A multisite survey of factors contributing to medically unnecessary ambulance transports

Pediatric Primary Care Provider Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs

INTRODUCTION

Many emergency medical services (EMS) agencies have implemented alternative disposition programs for low-acuity complaints, including transportation to clinics. Our objectives were to describe pediatric primary care providers' views on alternative EMS disposition programs.

METHOD

We conducted virtual focus groups with pediatric primary care providers. A hybrid inductive and deductive analytical strategy was used. Codes were grouped into themes by consensus.

RESULTS

Participants identified the benefits of alternative dispositions, including continuity of care, higher quality care, and freeing up emergency resources. Participants' concerns included undertriage, difficulty managing patients not previously known to a clinic, and inequitable implementation. Commonly identified logistical barriers included inadequate equipment, scheduling capacity, and coordinating triage.

DISCUSSION

Participants agreed there could be significant benefits from including clinics in EMS disposition programs. Participants identified several logistical constraints and raised concerns about patient safety and equitable implementation. These perspectives should be considered when designing pediatric alternative EMS disposition programs.

Ambulance deployment without transport: a retrospective difference analysis for the description of emergency interventions without patient transport in Bavaria

BACKGROUND

Not all patients who call the ambulance service are subsequently transported to hospital. In 2018, a quarter of deployments of an emergency ambulance in Bavaria were not followed by patient transport. This study describes factors that influence patient transport rates.

METHOD

This is a retrospective cross-sectional study based on data from all Integrated Dispatch Centres of the Free State of Bavaria in 2018. Included were ambulance deployments without emergency physician involvement, which were subdivided into ambulance deployments without transport and ambulance deployments with transport. The proportion of transported patients were determined for the primary reasons for deployment and for the different community types. On-scene time was compared for calls with and without patient transport. Differences were tested for statistical significance using Chi2 tests and the odds ratio was calculated to determine differences between groups.

RESULTS

Of 510,145 deployments, 147,621 (28.9%) could be classified as ambulance deployments without transport and 362,524 (71.1%) as ambulance deployments with transport.The lowest proportion of patients transported was found for activations where the fire brigade was involved ("fire alarm system" 0.6%, "fire with emergency medical services" 5.4%) and "personal emergency response system active alarm" (18.6%). The highest transport rates were observed for emergencies involving "childbirth/delivery" (96.9%) and "trauma" (83.2%). A lower proportion of patients is transported in large cities as compared to smaller cities or rural communities; in large cities, the odds ratio for emergencies without transport is 2.02 [95% confidence interval 1.98-2.06] referenced to rural communites. The median on-scene time for emergencies without transport was 20.8 min (n = 141,052) as compared to 16.5 min for emergencies with transport (n = 362,524). The shortest on-scene times for emergencies without transport were identified for activations related to "fire alarm system" (9.0 min) and "personal emergency response system active alarm" (10.6 min).

CONCLUSION

This study indicates that the proportion of patients transported depends on the reason for deployment and whether the emergency location is urban or rural. Particularly low transport rates are found if an ambulance was dispatched in connection with a fire department operation or a personal emergency medical alert button was activated. The on-scene-time of the rescue vehicle is increased for deployments without transport. The study could not provide a rationale for this and further research is needed. Trial registration This paper is part of the study "Rettungswageneinsatz ohne Transport" ["Ambulance deployment without transport"] (RoT), which was registered in the German Register of Clinical Studies under the number DRKS00017758.

Community-based transport system in Shinyanga, Tanzania: A local innovation averting delays to access health care for maternal emergencies

In achieving the sustainable development goal 3.1, Tanzania needs substantial investment to address the three delays which responsible for most of maternal deaths. To this end, the government of Tanzania piloted a community-based emergency transport intervention to address the second delay through m-mama program. This study examined secondary data to determine the cost-effectiveness of this intervention in comparison to the standard ambulance system alone. The m-mama program was implemented in six councils of Shinyanga region. The m-mama program data analyzed included costs of referral services using the Emergency Transportation System (EmTS) compared with the standard ambulance system. Analysis was conducted using Microsoft Excel, whose data was fed into a TreeAge Pro Healthcare 2022 model. The cost and effectiveness data were discounted at 5% to make a fair comparison between the two systems. During m-mama program implementation a total of 989 referrals were completed. Of them, 30.1% used the standard referral system using ambulance, while 69.9% used the EmTS. The Emergency transport system costed USD 170.4 per a completed referral compared to USD 472 per one complete referral using ambulance system alone. The introduction of m-mama emergency transportation system is more cost effective compared to standard ambulance system alone in the context of Shinyanga region. Scaling up of similar intervention to other regions with similar context and burden of maternal mortality may save cost of otherwise normal emergency ambulance system. Through lessons learned while scaling up, the intervention may be improved and tailored to local challenges and further improve its effectiveness.

Caregiver Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs: A Qualitative Study

OBJECTIVES

Almost half of pediatric EMS calls may be for low-acuity problems. Many EMS agencies have implemented alternative disposition programs for low-acuity patients, including transportation to clinics, substituting taxis for ambulances, and treatment in place without transport to an emergency department. Including children in such programs poses specific challenges, with one concern being potential caregiver opposition. Limited published evidence addresses caregiver perspectives on including children in alternative disposition programs. Our objective was to describe caregiver perspectives of alternative EMS disposition systems for low-acuity pediatric patients.

METHODS

We conducted six virtual focus groups (one in Spanish) with caregivers. A PhD-trained facilitator moderated all groups using a semi-structured moderator guide. A hybrid inductive and deductive analytical strategy was used. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus.

RESULTS

We recruited 38 participants. Participants had diverse race-ethnicity (39% non-Hispanic white, 29% non-Hispanic Black, and 26% Hispanic) and insurance status (42% Medicaid and 58% private health insurance). There was agreement that caregivers often utilize 9-1-1 for low-acuity complaints. Caregivers were generally supportive of alternative disposition programs, with some important caveats. Potential advantages of alternative dispositions included freeing up resources for more emergent cases, quicker access to care, and more cost-effective and patient-centered care. Caregivers had multiple concerns regarding the effects of alternative disposition programs, including timeliness in receiving care, capabilities of receiving sites (including pediatric expertise), and challenges to care coordination. Additional logistical concerns with alternative disposition programs for children included the safety of taxi services, the loss of parental autonomy, and the potential for inequitable implementation.

CONCLUSIONS

Caregivers in our study generally supported alternative EMS dispositions for some children and identified multiple potential benefits of such programs for both children and the health care system. Caregivers were concerned about the safety and logistical details of how such programs would be implemented and wanted to retain final decision-making authority. Caregiver perspectives should be considered when designing and implementing alternative EMS disposition programs for children.

Have the Diagnoses of Patients Transported by Ambulances Changed in the Early Stage of the COVID-19 Pandemic?

Introduction:

Since December 2019, emergency services and Emergency Medical Service (EMS) systems have been at the forefront of the fight against the coronavirus disease 2019 (COVID-19) pandemic world-wide.

Objective:

The objective of this study was to examine the reasons and the necessity of transportation to the emergency department (ED) by ambulance and the outcomes of these cases with the admissions during the COVID-19 pandemic period and during the same period in 2019.

Methods:

A retrospective descriptive study was conducted in which patients transported to the ED by ambulance in April 2019 and April 2020 were compared. The primary outcomes were the changes in the number and diagnoses of patients who were transferred to the ED by ambulance during the COVID-19 period. The secondary outcome was the need for patients to be transferred to the hospital by ambulance.

Results:

A total of 4,466 patients were included in the study. During the COVID-19 period, there was a 41.6% decrease in ED visits and a 31.5% decrease in ambulance calls. The number of critically ill patients transported by ambulance (with diagnoses such as decompensated heart failure [P <.001], chronic obstructive pulmonary disease [COPD] attack (P = .001), renal failure [acute-chronic; P = .008], angina pectoris [P <.001], and syncope [P <.001]) decreased statistically significantly in 2020. Despite this decrease in critical patient calls, non-emergency patient calls continued and 52.2% of the patients transported by ambulance in 2020 were discharged from the ED.

Conclusions:

Understanding how the COVID-19 pandemic is affecting EMS use is important for evaluating the current state of emergency health care and planning to manage possible future outbreaks.

EMS Curriculum Should Educate Beyond a Technical Scope of Practice: Position Statement and Resource Document

Position Statement and Resource document approved by the NAEMSP Board of Directors on April 27, 2021.

Trends in ambulance transports and costs among Medicare beneficiaries, 2007-2018

BACKGROUND

The primary purpose of this study was to evaluate trends in ambulance utilization and costs among Medicare beneficiaries from 2007 to 2018. Community characteristics associated with ambulance use and costs are also explored.

METHODS

Aggregated county-level fee-for-service (FFS) Medicare beneficiary claims data from 2007 to 2018 were used to assess ambulance transports per 1000 FFS Medicare beneficiaries and standardized inflation-adjusted ambulance costs. Multivariable linear mixed models were used to quantify trends in ambulance utilization and costs and to control for confounders.

RESULTS

A total of 37,675 county-years were included from 2007 to 2018. Ambulance transports per 1000 beneficiaries increased 15% from 299 (95% CI: 291.63, 307.30) to 345 (95% CI: 336.91, 353.10) from 2007 to 2018. Inflation-adjusted standardized per user costs exhibited an increasing (1.04, 95% CI: 1.04, 1.05), but non-linear relationship (0.996, 95% CI: 0.996, 0.996) over time with costs peaking in 2012. Indicators of lower socioeconomic status (SES) were associated with increases in both ambulance events and costs (p < .0001). A higher prevalence of Medicare beneficiaries utilizing Skilled Nursing Facilities was associated with increased levels of ambulance events per 1000 beneficiaries (95% CI: 8.06, 10.63). Rural location was associated with a 38% increase in ambulance costs (95% CI 1.30-1.47) compared to urban location.

CONCLUSIONS

Numerous policy solutions have been proposed to address growing ambulance costs in the Medicare program. While ambulance transports and costs continue to increase, a bend in the ambulance cost curve is detected suggesting that one or more policies altered Medicare ambulance costs, although utilization has continued to grow linearly. Ambulance use and costs vary significantly with community-level factors. As policy makers consider how to address growing ambulance use and costs, targeting identified community-level factors associated with greater costs and utilization, and their root causes, may offer a targeted approach to addressing current trends.

Use of prehospital emergency medical services according to income of residential area

Background

The increasing usage of emergency medical services (EMS) missions is a challenge in modern practice. This study was designed to examine the association of the income level of residential areas on the rate of EMS missions and the frequency of EMS use in these areas.

Methods

All EMS missions for adult patients (>18 years) encountered by one rescue department in Northern Finland between June 2015 and May 2017 were analysed. The area served was categorised into four categories, according to the median annual income of the postal code areas. EMS missions per 1000 person-years, rate of non-transport missions and the number of dispatches to frequent (>4 EMS calls/year and highly frequent (>10 calls/year)EMS users per area were investigated.

Results

There were 62 759 EMS missions, 34.8% of which resulted in non-transport. The crude rate of EMS dispatches was higher in the low-income area compared with other income areas (133.3 vs 108.9 vs 111.3 vs 73.6/1000 person-years) as well as the rate of high-frequency user dispatches (21.5 vs 11.5 vs 7.2 vs 4.3/1000-person years). The rate of non-transports missions was higher also (69.4 vs 43.4 vs 42.5. vs 30.6/1000 person-years). The highest crude rate of EMS use was found in people older than 65 years living in the lowest income areas (294.8/1000 person-years). After age adjustment, the highest rate of EMS use was found in rural areas with the lowest income (146.3/1000 person-years).

Conclusions

The rate of the EMS missions and non-transport missions differs significantly among different income areas. Resource usage was significantly higher in the low income areas. This information can be used in planning allocation of EMS and preventive healthcare resources.

Did UberX reduce ambulance volume?

Ambulances are a vital part of emergency medical services. However, they come in single, high intervention form, which is at times unnecessary, resulting in excessive costs for patients and insurers. In this paper, we ask whether UberX's entry into a city caused substitution away from traditional ambulances for low-risk patients, reducing overall volume. Using a city-panel over-time and leverage that UberX enter markets sporadically over multiple years, we find that UberX entry reduced the per capita ambulance volume by at least 6.7%. Our result is robust to numerous specifications.

Assessment of Inadequate Use of Pediatric Emergency Medical Transport Services: The Pediatric Emergency and Ambulance Critical Evaluation (PEACE) Study

Aim: To provide data on the inadequate use of emergency medical transports services (EMTS) in children and underlying contributing factors. Methods: This was a prospective single-center cohort study (01/2017-12/2017) performed at the Saarland University Children's Hospital, Homburg, Germany. Patients ≤20 years of age transported by EMTS for suspected acute illness/trauma were included and proportion of inadequate/adequate EMTS use, underlying contributing factors, and additional costs were analyzed. Results: Three hundred seventy-nine patients (mean age: 9.0 ± 6.3 years; 55.7% male, 44.3% female) were included in this study. The three most common reasons for EMTS use were: central nervous system (30.6%), respiratory system affection (14.0%), and traumas (13.2%). ETMS use was categorized as inadequate depending on physician's experience: senior physician (58.8%), pediatrician (54.9%), resident (52.7%). All three physicians considered 127 (33.5%) cases to be medically indicated for transportation by EMTS, and 177 (46.7%) to be medically not indicated. The following parameters were significantly associated with inadequate EMTS use: non-acute onset of symptoms (OR 2.5), parental perception as non-life-threatening (OR 1.7), and subsequent out-patient treatment (OR 4.0). Conversely, transport by an emergency physician (OR 3.5) and first time parental EMTS call (OR 1.7) were associated with adequate use of EMTS. Moreover, a significant relation existed between maternal, respectively, paternal educational status and inadequate EMTS use (each p = 0.01). Using multiple logistic regression analysis, non-acute onset of symptoms (OR 2.2) was associated with inadequate use of EMTS while first time parental EMTS call (OR 1.8), transport by an emergency physician (OR 3.3), and need for in-patient treatment (OR 4.0) were associated with adequate use of EMTS. Conclusion: A substantial number of pediatric EMTS is medically not indicated. Possibly, specific measures including multifaceted educational efforts may be helpful in reducing unnecessary EMTS use.

Epidemiology of Injuries Requiring Emergency Transport Among Collegiate and High School Student-Athletes

CONTEXT: 

Data regarding the epidemiology of emergency-transport incidents (ETIs) of patients with sport-related injuries are lacking. Understanding the use of emergency services by athletic trainers can help improve emergency preparedness and prehospital care for injured student-athletes.

OBJECTIVE: 

To determine the frequencies and types of ETIs resulting from athletic participation.

DESIGN: 

Descriptive epidemiology study.

SETTING: 

Participating colleges and high schools during 2009-2010 to 2014-2015 and 2011-2012 to 2013-2014, respectively.

PATIENTS OR OTHER PARTICIPANTS: 

Student-athletes in 23 high school and 25 intercollegiate sports.

MAIN OUTCOME MEASURE(S): 

Data on injuries requiring emergency transport were collected by each team's athletic trainer via their respective online injury-tracking software. Athletic trainers also collected data on athlete-exposures (AEs). Emergency-transport incident frequencies and injury rates per 10 000 AEs with 95% confidence intervals (CIs) were reported. For each ETI, the sport, body part, injury mechanism, and final diagnosis were recorded.

RESULTS: 

A total of 339 and 146 ETIs were reported in collegiate and high school players, respectively. Collegiate women's ice hockey had the highest ETI rate (1.28/10 000 AEs; 95% CI = 0.71, 1.86). In high school, football had the highest rate at 0.80 per 10 000 AEs (95% CI = 0.64, 0.97). Athletes with head or face injuries required the most transports in college (n = 71, 20.9%) and high school (n = 33, 22.6%) across all sports. Strains (n = 50, 14.7%) and fractures (n = 35, 24.0%) were the leading diagnoses for patients undergoing transport in college and high school, respectively.

CONCLUSIONS: 

Athletic trainers should maintain a high level of emergency preparedness when working with sports that have high rates and numbers of ETIs. Athletes with injuries to the head/face required the most frequent transport across competition levels. Athletic trainers should have the appropriate equipment and protocols in place to handle these patients. Future researchers should examine the differences between field and hospital diagnoses to help improve prehospital care and decrease the likelihood of unnecessary emergency transports.

Ambulance transport to the emergency department: A patient-selected signal of acuity and its effect on resource provision

OBJECTIVE

To determine whether ambulance arrival to the emergency department has remained an unidentified signal of perceived medical acuity. Informed by economic signaling theory, does arrival via ambulance affect resource utilization given varying levels of patient acuity?

METHODS

The analysis examined a nationally representative sample of de-identified emergency department patient encounters from 2011 to 2015, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Multivariate logistic regression analysis was employed using regional and time-fixed effects. The provision of twenty diagnostic and imaging services was analyzed. Patient encounters were also categorized into five acuity-levels.

RESULTS

Drawing from the NHAMCS dataset, 98,888 emergency department records were analyzed, weighted to represent 504.5 million estimated emergency department patient encounters. Findings suggest that patients transported to the hospital via ambulance are more likely than those who arrive by other means to receive 19 of the 20 analyzed diagnostic testing and imaging services. Furthermore, when analyzed by acuity-level, the disparity of service provision is the greatest among low-acuity patients, where medical complaints are argued to be the most subjective.

CONCLUSIONS

The results are consistent with the notion that emergency department medical providers readily accept ambulance transport as a valid signal of patient acuity, regardless of true acuity level. Consequently, patients transported to the hospital via ambulance may be receiving a disproportionate amount of medical resources in an increasingly cost-conscious environment.

Characteristics of Frequent Users of Emergency Medical Services in Singapore

OBJECTIVES

This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates.

METHODS

All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n = 243), with admission the primary outcome.

RESULTS

The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p = 0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p = 0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p < 0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p < 0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p < 0.001). Many were picked up from public areas (45.5% vs. 19.6%, p < 0.001), and had lower acuity triage scores at both EMS (p < 0.001) and ED (p = 0.001). They had lower admission rates (40.5% vs. 78.7%, p < 0.001) and shorter length of stay (4.3 vs. 5.9 days, p < 0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions.

CONCLUSION

Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission.

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care

BACKGROUND

Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service.

OBJECTIVE

The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service.

METHODS

We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient's own GP, using a questionnaire.

RESULTS

Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients' own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain.

CONCLUSION

Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain.

Identifying rural-urban differences in the predictors of emergency ambulance service demand and misuse

OBJECTIVE

This study aims to assess rural-urban differences in the predictors of emergency ambulance service (EAS) demand and misuse in New Taipei City. Identifying the predictors of EAS demand will help the EAS service managing authority in formulating focused policies to maintain service quality.

METHODS

Over 160,000 electronic EAS usage records were used with a negative binomial regression model to assess rural-urban differences in the predictors of EAS demand and misuse.

RESULTS

The factors of 1) ln-transformed population density, 2) percentage of residents who completed up to junior high school education, 3) accessibility of hospitals without an emergency room, and 4) accessibility of EAS were found to be predictors of EAS demand in rural areas, whereas only the factor of percentage of people aged above 65 was found to predict EAS demand in urban areas. For EAS misuse, only the factor of percentage of low-income households was found to be a predictor in rural areas, whereas no predictor was found in the urban areas.

CONCLUSION

Results showed that the factors predicting EAS demand and misuse in rural areas were more complicated compared to urban areas and, therefore, formulating EAS policies for rural areas based on the results of urban studies may not be appropriate.

Unnecessary emergency medical services transport associated with alcohol intoxication

Objective

This study investigated medically unnecessary emergency medical services (EMS) transportation by comparing non-intoxicated versus intoxicated patients who did not receive emergency department (ED) treatment but utilized EMS transport.

Methods

Patients who used EMS but did not receive ED treatment were classified into non-intoxicated and intoxicated groups. Reasons for not receiving ED treatment were categorized according to whether the decision was made by the patient against medical advice or if the decision was based on a physician’s evaluation and their recommendations.

Results

There were 212 patients reviewed; 120 in the non-intoxicated group and 92 in the intoxicated group. The intoxicated group had a higher proportion of males than the non-intoxicated group. The most common cause of non-disease symptoms in the intoxicated group was assault. In the non-intoxicated group, the most common reason for the lack of ED treatment was that treatment could take place on an outpatient basis, while in the intoxicated group, the reason was lack of patient cooperation.

Conclusions

The intoxicated group was older, male and more likely to present with symptoms not related to a disease process than those in the non-intoxicated group when using unnecessary EMS transport.

Areas of Potential Impact of the Patient Protection and Affordable Care Act on EMS: A Synthesis of the Literature

INTRODUCTION

This comprehensive review synthesizes the existing literature on the Patient Protection and Affordable Care Act (ACA) as it relates to emergency medical services (EMS) in order to provide guidance for navigating current and future healthcare changes.

METHODS

We conducted a comprehensive review to identify all existing literature related to the ACA and EMS and all sections within the federal law pertaining to EMS.

RESULTS

Many changes enacted by the ACA directly affect emergency care with potential indirect effects on EMS systems. New Medicaid enrollees and changes to existing coverage plans may alter EMS transport volumes. Reimbursement changes such as adjustments to the ambulance inflation factor (AIF) alter the yearly increases in EMS reimbursement by incorporating the multifactor productivity value into yearly reimbursement adjustments. New initiatives, funded by the Center for Medicare & Medicaid Innovation are exploring novel and cost-effective prehospital care delivery opportunities while EMS agencies individually explore partnerships with healthcare systems.

CONCLUSION

EMS systems should be aware of the direct and indirect impact of ACA on prehospital care due to the potential for changes in financial reimbursement, acuity and volume changes, and ongoing new care delivery initiatives.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Characteristics of Medicaid-Covered Emergency Department Visits Made by Nonelderly Adults: A National Study

BACKGROUND

The Affordable Care Act has added millions of new Medicaid enrollees to the health care system. These patients account for a large proportion of emergency department (ED) utilization.

OBJECTIVE

Our aim was to characterize this population and their ED use at a national level.

METHODS

We used the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) to describe demographics and clinical characteristics of nonelderly adults (≥18 years old and ≤64 years old) with Medicaid-covered ED visits. We defined frequent ED users as individuals who make ≥4 ED visits/year and business hours as 8 am to 5 pm. We used descriptive statistics to describe the epidemiology of Medicaid-covered ED visits.

RESULTS

NHAMCS included 21,800 ED visits by nonelderly adults in 2010, of which 5,659 (24.09%) were covered by Medicaid insurance. Most ED visits covered by Medicaid were made by patients who are young (25 and 44 years old) and female (67.95%; 95% confidence interval [CI] 66.00-69.89). A large proportion of the ED visits covered by Medicaid were revisits within 72 h (14.66%; 95% CI 9.13-20.19) and from frequent ED users (32.32%; 95% CI 24.29-40.35). Almost half of all ED visits covered by Medicaid occurred during business hours (45.44%; 95% CI 43.45-47.43).

CONCLUSIONS

The vast majority of Medicaid enrollees who used the ED were young females, with a large proportion of visits occurring during business hours. Almost one-third of all visits were from frequent ED users.

Why do patients with 'primary care sensitive' problems access ambulance services? A systematic mapping review of the literature

OBJECTIVE

Emergency ambulance use for problems that could be managed in primary care continues to rise owing to complex reasons that are poorly understood. The objective of this systematic review is to draw together published evidence across a variety of study methodologies and settings to gain a better understanding of why patients seek help from ambulance services for these problems.

DESIGN

Systematic searches were undertaken across the MEDLINE, EMBASE, PsychINFO, CINAHL, Health Management Information Consortium and Health Management Information Service publication databases. Google Scholar, Web of Science, OpenSigle, EThOS and DART databases were also systematically searched for reports, proceedings, book chapters and theses, along with hand-searching of grey literature sources. Studies were included if they reported on findings examining patient, carer, health professional or service management interactions with ambulance services for primary care problems. All study methodologies and perspectives were of interest. Data were extracted, quality assessed and systematically mapped according to key findings through generation of an iterative framework.

RESULTS

A total of 31 studies met inclusion criteria. Findings were summarised across 5 broad categories: factors associated with individual patients; actions of care-givers and bystanders; population-level factors; health infrastructure factors; challenges faced by health professionals. A number of subcategories were developed to explore these factors in more detail.

CONCLUSIONS

This review reports important factors that may impact on ambulance use for primary care problems across a global setting, including demographic measures associated with deprivation, minority status and individual social circumstances. Categorising ambulance calls for primary care problems as 'inappropriate' is context dependant and may be unhelpful. Potential implications for triage and risk management strategies are discussed.

The US emergency care system: meeting everyday acute care needs while being ready for disasters

The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving care, the emergency care system provides considerable support to physicians outside the emergency department and serves as an important safety-net provider. In times of disaster, the emergency care system must be able to surge rapidly to accommodate a massive influx of patients, sometimes with little or no notice. Extreme daily demands on the system can promote innovations and adaptations that are invaluable in responding to disasters. However, excessive and inappropriate utilization is wasteful and can diminish "surge capacity" when it is most needed. Certain features of the US health care system have imposed strains on the emergency care system. We explore policy issues related to moving toward an emergency care system that can more effectively meet both individuals' needs for acute care and the broader needs of the community in times of disaster. Strategies for the redesign of the emergency care system must include the active engagement of both patients and the community and a close look at how to align incentives to reward quality and efficiency throughout the health care system.

Swedish emergency medical services' identification of potential candidates for primary healthcare: Retrospective patient record study

OBJECTIVE

To investigate patients who called the emergency medical services (EMS) for primary healthcare (PHC) problems.

DESIGN

A retrospective and exploratory patient record study from an EMS perspective, comparing two groups: those who were potential candidates for PHC and those who were not. All data were gathered from EMS and hospital records.

SETTINGS

The study was completed at the EMS and five hospital areas in the western region of Sweden.

SUBJECTS

The patients (n = 3001) who called the EMS in 2011. Data were missing for 10%.

MAIN OUTCOME MEASURES

The frequency and the clinical characteristics of the patients who called the EMS and were actually potential candidates for PHC.

RESULTS

Of a total of 2703 patients, a group of 426 (16%) were assessed as potential candidates for PHC and could thus be treated at a level of care other than the emergency department. Patients who were classified as suitable for PHC were found at all priority levels and within all symptom groups, but were younger and healthier than the other group.

CONCLUSION

Numerous patients seeking help from the EMS do not end up at the most appropriate level in the healthcare system.

IMPLICATIONS

In the EMS, guidelines are needed to enable pre-hospital emergency nurses to assess and triage patients to the most appropriate level of healthcare. Key points Patients calling the emergency medical services do not always end up at an appropriate level of healthcare. In total, 16% of patients were identified by the Swedish emergency medical services as potential candidates for primary healthcare. These patients were younger and healthier than those needing care at the emergency department. They were found at all priority levels and within all symptom groups.

Should payment policy be changed to allow a wider range of EMS transport options?

The Institute of Medicine and other national organizations have asserted that current payment policies strongly discourage emergency medical services (EMS) providers from transporting selected patients who call 911 to non-ED settings (eg, primary care clinics, mental health centers, dialysis centers) or from treating patients on scene. The limited literature available is consistent with the view that current payment policies incentivize transport of all 911 callers to a hospital ED, even those who might be better managed elsewhere. However, the potential benefits and risks of altering existing policy have not been adequately explored. There are theoretical benefits to encouraging EMS personnel to transport selected patients to alternate settings or even to provide definitive treatment on scene; however, existing evidence is insufficient to confirm the feasibility or safety of such a policy. In light of growing concerns about the high cost of emergency care and heavy use of EDs, assessing EMS transport options should be a high-priority topic for outcomes research.

Value drivers: an approach for estimating health and disease management program savings

Health and disease management (HDM) programs have faced challenges in documenting savings related to their implementation. The objective of this eliminate study was to describe OptumHealth's (Optum) methods for estimating anticipated savings from HDM programs using Value Drivers. Optum's general methodology was reviewed, along with details of 5 high-use Value Drivers. The results showed that the Value Driver approach offers an innovative method for estimating savings associated with HDM programs. The authors demonstrated how real-time savings can be estimated for 5 Value Drivers commonly used in HDM programs: (1) use of beta-blockers in treatment of heart disease, (2) discharge planning for high-risk patients, (3) decision support related to chronic low back pain, (4) obesity management, and (5) securing transportation for primary care. The validity of savings estimates is dependent on the type of evidence used to gauge the intervention effect, generating changes in utilization and, ultimately, costs. The savings estimates derived from the Value Driver method are generally reasonable to conservative and provide a valuable framework for estimating financial impacts from evidence-based interventions.

Ambulance use is associated with higher self-rated illness seriousness: user attitudes and perceptions

OBJECTIVES

The objective was to study the role and effect of patients' perceptions on reasons for using ambulance services in Queensland, Australia.

METHODS

A cross-sectional survey was conducted of patients (n = 911) presenting via ambulance or self-transport at eight public hospital emergency departments (EDs). The survey included perceived illness severity, attitudes toward ambulance, and reasons for using ambulance. A theoretical framework was developed to inform this study.

RESULTS

Ambulance users had significantly higher self-rated perceived seriousness, urgency, and pain than self-transports. They were also more likely to agree that ambulance services are for everyone to use, regardless of the severity of their conditions. In compared to self-transports, likelihood of using an ambulance increased by 26% for every unit increase in perceived seriousness; and patients who had not used an ambulance in the 6 months prior to the survey were 66% less likely to arrive by ambulance. Patients who had presented via ambulance stated they considered the urgency (87%) or severity (84%) of their conditions as reasons for calling the ambulance. Other reasons included requiring special care (76%), getting higher priority at the ED (34%), not having a car (34%), and financial concerns (17%).

CONCLUSIONS

Understanding patients' perceptions is essential in explaining their actions and developing safe and effective health promotion programs. Individuals use ambulances for various reasons and justifications according to their beliefs, attitudes, and sociodemographic conditions. Policies to reduce and manage demand for such services need to address both general opinions and specific attitudes toward emergency health services to be effective.

Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process

BACKGROUND

Telephone calls for emergency ambulances are rising annually, increasing the pressure on ambulance resources for clinical problems that could often be appropriately managed in primary care.

OBJECTIVE

To explore and understand patient and carer decision making around calling an ambulance for primary care-appropriate health problems.

METHODS

Semistructured interviews were conducted with patients and carers who had called an ambulance for a primary care-appropriate problem. Participants were identified using a purposive sampling method by a non-participating research clinician attending '999' ambulance calls. A thematic analysis of interview transcripts was undertaken.

RESULTS

A superordinate theme, patient and carer anxiety in urgent-care decision making, and four subthemes were explored: perceptions of ambulance-based urgent care; contrasting perceptions of community-based urgent care; influence of previous urgent care experiences in decision making; and interpersonal factors in lay assessment and management of medical risk and subsequent decision making.

CONCLUSIONS

Many calls are based on fundamental misconceptions about the types of treatment other urgent-care avenues can provide, which may be amenable to educational intervention. This is particularly relevant for patients with chronic conditions with frequent exacerbations. Callers who have care responsibilities often default to the most immediate response available, with decision making driven by a lower tolerance of perceived risk. There may be a greater role for more detailed triage in these cases, and closer working between ambulance responses and urgent primary care, as a perceived or actual distance between these two service sectors may be influencing patient decision making on urgent care.

Descriptive analysis of patients' EMS use related to severity in Tokyo: a population-based observational study

Introduction

Few studies are available on the clinical characteristics of patients using emergency medical transports in Japan. In this study, we aimed to investigate reasons for emergency medical transports and their relation to clinical severity.

Methods

We conducted a 3-year population-based observational study of patients transported by ambulance to emergency departments (ED) in the capital of Japan, Tokyo, which has a population of about 13 million. Demographic data, reasons for transport, and the severity of initial assessment at ED were recorded. Logistic regression was used to determine the odds of the clinical severity of each reason for transport.

Results

The number of emergency medical transports in the three-year study period was 1,832,637. Mean age was 53±26. Males were 976,142 (53%). Overall, 92% of all transported patients were in a mild or moderate medical state and patients with the 17 most frequent reasons for transport occupied 82% (1,506,017) of all transports. Pain was the most frequent reason for transport, followed by traffic accident. Considering all the patients and their reasons for transport, patients whose reason was pain or a traffic accident (29% of all patients) were in a relatively mild state compared with patients with other reasons for transport. Patients in an altered mental state in the prehospital setting (6.8% of all patients) were in a more severe medical state than other patients.

Conclusions

In Tokyo, Japan, 92% of transported patients were in a mild or moderate medical state. In particular, most patients from traffic accidents were in a mild state, even though traffic accidents were the second most frequent reason for transport. Patients in an altered mental state were most likely to be in a severe medical state.

Triage Ability of Emergency Medical Services Providers and Patient Disposition: A Prospective Study

Study objective:

To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.

Methods:

A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.

Results:

A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, emergency medical services providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The emergency medical services providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath / respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).

Conclusion:

Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.

Factors associated with ambulance use among patients with low-acuity conditions

BACKGROUND

The use of ambulances for low-acuity medical complaints depletes emergency medical services (EMS) resources that could be used for higher-acuity conditions and contributes to emergency department (ED) overcrowding and ambulance diversion. Objective. We sought to understand the characteristics of patients who use ambulances for low-acuity conditions. We hypothesized that patients who arrive to the ED by ambulance for low-acuity conditions are more likely to be members of vulnerable populations.

METHODS

A secondary analysis was performed on the National Hospital Ambulatory Medical Care Survey (NHAMCS). We included only patients aged 18 years or older who were triaged to the "nonurgent" category upon presentation to the ED. To compare patients who arrived by ambulance with those who arrived by all other modes, multivariate logistic regression was performed using a generalized linear model, and adjusted relative risks (ARRs) were calculated.

RESULTS

A total of 16,109 records from 1997 to 2008 (excluding 2001-2002) were included in the analysis. Significantly higher rates of ambulance use for low-acuity conditions were associated with: 1) older age (ARR 1.30, 95% confidence interval [CI]: 1.18-1.43; per 10 years); 2) Medicare or Medicaid insurance (ARR 1.81, 95% CI: 1.36-2.41, and ARR 1.46, 95% CI: 1.12-1.91, respectively); 3) homelessness (ARR 3.30, 95% CI: 1.61-6.78); 4) arrival between 11 pm and 6:59 am (ARR 1.80, 95% CI: 1.43-2.27); and 5) certain chief complaint categories: psychiatric (ARR 1.78, 95% CI: 1.03-3.07), toxicologic/poisoning (ARR 3.26, 95% CI: 1.85-5.76), and neurologic/psychological (ARR 1.71, 95% CI: 1.34-2.18). Patients who arrived by ambulance were more likely than nonambulance patients to receive laboratory diagnostic tests (ARR 3.50, 95% CI: 2.80-4.39), radiographic imaging (ARR 2.26, 95% CI: 1.91-2.68), and admission to the hospital (ARR 3.99, 95% CI: 3.03-5.27).

CONCLUSION

Our study builds on a body of work highlighting the factors associated with ambulance transport to EDs, confirms that certain vulnerable populations disproportionately use ambulances, and may inform interventions aimed at increasing access to nonambulance transportation and urgent care for these patients.

Medical necessity in emergency medical services transports

The purpose of this study was to generate national estimates of the prevalence of medically unnecessary emergency medical services (EMS) transports to emergency departments (EDs) over time and to identify characteristics that may be associated with medically unnecessary transports. A previously published algorithm was applied to operationalize medical necessity based on ED diagnosis to 10 years of data from the National Hospital Ambulatory Medical Care Survey. The trend over time was reported using descriptive statistics weighted to produce national estimates. Nationally, the proportion of EMS transports that were medically unnecessary increased from 13% to 17% over the 10-year study period. Individual demographic characteristics, including insurance status, were not predictive of inappropriate utilization. EMS transports for medically unnecessary complaints increased from 1997 to 2007. Our findings from a nationally representative sample highlight the opportunity for alternative patient delivery strategies for select patients seeking EMS services.

Variations in ambulance use in the United States: the role of health insurance

OBJECTIVES

The purpose of this study was to describe the associations between individual health insurance and ambulance utilization using a national sample of patients who receive emergency department (ED) care.

METHODS

The data source was the National Hospital Ambulatory Medical Care Survey, years 2004 through 2006. Noninstitutionalized patients between ages 18 and 65 years were included. The primary dependent variable was ambulance use. Multivariable logistic regression methods were used to assess the associations between health insurance status and ambulance use and to adjust for confounders.

RESULTS

A total of 61,013 ED visits were included, representing a national sample of approximately 70 million annual ED visits over 3 years. Ambulance transport was used in 11% of private insurance visits, 16% of Medicaid visits, and 13% of uninsured visits. In the adjusted model, visits by patients with Medicaid (adjusted odds ratio [aOR] = 1.60, 99% confidence interval (CI) = 1.37 to 1.86) and the uninsured (aOR = 1.43, 99% CI = 1.23 to 1.66) were more likely to arrive by ambulance than visits by patients with private insurance. Ambulance use among the uninsured was most pronounced in metropolitan areas.

CONCLUSIONS

Ambulance use varies by health insurance status. Medicaid coverage and lack of insurance are each independently associated with increased odds of ambulance use, suggesting a disproportionate role for emergency medical services (EMS) in the care of patients with limited financial resources.

What is a health emergency? The difference in definition and understanding between patients and health professionals

BACKGROUND

Investigations into 'inappropriate' use of emergency health services are limited by the lack of definition of what constitutes a health emergency. Position papers from Australian and international sources emphasise the patient's right to access emergency healthcare, and the responsibility of emergency health care workers to provide treatment to all patients. However, discordance between the two perspectives remain, with literature labelling patient use of emergency health services as 'inappropriate'.

OBJECTIVE

To define a 'health emergency' and compare patient and health professionals perspectives.

METHOD

A sample of 600 emergency department (ED) patients were surveyed about a recent health experience and asked to rate their perceived urgency. This rating was compared to their triage score allocated at the hospital ED.

RESULTS

No significant relationship was found between the two ratings of urgency (P=0.51). CONCLUSIONS; Differing definitions of a 'health emergency' may explain patient help-seeking behaviour when accessing emergency health resources including hospital ED and ambulance services. A new definition of health emergency that encapsulates the health professional and patient perspectives is proposed. An agreed definition of when emergency health resources should be used has the potential to improve emergency health services demand and patient flow issues, and optimise emergency health resource allocation.

Paramedic determinations of medical necessity: a meta-analysis

INTRODUCTION

Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated.

RESULTS

From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

CONCLUSION

The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.

EMS-initiated refusal of transport: the current state of affairs

The objectives of this study were 1) to determine the number and characteristics of emergency medical services (EMS) agencies within the 200 largest US cities that sanction EMS-initiated refusal of transport; and 2) to determine the extent of no-cost alternative transport mechanisms among those agencies that allow EMS-initiated refusal of transport. EMS agencies located within the 200 largest US cities were contacted via telephone and surveyed as to whether their agency sanctioned EMS-initiated refusal of transport (EMS-IROT). Agencies with a policy were further questioned regarding its components and usage patterns. The telephone survey contacted 100% (200) of the target population. Currently, 7.0% (14) of EMS agencies have EMS-IROT protocols, with 64% (9) of those requiring direct medical oversight. Five (2.5%) of the 200 agencies sanctioned EMS-IROT without requiring online medical approval. Average annual call volume of the five agencies not requiring direct medical oversight was 70,800; their EMS-IROT protocols have been in existence a mean of 19.8 years. None of these agencies had a no-cost alternative transport mechanism. Three (1.5%) agencies terminated EMS-IROT protocols in the past. EMS-initiated refusal of transport continues to be a rare entity among US EMS agencies. Those that do not require direct medical oversight tend to have well-established programs, though no agency offered a formal no-cost alternative transport mechanism.

Why are people without medical needs transported by ambulance? A study of indications for pre-hospital care

OBJECTIVE

The purpose of this report was to describe the characteristics of patients transported by ambulance, in spite of being evaluated by the ambulance staff at the scene as not requiring prehospital care. A second aim was to compare these patients with those judged as being in need of this care.

METHODS

Three ambulance service districts located in different rural and metropolitan geographical areas were included in the study and all three were covered by a single emergency dispatch centre. Following the dispatch of ambulances, the staff assessed and recorded the medical needs of the patients at the scene, according to a questionnaire developed for the study. In addition to the questionnaire, data were extracted from the ambulance medical records database for each patient. If the patients were just transported by ambulance without receiving any other prehospital intervention, they were assessed as not being in need of the emergency service. The evaluation included events at the scene and during transportation. The ambulance staff making the needs assessments were emergency medical technicians and registered nurses. In this report, 604 patients who did not require prehospital care are described and compared with the remaining group of patients who required this care (1373). For analysis, descriptive statistics were used to analyse the data.

RESULTS

The ambulance staff assessed that, among patients reported by the emergency medical dispatch centre as having abdominal or urinary problems, 42% did not need the ambulance service. Even among intrahospital transports (patients for whom medical personnel made the request for an ambulance), 45% did not require ambulance transport, as judged by the ambulance staff. Among patients reported by the emergency medical dispatch centre as having chest pain or other heart symptoms or trauma/accidents, respectively, only small percentages (18%) and (17%) did not require the ambulance service, as assessed by the ambulance staff. Most of the patients without obvious medical needs had been allocated an ambulance response for nonurgent conditions, that is priority level 2 or 3, but patients without medical needs were even found at the highest priority level 1. Of the patients who did not require an ambulance, more than half (55%) would have been able to get to a hospital in their own car or by taxi, whereas the remainder of the patients needed a transport vehicle in which they could lie down, but which was not equipped and staffed like an ambulance.

CONCLUSION

Among the patients transported by the emergency medical service system in the study areas, a significant percentage were judged by the ambulance staff as not being in need of prehospital interventions. The majority were transported by a fully equipped emergency medical ambulance to an emergency medical department at a hospital, without requiring any prehospital interventions either at the scene or during transportation. The emergency medical service organization has to develop clear criteria for the utilization of ambulance services that can be accepted and implemented by the dispatch centres and by healthcare personnel. These criteria need to include safety margins and at the same time enable the appropriate use of resources.

Influence of socioeconomic factors on medically unnecessary ambulance calls

Background

Unnecessary ambulance use has become a socioeconomic problem in Japan. We investigated the possible relations between socioeconomic factors and medically unnecessary ambulance calls, and we estimated the incremental demand for unnecessary ambulance use produced by socioeconomic factors.

Methods

We conducted a self-administered questionnaire-based survey targeting residents of Yokohama, Japan. The questionnaire included questions pertaining to socioeconomic characteristics, dichotomous choice method questions pertaining to ambulance calls in hypothetical nonemergency situations, and questions on the city's emergency medical system. The probit model was used to analyze the data.

Results

A total of 2,029 out of 3,363 targeted recipients completed the questionnaire (response rate, 60.3%). Probit regression analyses showed that several demographic and socioeconomic factors influence the decision to call an ambulance. Male respondents were more apt than female respondents to state that they would call an ambulance in nonemergency situations (p < 0.05). Age was an important factor influencing the hypothetical decision to call an ambulance (p < 0.05); elderly persons were more apt than younger persons to state that they would call an ambulance. Possession of a car and hesitation to use an ambulance negatively influenced the hypothetical decision to call an ambulance (p < 0.05). Persons who do not have a car were more likely than those with a car to state that they would call an ambulance in unnecessary situations.

Conclusion

Results of the study suggest that several socioeconomic factors, i.e., age, gender, household income, and possession of a car, influence a person's decision to call an ambulance in nonemergency situations. Hesitation to use an ambulance and knowledge of the city's primary emergency medical center are likely to be important factors limiting ambulance overuse. It was estimated that unnecessary ambulance use is increased approximately 10% to 20% by socioeconomic factors.

Clinical and economic factors associated with ambulance use to the emergency department

BACKGROUND

Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods.

OBJECTIVES

To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED.

METHODS

This was a retrospective, cross-sectional study of all patients seen during 2001 (N = 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air-medical transport, walk-in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use.

RESULTS

In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0-10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight-8 am (OR, 2.0; 95% CI = 1.8 to 2.1), and age > or =65 years (OR, 1.3; 95% CI = 1.2 to 1.5).

CONCLUSIONS

Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means.

Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years

OBJECTIVES

Estimate the prevalence of medically unnecessary Emergency Medical Services (EMS) transports among children.

METHODS

We linked EMS and emergency department (ED) billing records for all EMS-to-hospital transports of children originating in three counties in South Carolina between January 1, 2001 and March 31, 2003. EMS responses resulting in no transport, transports to destinations other than the ED, or multiple trips for the same child in a single day could not be linked to ED data and were excluded. Medically unnecessary transports were identified with an algorithm using pre-hospital impressions, ED diagnoses and ED procedures. After exclusions, 5,693 transports of children between 0 and 17 years were available for study.

RESULTS

Sixteen percent (16.4%) of all transports were medically unnecessary. Among children through age 12, upper respiratory and viral problems were the most common diagnoses associated with medically unnecessary transports; among older children, behavioral problems such as conduct disturbance or drug abuse were common. In multivariable analysis, the odds of an unnecessary transport were higher among younger children, non-white children, rural children, and children insured by Medicaid.

CONCLUSIONS

The proportion of EMS transports which may be medically unnecessary is relatively modest compared to previous studies. However, many questions remain for future research. Further investigation should include examination of primary care availability and occurrence of unnecessary EMS use, existence of race-based disparities, and transports involving conduct disturbance and other behavioral conditions among children.

Expected Annual Emergency Miles per Ambulance: An Indicator for Measuring Availability of Emergency Medical Services Resources

CONTEXT

To ensure equitable access to prehospital care, as recommended by the Rural and Frontier Emergency Medical Services (EMS) Agenda for the Future, policymakers will need a uniform measure of EMS infrastructure.

PURPOSE AND METHODS

This paper proposes a county-level indicator of EMS resource availability that takes into consideration existing EMS resources (ambulances), population health and demographics, and geographic factors. The indicator, the EXpected annual emergency miles per AMBulance (EXAMB), provides a basis for comparing ambulance availability across counties within states. A method for calculating the EXAMB indicator is demonstrated using data from 5 states.

FINDINGS

The EXAMB indicator was negatively correlated with ambulance availability per 100,000 population in 4 of the 5 states in the study. The indicator was positively correlated with rurality in 3 states. In Mississippi, South Carolina, and Wyoming, whole-county health professional shortage areas had median EXAMB values 45%-81% higher than those of the non-health professional shortage areas counties.

CONCLUSIONS

Future research should explore the relationship of the EXAMB to EMS outcomes, with the ultimate goal of developing a nationally recognized indicator of "adequate" EMS resource availability.

Making up one's mind:--patients' experiences of calling an ambulance

The issue of the inappropriate use of ambulance transport and care has mainly been studied from the professionals' and caregivers' perspective, with few studies focusing on the patient and his/her experiences. To further understand whether patients use ambulance care in an inappropriate manner and, if so, why, it is important to obtain an overall picture of the patients' existential situation at the time they call an ambulance. The aim of this study was to analyse and describe patients' experiences related to the decision to call an ambulance and the wait for it to arrive. The design was explorative, and twenty informants aged between 34 and 82 years were interviewed. Qualitative content analyses were performed. The findings showed that calling for an ambulance is a major decision that is preceded by hesitation and attempts to handle the situation by oneself. Our conclusion is that the definition of inappropriate use of valuable health care resources should not be based solely on the professionals' point of view but also take account of the patients' reactions when they experience a threat to their life and health.

Outcomes of patients not transported after calling 911

To compare the outcomes of patients who were denied transport by emergency medical services (EMS) with those who refused to be transported, all EMS non-transports were reviewed to determine who refused the transport and adherence to mandatory transport guidelines. Patients were contacted for telephone survey. Of 906 non-transported patients, 310 consented to the survey. Of these, 205 were patient refusals and 105 were EMS refusals. There was no significant difference between the patient and EMS refusal groups in reported change in medical care, hospitalization, or death. One hundred ten non-transported patients met mandatory transport criteria (85 patient refusals vs. 25 EMS refusals, p = 0.002). In conclusion, patient non-transport may result in adverse outcomes that are as likely to occur in patients who are denied transport by EMS as those who refuse to be transported. Patients who refuse transport are more likely to meet mandatory transport guidelines.