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

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Were decreases in emergency medical services (EMS) and emergency department volumes associated with voluntary avoidance of emergency care during a COVID-19 outbreak in Detroit?

Findings  In this cohort study of 80 487 EMS responses with intended ED transport, voluntary refusal of care was associated with lower EMS to emergency department transports during a COVID-19 outbreak from March 1 to June 30, 2020, independent of age, COVID-19 incidence, public health restrictions, and prehospital deaths. The probability of prehospital death returned to baseline when COVID-19 incidence and public health restrictions receded, but the rate of voluntary refusals remained elevated (25% in 2020 vs 15% in 2019), particularly for women and socially vulnerable communities.

Meaning  The findings of this study suggest that the decreasing volume of EMS to emergency department transports was primarily associated with voluntary refusal.


Importance  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.

Objective  To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths.

Design, Setting, and Participants  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.

Exposures  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.

Main Outcomes and Measures  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.

Results  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, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir).

Conclusions and Relevance  In this cohort study, EMS transport refusals increased with the COVID-19 outbreak’s peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

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Article Information

Accepted for Publication: June 8, 2021.

Published: August 20, 2021. doi:10.1001/jamanetworkopen.2021.20728

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

Corresponding Author: Nicholas E. Harrison, MD, MS, Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Ave, Indianapolis, IN 46202 (harrisne@iu.edu; nicholas.e.harrison@gmail.com).

Author Contributions: Dr Harrison had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Harrison, Dunne.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Harrison, Ehrman, Curtin, Gorelick, Brennan, Dunne.

Critical revision of the manuscript for important intellectual content: Harrison, Ehrman, Hill, Brennan, Dunne.

Statistical analysis: Harrison, Ehrman.

Administrative, technical, or material support: Ehrman, Gorelick, Dunne.

Supervision: Harrison, Brennan, Dunne.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: Preliminary results of this analysis were presented virtually at the National Association of EMS Physicians Conference; December 2020.

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