Primary health care vs. emergency medical assistance: a conceptual framework

Primary health care (PHC) and emergency medical assistance (EMA) are discussed as two fundamentally different strategies of delivering health care. PHC is conceptualized as part of overall development, while EMA is delivered in disaster or emergency situations. The article contrasts the underlying paradigms, and the characteristics of care in PHC and EMA. It then analyzes the characteristics of PHC and EMA health services, their structure, management and support systems. In strategic aspects, it contrasts how managerial and financial sustainability are fundamentally different, and how the term accountability is used differently in development and disaster situations. However, while PHC and EMA, development and disaster, are clear opposite poles, many field situations in the developing world are today somewhere in-between. In such non-development, non-emergency situations, the objectives and approach will have to vary and an adapted strategy combining characteristics from PHC and EMA will have to be developed.

Development of prehospital emergency medical services: strategies for system assessment and planning

Increasing economic capacity in the Pacific Rim has led to a greater demand for integrated pre-hospital care systems. The economic and technological growth of Taiwan, South Korea, Japan, Singapore and Hong Kong has lead to health system developments and growth of advanced healthcare and prehospital medical services. Changing economies and population distribution of many of the Southwestern countries and island regions in the South Pacific, as well as the geographical constraints necessitate a systematic and individually tailored planning process, while standardizing communication and quality of service with more will developed neighbors. While EMS systems in such a broad geographical region may take a variety of forms, each system contains some system components similar to those found in the United States and Southwest Pacific regions such as Australia and New Zealand. In evaluating EMS abroad, it is useful to compare the developing system type to one of five models: hospital based, municipal, private, volunteer, and complex. In so doing, the appropriate model system may be constructed to accommodate the demands of an evolving system.

Ambulance services. Get your kit off

An ambulance trust with a deficit of 1 m Pounds in 2000 and poor response times has balanced its books and exceeded response-time targets. A hierarchical, military culture has been changed into a more participative one. Union representatives now sit on the interviewing board for management jobs. These changes have allowed the trust to become more integrated with the NHS as a whole.

[The experience in emergency medical care in Lagos (Nigeria): cost-benefit analysis ... politics?]

In both the South and North, meeting the demand for health care services is a major issue in establishing political stability for sustainable development. Neither the need for emergency medicine nor the emergency need for medical care can escape this reality. At first glance, "bringing medical care outside hospitals ... to the bottom of the tree" by implementing an advanced rescue system would seem to overstep the usual goal of providing basic health services and capabilities in a developing country. However, the operational, tactical and strategic implications of a "French style SAMU" medical controlled system may contribute to the fair and equitable distribution of emergency health care resources during critical situations in a given environment. In this respect, such system cannot only become a measurable component in responding to increasingly intolerable health disasters, but also an institutional tool for health resources management in any insecure environment, where access to medical facilities usually involves a number of economic, structural, and ethical obstacles. In France, the effectiveness of such a system is still under evaluation with good results in terms of overall health performance for the year 2000. In 1997 the Nigerian authorities with the support of the French Embassy began a novel experience by setting up a state run SAMU services in Lagos. The purpose of this prospective approach was to answer the question "what emergency care system, for what environment?" with an ultimate goal: developing a sustainable service, not only in terms of medical and economic factors, but also ethical and political considerations.

Estimated cost effectiveness of a police automated external defibrillator program in a suburban community: 7 years experience

OBJECTIVE

To estimate the cost effectiveness of a 7-year police automatic external defibrillator (AED) program in four suburban communities.

METHOD

10-year retrospective study (7/89-7/99) of patients of four suburban communities during two study periods: (1) police first response and advanced life support (ALS) care (No-AED) and; (2) AED equipped police first response (P-AED) with subsequent ALS care. Using the perspective of the communities, we obtained costs of AED program from police agencies. We estimated cost/life saved and cost/year lives saved using decreased time to VF shock by EMS. We performed a sensitivity analysis for estimates of potential benefit using estimated improved survival as a result of decreased EMS response interval and obtained survival data. We used literature-based estimates of life expectancy after cardiac arrest survival to estimate cost/year life saved. We used student's t-test and chi(2) to estimate differences between groups.

RESULTS

During the 10-year study period 208 patients met study criteria; (81 No-AED, 128 P-AED). The two groups were not different by patient age, ALS response interval, percent in VF, percent witnessed (WIT), or arrest location. Interval to first defibrillator equipped EMS vehicle arrival was less in the P-AED group (2.0 vs. 5.4 min, P<0.001) as was the interval from the emergency (911) call to first VF shock (6.6 vs. 8.4 min, P=0.02). Survival to DC was not statistically different with P-AED (11.9 vs. 9.9%, P=0.66) but this study was not powered to detect a difference. Estimated cost per life saved with P-AED varied from $23542 to $70342 and cost per year life saved ranged from $1582 to $16060.

CONCLUSION

Police AED appears to be a cost-effective intervention in these suburban communities which have relatively rapid EMS response intervals.

Reimbursement in emergency medical services: how to adapt in a changing environment

The proposed Medicare fee schedule for medically necessary ambulance transportation will have a profound impact on emergency medical services (EMS) systems throughout the country. When the new Medicare rules are implemented, reimbursement for Medicare patients will be largely based on national relative value units that vary depending on the level of service provided, from basic life support to advanced life support emergency. Under the new fee schedule, nearly all EMS systems will lose money when compared with the actual cost of providing the service, particularly advanced life support services, rural services, efficient systems, and those that bill for services. To adapt to these impending changes, EMS administrators and medical directors must work together to diversify and solidify their revenue sources and to seek out ways to make their systems even more efficient while maintaining a high quality of clinical care.

[Creation of emergency care services in developing countries: luxury or necessity?]

Organization of emergency care services prior to hospital admission has progressed at a satisfactory pace in developed countries. A performance model in this field is the French emergency service called service d'aide médicale d'urgence (SAMU). Socioeconomic conditions prevailing in developing countries have pushed authorities to give priority to preventive medicine. However numerous patients especially young people and women during childbirth die as a result of inadequate facilities for transportation from hospitals and dwellings in outlying areas to major medical centers where the best medical equipment and staff are available. As a result, it may be asked if emergency care services is really a luxury. The authors base their conclusion on analysis of the conditions and outcome of emergency patient care in three African countries in which it is essentially a requirement.

The impact of information technology on emergency health care outcomes

We analyze the productivity of information technology in emergency response systems. "Enhanced 911" (E911) is information technology that links caller identification to a location database and so speeds up emergency response. We assess the impact of E911 on health outcomes using Pennsylvania ambulance and hospital records between 1994 and 1996, a period of substantial adoption. We find that as a result of E911 adoption, patient health measured at the time of ambulance arrival improves, suggesting that E911 speeds up emergency response. Further analysis using hospital discharge data shows that E911 reduces mortality and hospital costs.

Rationing and the role of the emergency department as society's safety net

Emergency medicine has an integral role in the establishment of universal access to health care for all persons living in the United States. Currently, emergency departments provide the only unfunded mandate available to millions of American residents who otherwise have no access to health care coverage. Any effort to establish universal care must accept health care rationing as a basic principle, and establish a minimum standard of benefits to which all human beings are entitled in this country. People and employers should be allowed to purchase additional care based on their willingness and ability to pay, but under no circumstances should anyone be denied a basic package of health care benefits. Emergency care must be part of those basic benefits. Emergency medicine charges should be structured so that they are not unduly onerous to society, and should reflect true expenses, including marginal costs for nonurgent care. Emergency physicians (EPs) and hospital administrations should recognize their critical role in serving society in roles that are not strictly medical, and allocate resources to benefit the general population in the greatest way. This role will be expanded to include preventive care, to provide for basic pharmacologic coverage as needed, and to provide necessary immunizations when traditional primary care has failed. We have a moral obligation to recognize that resources are limited and to allocate them so as to benefit the greatest number of patients in the greatest way. As members of the medical profession best equipped to assume such a task, it is incumbent upon EPs to act as advocates to the public to enable us to fulfill this mission.

Rochester, New York: a decade of emergency department overcrowding

Overcrowding is common in emergency departments (EDs) throughout the United States. The history of ED overcrowding in Rochester, New York, is notable due to its unique health care system that introduced the concepts of managed care as early as the 1950s. An effect of this system was to intentionally restrict resources and allow the issue of access to limit utilization. Overcrowding in EDs was severe in the late 1990s-2000, and became an accepted local standard of care.

OBJECTIVE

To study the strategies to reduce ED overcrowding in Rochester in the last decade.

METHODS

A descriptive analysis of individual hospital and community efforts to decrease ED overcrowding.

RESULTS

Of the strategies tried, those that had little effect on ED overcrowding were based from the ED, such as ambulance diversion. Those that were successful were those that addressed factors external to the ED such as increased flexibility of inpatient resources; float nurses who responded to acute care needs; a transition team (mid-level provider along with registered nurse (RN)/licensed practical nurse) who cared for inpatients boarded in the ED; integrated services across affiliated hospitals/systems; an early alert system that notified key personnel before "code red" criteria were met; and a multidisciplinary team to round in the ED and analyze resource needs. Current community-wide initiatives include precise tracking of code red hours; monitoring patient length of stay (LOS) in the ED and inpatient units; education of physicians and nursing homes regarding ED alternatives; exploration of additional resources for subacute and long-term care; establishing a regional forum to address the nursing shortage; development of an ED triage system to coordinate diversion activities during code red; and consideration of a county-wide state of emergency when needed.

CONCLUSIONS

Emergency department overcrowding is the end result of a variety of factors that must be addressed system-wide.

Threats to the health care safety net

The American health care safety net is threatened due to inadequate funding in the face of increasing demand for services by virtually every segment of our society. The safety net is vital to public safety because it is the sole provider for first-line emergency care, as well as for routine health care of last resort, through hospital emergency departments (ED), emergency medical services providers (EMS), and public/free clinics. Despite the perceived complexity, the causes and solutions for the current crisis reside in simple economics. During the last two decades health care funding has radically changed, yet the fundamental infrastructure of the safety net has change little. In 1986, the Emergency Medical Treatment and Active Labor Act established federally mandated safety net care that inadvertently encouraged reliance on hospital EDs as the principal safety net resource. At the same time, decreasing health care funding from both private and public sources resulted in declining availability of services necessary to support this shift in demand, including hospital inpatient beds, EDs, EMS providers, on-call specialists, hospital-based nurses, and public hospitals/clinics. The result has been ED/hospital crowding and resource shortages that at times limit the ability to provide even true emergency care and threaten the ability of the traditional safety net to protect public health and safety. This paper explores the composition of the American health care safety net, the root causes for its disintegration, and offers short- and long-term solutions. The solutions discussed include restructuring of disproportionate share funding; presumed (deemed) eligibility for Medicaid eligibility; restructuring of funding for emergency care; health care for foreign nationals; the nursing shortage; utilization of a "health care resources commission"; "episodic (periodic)" health care coverage; best practices and health care services coordination; and government and hospital providers' roles.

CONCLUSIONS

There is a base amount of funding that must be available to the American health care safety net to maintain its infrastructure and provide appropriate growth, research, development, and expansion of services. Fall below this level and the infrastructure will eventually crumble. America must patch the safety net with short-term funding and repair it with long-term health care policy and environmental changes.

[Theme: High utilizers of health care services. How do we help the patients who constantly top visitors' statistics?]

A series of articles reviews the problem of patients with high utilization of health care. Many of these patients display somatization behaviour, presenting with physical symptoms unaccounted for by any demonstrable medical condition. High utilizers often get insufficient help from doctors and other health care providers, who are not trained to understand and manage the underlying psychosocial problems. The same problem occurs in different settings of health care, such as: Primary care: Seven out of ten high utilizers of primary care have no physical disease; they attend primarily for somatic symptoms, although there is a predominance of psycho-social problems. Emergency room care: High utilizers of emergency room care are characterized by insufficient social support, often in combination with substance abuse. Physical symptoms are often perceived as life-threatening, even though there is no known underlying disease. Non-psychiatric hospital care: There is a six fold increase in high utilization of non-psychiatric hospital care among patients with a somatoform diagnosis.

MEDICATION

Patients treated with anti-depressants--implying depressive disorder--have a two or three fold increased utilization of non-psychopharmacological drugs, of primary care and of non-psychiatric hospital care as compared to those with no treatment for depression.

[Social criteria for selecting patients in emergency services]

OBJECTIVE

To identify the social first-year and senior undergraduate students of a healthcare management course used for selecting patients who need emergency medical care.

METHODS

A random sample of 64 first-year and 25 senior year students of a healthcare management course in São Paulo, Brazil, were studied. To collect data, a survey instrument was developed with nine hypothetical simulated case scenarios, including the social criteria involved in the patient selection process, such as age, sex, economical status, life-style, and social duty.

RESULTS

There were significant differences in the two groups concerning criteria such as the patient's life-style and economic status.

CONCLUSIONS

The results suggest that the respondents accept the inclusion of social criteria in the decision-making process in a situation of scarce resources.

JEMS Salary Survey 2001

EMS organizations have made strides in recent years in recruiting women into all employment categories. However, this year's small glimpse of top management pay inequities for women indicates the need for additional research and attention to correcting salary imbalances. On the bright side, as EMS organizations tighten their belts in preparation for potential cutbacks due to the impending Medicare fee schedule, we find it encouraging to see modest salary increases in most provider categories this year.