Inappropriate use and unmet need in paramedic and nonparamedic ambulance systems

doi:10.1016/S0196-0644(87)80684-4

Annals of Emergency Medicine

Volume 16, Issue 5, May 1987, Pages 553-556

https://doi.org/10.1016/S0196-0644(87)80684-4 Get rights and content

A survey of emergency department visits was conducted over a 56-week period between November 1980 and November 1981. Inappropriate ambulance use and unmet ambulance need were compared between two cities (one large and one small) with paramedic ambulance services and two cities (one large and one small) with nonparamedic ambulance services. A total of 6,405 visits was evaluated, resulting in overall rates of inappropriate use and unmet need of 42% and 58%, respectively. When paramedic ambulance services were compared to nonparamedic services, the results indicated less inappropriate use in cities with paramedic services (34% vs 49%, P < .001) as well as less unmet need in cities with paramedic services (48% vs 67%, P < .001). These results remain consistent within most sample subgroups based on age, sex, time of arrival at ED, and disposition, except that no differences were found for small cities or for patients 50 years and older. The results indicate that paramedic ambulance systems are beneficial to the general population of emergency department users.

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Cited by (54)

Ambulance transport to the emergency department: A patient-selected signal of acuity and its effect on resource provision
2019, American Journal of Emergency Medicine
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?
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.
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.
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.
Identifying rural–urban differences in the predictors of emergency ambulance service demand and misuse
2019, Journal of the Formosan Medical Association
Citation Excerpt :
It has been noted that studies assessing rural–urban differences in the predictors of EAS demand and misuse are rare. Since earlier studies suggested the presence of rural–urban differences,13–15 the present study aims to use 160,000 electronic EAS usage records to assess rural–urban differences in the predictors of EAS demand and misuse in New Taipei City. Identifying the predictors of EAS demand will help the EAS service managing authority to formulate focused policies to maintain service quality.
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.
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.
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.
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.
Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization
2018, American Journal of Emergency Medicine
Citation Excerpt :
Many studies use these terms [6,24,29-31], nonetheless, there is not a universally accepted definition of “misuse” or “inappropriate use [32,34].” Previous studies support that the majority of patients who are transported by EMS have emergent complaints [24-26,30,31,33,35]. However, the use of EMS “simply as a convenient means of transportation to the ED” clearly reflects “a misunderstanding of the purpose…or disregard for the social cost of the service” [7].
To identify health beliefs of emergency department (ED) patients with low acuity conditions and how these affect ambulance (AMB) utilization.
We performed a prospective, observational study on a convenience sample of patients 18 years or older, who presented to the ED of an urban, academic hospital with an Emergency Severity Index (ESI) triage level of 4 or 5. Demographics, treatment, and disposition data were obtained along with self-administered surveys. Characteristics of patients with low acuity conditions who presented to the ED by AMB were compared to the patients who came to the ED by private transportation (PT). Data were analyzed with the chi-square test, t-test, and Mann-Whitney test.
A total of 197 patients (97 AMB and 100 PT) were enrolled. Compared to PT, AMB patients were more likely to: be insured (82% vs. 56%; p = 0.000), have a primary care provider (62% vs. 44%; p = 0.048), and lack a regular means of transportation (53% vs. 33%; p = 0.005). Three surveys were used the SF-8, Short Test of Functional Health Literacy in Adults [STOFHLA], and Health Belief Model [HBM]. Answers to HBM showed patients perceive that their illness required care within one hour of arrival (38% vs. 21%; p = 0.04), have used an ambulance in the past year (76% vs. 33%; p = 0.001) and to utilize an ambulance in the future for similar concerns (53% vs. 15%; p = 0.000). AMB patients were more likely to call an ambulance for any health concern (p = 0.035) and felt that there were enough ambulances for all patients in the city (p = 0.01). There were no differences in age, employment, level of income and education, nor hospital admission rate between groups.
Ambulance use in low-acuity ED patients is associated with misperceptions regarding severity of illness and resource allocation as well as limited access to private transportation. Understanding patient perceptions of illness and other barriers to receiving care is imperative for the development of interventions aimed at enabling change in health behaviors such as the elective use of limited resources.
EMS-Initiated Refusal of Transport: The Current State of Affairs
2009, Journal of Emergency Medicine
Citation Excerpt :
Emergency medical services are designed to rapidly treat and transport seriously ill or injured patients to the Emergency Department (ED). Currently, US emergency medical services (EMS) systems are being overburdened with a high volume of patients complaining of low-acuity illness or injury (1–3). Inappropriate EMS calls consume already-limited resources, making patients with true emergencies wait longer for appropriate care.
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.
Making up one's mind: - Patients' experiences of calling an ambulance
2006, Accident and Emergency Nursing
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.
Defining Research Criteria to Characterize Medical Necessity in Emergency Medical Services: A Consensus among Experts at the Neely Conference
2004, Prehospital Emergency Care
Researchers interested in ensuring appropriate use of emergency medical services (EMS) resources have attempted to define safe and effective protocols for triage either at the time of dispatch or after on-scene evaluation. Published work in this area is difficult to evaluate because protocols and outcome criteria vary from study to study. The goal of the Neely Conference was to bring together EMS experts to define a set of criteria to be used in research studies evaluating dispatch triage and field triage systems.
Thirty-one experts in EMS systems and research attended a day-long workshop to assess the current literature regarding dispatch triage and field triage, and make recommendations to standardize methods used to evaluate future triage protocols. Participants were surveyed during the workshop; consensus analysis techniques were used to determine if a formal consensus was reached. A Bayesian posterior probability of 0.99 was required to consider responses a “consensus.”
Participants considered current evidence regarding the usefulness of EMS triage criteria to be “weak.” However, respondents agreed on a set of research criteria that could define the need for an EMS response and/or EMS transport. Field triage criteria were considered more plausible than dispatch criteria. Valid outcome criteria for assessing the effectiveness of triage protocols included ED assessment and the need for immediate surgery. Hospital admission, final diagnosis, and expert opinion were not considered adequate outcome measures.
EMS experts agreed on a standard set of triage criteria and outcome measures for evaluating triage protocols supporting alternative forms of transport and care.

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: Presented in part at the Statistical Society of Canada, June 1981; and The Royal College of Physicians and Surgeons of Canada, September 1985.

: Supported by Grant Number 6609-1136-42 from the National Health Research and Development Program, Health and Welfare Canada.

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Original contributionInappropriate use and unmet need in paramedic and nonparamedic ambulance systems

Evaluative criteria for emergency ambulance systems

Soc Sci Med

Guidelines for research and evaluation of emergency medical services

Health Serv Rep

Measures of emergency ambulance effectiveness: Unmet need and inappropriate use

JACEP

The use and misuse of ambulance services by the population using the emergency department at the Hospital of St Raphael

Conn Med

Is the emergency ambulance service abused?

Br Med J

Original contribution
Inappropriate use and unmet need in paramedic and nonparamedic ambulance systems