Black children have more severe asthma episodes but use less EMS transport

Key takeaways:

• Black non-Hispanic children were 15% less likely to receive EMS transport than white children.
• Black non-Hispanic children also were 55% more likely to receive bronchodilator care.

Black children were more likely to require EMS and receive bronchodilator treatment for an asthma episode than white children, but were less likely to receive EMS transport, according to a study published in Prehospital Emergency Care.

These adjusted analyses accounted for community socioeconomic status, Sylvia Owusu-Ansah, MD, pediatric emergency medicine physician and EMS medical director at UPMC Children’s Hospital of Pittsburgh, and colleagues wrote.

“There is a paucity of data on health disparities in children being managed and treated in the prehospital environment, and asthma is one of the most common illnesses in childhood,” Owusu-Ansah told Healio.

Sylvia Owusu-Ansah

“We wanted to characterize differences in prehospital treatment and transport of children with suspected asthma exacerbations by race and ethnicity, within the context of community socioeconomic status,” she continued.

Study design, results

The retrospective study examined 5,266 encounters involving children aged 2 to 17 years with 633 EMS agencies nationwide between Jan. 1 and Dec. 31, 2019.

The cohort included Black non-Hispanic (53%; median age, 9 years), white non-Hispanic (32%; median age, 6 years) and Hispanic (12%; median age, 8 years) children.

Also, 50% of the Black non-Hispanic children, 36% of the Hispanic children and 20% of the white non-Hispanic children had an EMS encounter within the most socioeconomically vulnerable communities, which researchers assessed using the social vulnerability index.

EMS transported 77% of these children overall, including 75% of the Black non-Hispanic children and 82% of the white non-Hispanic children (risk differences, –6.9%; 95% CI, –9.9% to –4%), with similar transport rates across community socioeconomic strata.

Based on adjustments, the researchers found that Black non-Hispanic children were 15% less likely to receive EMS transport (adjusted OR = 0.75; 95% CI, 0.58-0.96).

Also, 76% (n = 4,020) of these children received at least one inhaled bronchodilator from EMS — which included 81% of Black children, 73% of Hispanic children and 68% of white children — with albuterol accounting for 87% of these first-line administrations. Systemic corticosteroids were used in 3% (n = 178) of all encounters, with dexamethasone and methylprednisolone representing 93% of these initial administrations.

After controlling for scene socioeconomic status and other potential confounders, the researchers found that Black non-Hispanic children were 55% more likely to receive a bronchodilator from EMS than white non-Hispanic children (aOR = 1.55; 95% CI, 1.25-1.93).

Owusu-Ansah called this persistence of increased bronchodilator administration among Black non-Hispanic children after accounting for community socioeconomic status significant.

“After adjustment, the point estimate for communities of greater socioeconomic vulnerability favored greater bronchodilator use, but this finding did not reach statistical significance,” she continued.

These differences may reflect greater disease severity, the researchers wrote. Also, the researchers did not find any statistically significant differences in prehospital steroid administration based on patient race, ethnicity or socioeconomic status.

Conclusions, next steps

Owusu-Ansah called these findings surprising, as she had hypothesized that Black non-Hispanic children would be more likely to be transported by EMS, not less likely.

“This hypothesis was secondary to hospital studies showing the adverse relationship structural determinants of health has on asthma severity in Black non-Hispanic children, compared to other racial/ethnic groups,” she said.

Also, Owusu-Ansah said that increased bronchodilator use in the prehospital environment may be due to structural determinants of health.

“Although not statistically significant, it may be clinically significant that communities with greater [socioeconomic status] vulnerability have greater bronchodilator use,” she said.

Collectively, the researchers wrote, these findings suggest additional social or clinical factors are associated with bronchodilator administration beyond financial resources.

The researchers did not find distinct correlations or causations for why the non-Hispanic Black children more often required bronchodilator treatment, indicating more severe asthma attacks, yet had less use of EMS transport; but, based on previous data, they have some theories.

“This finding may be partially attributed to higher proportions of albuterol use among Black non-Hispanic and Hispanic [children] prior to EMS arrival relative to white non-Hispanic children,” Owusu-Ansah said.

Or, she continued, EMS clinicians may be less likely to recognize the symptoms of severe asthma for Black non-Hispanic children and Hispanic children.

Additionally, Hispanic children may face cultural barriers, in addition to these communities often displaying mistrust in health care providers.

“In essence, further studies on pediatric EMS nontransports may help to better elucidate disparities in the prehospital environment,” Owusu-Ansah said.

For example, Owusu-Ansah said, Black non-Hispanic children had a death rate 7.6 times that of non-Hispanic white children and were 4.5 times more likely to be admitted to the hospital for asthma compared with non-Hispanic white children in 2019.

Owusu-Ansah also recalled a Black non-Hispanic patient with a history of severe asthma attacks who was treated with aggressive asthma management strategies while she was transported by Pittsburgh’s EMS service to UPMC Children’s Hospital.

“When she arrived in the emergency department, she had improved dramatically,” Owusu-Ansah said.

This patient had frequently come to the ED for asthma management and had been admitted to the hospital, many times to ICU, in many of those events.

“This time, she was spared an intensive care unit visit thanks to the equitable care provided by Pittsburgh EMS,” Owusu-Ansah said.

By understanding these disparities, the researchers said, targeted efforts may be able to prevent disease, promote health and deliver appropriate care.

At the system level, Owusu-Ansah said that providing equitable care in the prehospital environment for children with asthma from communities of color could help mitigate the structural determinants of health.

Also, she said, being attuned to the disparities can aid in improving treatment and outcomes.

“EMS clinicians can focus on community paramedicine programs that focus on pediatric asthma care for the most vulnerable patients from communities of color,” Owusu-Ansah said. “EMS can provide education around improving outcomes secondary to mitigating structural determinant of health.”

Further research should aim to elucidate social factors beyond financial resources that affect pediatric prehospital treatment and management for Black non-Hispanic children and children from communities of color, Owusu-Ansah said.

Reference:

• New study finds disparities among management of pediatric chronic asthma. https://www.eurekalert.org/news-releases/1002747. Published Sept. 26, 2023. Accessed Sept. 26, 2023.

For more information:

Sylvia Owusu-Ansah, MD, can be reached at sylvia.owusuansah@chp.edu.