The way back home: The invisible burden of the emergency healthcare services

Ambulance services around the world vary according to regional, cultural and socioeconomic conditions. Many countries apply different health policies locally. In Turkey, transportation from hospital to home has started to form an important part of ambulance services in recent years. The increase in the number of patients whose treatment has been completed and waiting to be referred may hinder the work of the emergency services. The aim of this study was to examine the costs, indications, and impact on workload of patients sent home by ambulance. Patients were divided into two groups according to the reasons for referral. The distance to home, transport time and cost were calculated according to the reasons for transport. Patients who were transferred to other clinics or hospitals by ambulance were excluded from the study. The findings showed that the hospital-to-home transfer rate during the study period was 11.4%. Although 9.7% of all cases transferred from our hospital to home were due to social indications, these cases accounted for 16.26% of the total costs. These results suggest that providing home transport services to selected patient groups for medical reasons should be seen as part of the treatment. However, the indications for home transport should not be exceeded and an additional burden should not be placed on the fragile health service.

Addressing transportation barriers in oncology: existing programs and new solutions

Transportation is an underrecognized, but modifiable barrier to accessing cancer care, especially for clinical trials. Clinicians, insurers, and health systems can screen patients for transportation needs and link them to transportation. Direct transportation services (i.e., ride-sharing, insurance-provided transportation) have high rates of patient satisfaction and visit completion. Patient financial reimbursements provide necessary funds to counteract the effects of transportation barriers, which can lead to higher trial enrollment, especially for low socioeconomic status and racially and ethnically diverse patients. Expanding transportation interventions to more cancer patients, and addressing knowledge, service, and system gaps, can help more patients access needed cancer care.

Factors associated with destination of pediatric EMS transports

OBJECTIVE

Pediatric patients comprise 13% of emergency medical services (EMS) transports, and most are transported to general emergency departments (ED). EMS transport destination policies may guide when to transport patients to a children's hospital, especially for medical complaints. Factors that influence EMS providers 'decisions about where to transport children are unknown. Our objective was to evaluate the factors associated with pediatric EMS transports to children's hospitals for medical complaints.

METHODS

We performed a cross-sectional study of a large, urban EMS system over a 12-month period for all transports of patients 0-17 years old. We electronically queried the EMS database for demographic data, medical presentation and management, comorbidities, and documented reasons for choosing destination. Distances to the destination hospital and nearest children's and community hospital (if not the transport destination) were calculated. Univariate and multiple logistic regression analyses were conducted to determine the association between independent variables and the transport destination.

RESULTS

We identified 10,065 patients, of which 6982 (69%) were for medical complaints. Of these medical complaints, 3518 (50.4%) were transported to a children's hospital ED. Factors associated with transport to a children's hospital include ALS transport, greater transport distance, protocol determination, developmental delay, or altered consciousness. Factors associated with transport to general EDs were older age, unknown insurance status, lower income, greater distance to children's or community hospital, destination determined by closest facility or diversion, abnormal respiratory rate or blood glucose, psychiatric primary impression, or communication barriers present.

CONCLUSIONS

We found that younger patient age, EMS protocol requirements, and paramedic scene response may influence pediatric patient transport to both children's and community hospitals. Socioeconomic factors, ED proximity, diversion status, respiratory rate, chief complaints, and communication barriers may also be contributing factors. Further studies are needed to determine the generalizability of these findings to other EMS systems.

Outreach physiatry clinics in remote Manitoba communities: an economic cost analysis

BACKGROUND

One in 5 people in Canada have a disability affecting daily activities, and, for rural patients, accessing lifelong physiatry care to improve function and manage symptoms requires complex and expensive travel. We compared the costs of new outreach physiatry clinics with those of conventional urban clinics in Manitoba.

METHODS

Six outreach clinics were held from January 2018 to September 2019 in the remote communities of St. Theresa Point and Churchill, Manitoba. A general physiatry population was seen in these clinics, including patients with musculoskeletal and neurologic conditions seen in consultation and follow-up. We performed a societal cost-minimization analysis comparing outreach clinic costs to estimated costs of standard care at conventional outpatient clinics in Winnipeg. Outcomes of interest included direct costs to government health services and patients, and indirect opportunity cost of travel time. We calculated total costs, average cost per clinic visit and incremental costs for outreach clinics compared to conventional urban clinics. Costs were inflated to 2020 Canadian dollars.

RESULTS

Thirty-one patients (48 visits) were seen at the outreach clinics. The total cost of providing outreach clinics, $33 136, was 21% of the estimated cost of standard care, $158 344. When only direct costs were included, outreach clinics cost an estimated 24% of conventional care costs. The average unit cost per outreach visit was $690, compared to $3299 per conventional visit, for an incremental cost of -$2609 per outreach visit.

INTERPRETATION

An outreach physiatry visit in Manitoba cost an estimated 21% of a conventional urban outpatient visit, or 24% when only direct costs were included, with costs savings largely related to travel. Outreach physiatry care in this model provides substantial cost savings for the public health care system as the primary payer, and can reduce the travel cost burden for patients who do not have public travel funding.

Influencing Factors of Transportation Costs Regarding Healthcare Service Utilization in Korea

BACKGROUND

Transportation costs can be a barrier to healthcare services, especially for low-income, disabled, elderly, and geographically isolated populations. This study aimed to estimate the transportation costs of healthcare service utilization and related influencing factors in Korea in 2016.

METHODS

Transportation costs were calculated using data from the 2016 Korea Health Panel Study. A total of 14,845 participants were included (males, 45.07%; females, 54.93%), among which 2,148 participants used inpatient and 14,787 used outpatient care services. Transportation costs were estimated by healthcare types, transportation modes, and all disease and injury groups that caused healthcare service utilization. The influencing factors of higher transportation costs were analyzed using multivariable regression analysis.

RESULTS

In 2016, the average transportation costs were United States dollars (USD) 43.70 (purchasing power parity [PPP], USD 32.35) per year and USD 27.67 (PPP, USD 20.48) per visit for inpatient care; for outpatient case, costs were USD 41.43 (PPP, USD 30.67) per year and USD 2.09 (PPP, USD 1.55) per visit. Among disease and injury groups, those with neoplasms incurred the highest transportation costs of USD 9.73 (PPP, USD 7.20). Both inpatient and outpatient annual transportation costs were higher among severely disabled individuals (inpatient, +USD 44.71; outpatient, +USD 23.73) and rural residents (inpatient, +USD 20.40; outpatient, +USD 28.66). Transportation costs per healthcare visit were influenced by healthcare coverage and residential area. Sex, age, and income were influencing factors of higher transportation costs for outpatient care.

CONCLUSION

Transportation cost burden was especially high among those with major non-communicable diseases (e.g., cancer) or living in rural areas, as well as elderly, severely disabled, and low-income populations. Thus, there is a need to address the socioeconomic disparities related to healthcare transportation costs in Korea by implementing targeted interventions in populations with restricted access to healthcare.

Epidemiological and clinical profile of Korean travelers receiving international medical repatriation

The aim of this study was to investigate the experiences of medical transportation of Korean travelers who suffered accidents abroad and then transferred home by our aeromedical team.We collected demographic and clinical data on patients injured while traveling abroad from January 2013 to July 2017. Descriptive analyses based on 4 different transportation methods and transport time since hospitalization were performed.A total of 33 patients were repatriated during the study period. Of these, 28 (84.8%) were trauma cases with pedestrian injuries being the most common (11 cases; 39.3%). Twenty patients were repatriated by flight-stretchers, 6 by flight-prestige, 2 by ship, and 5 by air ambulance. The air ambulance was the most expensive (average 61,124 US Dollars) mode of transportation (P = .001) and the ship took the longest time (14 hours) to transport patients back to Korea from regions with similar distance (P = .0023).We experienced medical repatriation of 33 seriously injured Korean travelers back to South Korea. Transfer time should be an important considering factor and directly contacting and communicating with the specialized staff of foreign hospitals could also be very important to reduce unnecessary overseas hospital stay and cost incidence.

Participant preferences for an Aboriginal-specific fall prevention program: Measuring the value of culturally-appropriate care

BACKGROUND

Culturally-specific services are central to efforts to improve the health of Aboriginal Australians. Few empirical studies have demonstrated the value of such services relative to mainstream alternatives.

OBJECTIVE

To assess the preferences and willingness to pay (WTP) of participants for attending a class and the relative importance of transport, cost and cultural-appropriateness in the choices made by participants.

DESIGN

A discrete choice experiment (DCE) was conducted alongside a study of a culturally-specific fall-prevention service. Attributes that were assessed were out-of-pocket costs, whether transport was provided and whether the class was Aboriginal-specific. Choices of participants were modelled using panel-mixed logit methods.

RESULTS

60 patients completed the DCE. Attending a service was strongly preferred over no service (selected 99% of the time). Assuming equivalent efficacy of fall-prevention programs, participants indicated a preference for services that were culturally-specific (OR 1.25 95% CI: 1.00-1.55) and incurred lower out-of-pocket participant costs (OR 1.19 95% CI 1.11-1.27). The provision of transport did not have a statistically significant influence on service choice (p = 0.57).

DISCUSSION AND CONCLUSIONS

This represents the first published DCE in the health field examining preferences amongst an Aboriginal population. The results empirically demonstrate the value of the culturally-specific element of a program has to this cohort and the potential that stated-preference methods can have in incorporating the preferences of Aboriginal Australians and valuing cultural components of health services.

NOTE ON TERMINOLOGY

As the majority of the NSW Aboriginal and Torres Strait Islander population is Aboriginal (97.2%), this population will be referred to as 'Aboriginal' in this manuscript.

Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program

BACKGROUND

Transportation to primary care is a well-documented barrier for patients with Medicaid, despite access to non-emergency medical transportation (NEMT) benefits. Rideshare services, which offer greater convenience and lower cost, have been proposed as an NEMT alternative.

OBJECTIVE

To evaluate the impact of rideshare-based medical transportation on the proportion of Medicaid patients attending scheduled primary care appointments.

DESIGN

In one of two similar practices, all eligible Medicaid patients were offered rideshare-based transportation ("rideshare practice"). A difference-in-difference analytical approach using logistic regression with robust standard errors was employed to compare show rate changes between the rideshare practice and the practice where rideshare was not offered ("control practice").

PARTICIPANTS

Our study population included residents of West Philadelphia who were insured by Medicaid and were established patients at two academic general internal medicine practices located in the same building.

INTERVENTION

We designed a rideshare-based transportation pilot intervention. Patients were offered the service during their reminder call 2 days before the appointment, and rides were prescheduled by research staff. Patients then called research staff to schedule their return trip home.

MAIN MEASURES

We assessed the effect of offering rideshare-based transportation on appointment show rates by comparing the change in the average show rate for the rideshare practice, from the baseline period to the intervention period, with the change at the control practice.

KEY RESULTS

At the control practice, the show rate declined from 60% (146/245) to 51% (34/67). At the rideshare practice, the show rate improved from 54% (72/134) to 68% (41/60). In the adjusted model, controlling for patient demographics and provider type, the odds of showing up for an appointment before and after the intervention increased 2.57 (1.10-6.00) times more in the rideshare practice than in the control practice.

CONCLUSIONS

Results of this pilot program suggest that offering a rideshare-based transportation service can increase show rates to primary care for Medicaid patients.

A mathematical model for efficient emergency transportation in a disaster situation

This work focuses on a real-life patient transportation problem derived from emergency medical services (EMS), whereby providing ambulatory service for emergency requests during disaster situations. Transportation of patients in congested traffic compounds already time sensitive treatment. An urgent situation is defined as individuals with major or minor injuries requiring EMS assistance simultaneously. Patients are either (1) slightly injured and treated on site or (2) are seriously injured and require transfer to points of care (PoCs). This paper will discuss enhancing the response-time of EMS providers by improving the ambulance routing problem (ARP). A genetic based algorithm is proposed to efficiently guide the ARP while simultaneously solving two scenarios.

Department of Veterans Affairs. Reimbursement for Emergency Treatment. Interim final rule

The Department of Veterans Affairs (VA) revises its regulations concerning payment or reimbursement for emergency treatment for non-service-connected conditions at non-VA facilities to implement the requirements of a recent court decision. Specifically, this rulemaking expands eligibility for payment or reimbursement to include veterans who receive partial payment from a health-plan contract for non-VA emergency treatment and establishes a corresponding reimbursement methodology. This rulemaking also expands the eligibility criteria for veterans to receive payment or reimbursement for emergency transportation associated with the emergency treatment, in order to ensure that veterans are adequately covered when emergency transportation is a necessary part of their non-VA emergency treatment.

Comparison of tissue-interface pressure in healthy subjects lying on two trauma splinting devices: The vacuum mattress splint and long spine board

BACKGROUND

Most emergency transport protocols in the United States currently call for the use of a spine board (SB) to help immobilize the trauma patient. However, there are concerns that their use is associated with a risk of pressure ulcer development. An alternative device, the vacuum mattress splint (VMS) has been shown by previous investigations to be a viable alternative to the SB, but no single study has explicated the tissue-interface pressure in depth.

METHODS

To determine if the VMS will exert less pressure on areas of the body susceptible to pressure ulcers than a SB we enrolled healthy subjects to lie on the devices in random order while pressure measurements were recorded. Sensors were placed underneath the occiput, scapulae, sacrum, and heels of each subject lying on each device. Three parameters were used to analyze differences between the two devices: 1) mean pressure of all active cells, 2) number of cells exceeding 9.3kPa, and 3) maximal pressure (Pmax).

RESULTS

In all regions, there was significant reduction in the mean pressure of all active cells in the VMS. In the number of cells exceeding 9.3kPa, we saw a significant reduction in the sacrum and scapulae in the VMS, no difference in the occiput, and significantly more cells above this value in the heels of subjects on the VMS. Pmax was significantly reduced in all regions, and was less than half when examining the sacrum (104.3 vs. 41.8kPa, p<0.001).

CONCLUSION

This study does not exclude the possibility of pressure ulcer development in the VMS although there was a significant reduction in pressure in the parameters we measured in most areas. These results indicate that the VMS may reduce the incidence and severity of pressure ulcer development compared to the SB. Further prospective trials are needed to determine if these results will translate into better clinical outcomes.

Telemedicine for acute burn treatment: the time has come

This brief paper sets out the arguments for the routine use of telemedicine in the evaluation of burns. Two cases are reported from the author's practice that show the need for it.

Department of Veterans Affairs. Automobile or Other Conveyance and Adaptive Equipment Certificate of Eligibility for Veterans or Members of the Armed Forces With Amyotrophic Lateral Sclerosis Connected to Military Service. Final rule

The Department of Veterans Affairs (VA) published an Interim Final Rule on February 25, 2015, to amend its adjudication regulations to provide a certificate of eligibility for financial assistance in the purchase of an automobile or other conveyance and adaptive equipment for all veterans with service-connected amyotrophic lateral sclerosis (ALS) and servicemembers serving on active duty with ALS. The amendment authorized automatic issuance of a certificate of eligibility for financial assistance in the purchase of an automobile or other conveyance and adaptive equipment to all veterans with service-connected ALS and members of the Armed Forces serving on active duty with ALS. The intent of this final rule is to confirm the amendment made by the interim final rule without change.

Frequency and costs of hospital transfers for ambulatory care-sensitive conditions

OBJECTIVES

Nursing home (NH) patients are frequently transferred to emergency departments (EDs) and/or hospitalized in situations in which transfer might have been avoided. This study describes the frequency of NH transfers for ambulatory care-sensitive conditions (ACSCs) and estimates associated expenditures.

STUDY DESIGN

Retrospective cohort study of 62,379 NH patients with Medicare coverage receiving care in South Carolina between 2007 and 2009.

METHODS

Subjects were analyzed to determine the frequency of acute ED or hospital care for conditions. Comparison is made to similar patients transferred for acute treatment of non-ACSCs. Generalized linear models were used to estimate the costs attributable to treating ACSCs.

RESULTS

Over 3 years, 20,867 NH subjects were transferred from NHs to acute care facilities, and 85.3% of subjects had at least 1 episode of care for an ACSC. An average of 13,317 subjects per year were transferred for an average of 17,060 episodes of ED or hospital care per year between 2007 and 2009. More ACSC patients transferred to EDs were subsequently admitted to the hospital (50.4% vs 25%; P < .0001). In adjusted analyses, mean ED costs per episode of care ($401 vs $294; P < .0001) were higher, but mean hospitalization costs per episode of care were lower ($8356 vs $10,226; P < .0001) for ACSC patients compared with non-ACSC patients.

CONCLUSIONS

A significant proportion of Medicare NH patients are treated acutely for ACSCs, which are associated with higher healthcare utilization and costs. Better access to onsite evaluation might enable significant cost savings and reduce morbidity in this population.

[Analysis of reimbursement of dialysis patients' transport expenses in Lorraine]

INTRODUCTION

Renal failure is defined as impairment of the excretory function of the kidney. Chronic Kidney Disease (CKD) gets progressively worse and end-stage renal disease (ESRD) constitutes thefinal stage. In France, overall spending generated by CKD in 2011 amounted to €3.3 billion. More than 80% of this cost was related to dialysis. Transport of patients in 2012 also cost €3.8 billion and 17% of this expenditure concerned patients with ESRD.

METHODS

The aim of this study was to analyze reimbursement of transport expenses of dialysis patients in order to develop a regional action plan to optimize this reimbursement in Lorraine. PMSI-DCIR data from SNIIRAM portal were used to study the characteristics of the Lorraine population of general scheme patients (including Local Mutualist Sections) dialyzed at least once with or without reimbursement of transport expenses in 2012.

RESULTS

In 2012, 1,692 patients in Lorraine received at least one dialysis session. Nearly €22 millions were reimbursed for transportation of these patients. An analysis of the population of patients treated exclusively by hemodialysis throughout 2012 showed significant differences in the cost of transport according to their age, their department and the distance of the dialysis center from their home, the type of transport and long-term disease status.

DISCUSSION

Among all ofthe possible actions, patient intervention in health centers could be considered during training at the beginning of dialysis depending on the distance of the center from their home, in order to explain the modalities ofreimbursement of theirfuture transport by health insurance (the more "attractive" Personal Vehicle package, combined transportation, seated transportation card), to partially relieve health centers of this burden and to ensure that the transport is adapted to the patient's state of health.

Economic burden of heart failure: investigating outpatient and inpatient costs in Abeokuta, Southwest Nigeria

Background: Heart failure (HF) is a deadly, disabling and often costly syndrome world-wide. Unfortunately, there is a paucity of data describing its economic impact in sub Saharan Africa; a region in which the number of relatively younger cases will inevitably rise.

Methods: Heath economic data were extracted from a prospective HF registry in a tertiary hospital situated in Abeokuta, southwest Nigeria. Outpatient and inpatient costs were computed from a representative cohort of 239 HF cases including personnel, diagnostic and treatment resources used for their management over a 12-month period. Indirect costs were also calculated. The annual cost per person was then calculated.

Results: Mean age of the cohort was 58.0±15.1 years and 53.1% were men. The total computed cost of care of HF in Abeokuta was 76, 288,845 Nigerian Naira (US$508, 595) translating to 319,200 Naira (US$2,128 US Dollars) per patient per year. The total cost of in-patient care (46% of total health care expenditure) was estimated as 34,996,477 Naira (about 301,230 US dollars). This comprised of 17,899,977 Naira- 50.9% ($US114,600) and 17,806,500 naira −49.1%($US118,710) for direct and in-direct costs respectively. Out-patient cost was estimated as 41,292,368 Naira ($US 275,282). The relatively high cost of outpatient care was largely due to cost of transportation for monthly follow up visits. Payments were mostly made through out-of-pocket spending.

Conclusion: The economic burden of HF in Nigeria is particularly high considering, the relatively young age of affected cases, a minimum wage of 18,000 Naira ($US120) per month and considerable component of out-of-pocket spending for those affected. Health reforms designed to mitigate the individual to societal burden imposed by the syndrome are required.

A qualitative study of transportation challenges among intracerebral hemorrhage survivors and their caregivers

Post-discharge barriers of hemorrhagic stroke survivors in Hawai'i have not been extensively studied. The purpose of this qualitative study was to identify common driving and transportation barriers among patients with intracerebral hemorrhage (ICH) and their caregivers in the Honolulu community. Semi-structured interviews were conducted with ICH patients (n = 10) and caregivers (n = 11) regarding their driving and transportation barriers. Inductive content analysis was used to analyze the interviews. Participants reported that they needed transportation to attend to their recovery and remain safe. Informal transportation was desired, yet not always available to patients. A local paratransit service for people with disabilities was the most common form of alternative transportation used by patients; however, they reported difficulty obtaining this method of transportation. Participants with no other option used costly, private transportation. Most ICH survivors expressed great challenges with the available transportation services that are essential to their reintegration into the community after hospitalization. Greater effort to provide transportation options and eligibility information to the ICH patients and their caregivers may be needed to improve their post-discharge care.

The financial impact of increasing home-based high dose haemodialysis and peritoneal dialysis

BACKGROUND

Evidence suggests that high dose haemodialysis (HD) may be associated with better health outcomes and even cost savings (if conducted at home) versus conventional in-centre HD (ICHD). Home-based regimens such as peritoneal dialysis (PD) are also associated with significant cost reductions and are more convenient for patients. However, the financial impact of increasing the use of high dose HD at home with an increased tariff is uncertain. A budget impact analysis was performed to investigate the financial impact of increasing the proportion of patients receiving home-based dialysis modalities from the perspective of the England National Health Service (NHS) payer.

METHODS

A Markov model was constructed to investigate the 5 year budget impact of increasing the proportion of dialysis patients receiving home-based dialysis, including both high dose HD at home and PD, under the current reimbursement tariff and a hypothetically increased tariff for home HD (£575/week). Five scenarios were compared with the current England dialysis modality distribution (prevalent patients, 14.1% PD, 82.0% ICHD, 3.9% conventional home HD; incident patients, 22.9% PD, 77.1% ICHD) with all increases coming from the ICHD population.

RESULTS

Under the current tariff of £456/week, increasing the proportion of dialysis patients receiving high dose HD at home resulted in a saving of £19.6 million. Conducting high dose HD at home under a hypothetical tariff of £575/week was associated with a budget increase (£19.9 million). The costs of high dose HD at home were totally offset by increasing the usage of PD to 20-25%, generating savings of £40.0 million - £94.5 million over 5 years under the increased tariff. Conversely, having all patients treated in-centre resulted in a £172.6 million increase in dialysis costs over 5 years.

CONCLUSION

This analysis shows that performing high dose HD at home could allow the UK healthcare system to capture the clinical and humanistic benefits associated with this therapy while limiting the impact on the dialysis budget. Increasing the usage of PD to 20-25%, the levels observed in 2005-2008, will totally offset the additional costs and generate further savings.

An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso

BACKGROUND

To bring down its high maternal mortality ratio, Burkina Faso adopted a national health policy in 2007 that designed to boost the assisted delivery rate and improving quality of emergency obstetrical and neonatal care. The cost of transportation from health centres to district hospitals is paid by the policy. The worst-off are exempted from all fees.

METHODS

The objectives of this paper are to analyze perceptions of this policy by health workers, assess how this health policy was implemented at the district level, identify difficulties faced during implementation, and highlight interactional factors that have an influence on the implementation process. A multiple site case study was conducted at 6 health centres in the district of Djibo in Burkina Faso. The following sources of data were used: 1) district documents (n = 23); 2) key interviews with district health managers (n = 10), health workers (n = 16), traditional birth attendants (n = 7), and community management committees (n = 11); 3) non-participant observations in health centres; 4) focus groups in communities (n = 62); 5) a feedback session on the findings with 20 health staff members.

RESULTS

All the activities were implemented as planned except for completely subsidizing the worst-off, and some activities such as surveys for patients and the quality assurance service team aiming to improve quality of care. District health managers and health workers perceived difficulties in implementing this policy because of the lack of clarity on some topics in the guidelines. Entering the data into an electronic database and the long delay in reimbursing transportation costs were the principal challenges perceived by implementers. Interactional factors such as relations between providers and patients and between health workers and communities were raised. These factors have an influence on the implementation process. Strained relations between the groups involved may reduce the effectiveness of the policy.

CONCLUSIONS

Implementation analysis in the context of improving financial access to health care in African countries is still scarce, especially at the micro level. The strained relations of the providers with patients and the communities may have an influence on the implementation process and on the effects of this health policy. Therefore, power relations between actors of the health system and the community should be taken into consideration. More studies are needed to better understand the influence of power relations on the implementation process in low-income countries.

National Association of EMS Physicians. Reimbursement for EMS response, medical care, and transport

The National Association of EMS Physicians (NAEMSP) believes that emergency medical services (EMS) response, care, and transport should be fairly reimbursed based on the prudent layperson standard. This paper is the official position of the NAEMSP. Key words: EMS; reimbursement; medical care; position statement; NAEMSP.

Quantifying the reduction in nonmedical costs after the introduction of a rural county hospital in Ecuador

OBJECTIVE

This study attempts to quantify the impact of the introduction of local second-level health services on nonmedical costs (NMCs) for residents of the rural Ecuadorian county of La Maná.

METHODS

NMCs for patients accessing second-level health care were assessed by using a quasi-experimental pre- and postintervention study design. In 2007, before local second-level health care services existed, and then in 2008, after the introduction of second-level health care services in the form of a county hospital, 508 patients from the county who sought second-level health care were interviewed.

RESULTS

Mean NMCs per patient per illness episode were US$ 93.58 before the county hospital opened and US$ 12.62 after it opened. This difference was largely due to reductions in transport costs (US$ 50.01 vs. US$ 4.28) and food costs (US$ 25.38 vs. US$ 7.28) (P < 0.001 for each category).

CONCLUSIONS

NMCs can be decreased sevenfold with the introduction of a county hospital in a rural province previously lacking second-level health care. Introduction of rural second-level health care reduces financial barriers and thus may increase access to these health services for poorer patients in rural communities.

Peripatetic intravenous service for metabolic bone disease: case study in patient centred-care for new NHS

OBJECTIVE

To develop a 'close to patient' peripatetic intravenous service (PIVS) for delivery of specialist osteoporosis care in a community setting without increasing cost and with a reduced carbon footprint.

RESEARCH DESIGN AND METHODS

Cost and feasibility of a PIVS for intravenous (i.v.) bisphosphonate treatment were modelled using UK National Health Service costings and then tested in the field for 1 year. Average patient mileage to peripatetic sites was compared with mileage travelled if treated at the base hospital (current practice). The method of travel to hospital (current practice) or peripatetic sites (new study) was ascertained together with patients' preference for the new or the current system. Peripatetic sites were researched and those with suitable facilities selected. Data for fuel consumption were based on a usage of 1 litre per 14.5 km.

MAIN OUTCOME MEASURES

The main outcome measure was cost comparison between hospital and peripatetic services. Others included patient satisfaction, miles saved, method of travel to the clinic and changes in CO(2) emissions.

RESULTS

Cost per patient, including drugs, lies between pound557 and pound622 annually for 1000 and 500 patients, respectively which is cost-neutral compared with hospital attendance. PIVS was rated more convenient by 98% of patients. Hospital transport was significantly reduced and the total monthly saving of 2000 miles has reduced CO(2) emission by 6072 kg p.a. No medical emergency occurred in 410 infusions.

CONCLUSIONS

PIVS is cost neutral compared with a conventional service, leads to a better patient experience, a significant cutback in hospital transport costs and a reduction of the NHS carbon footprint. However not all drugs may be suitable for this service: the area served was rural with large distances and poor public transport and mileage savings may not accrue in urban areas. Insurance was not included in the calculation of costs.

Economic aspects of mandibular third molar surgery

OBJECTIVE

The aim of this study was to make estimates from a dental care and societal perspective on costs of mandibular third molar surgery.

MATERIAL AND METHODS

A total of 64 patients were recruited from three Swedish oral and maxillofacial specialist clinics. Calculations were made prospectively on utilization of labor time, specific medical services and materials, and standardized utilization of other direct costs. Indirect costs were identified from patient surveys.

RESULTS

The base case average direct cost of surgery was 217 Euro. Adding the patient's average cost due to absence from work and transportation of 333 Euro increased overall costs to 550 Euro per patient. About 86% of the patients reported some absence following surgery.

CONCLUSIONS

The indirect costs were on average higher than the direct costs, i.e. the patient's loss of time caused higher costs than the intervention per se. Appropriate indications for mandibular third molar removal can minimize the risks of complications and individual or societal costs.

Medicaid's medical transportation assurance: origins, evolution, current trends, and implications for health reform

This policy brief examines Medicaid's assurance of medical transportation in the context of medically necessary but non-emergency health care. Reviewing the origins and evolution of the assurance and presenting the results of a 2009 survey of state Medicaid programs, the results of this analysis underscore Medicaid's unique capacity to not only finance medically necessary health care but also the services and supports that enable access to health care by low income persons since Medicaid covers non-emergency medical transportation. This ability to both finance health care and enable its use moves to the forefront as Congress considers whether to assist low income persons in health reform through Medicaid expansions or via subsidies for traditional health insurance, which typically does not provide comparable transportation coverage.

Evaluating the effects of providing financial incentives to tuberculosis patients and health providers in China

SETTING

A project was implemented in 50 low-income counties of Shanxi, where transport incentives were provided to poor patients for their first visit for tuberculosis (TB) diagnosis as well as for referral and supervision incentives for doctors.

OBJECTIVE

To evaluate the effects of providing incentives on TB case detection and treatment.

METHODS

A group of 51 control counties in Shanxi comparable to the intervention counties was selected. Routine TB reporting was reviewed at baseline (January-September 2004) and during the project period (January-September 2005) in both groups. A patient survey was conducted in two counties in each group, with interviews of 119 new smear-positive patients treated during the intervention.

RESULTS

Patients who received travel incentives had an annual individual income similar to those who did not. The notification rates of new smear-positive cases improved in both groups; however, improvement was less marked in the intervention group (70%) than in the control group (99%). Travel incentives did not reduce patient and doctor delays in the intervention group compared with the control group (P > 0.05).

CONCLUSION

Providing incentives was not effective in improving TB control. There are two possible reasons for this: the poor were not well-targeted due to a lack of operational tools, and more influential health systems issues were not addressed.

Continuous positive airway pressure therapy for infants with respiratory distress in non tertiary care centers: a randomized, controlled trial

OBJECTIVE

Our objective was to determine whether continuous positive airway pressure therapy would safely reduce the need for up-transfer of infants with respiratory distress from nontertiary centers.

METHODS

We randomly assigned 300 infants at >30 weeks of gestation with respiratory distress to receive either Hudson prong bubble continuous positive airway pressure therapy or headbox oxygen treatment (standard care). The primary end point was "up-transfer or treatment failure." Secondary end points included death, length of nursery stay, time receiving oxygen therapy, cost of care, and other measures of morbidity.

RESULTS

Of 151 infants who received continuous positive airway pressure therapy, 35 either were up-transferred or experienced treatment failure, as did 60 of the 149 infants given headbox oxygen treatment. There was no difference in the length of stay or the duration of oxygen treatment. For every 6 infants treated with continuous positive airway pressure therapy, there was an estimated cost saving of $10,000. Pneumothorax was identified for 14 infants in the continuous positive airway pressure group and 5 in the headbox group. There was no difference in any other measure of morbidity or death.

CONCLUSIONS

Hudson prong bubble continuous positive airway pressure therapy reduces the need for up-transfer of infants with respiratory distress in nontertiary centers. There is a clinically relevant but not statistically significant increase in the risk of pneumothorax. There are significant benefits associated with continuous positive airway pressure use in larger nontertiary centers.

Financial analysis of acetaminophen suicide in a teen girl

There is no doubt that prevention and primary care treatment is less costly than emergency room efforts and tertiary care to save someone's life. Preventive health care is the cornerstone of any health care system designed to reduce costs and human suffering (American Nurses Association, 1997). Unfortunately, emergency room and intensive care nurses frequently care for critically ill children and adults who suffer from conditions that might have been prevented. This case study presents the financial breakdown of the costs at each level of care for an 18-year-old college student who suffers terrible consequences of an acetaminophen overdose.

[Health care costs of acute myocardial infarction in Hungary, 2003-2005]

BACKGROUND

The morbidity of acute myocardial infarction (AMI) is remarkable in Hungary, therefore understanding the disease burden more accurately is inevitable.

AIM

We assessed the hospitalized AMI patient's burden on the financer both in active and chronic hospital care as well as outpatient visits and we estimated the size of indirect social costs.

METHODS

We assessed the active and chronic hospital care costs of 'new' AMI patients having the event in May 2003. The costs were assessed in the subsequent 12 and 24 months to the event in the population over 25 with the morbidity from the database of the National Health Insurance Fund Administration (NHIFA). Data were collected by gender and age (age groups 25-44, 45-64, 65 and over). Costs of GPs, specialist visits, transportation and productivity losses were taken into account as other costs.

RESULTS

Average health insurance costs of AMI's active hospital care in the first 12 months are generally higher in females as in males; 476.3 thousand HUF vs 391.1 thousand HUF (65 and over), 429.1 thousand HUF vs 389.4 thousand HUF (45-64) and 229.5 thousand HUF vs 240.6 thousand HUF (25-44). The burden in the chronic care is 15-40 thousand HUF per patient in the first year, which is similar to the active care costs in the 13-24th months after the AMI (22-54 thousand HUF).

CONCLUSION

NHIFA was estimated to spend 4.4 billion HUF on direct health care on behalf of the nearly 12 thousand annual AMI patients in the first 12 months, 3.6 billion HUF on the active and 370 million on the chronic hospital care. Avoiding one AMI could save 345-565 thousand HUF (depending on gender and age) direct health care cost in the first 12 months. In our estimation the annual indirect costs of AMI exceed 840 million HUF (177 829 HUF/patient) in the working age group.

Reverse transport of children from a tertiary pediatric hospital

INTRODUCTION

The purpose of this study was to determine the epidemiology and resources used and to study the potential savings of pediatric reverse transport patients.

METHODS

A case control study was performed with patients undergoing a reverse or outbound transport from a large, pediatric hospital. Twenty-five children undergoing reverse transport were compared with matched controls. Lengths of stay and costs were compared between the reverse transport and matched control patients.

RESULTS

Fifty-two percent of the reverse transport patients returned home, whereas 32% went home for end-of-life care and 16% went to other facilities. The average reverse transport was more than 400 miles and cost $6,064. The reverse transport of these patients did not save pediatric intensive care unit (PICU) days but did result in a shorter hospital stay compared with the matched controls (10 vs. 19 days, P = .03). Decreased utilization of bed days came from less use of intermediate care unit resources.

CONCLUSIONS

Pediatric patients undergo reverse transports for a variety of reasons, often for end-of-life care. The ability to reverse transport pediatric patients may not save PICU bed days but may offer pediatric tertiary care hospitals a means to provide more intermediate care bed availability.

Does distance affect utilization of substance abuse and mental health services in the presence of transportation services?

Long travel times have been identified as a significant barrier to accessing mental health and other critical services. This study examines whether distance to treatment was a barrier to receiving outpatient mental health and substance abuse care for HIV-positive persons when transportation was provided. Data from a cohort of HIV-positive persons who participated in a year-long substance abuse and mental health treatment programme were examined longitudinally. Transportation, which included buses, taxis, and mileage reimbursement for private transportation, was provided free of charge for participants who needed this assistance. Nearly three-quarters (74%) of participants utilized the transportation services. No statistically significant differences in retention in, or utilization of, the mental health and substance abuse treatment programme were identified by distance to the treatment site. This analysis demonstrated that increased distance to care did not decrease utilization of the treatment programme when transportation was provided to the client when necessary. These results provide preliminary evidence that distance to substance abuse and mental health services need not be a barrier to care for HIV-positive individuals when transportation is provided. Such options may need to be considered when trying to treat geographically dispersed individuals so that efficiencies in treatment can be attained.

Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport

Background

A study was conducted among newly registered HIV-positive tuberculosis (TB) patients systematically offered anti-retroviral treatment (ART) in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between “cost of transport” and ART acceptance.

Methodology/Principal Findings

A retrospective cross-sectional analysis was performed on routine program data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient's residence. Of 1,290 newly registered TB patients, 1,003(78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (X² for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (Adjusted Odds ratio = 4.0, 95% confidence interval: 2.0–8.1, P<0.001).

Conclusions/Significance

ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centers that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.

After hours healthcare for older patients in New Zealand--barriers to accessing care

AIM

To explore older people's attitudes and their perceptions of barriers when seeking medical care after hours.

METHOD

In-depth interviews and a focus group of older people were conducted and key informants were interviewed. The data was analysed using qualitative techniques.

RESULTS

Reluctance to be a nuisance, transport problems, cost, lack of information, and reluctance to see an unfamiliar doctor are among the barriers described by older people.

CONCLUSIONS

There were transport, cost, and social barriers to older people obtaining after hours medical care.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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