Don't Have a Heart Attack in a Poor Neighborhood

New research finds it takes longer for ambulances to arrive and transport a critically ill patient to a hospital in low-income areas.
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The total time from ambulance dispatch to arrival at the emergency room was 10 percent longer for people in poorer neighborhoods than for those in wealthier ones.

There are perils to living in a poor neighborhood. Some common hazards, such as stress-producing personal-safety fears and meager access to healthy food, can contribute to long-term health problems.

But new research pinpoints another disadvantage that can create immediate mortal danger: It takes longer for heart-attack victims in low-income areas to get transported to the hospital.

"Our findings are disturbing, given that poorer neighborhoods have higher rates of disease and other structural disparities for health-care access," writes a research team led by Dr. Renee Hsia of the University of California–San Francisco. "Whether or not a patient survives cardiac arrest can depend on a matter of minutes."

The study looked at 63,600 cases where an ambulance was called in response to a cardiac arrest. Using four different measures (initial response time, time spent on-scene, time spent traveling the hospital, and total time), they noted the precise length of each encounter.

The statistics, from 2014, featured data from 46 states, and included the zip code where each heart attack occurred. Using Census Bureau data on total household income, the researchers ranked each neighborhood by wealth, placing it in the top 25 percent nationally, the bottom 25 percent, or in between.

Even after taking into account such factors as rush-hour traffic, "We found a persistent and significant time difference between high-income and low-income zip codes," the researchers report in the journal JAMA Network Open.

Specifically, the total time from ambulance dispatch to arrival at the emergency room was 10 percent longer for people in poorer neighborhoods than for those in wealthier ones (that is, those in the bottom 25 percent compared to the top 25 percent).

That amounts to an average delay of 3.8 minutes. A 4.4-minute delay in treatment has been associated with a 13 percent increase in mortality over the 30 days after the initial attack.

The reasons for this disparity are multifaceted. Hsia and her colleagues point to the "increasing number of hospital and emergency-department shutdowns" in poor neighborhoods—a disturbing trend that inevitably lengthens ambulance trips. Hospitals that specialize in cardiac care tend to be "located in wealthier and insured communities," they write.

In addition, "the new, shifting landscape to privately owned ambulance companies may lead to a greater focus on profitability over public need, which could drive more companies to serve wealthier neighborhoods," they add. If this trend continues, "poorer neighborhoods would have fewer ambulances and personnel to go around."

The researchers offer no specific policy recommendations, and in an accompanying commentary, University of Colorado health economist Andrew Friedson suggests that, given its multiple causes, a single solution is unlikely to suffice.

Nevertheless, he writes, the study "shines a light on inequality (in the United States), not just in wealth, but in health care." Surely, no one should be forced to spend more time than necessary anxiously awaiting the sound of that siren.

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