Prehospital Chest Pain Management: Disparity Based on Homeless Status

Abstract

Background

People experiencing homelessness may use emergency medical services to access health care. We sought to examine the relationship between homelessness and prehospital evaluation and treatment of chest pain.

Methods

We obtained 2019 data of all emergency medical services activations from a single 9-1-1 provider in San Francisco, California with a clinician’s primary impression of chest pain. Using chart review, we categorized patients as experiencing homelessness or not and determined treatment rates between the two groups based on local chest pain/acute coronary syndrome protocol. We then stratified the two groups based on primary impression subcategories: “chest pain–not cardiac” and “chest-pain–cardiac/STEMI”; ST elevation myocardial infarction (STEMI).

Results

A total of 601 chest pain calls were analyzed after excluding non-transports and pediatric patients. 120 incidents (20%) involved patients experiencing homelessness. Across all chest pain impressions, people experiencing homelessness were less likely to receive aspirin (35% vs 53%; p < 0.001), intravenous access (38% vs 62%; p < 0.001), and nitroglycerin (21% vs 39%; p < 0.001). No patients experiencing homelessness received analgesic medication, though only 4% of other patients received this intervention (0% vs 4%; p = 0.020). People experiencing homelessness were more likely to receive a clinical impression of “chest pain–not cardiac” compared to “chest pain–cardiac/STEMI” (68% vs 32%; p < 0.001). Results were less significant in most fields when adjusted for impression sub categorizations: “chest pain–not cardiac” versus “chest pain–cardiac/STEMI.” Greater than 97% of all patients received 12 lead electrocardiograms.

Conclusions

Significant disparities were observed between patients experiencing and not experiencing homelessness in the prehospital treatment of chest pain. Larger scale evaluations are needed to further assess potential disparities in care for people experiencing homelessness in the prehospital setting. Using prehospital clinician impression as a proxy for acuity may mask existing bias and disparity; however, 12-lead ECG acquisition, the key diagnostic tool, was appropriately performed in more than 97% of all chest pain patients.

Acknowledgments

This study was supported by The City and County of San Francisco’s EMS Agency, and its medical director, John Brown, MD. This study solely represents the views of its authors and not SFEMSA or San Francisco prehospital providers.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

There was no financial support provided for this study.