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Ulintz AJ, Quatman CE. Beyond flashing lights and sirens: Community paramedicine as health safety nets for older adults. J Am Geriatr Soc 2024; 72:2640-2643. [PMID: 39007359 PMCID: PMC11368620 DOI: 10.1111/jgs.19087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/04/2024] [Accepted: 06/23/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Alexander J Ulintz
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Carmen E Quatman
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Tarride JE, Stennett D, Coronado AC, Moxam RS, Yong JHE, Carter AJE, Cameron C, Xie F, Grignon M, Seow H, Blackhouse G. Economic evaluation of the "paramedics and palliative care: bringing vital services to Canadians" program compared to the status quo. CAN J EMERG MED 2024; 26:671-680. [PMID: 39083199 PMCID: PMC11377656 DOI: 10.1007/s43678-024-00738-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 06/16/2024] [Indexed: 09/06/2024]
Abstract
OBJECTIVE Based on programs implemented in 2011-2013 in three Canadian provinces to improve the support paramedics provide to people receiving palliative care, the Canadian Partnership Against Cancer and Healthcare Excellence Canada provided support and funding from 2018 to 2022 to spread this approach in Canada. The study objectives were to conduct an economic evaluation of "the Program" compared to the status quo. METHODS A probabilistic decision analytic model was used to compare the expected costs, the quality-adjusted life years (QALYs) and the return on investment associated with the Program compared to the status quo from a publicly funded healthcare payer perspective. Effectiveness data and Program costs, expressed in 2022 Canadian dollars, from each jurisdiction were supplemented with literature data. Probabilistic sensitivity analyses varying key model assumptions were conducted. RESULTS Analyses of 5416 9-1-1 calls from five jurisdictions where paramedics provided support to people with palliative care needs between April 1, 2020 and March 31, 2022 indicated that 60% of the 9-1-1 calls under the Program enabled people to avoid transport to the emergency department and receive palliative care at home. Treating people at home saved paramedics an average of 31 min (range from 15 to 67). The Program was associated with cost savings of $2773 (95% confidence interval [CI] $1539-$4352) and an additional 0.00069 QALYs (95% CI 0.00024-0.00137) per 9-1-1 palliative care call. The Program return on investment was $4.6 for every $1 invested. Threshold analyses indicated that in order to be cost saving, 33% of 9-1-1 calls should be treated at home under the Program, the Program should generate a minimum of 97 calls per year with each call costing no more than $2773. CONCLUSION The Program was cost-effective in the majority of the scenarios examined. These results support the implementation of paramedic-based palliative care at home programs in Canada.
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Affiliation(s)
- J E Tarride
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
| | - D Stennett
- Healthcare Excellence Canada, Ottawa, ON, Canada
| | - A C Coronado
- Canadian Partnership Against Cancer, Toronto, ON, Canada
| | - R Shaw Moxam
- Canadian Partnership Against Cancer, Toronto, ON, Canada
| | - J H E Yong
- Canadian Partnership Against Cancer, Toronto, ON, Canada
| | - A J E Carter
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
- Emergency Health Services Nova Scotia, Halifax, NS, Canada
- Schulich School of Medicine, Western University, London, ON, Canada
| | - C Cameron
- Canadian Virtual Hospice, Winnipeg, MB, Canada
- McNally Project for Paramedicine Research, Toronto, ON, Canada
- Department of Paramedicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - F Xie
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - M Grignon
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada
- Department of Health, Aging and Society, Faculty of Social Sciences, McMaster University, Hamilton, ON, Canada
| | - H Seow
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - G Blackhouse
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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O'Connor L, Sison S, Eisenstock K, Ito K, McGee S, Mele X, Del Poza I, Hall M, Smiley A, Inzerillo J, Kinsella K, Soni A, Dickson E, Broach JP, McManus DD. Paramedic-Assisted Community Evaluation After Discharge: The PACED Intervention. J Am Med Dir Assoc 2024; 25:105165. [PMID: 39030939 DOI: 10.1016/j.jamda.2024.105165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVES Early rehospitalization of frail older adults after hospital discharge is harmful to patients and challenging to hospitals. Mobile integrated health (MIH) programs may be an effective solution for delivering community-based transitional care. The objective of this study was to assess the feasibility and implementation of an MIH transitional care program. DESIGN Pilot clinical trial of a transitional home visit conducted by MIH paramedics within 72 hours of hospital discharge. SETTING AND PARTICIPANTS Patients aged ≥65 years discharged from an urban hospital with a system-adapted eFrailty index ≥0.24 were eligible to participate. METHODS Participants were enrolled after hospital discharge. Demographic and clinical information were recorded at enrollment and 30 days after discharge from the electronic health record. Data from a comparison group of patients excluded from enrollment due to geographical location was also abstracted. Primary outcomes were intervention feasibility and implementation, which were reported descriptively. Exploratory clinical outcomes included emergency department (ED) visits and rehospitalization within 30 days. Categorical and continuous group comparisons were conducted using χ2 tests and Kruskal-Wallis testing. Binomial regression was used for comparative outcomes. RESULTS One hundred of 134 eligible individuals (74.6%) were enrolled (median age 81, 64% female). Forty-seven participants were included in the control group (median age 80, 55.2% female). The complete protocol was performed in 92 (92.0%) visits. Paramedics identified acute clinical problems in 23 (23.0%) visits, requested additional services for participants during 34 (34.0%) encounters, and detected medication errors during 34 (34.0%). The risk of 30-day rehospitalization was lower in the Paramedic-Assisted Community Evaluation after Discharge (PACED) group compared with the control (RR, 0.40; CI, 0.19-0.84; P = .03); there was a trend toward decreased risk of 30-day ED visits (RR, 0.61; CI, 0.37-1.37; P = .23). CONCLUSIONS AND IMPLICATIONS This pilot study of an MIH transition care program was feasible with high protocol fidelity. It yields preliminary evidence demonstrating a decreased risk of rehospitalization in frail older adults.
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Affiliation(s)
- Laurel O'Connor
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Stephanie Sison
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Kimberly Eisenstock
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Kouta Ito
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Sarah McGee
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA; Department of Family Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Xhenifer Mele
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Israel Del Poza
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Michael Hall
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Abbey Smiley
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Julie Inzerillo
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Kerri Kinsella
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Apurv Soni
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Eric Dickson
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John P Broach
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Lee S, Skains RM, Magidson PD, Qadoura N, Liu SW, Southerland LT. Enhancing healthcare access for an older population: The age-friendly emergency department. J Am Coll Emerg Physicians Open 2024; 5:e13182. [PMID: 38726466 PMCID: PMC11079440 DOI: 10.1002/emp2.13182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/29/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.
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Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Rachel M. Skains
- University of Alabama at BirminghamBirminghamAlabamaUSA
- Geriatric Research, Education, and Clinical CenterBirmingham VA Medical CenterBirminghamAlabamaUSA
| | | | - Nadine Qadoura
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Shan W. Liu
- Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Newton J, Carpenter T, Zwicker J. Exploring paramedic perspectives on emergency medical service (EMS) delivery in Alberta: a qualitative study. BMC Emerg Med 2024; 24:66. [PMID: 38627662 PMCID: PMC11020468 DOI: 10.1186/s12873-024-00986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE Emergency Medical Services (EMS) in Alberta are facing critical challenges. This qualitative study aims to describe and understand the frontline perspective regarding system level issues and propose provider-informed policy recommendations. METHODS 19 semi-structured one-on- one interviews were conducted with Primary or Advanced Care Paramedics (PCP/ACP) across Alberta. Participants were asked to share their perspectives, experiences and recommendations in relation to EMS response times and the working environment. Interviews were analyzed using thematic analysis to identify themes and subthemes. RESULTS Two core themes were identified as areas of concern: poor response times and the EMS working environment, which each influence and impact the other. Within response times, paramedics highlighted specific difficulties with ED offloading, a lack of resources, low-acuity calls, and rural challenges. In terms of the EMS working environment, four subthemes were apparent including attrition, unhealthy culture, organizational barriers and the need for paramedic empowerment. Providers made many recommendations including creating and expanding emergency mobile integrated health (MIH) branches, sharing 811 and 911 responses, and enforcing ED target offload times amongst other suggestions. CONCLUSIONS While response times are a key and highly visible problem, there are many critical factors like the EMS working environment that degrade patient care and cause concern amongst frontline practitioners. Multifaceted policy changes are to be explored to reduce disfunction within EMS services, enhance the well-being of the workforce and deliver improved patient care. Specific EMS-oriented policies are important for moving forward to reduce transfers to EDs, but the broader health system which is over capacity is causing downstream effects into EMS must be addressed by government and health administrators.
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O’Connor L, Behar S, Refuerzo J, Mele X, Sundling E, Johnson SA, Faro JM, Lindenauer PK, Mattocks KM. Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults. PREHOSP EMERG CARE 2024:1-9. [PMID: 38498782 PMCID: PMC11436480 DOI: 10.1080/10903127.2024.2333034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/03/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners. METHODS Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups. RESULTS The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs. CONCLUSIONS Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.
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Affiliation(s)
- Laurel O’Connor
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Stephanie Behar
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Jade Refuerzo
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Xhenifer Mele
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Elsa Sundling
- Department of Industrial Management, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Sharon A. Johnson
- Robert A. Foisie School of Business, Worcester Polytechnic Institute, Worcester Massachusetts, United States
| | - Jamie M. Faro
- Department of Population Health and Quantitative Sciences, University of Massachusetts Chan Medical School Worcester Massachusetts, United States
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences and Department of Medicine, University of Massachusetts Chan Medical School–Baystate, Springfield, MA
| | - Kristin M. Mattocks
- Department of Population Health and Quantitative Sciences, University of Massachusetts Chan Medical School Worcester Massachusetts, United States
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Lurie T, Adibhatla S, Betz G, Palmer J, Raffman A, Andhavarapu S, Harris A, Tran QK, Gingold DB. Mobile integrated health-community paramedicine programs' effect on emergency department visits: An exploratory meta-analysis. Am J Emerg Med 2023; 66:1-10. [PMID: 36640693 DOI: 10.1016/j.ajem.2022.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Mobile Integrated Health Community Paramedicine (MIH-CP) programs are designed to increase access to care and reduce Emergency Department (ED) and Emergency Medical Services (EMS) usage. Previous MIH-CP systematic reviews reported varied interventions, effect sizes, and a high prevalence of biased methods. We aimed to perform a meta-analysis on MIH-CP effect on ED visits, and to evaluate study designs' effect on reported effect sizes. We hypothesized biased methods would produce larger reported effect sizes. METHODS We searched Pubmed, Embase, CINAHL, and Scopus databases for peer-reviewed MIH-CP literature from January 1, 2000, to July 24, 2021. We included all full-text English studies whose program met the National Associations of Emergency Medical Technicians definition, reported ED visits, and had an MIH-CP related intervention and outcome. We established risk ratios for each included study through interpreting the reported data. We performed a random-effects and cumulative meta-analysis of ED visit data, tests of heterogeneity, and a moderator analysis to assess for factors influencing the magnitude of observed effect. RESULTS We identified 16 studies that reported ED visit data and included 12 in our meta-analysis. All studies were observational; 3 used matched controls, 6 pre-post controls, and 3 without controls. 7 studies' intervention were diversion/triage while 5 studies intervened with health education/home primary care services. Pooled risk ratio for our data set was 0.56 (95% confidence interval 0.42-0.74). Cumulative meta-analysis revealed that as of 2018 MIH-CP programs began to show consistent reductions in ED visits. Significant heterogeneity was seen among studies, with I-squared >90%. Moderator analysis showed reduced heterogeneity for matched-control studies. CONCLUSION Our data revealed MIH-CP programs were associated with a reduced risk of ED visits. Study design did not have a statistically significant influence on effect size, though it did influence heterogeneity. We would recommend future studies continue to use high levels of control to produce reliable data with lower heterogeneity.
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Affiliation(s)
- Tucker Lurie
- Wellspan York Hospital, Department of Emergency Medicine, 1001 South George Street, York, PA 17403, USA.
| | - Srikar Adibhatla
- University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA.
| | - Gail Betz
- University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA.
| | - Jamie Palmer
- University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA.
| | - Alison Raffman
- Hennepin County Medical Center, Department of Emergency Medicine, 730 S 8th St, Minneapolis, MN 55415, United States of America.
| | - Sanketh Andhavarapu
- University of Maryland at College Park, College Park, MD 20742, USA; The Research Associate Program in Emergency Medicine & Critical Care, University of Maryland School of Medicine, Baltimore, MD; 22 South Greene Street, suite P1G01, Baltimore, MD 21201, USA.
| | - Andrea Harris
- University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA.
| | - Quincy K Tran
- University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA; Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street; 6th Floor, Suite 200, Baltimore, MD 21201, USA; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD; 22 South Greene Street, Baltimore, MD 21201, USA; The Research Associate Program in Emergency Medicine & Critical Care, University of Maryland School of Medicine, Baltimore, MD; 22 South Greene Street, suite P1G01, Baltimore, MD 21201, USA.
| | - Daniel B Gingold
- University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA; Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street; 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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Louras N, Reading Turchioe M, Shafran Topaz L, Demetres MR, Ellison M, Abudu-Solo J, Blutinger E, Munjal KG, Daniels B, Masterson Creber RM. Mobile Integrated Health Interventions for Older Adults: A Systematic Review. Innov Aging 2023; 7:igad017. [PMID: 37090165 PMCID: PMC10114527 DOI: 10.1093/geroni/igad017] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Indexed: 03/04/2023] Open
Abstract
Background and Objectives Mobile integrated health (MIH) interventions have not been well described in older adult populations. The objective of this systematic review was to evaluate the characteristics and effectiveness of MIH programs on health-related outcomes among older adults. Research Design and Methods We searched Ovid MEDLINE, Ovid EMBASE, CINAHL, AgeLine, Social Work Abstracts, and The Cochrane Library through June 2021 for randomized controlled trials or cohort studies evaluating MIH among adults aged 65 and older in the general community. Studies were screened for eligibility against predefined inclusion/exclusion criteria. Using at least 2 independent reviewers, quality was appraised using the Downs and Black checklist and study characteristics and findings were synthesized and evaluated for potential bias. Results Screening of 2,160 records identified 15 studies. The mean age of participants was 67 years. The MIH interventions varied in their focus, community paramedic training, types of assessments and interventions delivered, physician oversight, use of telemedicine, and post-visit follow-up. Studies reported significant reductions in emergency call volume (5 studies) and immediate emergency department (ED) transports (3 studies). The 3 studies examining subsequent ED visits and 4 studies examining readmission rates reported mixed results. Studies reported low adverse event rates (5 studies), high patient and provider satisfaction (5 studies), and costs equivalent to or less than usual paramedic care (3 studies). Discussion and Implications There is wide variability in MIH provider training, program coordination, and quality-based metrics, creating heterogeneity that make definitive conclusions challenging. Nonetheless, studies suggest MIH reduces emergency call volume and ED transport rates while improving patient experience and reducing overall health care costs.
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Affiliation(s)
- Nathan Louras
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Leah Shafran Topaz
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Michelle R Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medical College, New York, New York, USA
| | - Melani Ellison
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Jamie Abudu-Solo
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Erik Blutinger
- Department of Emergency Medicine, Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - Kevin G Munjal
- Department of Emergency Medicine, Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - Brock Daniels
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
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Ridgeway JL, Gerdes EOW, Dodge A, Liedl CP, Juntunen MB, Sundt WJS, Glasgow A, Lampman MA, Fink AL, Severson SB, Lin G, Sampson RR, Peterson RP, Murley BM, Klassen AB, Luke A, Friedman PA, Buechler TE, Newman JS, McCoy RG. Community paramedic hospital reduction and mitigation program: study protocol for a randomized pragmatic clinical trial. Trials 2023; 24:122. [PMID: 36805692 PMCID: PMC9940335 DOI: 10.1186/s13063-022-07034-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/16/2022] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND New patient-centered models of care are needed to individualize care and reduce high-cost care, including emergency department (ED) visits and hospitalizations for low- and intermediate-acuity conditions that could be managed outside the hospital setting. Community paramedics (CPs) have advanced training in low- and high-acuity care and are equipped to manage a wide range of health conditions, deliver patient education, and address social determinants of health in the home setting. The objective of this trial is to evaluate the effectiveness and implementation of the Care Anywhere with Community Paramedics (CACP) program with respect to shortening and preventing acute care utilization. METHODS This is a pragmatic, hybrid type 1, two-group, parallel-arm, 1:1 randomized clinical trial of CACP versus usual care that includes formative evaluation methods and assessment of implementation outcomes. It is being conducted in two sites in the US Midwest, which include small metropolitan areas and rural areas. Eligible patients are ≥ 18 years old; referred from an outpatient, ED, or hospital setting; clinically appropriate for ambulatory care with CP support; and residing within CP service areas of the referral sites. Aim 1 uses formative data collection with key clinical stakeholders and rapid qualitative analysis to identify potential facilitators/barriers to implementation and refine workflows in the 3-month period before trial enrollment commences (i.e., pre-implementation). Aim 2 uses mixed methods to evaluate CACP effectiveness, compared to usual care, by the number of days spent alive outside of the ED or hospital during the first 30 days following randomization (primary outcome), as well as self-reported quality of life and treatment burden, emergency medical services use, ED visits, hospitalizations, skilled nursing facility utilization, and adverse events (secondary outcomes). Implementation outcomes will be measured using the RE-AIM framework and include an assessment of perceived sustainability and metrics on equity in implementation. Aim 3 uses qualitative methods to understand patient, CP, and health care team perceptions of the intervention and recommendations for further refinement. In an effort to conduct a rigorous evaluation but also speed translation to practice, the planned duration of the trial is 15 months from the study launch to the end of enrollment. DISCUSSION This study will provide robust and timely evidence for the effectiveness of the CACP program, which may pave the way for large-scale implementation. Implementation outcomes will inform any needed refinements and best practices for scale-up and sustainability. TRIAL REGISTRATION ClinicalTrials.gov NCT05232799. Registered on 10 February 2022.
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Affiliation(s)
- Jennifer L. Ridgeway
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN USA
| | - Erin O. Wissler Gerdes
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN USA
| | - Andrew Dodge
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN USA
| | | | | | - Wendy J. S. Sundt
- Research Services – Clinical Trials Office, Mayo Clinic, Rochester, MN USA
| | - Amy Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN USA
| | - Michelle A. Lampman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN USA
| | - Angela L. Fink
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN USA
| | - Sara B. Severson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN USA
| | - Richard R. Sampson
- Department of Family Medicine, Mayo Clinic Health System - Northland, Barron, WI USA
| | - Robert P. Peterson
- Division of Hospital Internal Medicine, Mayo Clinic Health System - Northland, Barron, WI USA
| | | | - Aaron B. Klassen
- Department of Emergency Medicine, Mayo Clinic Ambulance, Rochester, MN USA
| | - Anuradha Luke
- Department of Emergency Medicine, Mayo Clinic Ambulance, Rochester, MN USA
| | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN USA
| | | | - James S. Newman
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Rozalina G. McCoy
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN USA
- Mayo Clinic Ambulance, Rochester, MN USA
- Department of Medicine, Division of Community Internal Medicine, Geriatrics, and Palliative Care, Rochester, MN USA
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Adibhatla S, Lurie T, Betz G, Palmer J, Raffman A, Andhavarapu S, Harris A, Tran QK, Gingold DB. A Systematic Review of Methodologies and Outcome Measures of Mobile Integrated Health-Community Paramedicine Programs. PREHOSP EMERG CARE 2022; 28:168-178. [PMID: 36260780 DOI: 10.1080/10903127.2022.2138654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/10/2022] [Accepted: 10/16/2022] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Mobile integrated health-community paramedicine (MIH-CP) uses patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce unnecessary emergency department (ED) usage. The objective of this systematic review is to characterize the outcomes and methodologies used by MIH-CP programs around the world and assess the validity of the ways programs evaluate their effectiveness. METHODS The PubMed, Embase, CINAHL, and Scopus databases were searched for peer-reviewed literature related to MIH-CP programs. We included all full-length studies whose programs met the National Association of Emergency Medical Technicians definition, had MIH-CP-related interventions, and measured outcomes. We excluded all non-English papers, abstract-only, and incomplete studies. RESULTS Our initial literature review identified 6434 titles. We screened 178 full-text studies to assess for eligibility and identified 33 studies to include in this review. These 33 include four randomized controlled trials, 17 cohort studies, eight 8 case series, and four 4 cross-sectional studies. Of the 29 non-randomized trials, five used matched controls, 13 used pre-post, and 11 used no controls. Outcomes measured were hospital usage (24 studies), ED visits (15), EMS usage (23), patient satisfaction (8), health-related outcomes (8), and cost (9). Studies that evaluated hospital usage reported one of several outcome measures: hospital admissions (11), ED length of stay (3), and hospital readmission rate (2). EMS usage was measured by ambulance transports (12) and EMS calls (10). Cost outcomes observed were ambulance transport savings (7), ED visit savings (4), hospital admission savings (3), and cost per quality-adjusted life year (2). CONCLUSION Most studies assessing MIH-CP programs reported success of their interventions. However, significant heterogeneity of outcome measures and varying quality of study methodologies exist among studies. Future studies designed with adequately matched controls and applying uniform core metrics for cost savings and health care usage are needed to better evaluate the effectiveness of MIH-CP programs.
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Affiliation(s)
| | - Tucker Lurie
- Department of Emergency Medicine, Wellspan York Hospital, York, Pennsylvania
| | - Gail Betz
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Jamie Palmer
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Alison Raffman
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Sanketh Andhavarapu
- University of Maryland at College Park, College Park, Maryland
- The Research Associate Program in Emergency Medicine & Critical Care, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrea Harris
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Quincy K Tran
- University of Maryland School of Medicine, Baltimore, Maryland
- University of Maryland at College Park, College Park, Maryland
- The Research Associate Program in Emergency Medicine & Critical Care, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel B Gingold
- University of Maryland School of Medicine, Baltimore, Maryland
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Shannon B, Eaton G, Lanos C, Leyenaar M, Nolan M, Bowles K, Williams B, O'Meara P, Wingrove G, Heffern JD, Batt A. The development of community paramedicine; a restricted review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e3547-e3561. [PMID: 36065522 PMCID: PMC10087318 DOI: 10.1111/hsc.13985] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/01/2022] [Accepted: 08/13/2022] [Indexed: 05/22/2023]
Abstract
Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.
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Affiliation(s)
- Brendan Shannon
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Georgette Eaton
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | | | - Matthew Leyenaar
- Department of Health and Wellness, Emergency Health ServicesGovernment of Prince Edward IslandPrince Edward IslandCanada
| | - Mike Nolan
- County of Renfrew Paramedic ServicePembrokeCanada
| | - Kelly‐Ann Bowles
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Brett Williams
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Peter O'Meara
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Gary Wingrove
- International Roundtable on Community ParamedicineDuluthMNUSA
| | - JD Heffern
- Indigenous Services Canada, Government of CanadaOttawaOntarioCanada
| | - Alan Batt
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
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