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Invited Commentary
Emergency Medicine
August 20, 2021

Avoidance of Emergency Care—A Marker of Long-standing Inequities

Author Affiliations
  • 1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Department of Health Policy & Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
JAMA Netw Open. 2021;4(8):e2121057. doi:10.1001/jamanetworkopen.2021.21057

The impact of the COVID-19 pandemic has been devastating, leading to large disruptions of the health care delivery system throughout the US, often in paradoxical ways. Across the US, hospitals and emergency departments initially prepared for a wave of critically ill patients expected to overwhelm the health care system. However, at the height of the pandemic, emergency department visits and hospitalizations decreased sharply for both low-acuity problems and life-threatening illnesses, even as mortality due to the novel coronavirus and excess mortality unrelated to the virus mounted across communities. Frontline clinicians and national experts hypothesized that voluntary avoidance of needed emergency care could explain this phenomenon. Yet, to date, there has been relatively little direct evidence to inform this hypothesis.

Harrison and colleagues1 performed a cross-sectional study using a comprehensive emergency medical services (EMS) data set from the greater Detroit, Michigan, area to evaluate the extent to which voluntary EMS refusals, situations in which EMS was contacted but the patient declined to be taken to the hospital, may be playing a role. The authors found that rates of ambulance refusal rose substantially at the height of the COVID-19 pandemic—from March to June 2020—compared with the corresponding months in the year before. Even as the COVID-19 incidence declined across Detroit communities, rates of EMS refusals remained high and did not return to their prepandemic baseline, largely mirroring the changes in emergency department volume throughout the US. These results are concerning, and they provide evidence that patient avoidance of care is likely an important aspect of decreasing acute care use during the COVID-19 pandemic.

In addition to higher rates of patient refusal, the authors found increased rates of prehospital mortality compared with the year before the pandemic.1 It is possible that individuals who died before or during transport may have survived if they had received care sooner. Anecdotal reports by frontline physicians indicate that patients arriving to the hospital during the pandemic are coming later in the course of illness and have more severe illnesses as a result. Thus, care avoidance may be considered on a spectrum from outright refusal of care to simply a delay in being examined. The results of this study suggest that both factors may be playing a role in adverse outcomes during the pandemic period, but work further exploring the link between avoidance of care and patient outcomes is warranted.1

Harrison and colleagues1 were unable to determine the exact reason for the emergency call (eg, chest pain, shortness of breath, trauma) and whether refusal rates were higher for certain conditions. Another potential explanation for higher rates of refusal in the postpandemic period may be a change in the types of conditions being treated. For example, patients with nonfatal opioid overdoses may have relatively high rates of refusing ambulance transport. There has been an increase in opioid overdoses during the pandemic as well as an increasing EMS refusal rate among those with overdose.2 Thus, it is possible that the increased rates of EMS refusal may reflect a change in the relative frequency of conditions for which EMS was called as well as changing behavior patterns for similar conditions.

The authors further examined whether these trends were different across patient subgroups and communities.1 Their results echo what other studies have reported over the past year: the consequences of the COVID-19 pandemic have not been borne equally. The pandemic-related increase in EMS refusals was more pronounced for the most marginalized communities, as measured by the Social Vulnerability Index, and among neighborhoods with a greater proportion of racial and ethnic minorities, more poverty, and higher unemployment rates. Prior work has shown that these types of communities experienced a disproportionate burden of COVID-19–related hospitalizations and deaths,3 and they also experienced higher rates of excess mortality due to non–COVID-19 conditions.4 The inequities highlighted in this study suggest that care avoidance might be one potential mediator of the racial and socioeconomic disparities in health outcomes during the COVID-19 pandemic.

Understanding issues of care avoidance is necessary for mitigating the health inequities experienced by marginalized communities. A recent survey5 reported that care avoidance, even in instances when an individual believes they are having symptoms concerning for a myocardial infarction or a stroke, is substantially higher among Black and Latino individuals compared with White individuals. A growing body of literature suggests that at the root of care avoidance is an underlying distrust of the health care system and its medical paractitioners. Medical distrust has been described as an “absence of trust that health care providers and organizations genuinely care for patients’ interests, are honest, practice confidentiality, and have the competence to produce the best possible results.”6 Reasons for medical distrust among racial and ethnic minorities are multifactorial and stem from a long history of mistreatment, especially among Black Americans, and structural racism in US policy. From experiments on enslaved people, undertreatment of pain, to the Tuskegee syphilis study, Black Americans have numerous valid reasons to distrust the medical establishment. Among Latino communities, the revised public charge rule under the Trump administration implemented in 2020 discouraged people from seeking care, even when they were experiencing symptoms concerning for COVID-19, because of their fear that seeking any public aid would negatively affect their future residency status in the US.7

There are other potential reasons why care avoidance was more prominent during the COVID-19 pandemic. Harrison and colleagues1report that refusal rates were higher among communities with more single-parent households and also among women. The authors hypothesize that care avoidance by women may be associated with family responsibilities at a time that burden on caregivers became even greater than before the pandemic. Financial considerations may play a role in the decision to refuse care among individuals in poverty. Fear of contracting COVID-19 during hospitalization is also likely playing a substantial role.

Regardless of the precise reason that people, particularly those from marginalized communities, are choosing to avoid care, it is important that patients are not blamed for their choices, because these choices are almost certainly rooted in valid concerns. Instead, it is necessary that health care professionals work toward a greater understanding of the specific motivations for avoiding care in patient populations and begin to rebuild trust among communities of racial and ethnic minority groups. Strategies for doing so include investing in the patient-clinician relationship, building relationships outside traditional health care settings and into the community, uncovering instances of institutional racism and implementing strategies to correct them, and creating a safe environment for patients where they are treated with dignity and respect.6

The COVID-19 pandemic has posed an unprecedented challenge in modern times, and evidence continues to mount on the unequal distribution of its burden across different groups of people and communities. The pandemic has also exposed the vulnerability of our health care system and serves as a reminder of how much more work needs to be done to overcome the challenges and injustices that some communities have faced for generations.

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Article Information

Published: August 20, 2021. doi:10.1001/jamanetworkopen.2021.21057

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Burke LG et al. JAMA Network Open.

Corresponding Author: Laura G. Burke, MD, MPH, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA 02215 (lgburke@bidmc.harvard.edu).

Conflict of Interest Disclosures: Dr Burke reported receiving grants from the Association of American Medical Colleges and the Emergency Medicine Foundation, and consulting fees from the Emergency Medicine Policy Institute outside the submitted work. Dr Figueroa reported receiving grants from the Commonwealth Fund, Robert Wood Johnson Foundation, Harvard Center for AIDS Research, and National Institutes of Health; personal fees from Tufts Health Plan; and personal fees from Humana outside the submitted work.

Harrison  NE, Ehrman  RR, Curtin  A,  et al.  Factors associated with voluntary refusal of emergency medical system transport for emergency care in Detroit during the early phase of the COVID-19 pandemic.   JAMA Netw Open. 2021;4(8):e2120728. doi:10.1001/jamanetworkopen.2021.20728Google Scholar
Glenn  MJ, Rice  AD, Primeau  K,  et al.  Refusals after prehospital administration of naloxone during the COVID-19 pandemic.   Prehosp Emerg Care. 2021;25(1):46-54. doi:10.1080/10903127.2020.1834656 PubMedGoogle ScholarCrossref
Figueroa  JF, Wadhera  RK, Mehtsun  WT, Riley  K, Phelan  J, Jha  AK.  Association of race, ethnicity, and community-level factors with COVID-19 cases and deaths across US counties.   Healthc (Amst). 2021;9(1):100495. doi:10.1016/j.hjdsi.2020.100495 PubMedGoogle Scholar
Stokes  AC, Lundberg  DJ, Elo  IT, Hempstead  K, Bor  J, Preston  SH.  COVID-19 and excess mortality in the United States: a county-level analysis.   PLoS Med. 2021;18(5):e1003571. doi:10.1371/journal.pmed.1003571 PubMedGoogle Scholar
American Heart Association. Fueled by COVID-19 fears, approximately half of Hispanics and Black Americans would fear going to the hospital if experiencing symptoms of a heart attack or strokeAccessed August 3, 2021. https://newsroom.heart.org/news/fueled-by-covid-19-fears-approximately-half-of-hispanics-and-black-americans-would-fear-going-to-the-hospital-if-experiencing-symptoms-of-a-heart-attack-or-stroke
Hostetter  M, Klein  S. Understanding and ameliorating medical mistrust among Black Americans. The Commonwealth Fund. January 14, 2021. Accessed July 20, 2021. https://www.commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans
Sommers  BD, Allen  H, Bhanja  A, Blendon  RJ, Orav  EJ, Epstein  AM.  Assessment of perceptions of the public charge rule among low-income adults in Texas.   JAMA Netw Open. 2020;3(7):e2010391. doi:10.1001/jamanetworkopen.2020.10391 PubMedGoogle Scholar
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