Economic Value of Out-of-Hospital Emergency Care: A Structur

[Ace844]

(Annals of Emergency Medicine

Volume 47 @ Issue 6 , June 2006, Pages 515-524

doi:10.1016/j.annemergmed.2006.01.012

Copyright © 2006 American College of Emergency Physicians Published by Mosby, Inc.

Emergency medical service/airway/review article

Economic Value of Out-of-Hospital Emergency Care: A Structured Literature Review

Presented at the International Interdisciplinary Conference on Emergencies, June 2005, Montreal, Quebec, Canada.

E. Brooke Lerner PhDa, , , Ronald F. Maio DO, MSb, Herbert G. Garrison MD, MPHc, Daniel W. Spaite MDd and Graham Nichol MDe

aDepartment of Emergency Medicine and Department of Community and Preventive Medicine, University of Rochester, Rochester, NY

bDepartment of Emergency Medicine, University of Michigan, Ann Arbor, MI

cDepartment of Emergency Medicine, East Carolina University, Greenville, NC

dDepartment of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ

eUniversity of Washington–Harborview Center for Prehospital Emergency Care and Emergency Services, Harborview Medical Center, University of Washington, Seattle, WA.

Received 9 November 2005; revised 5 January 2006; accepted 6 January 2006. Available online 24 March 2006.)

Study objective

The evaluation of the impact of out-of-hospital emergency care is a relatively new research focus. As such, there is a compelling need to determine how finite health care resources should be used in this setting. The objective of this study is to conduct a structured review of published economic evaluations of out-of-hospital emergency care to assess its economic value.

Methods

A structured literature search and structured review of articles pertaining to the economic value of out-of-hospital care was performed. The bibliographic database MEDLINE was searched for pertinent English-language articles published between 1966 and 2003. The search used the medical subject headings “emergency medical services” and “emergency medical technician” and was limited to the subheading “economics” and crossed with the medical subject heading “economics.” The titles generated by this search were systematically reviewed and limited by topic. Abstracts from the identified titles were reviewed to select a final set of pertinent articles. These articles were further limited based on explicit inclusion and exclusion criteria. Authors used a previously published structured evaluation tool to review the final set of identified articles for quality and content.

Results

The initial MEDLINE search identified 3,533 citations. From this set, 535 potentially relevant abstracts were reviewed. From the abstract review, 46 articles were identified, along with an additional 14 from searching the secondary references. Of these 60 articles, 32 met the review inclusion criteria and were subjected to a full structured review. These studies predominantly addressed the cost of cardiac arrest (n=13, 41%), major trauma (n=8, 25%), and emergency medical services treatment in general (n=8, 25%). Only 14 studies considered the costs and consequences of competing alternatives. Of these, 2 were cost-benefit and 12 were cost-effectiveness evaluations. Two of the 14 studies met all 10 criteria for high-quality economic evaluation, whereas 2 others met none.

Conclusion

There is a paucity of out-of-hospital care literature that addresses cost and economic value. The extant literature is limited in scope, poor in quality, and evaluates small subsets of out-of-hospital emergency care costs. Favorable cost-effectiveness has not been firmly established for most aspects of out-of-hospital emergency care.

Introduction

Background

Although few would argue the need for out-of-hospital emergency care within a community, which services and resources should be provided and rapidity of response are topics of considerable debate.1, 2, 3, 4 and 5 As new technologies and skills emerge, decisions about which services a community should provide become even more difficult. Recent studies such as the Ontario Prehospital Life Support project have evaluated the effectiveness of several out-of-hospital interventions.6, 7 and 8 However, determining which out-of-hospital interventions to use within a community is more than merely a matter of efficacy and effectiveness. To properly make this determination, cost and cost-effectiveness must also be considered.

Out-of-hospital emergency medical services (EMS) is a relatively young field. Therefore, the level of research has been nascent.5 and 9 The natural evolution of research can be thought of as a continuum from laboratory to efficacy to effectiveness research. Economic evaluations done in a variety of settings are at the end of this continuum.6 Once effectiveness has been established and there are at least 2 competing alternatives, economic evaluations are used to determine which alternative is more desirable from a cost perspective. There are myriad out-of-hospital care activities that need to be evaluated from a cost perspective to assist communities in determining how their finite resources should be used.

Interest in out-of-hospital care is high, as evidenced by the recent creation of an out-of-hospital subcommittee for the committee on the Future of Emergency Care in the United States at the Institute of Medicine.10 Simultaneously, health care costs are increasing at alarming rates.11 In the case of out-of-hospital emergency care, a significant proportion of this cost is often paid by taxpayers, who subsidize the out-of-hospital emergency care system to maintain its availability. For example, in Los Angeles the Reason Public Policy Institute found that the cost per patient transport was $476, and, because of a low rate of fee collection, there was a $12 per-capita tax subsidy required to maintain the system.12

The current study was conducted to determine the evidence available on the cost of out-of-hospital emergency care in general, as well as various out-of-hospital interventions. The objective was to systematically review published economic evaluations of out-of-hospital emergency care in order to assess its economic value.

Materials and methods

Data Sources

A structured literature search and a structured review of articles pertaining to the economic value of out-of-hospital emergency care were performed. The initial phase consisted of a search of the bibliographic database MEDLINE to identify relevant English-language articles published between 1966 and 2003. An initial set of references was developed by searching for the medical subject headings “emergency medical services” and “emergency medical technician.” These medical subject headings were limited to the subheading “economics.” A second search was conducted by not limiting the medical subject headings and cross-referencing them by using the “and” command, with a third medical subject heading “economics.” A secondary review was then performed by searching the reference sections of all identified articles for additional relevant articles.

Study Selection

A single investigator (E.B.L.) reviewed this initial set of reference titles to identify those articles that potentially addressed the cost or economic value of out-of-hospital care. Titles for which it was obvious that out-of-hospital emergency care was not addressed were excluded. We created a working definition of “out-of-hospital emergency care.” It was defined as acute, unscheduled health care delivered outside the hospital by a system that deploys health resources in response to calls to a public safety answering point.

Any title that failed to indicate that a cost or economic evaluation was conducted was excluded. However, to ensure that no relevant articles were missed, any title that could possibly contain a cost or economic evaluation of out-of-hospital emergency care was included for further review.

The abstracts of the selected reference titles were obtained and reviewed by 2 investigators (E.B.L., R.F.M.). Abstracts that indicated that the manuscript might discuss some aspect of the evaluation of out-of-hospital care from a cost or economic perspective were included for further analysis. Again, any questionable abstracts were retained for further review.

The full articles for the selected abstracts were retrieved and reviewed. A single author (E.B.L.) reviewed all of the manuscripts and selected those that met the study definition of out-of-hospital emergency care. Editorials, non–peer-reviewed reports, and review articles were excluded, as well as strictly methods articles. Several investigators (E.B.L., R.F.M., H.G.G., D.W.S.) read the remaining articles and categorized them into 3 groups by using a consensus process. Each categorization was discussed until there was unanimous agreement on all decisions. The categories were those that did any type of cost analysis, those that mentioned the word “cost” but failed to analyze costs, and those that had no mention of cost. The reference sections of all articles that were reviewed were hand searched for additional relevant articles.

Data Extraction

All articles that reported economic analyses of out-of-hospital EMS were evaluated using a previously published checklist for assessing economic evaluations developed by Drummond et al.13 Before the checklist was applied, the articles were classified by whether they were full or partial economic evaluations and by the type of economic evaluation (Figure 1). Drummond defined economic evaluations as full evaluations if they compared the costs and consequences of 2 or more competing alternatives.13

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Figure 1. Method of categorizing full economic evaluations and partial evaluations. By permission of Oxford University Press. Adapted from Methods for the Economic Evaluation of Healthcare Programmes, 2nd edition.13

Four types of full economic evaluations were considered: cost-benefit, cost-effectiveness, cost utility, and cost minimization. In a cost-benefit analysis, consequences are measured in dollars. In a cost-effectiveness analysis, consequences are measured in natural units such as the amount of disability or health care resources consumed. In a cost-utility analysis, consequences are measured in quality-adjusted life years (some authors consider a cost-utility analysis to be a cost-effectiveness study with a more comprehensive outcome that accounts for both the quality and quantity of life).14 A cost-minimization analysis compares 2 competing alternatives with equivalent outcomes to determine which results in the lowest cost. Cost minimization can also be considered a form of cost-effectiveness analysis in which the effectiveness of the competing alternatives is equivalent.

Once the type of evaluation was identified, all references were assessed with a checklist for assessing economic evaluations described by Drummond et al13 (Table 1). This checklist was selected because it is comprehensive and widely accepted in the field of health economics.

Table 1.

Structured review of articles using the check list for assessing economic evaluations published by Drummond et al.13⁎ First Author (Year) Type of Analysis Well-defined Question Comprehensive Description of Competing Alternatives Effectiveness Established Important and Relevant Costs and Consequences for Each Alternative Costs and Consequences Measured Accurately in Appropriate Physical Units Costs and Consequences Valued Credibly Costs and Consequences Adjusted for Differential Timing Incremental Analysis of Costs and Consequences of Alternatives Performed Allowance Made for Uncertainty in the Estimates of Costs and Consequences Presentation and Discussion of Study Results Include All Issues of Concern to Users

Riediger (1990)15 Cost benefit

Cretin (1977)16 Cost benefit

De Wing (2000)17 Cost minimization

Brazier (1996)18 Cost minimization

Turner (2000)19 Cost minimization

Nichol (2003)20 Cost utility

Nichol (1996)21 Cost utility

Nichol (1998)22 Cost utility

Jermyn (2000)23 Cost-effectiveness

Ornato (1988)24 Cost-effectiveness

Urban (1981)25 Cost-effectiveness

Hallstrom (1981)26 Cost-effectiveness

Forrer (2002)27 Cost-effectiveness

Valenzuela (1990)28 Cost-effectiveness

Suchard (1999)29 Cost description

Rosemurgy (1993)30 Cost description

Daberkow (1977)31 Cost description

Pascarelli (1978)32 Cost description

Kriegsman (1998)33 Cost description

Altintas (1999)34 Cost description

Snooks (1996)35 Cost description

Jackobsson (1987)36 Cost description

Kurola (2002)37 Cost outcome description

Gearhart (1997)38 Cost outcome description

Bur (2001)39 Cost outcome description

Hauswald (1997)40 Cost outcome description

Brady (1996)41 Cost analysis

Lammers (1995)42 Cost analysis

Fischer (2000)43 Cost analysis

Lechleuthner (1994)44 Cost analysis

Bruhn (1993)45 Cost analysis

Nicholl (1994)46 Cost analysis

⁎ Checkmarks indicate that the criteria were present.

Results

Data Synthesis

The initial MEDLINE search created a reference set of 3,533 references (Figure 2). From this set, 535 references were selected for abstract review, and of these, 46 were selected for a complete manuscript review. Searching the reference sections of selected manuscripts identified an additional 14 references. Of these 60 articles, 32 met the review inclusion criteria and were subjected to a full structured review by several authors (E.B.L., R.F.M., D.W.S., H.G.G.) (Table 1).

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Figure 2. Article analysis.

Of the 32 studies identified, only 14 were full economic evaluations.15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28 Of these evaluations, 2 were cost-benefit analyses.15 and 16 The remaining 12 studies were some form of cost-effectiveness study. Three were cost-minimization analyses.17, 18 and 19 Three studies used quality-adjusted life years as the outcome.20, 21 and 22 The remaining 6 studies were traditional cost-effectiveness studies that described the outcome in natural units, primarily cost per life saved.23, 24, 25, 26, 27 and 28

Eighteen of the 32 studies were identified as partial economic evaluations. Eight were cost descriptions: they examined only the cost of 1 alternative, there was no comparison, or the consequences or outcomes were not considered.29, 30, 31, 32, 33, 34, 35 and 36 Four were cost-outcome descriptions, meaning that they examined only 1 alternative but considered the costs and the consequences of that alternative.37, 38, 39 and 40 Six were cost-analyses because they examined the cost of 2 alternative treatments but not the consequences.41, 42, 43, 44, 45 and 46

Using the checklist for economic evaluations, the investigators evaluated how well the articles met the checklist criteria (Table 1). Two of the 14 full economic evaluation studies met none of the 10 checklist criteria,15 and 17 whereas 2 of the studies met all of the checklist criteria.19 and 21 The others covered various amounts of the checklist criteria.

Among the 32 studies, 13 (41%) addressed interventions for cardiac arrest, 8 (25%) investigated major trauma (1 study addressed both cardiac arrest and major trauma), and 8 (25%) investigated the general cost of an EMS system. Of the 14 full economic evaluations, 9 (64%) addressed cardiac arrest and 3 (21%) studied major trauma. There was 1 partial analysis that specifically addressed pediatric patients.

Among the 14 full economic evaluations, 4 reported that they calculated costs from the societal perspective. The remaining 10 studies did not clearly state the perspective they were using. However, it appears that 4 used a societal perspective and 6 used the EMS perspective in calculating costs. In terms of comparing the outcomes of the 14 full economic evaluations, only 9 studies reported which calendar year’s dollars were used to calculate costs, thus making difficult the comparison of the other 5 studies to each other or other economic evaluations of interventions (Table 2).

Table 2.

Results of the full economic evaluation studies. Article by First Author Type of Evaluation Perspective EMS Cost Factors Year in Which Dollars Are Expressed Conclusion

Riediger (1990)15 Cost benefit Not stated, appears societal Few details given Not stated EMS saves $44.3 million per year to the community, and the cost-effective ratio for EMS is 5.3.

Cretin (1977)16 Cost benefit Not stated, appears societal Attendant salary and benefits, equipment, support personnel, maintenance, and other costs Not stated It costs between $3,141 and $6,100 per added year of life for a mobile coronary care unit, depending on how the cost is discounted.

De Wing (2000)17 Cost minimization Not stated, appears agency Used charges by the agency Not stated There is a 7- to 8-fold increase in charges for helicopter transport compared to ground transport. There is a potential $500,000 saving over 2 years if ground transport used instead.

Brazier (1996)18 Cost minimization Not stated, appears societal Aircraft, pilots, medical personnel, maintenance, landing facilities, and ambulance control staff involved in deployment Fiscal year 1991–1992 The incremental cost of helicopter transport was $1.97 million annually.

Turner (2000)19 Cost minimization Not stated, appears societal Consumable equipment, cost per minute on call Fiscal year 1997–1998 No statistically significant difference in cost between the 2 groups.

Nichol (2003)20 Cost utility Societal Defibrillator (cost depreciated), nontraditional responder training (including instructor costs), nontraditional responder retraining (including cost of drills) 2003 Nontraditional responders had an incremental cost of a median $56,700 per QALY gained.

Nichol (1996)21 Cost utility Societal 911 Service, ambulance communication center, ambulance bases, vehicles, equipment, wages, benefits, and education 1991 Incremental cost of adding more EMS providers in a single-tier EMS system was $368,000 per QALY. In a 2-tier system in which more BLS is added, the cost is $53,000 per QALY if they respond in fire department pump vehicles or $159,000 per QALY if respond in ambulances. Changing from a 1-tier system to a 2-tier system was $40,000 per QALY in a pump vehicle or $94,000 per QALY in an ambulance.

Nichol (1998)22 Cost utility Societal AED annual training, AED maintenance, police defibrillator 1996 Incremental cost of PAD by lay providers was $44,000 per QALY or $27,200 per QALY when PAD was provided by a police officer.

Jermyn (2000)23 Cost-effectiveness Not stated, appears agency Defibrillators, ancillary equipment, biomedical services for preventive maintenance on defibrillators, routine nonwarranty work, training equipment, trainer/provider certification, call review by medical control, attrition of providers and trainers 1996 Canadian dollars Cost per life saved in an urban area was $6,776; $49,274 for a rural area.

Ornato (1988)24 Cost-effectiveness Not stated, appears agency EMT training, ambulance, radio equipment, medical equipment (eg, stretcher, oxygen, first aid supplies), defibrillator, UHF radio for telemetry, and drug box Not stated Total initial training personnel and equipment cost per life saved from ventricular defibrillation was $7,687 for a basic EMT, $2,125 for an EMT-D, and $2,289 for a paramedic.

Urban (1981)25 Cost-effectiveness Societal Paramedic training (depreciated during 5 years), equipment, vehicle (depreciated during 2–5 years), salaries, benefits, relief pay, supplies, support services, equipment, maintenance, dispatching, management, vehicle operating and maintenance 1978 The marginal cost per life saved was between $6,521 and $42,358 for a suburban paramedic program in regard to cardiac arrest.

Hallstrom (1981)26 Cost-effectiveness Not stated, appears agency Could not be determined Not stated For an EMT-only system, the cost-effectiveness (calculated as cost in thousands of dollars divided by percentage of cardiac arrest patients discharged alive) was 52.6 for an EMT defibrillation program and 25.6 when a paramedic fly car was added.

Forrer (2002)27 Cost-effectiveness Not stated, appears societal Defibrillator training costs included the instructor stipend and overtime for officer training time. Equipment costs included the cost of the defibrillator, battery, pads, and other miscellaneous equipment. Miscellaneous costs included equipment maintenance costs. 1999 The cost per life saved as a result of decreasing time to first shock with a PAD program was between $23,542 and $70,342, with a cost per year of life saved of between $1,582 and $16,060.

Valenzuela (1990)28 Cost-effectiveness Not stated, appears agency Cost included 4 items: personnel costs, which were the dollar difference between ALS and ILS personnel salary and benefits; training costs, including the cost to train an ALS provider per year; equipment costs, including the cost of maintaining monitor defibrillator units on all vehicles; maintaining response time, which was achieved by adding 1 more unit. 1989 The cost per year of life saved was $8,886.

EMS, Emergency medical services; QALY, quality adjusted life year; AED, automated external defibrillator; PAD, public access defibrillator; EMT, emergency medicine technician; EMT-D, emergency medicine technician-defibrillator; ALS, advanced life support; ILS, intermediate life support.

Among the 10 analyses in which cost per life saved could be compared, we observed large variations in estimation of cost per life saved, reflecting differences in the comprehensiveness of the costs included, as well as the nature of the interventions considered and their estimated effectiveness. These studies evaluated a range of EMS interventions for cardiac arrest. Using the available data, we next estimated cost per life saved expressed in 2005 dollars (Table 3). For studies that did not state the year of data collection, we assumed that costs were calculated in the year of publication. Insufficient data were available on cost per life saved to include any of the other identified studies in this analysis.

Table 3.

Summary of published economic evaluations of EMS interventions for cardiac arrest, with all results adjusted for inflation. First Author (Year) Intervention Comparator Perspective Costs Included Incremental Cost: Effectiveness, $/Life Saved

Nichol (1996)21 Reducing response time for cardiac arrest Existing EMS agency Society EMS and initial hospital costs only; not ICD or ambulatory costs In all-ALS system by adding ALS providers: $2,627,00

In BLS+ALS system by adding defibrillator-capable first responders in:

fire vehicles: $383,500

EMS vehicles: $1,134,400

Changing from an all-ALS system to a BLS+ALS system by adding defibrillator-capable first responders in:

fire vehicles: $286,900

EMS vehicles: $678,2000

Ornato (1988)24 Treatment by range of EMT Existing EMS agency Agency Training costs only EMT: $12,900

Defibrillation-capable

EMT: $3,600 Paramedic: $3,800

Urban (1981)25 Advanced cardiac life support Existing EMS agency Societal EMS and initial hospital costs only $91,900

Valenzuela (1990)28 Advanced cardiac life support Existing EMS agency Agency Training, equipment, and on-time costs $181,000

Jackobsson (1987)36 EMTs Existing EMS agency Societal EMS and hospital only $2,800

Jermyn (2000)23 First-responder defibrillation Existing EMS agency Agency Training and consumables but not capital equipment In urban setting: $7,800

In rural setting: $57,400

Hallstrom (1981)26 Defibrillation EMTs without defibrillation Agency EMS costs assumed By EMTs: $48,100

By EMTs with paramedic backup: $80,900

Forrer (2002)27 Defibrillation Existing EMS agency Agency Training and equipment but not medical oversight or quality assurance By police: $84,000

Nichol (1998)22 Defibrillation Standard EMS agency Society EMS and hospital but not ambulatory or ICD costs By police: $107,000

By lay responders: $190,000

Nichol (2003)20 Defibrillation Standard EMS agency Society EMS, hospital, ICD, and ambulatory costs By security guards in casinos: $183,000

BLS, Basic life support; ICD, implantable cardioverter-defibrillator.

Discussion

Only 32 studies that were economic analyses of out-of-hospital care could be identified by rigorous evaluation of the past 38 years of peer-reviewed health care literature. In general, economic evaluations are most useful when there is evidence that an intervention is effective. Only a handful of out-of-hospital interventions have been proven unequivocally to be effective.5, 47 and 48 The paucity of science about the effectiveness and cost of out-of-hospital EMS dramatically compromises the ability of communities to optimize the use of limited health care resources.

This comprehensive review yielded only 14 full economic evaluations. The majority of studies were partial economic evaluations that failed to compare competing alternatives or to consider both the costs and consequences of the interventions. Although partial evaluations have some utility, the optimal purpose of an economic evaluation is to assist in making choices about the use of community resources.13 Therefore, accurate assessment of the economics of EMS care requires full economic evaluations.

Only 8 of the 14 full economic evaluations met a majority of the criteria for a high-quality analysis. Therefore, there are even fewer studies in the medical literature of sufficient quality to truly assist community decisionmakers. These findings support our initial hypothesis about the near absence of high-quality out-of-hospital-care economic analyses. EMS cost analyses must follow guidelines for the standardization of economic analysis, such as those suggested by the Panel on Cost-effectiveness in Health and Medicine,14 but there is also a need for a conceptual framework specific to EMS to assist EMS researchers in designing and reporting economic evaluations.

The existing full economic evaluations primarily analyzed cardiac arrest and major trauma. These 2 areas account for only a small percentage of adults transported within the EMS system and an even smaller proportion of pediatric patients transported.49 Therefore, the existing economic literature applies to only a small proportion of patients treated by EMS providers. To meaningfully assist communities in determining how their limited resources should best be used, the scope of economic analyses in out-of-hospital emergency care needs to be expanded and the quality improved.

How much a society is willing to pay for EMS will vary between communities and depends, in part, on total funds available. Therefore, different communities are likely to be willing to pay for out-of-hospital care according to their available resources and the competing alternatives, making it difficult to create a universal definition of what incremental cost should be considered a decisionmaking criterion for different EMS systems. It also means that the cost of readiness may be higher in some communities compared to others because of their system demands (eg, minimum response times).

Finally, because of the heterogeneous nature of out-of-hospital emergency care agencies, the effectiveness of a given intervention can be highly variable between agencies.50 This factor makes it difficult to determine overall cost-effectiveness for a given intervention across all out-of-hospital emergency care agency types.

To our knowledge, this is the first comprehensive literature search on the economic evaluation of out-of-hospital emergency care. It included an objective assessment of the literature conducted by multiple authors using previously validated criteria for identifying high-quality analyses. The state of the literature on economic evaluation of EMS is poor.

Recommendations

Future evaluations of the economics of out-of-hospital emergency care interventions should apply rigorous methods to define the population under consideration, the intervention, what it is being compared to, the perspective of the study, the effects of the intervention and its alternatives, and their costs.14

Limitations

This study was a comprehensive literature search that applied a priori qualitative criteria. However, it had several limitations. The existing literature is sparse. It is available for only a few interventions. The methods used were variable between studies, complicating our ability to pool the results meaningfully. Comparisons were even further complicated by the variability between studies in terms of time and place.

Our search was limited in that we restricted it to only published English-language literature because of the expense of translation and our inability to identify unpublished studies. Further, because an expert panel conducted this review, it is limited by the biases inherent in a review by only a handful of individuals. However, because consensus required unanimity among all the reviewers and explicit review criteria were used, these biases were limited.

Conclusion

In conclusion, there is a paucity of literature that addresses the economics of out-of-hospital emergency care. The existing literature is of poor quality, limited to a narrow scope, and does not reflect the broad array of care provided within EMS systems. A conceptual framework for evaluating costs and consequences of care delivered in the out-of-hospital setting is needed. Future studies should evaluate the costs and consequences of out-of-hospital interventions by using high-quality methods. Only with the development of the methodologies for this purpose will the much-needed understanding of how to optimize EMS care be possible.

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Supervising editor: Donald M. Yealy, MD

Funding and support: This work was funded by the National Highway Traffic Safety Administration through Cooperative Agreement DTNH22-98-H-05117 awarded to the National Association of State EMS Directors. The sponsor played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

Reprints not available from the authors.

Address for correspondence: E. Brooke Lerner, PhD, Department of Emergency Medicine, University of Rochester, 601 Elmwood Ave, Box 655, Rochester, NY 14642; 585-273-1468, fax 585-473-3516

[AZCEP]

So how do we justify the costs of full ALS capability? Unfortunately, the evidence doesn't support ALS being used very often. Even less when we look at each individual cost of having full ALS. Even as providers, we know that most of our transports could be handled by a BLS provider that is allowed to administer a couple of medications, and perhaps use an AED.

Rare is the case that the full ALS system shows it's merits, but when they do happen nobody wants to think about the differences.

Is cost effectiveness the best measure to judge a system by? Seems the ER physician, as an example, gets the same bill generated regardless of what type of patient they see, and no one is judging them by this standard. Yes, facilities have instituted PA's and NP's to supplement the physicians, but isn't that what EMS is as well-->physician extenders. Unusual to see doctors making house calls in the U.S. anymore.

[Ace844]

I thought this was a very interesting study as it made plain a number of issues including some of the ones you mention. Additional issues and areas that we need to look ta are as follows.

A.) We need to work to get a 'fair' reimbersement and billing system which covers the costs actually incurred during pt care. There was a big push a couple of years ago to get the ICD-9 system set up with an EMS variant. The issue here is that they continuously lower the billing and re-imbursemnet thus decreasing the ability of systems to cover costs.

B.) The issue you mention which is pooint of care fees. Until we get our profession, well professional standardized and recognized there is no way other health care providers will sit by and let us take a fair share of the billing pie. I do agree though in EMS we are essential physician extenders, and should be compensated as such.

C.) With the scope of practice and higher rates of tort and care increasing how long will it be before we all see our malpractice insurance rates climb without the ability for providers and agencies to 'bill' to cover this?

There are more but I will stop here for now, what do you all think?

Out Here,

ACE844

[AZCEP]

I think... I think... I think... I'm glad I don't do billing, is what I think.

Seems we have gotten back to the issue of how to prove we are doing a job that no one else can, and doing it well enough we can't be replaced with reduced levels of care.

Whole other topic for discussion though.

[TerrfyinFlyinSrvc]

Rare is the case that the full ALS system shows it's merits, but when they do happen nobody wants to think about the differences.

Something else that I really have no idea how to quantify, but would like to see, is how much money the EMS system actually saves a society in shorter hospital stays, less drastic interventions at hospital level, and overall better outcomes. I'd also want to factor in wages and assets that would otherwise be lost due to death, disability, lost work time of other family members, etc, etc.

I'm really tired so if that statement is unclear, I apologize.

neal

[Amhet1]

Heres a response that should push some buttons......

Calculate the entire cost of providing the service and divide that by all of the Cardiac Arrests that walk out of the Hospital with mental function intact (I think its defined as CPC Level 1). The answer is the real cost of providing the service.

I use Cardiac Attest because that is the best defined standard we have going. ALS is supposed to provide 100% ROSC, mentation intact, and delivered with 8:59. Whether we staff one ambulance with volunteers, or 60+ ambulances with 2 or more fully qualified paramedics (or nurses, or docs), the expectation is that we will save every life. Thinking we have a save everytime our patient doesnt leave the hospital in a bodybag is rubbish.

You may think that saving a multi-trauma or intubating the first time every time is a save, but its not. Those are meerly expectations of any ambulance. Any ambulance is expected to save the patient, minimize pain and suffering, and consoul the family, and that applies equally whether your population density is 2 people per square mile to 3000 sq/m.

95% of the patients we transport are treated and streeted (some before we can even get back in service). The other 5% end up in the OR, ICU, floor and luckily, only a few leave horizontally.

Back to the point.... Is it really cost effective to provide 100% ALS to 100% of the US? Far from it. Is it cost effective to have ALS Fire and ALS Ambulance? Doubtful. (Withholding personal opinion) A case could be made that some level between full BLS and full ALS would meet the criteria necessary save more lives, be cost effective, and meet the communities needs and expectations.