UCSF studies ambulance diversion by race, health care for released prisoners in journal issue

Black heart attack patients suffered higher mortality rates than white patients when ambulances are diverted because hospital emergency rooms are too busy to receive new patients, according to a new study led by UC San Francisco.

In a separate study led by a UCSF researcher, the investigators found that better coordination between correctional and community health care systems can improve overall health equity for released prisoners with chronic health conditions.

The two studies appear in a June 2017 special issue of Health Affairs on pursuing health equity.

In the analysis of 91,263 patients in California between 2001 and 2011, researchers found a 19-percent increase in 90-day mortality and a 14-percent increase in one-year mortality to black patients compared to white patients.

"Here we have fairly robust evidence documenting that blacks face a 'double burden' of inequity in our current health care system," said lead author Renee Hsia, MD, MSc, professor of emergency medicine and health policy at UCSF. "We found that blacks experience a much higher level of diversion compared to whites in California. In addition, when blacks undergo the same amount of diversion, they experience higher levels of mortality compared to whites, even when we control for factors such as access to cardiac technology, as well as treatment."

In the study, investigators examined differences in mortality between black and white heart attack patients experiencing various levels of diversion, an event in which an ambulance diverts to the next closest emergency department because the closest one is crowded and cannot take more patients. During the research period, 16 percent of black patients, compared to 10 percent of white patients, were seen in the emergency department during severe levels of diversion, amounting to 12 or more hours.

During moderate diversion, defined as between 6 to 12 hours per day, black patients had a 21-percent increase in 90-day mortality and a 19-percent increase in one-year mortality compared to white patients. Findings showed even larger disparities in mortality when examining communities whose nearest emergency department was a black-serving hospital. In these communities, black patients had a 23-percent increase in 1-year mortality relative to white patients under both moderate and severe levels of diversion.

"These findings suggest that black patients could be experiencing poorer quality care, delayed care or a combination of those factors," Hsia said. "Efforts to increase quality of care and reduce emergency department crowding - specifically in these communities - may help close these disparities."

In a separate study in the same issue of Health Affairs, lead author Shira Shavit, MD, associate professor of family and community medicine at UCSF, used data from the Transitions Clinic Network (TCN) to examine whether using primary care within a month after being released from prison and being referred to the TCN program by correctional agencies were correlated with use of acute health care and recidivism during the first 12 months after release. TCN is a national consortium of primary care clinics working to increase access to health care services among chronically ill people recently released from prison.

The researchers evaluated 751 TCN patients from May 2013 to February 2016 who had been released from prison for no more than six months before being served, reported at least one chronic condition requiring primary care or were at least age 50, were able to provide consent, and planned to live in a TCN clinic service area for at least 12 months.

Compared to referral from community partners, referral from correctional agencies was associated with significantly fewer emergency room visits and hospitalizations.

"Correctional agencies are critical in achieving positive health outcomes for individuals returning from incarceration, but to date, health systems face challenges in forging these partnerships," said Shavit, TCN executive director. "Lack of discharge planning services from prisons and little access to prison medical records create significant challenges in caring for sick individuals in the community who are recently released from prison."

Another factor associated with increased utilization in this population included food security, or not having access to food for 24 hours. Researchers found a strong association between food insecurity and higher use of the ER and hospitalizations, even after accounting for differences in sociodemographic and medical conditions between those with and without food insecurity.

"In many states, people returning from prison convicted of drug felonies are barred from Supplemental Nutrition Assistance Program (SNAP) food benefits," Shavit said. "This finding suggests that we need to look more closely at the health impacts and costs to communities of widely accepted correctional policies."

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Co-authors of the ambulance diversion study were senior author Yu-Chu Shen of the Naval Postgraduate School and National Bureau of Economic Research (NBER), and Nandita Sarkar of NBER. Funding was provided by the National Institutes of Health, National Heart, Lung, and Blood Institute (1R01HL114822), and American Heart Association (13CRP14660029).

Contributors to the prisoner study were senior author Emily Wang, MD, MAS, Jenerius Aminawung, MD, and Scott Greenberg, Yale School of Medicine; Nathan Birnbaum, UC Irvine; Timothy Berthold, MPH, City College of San Francisco; Amy Fishman, San Francisco Department of Public Health; and Susan Busch, PhD, Yale School of Public Health. Funding was provided by the Langeloth Foundation, U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services (1CMS331071-01-00), and the Bureau of Justice Administration (2015-RY-BX-K002).

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children's Hospitals in San Francisco and Oakland, and other partner and affiliated hospitals and healthcare providers throughout the Bay Area. Please visit http://www.ucsf.edu/news.

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