 2020;9(4):e014178.

 PubMed Web of Science ®Google Scholar

Cline SL, von Der Lohe E, Newman MM, Groh WJ. Factors associated with poor survival in women experiencing cardiac arrest in a rural setting. Heart Rhythm. 2005;2(5):492–6.

 PubMed Web of Science ®Google Scholar

Hill T, Weber T, Roberts M, Garzon H, Fraga A, Wetterer C, et al. Retrospective cross sectional analysis of demographic disparities in outcomes of CPR performed by EMS providers in the United States. JRSM Cardiovasc Dis. 2021. doi:10.1177/20480040211000619

 PubMed Web of Science ®Google Scholar

Kim C, Fahrenbruch CE, Cobb LA, Eisenberg MS. Out-of-hospital cardiac arrest in men and women. Circulation. 2001;104(22):2699–703.

 PubMed Web of Science ®Google Scholar

Kotini-Shah P, Del Rios M, Khosla S, Pugach O, Vellano K, McNally B, et al. Sex differences in outcomes for out-of-hospital cardiac arrest in the United States. Resuscitation. 2021;163:6–13.

 PubMed Web of Science ®Google Scholar

Becker LB, Han BH, Meyer PM, Wright FA, Rhodes KV, Smith DW, et al. Racial differences in the incidence of cardiac arrest and subsequent survival. The CPR Chicago Project. N Engl J Med. 1993;329(9):600–6.

 PubMed Web of Science ®Google Scholar

Brookoff D, Kellermann AL, Hackman BB, Somes G, Dobyns P. Do blacks get bystander cardiopulmonary resuscitation as often as whites? Ann Emerg Med. 1994;24(6):1147–50.

 PubMed Web of Science ®Google Scholar

Ghobrial J, Heckbert SR, Bartz TM, Lovasi G, Wallace E, Lemaitre RN, et al. Ethnic differences in sudden cardiac arrest resuscitation. Heart Br Card Soc. 2016;102(17):1363–70.

 PubMed Web of Science ®Google Scholar

Lupton JR, Schmicker RH, Aufderheide TP, Blewer A, Callaway C, Carlson JN, et al. Racial disparities in out-of-hospital cardiac arrest interventions and survival in the Pragmatic Airway Resuscitation Trial. Resuscitation. 2020;155:152–8.

 PubMed Web of Science ®Google Scholar

Moeller S, Hansen CM, Kragholm K, Dupre ME, Sasson C, Pearson DA, et al. Race differences in interventions and survival after out-of-hospital cardiac arrest in North Carolina, 2010 to 2014. J Am Heart Assoc. 2021;10(17):e019082.

 PubMed Web of Science ®Google Scholar

Starks MA, Schmicker RH, Peterson ED, May S, Buick JE, Kudenchuk PJ, et al. Association of neighborhood demographics with out-of-hospital cardiac arrest treatment and outcomes: where you live may matter. JAMA Cardiol. 2017;2(10):1110–8.

 PubMed Web of Science ®Google Scholar

Wilde ET, Robbins LS, Pressley JC. Racial differences in out-of-hospital cardiac arrest survival and treatment. Emerg Med J EMJ. 2012;29(5):415–9.

 PubMed Web of Science ®Google Scholar

Contreras JP. Factors associated with delayed pre-hospital time in patients with suspected acute coronary syndrome: effect of gender. Tufts University; 2010.

 Google Scholar

Faul M, Stevens JA, Sasser SM, Alee L, Deokar AJ, Kuhls DA, et al. Older adult falls seen by emergency medical service providers: a prevention opportunity. Am J Prev Med. 2016;50(6):719–26.

 PubMed Web of Science ®Google Scholar

Gardener H, Pepe PE, Rundek T, Wang K, Dong C, Ciliberti M, et al. Need to prioritize education of the public regarding stroke symptoms and faster activation of the 9-1-1 system: findings from the florida-puerto rico CReSD stroke registry. Prehosp Emerg Care. 2019;23(4):439–46.

 PubMed Web of Science ®Google Scholar

Kleindorfer DO, Lindsell CJ, Broderick JP, Flaherty ML, Woo D, Ewing I, et al. Community socioeconomic status and prehospital times in acute stroke and transient ischemic attack: do poorer patients have longer delays from 911 call to the emergency department? Stroke. 2006;37(6):1508–13.

 PubMed Web of Science ®Google Scholar

Wigginton JG, Pepe PE, Bedolla JP, DeTamble LA, Atkins JM. Sex-related differences in the presentation and outcome of out-of-hospital cardiopulmonary arrest: a multiyear, prospective, population-based study. Crit Care Med. 2002;30(4 Suppl):S131–S136.

 PubMed Web of Science ®Google Scholar

Chu K, Swor R, Jackson R, Domeier R, Sadler E, Basse E, et al. Race and survival after out-of-hospital cardiac arrest in a suburban community. Ann Emerg Med. 1998;31(4):478–82.

 PubMed Web of Science ®Google Scholar

Moon S, Bobrow BJ, Vadeboncoeur TF, Kortuem W, Kisakye M, Sasson C, et al. Disparities in bystander CPR provision and survival from out-of-hospital cardiac arrest according to neighborhood ethnicity. Am J Emerg Med. 2014;32(9):1041–5.

 PubMed Web of Science ®Google Scholar

Vadeboncoeur TF, Richman PB, Darkoh M, Chikani V, Clark L, Bobrow BJ. Bystander cardiopulmonary resuscitation for out-of-hospital cardiac arrest in the Hispanic vs the non-Hispanic populations. Am J Emerg Med. 2008;26(6):655–60.

 PubMed Web of Science ®Google Scholar

Benson NH, Sylvain H, Nimmo MJ, Dunn KA, Goodman P, O’Brien K. Influence of demographic variables in prehospital treatment of patients with chest pain. Prehosp Emerg Care. 1997;1(1):19–22.

 PubMedGoogle Scholar

Cui ER, Beja-Glasser A, Fernandez AR, Grover JM, Mann NC, Patel MD. Emergency medical services time intervals for acute chest pain in the United States, 2015–2016. Prehosp Emerg Care. 2020;24(4):557–65.

 PubMed Web of Science ®Google Scholar

Caceres BA, Turchioe MR, Pho A, Koleck TA, Creber RM, Bakken SB. Sexual identity and racial/ethnic differences in awareness of heart attack and stroke symptoms: findings from the National Health Interview Survey. Am J Health Promot AJHP. 2021;35(1):57–67.

 PubMed Web of Science ®Google Scholar

Tataris K, Kivlehan S, Govindarajan P. National trends in the utilization of emergency medical services for acute myocardial infarction and stroke. West J Emerg Med. 2014;15(7):744–8.

 PubMedGoogle Scholar

DuBard CA, Garrett J, Gizlice Z. Effect of language on heart attack and stroke awareness among U.S. Hispanics. Am J Prev Med. 2006;30(3):189–96.

 PubMed Web of Science ®Google Scholar

Lewis JF, Zeger SL, Li X, Mann NC, Newgard CD, Haynes S, et al. Gender differences in the quality of EMS care nationwide for chest pain and out-of-hospital cardiac arrest. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2019;29(2):116–24.

 PubMed Web of Science ®Google Scholar

David G, Harrington SE. Population density and racial differences in the performance of emergency medical services. J Health Econ. 2010;29(4):603–15.

 PubMed Web of Science ®Google Scholar