Review of:Brown LH, Hubble MW, Cone DC, et al: "Paramedic determinations of medical necessity: A meta-analysis."Prehospital Emergency Care. 13(4):516 527, 2009.
This is a meta-analysis study of multiple types of research on a broad topic. In this case, the authors wanted to evaluate U.S. paramedics' ability to determine medical necessity of ambulance transport. Using multiple medical library databases the authors searched for the following terms:
- Utilization review,
- Health services misuse,
- Severity of illness index and
- Trauma severity indices.
The initial search revealed more than 9,000 articles and abstracts, which were whittled down to five for full review. The reference standards included physician opinion (n=3), hospital admission (n=1), and a composite of physician opinion and patient clinical circumstances (n=1). The conclusion was that the results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport varied considerably, and only two studies reported complete data. The aggregate negative predictive value (NPV) of their determinations was 0.91, with a lower confidence limit of 0.71 (or under-triage rate of 9 29%).
These data don't support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments (EDs) and third-party payers.
To transport or not to transport? For some services this is not a question. But for others with limited resources and overcrowded EDs, the concept of allowing paramedics to "triage" patients for alternative means of transport might be a welcome idea.
In our review, Dr. Wesley trusts the fundamental research but disagrees with the authors' conclusions, while Medic Marshall examines the underlying issues that may be contributing to this controversial topic.
Doc Wesley:In the hierarchy of medical research, the pinnacle is randomized, double-blind controlled trials. For ethical and practical reasons, these are virtually impossible to do in EMS. The next level of evidence is to review as many similar studies and rank them as according to the quality of their data and strength of their conclusions, and attempt to combine their results into some semblance of order to provide a stronger foundation upon which to base a conclusion. This is called a meta-analysis, and it isn't easy to do.
The authors of this study have attempted to tackle a very difficult question: Can paramedics decide who can safely NOT be transported by ambulance? Unfortunately, there is no clear definition as to what "safe non transport" means. Their examination of 61 studies they accepted for analysis revealed extraordinary variability in the definitions and protocols utilized. Because of this, I believe the authors have misstated their conclusion. If the hypothesis is that such a practice is harmful. then the burden is on them to show the frequency with which it caused harm. The fact that there was such great variability in concordance (agreement) merely indicates there's insufficient evidence to support adopting this practice without further clarification of the definition, appropriate protocols to use and continuous quality improvement (CQI) process to ensure compliance.
One could make a similar meta-analysis of cardiac arrest survival across the nation. We have modern cities survival rates that continue to be less than 5% and others with remarkable rates exceeding 35%. Does this mean the evidence indicates that continued efforts to pursue improving cardiac arrest survival should be ceased? Of course not. It means we should learn from best practices to determine the factors that promote survival and incorporate them into our protocols.
Can paramedics determine who can safely be left at home to seek medical attention from an alternative source? Of course. It's just a matter of education, protocol development and medical oversight. Is it something you should consider in your service? Doubtful. Until the healthcare system back us up and provides our patients the resources they need, we'll continue to be the safety net.
So for the now the motto continues to be: "You call, we haul."
Medic Marshall:I'm concerned about the implications of this study. This meta-analysis is disturbing from a medic standpoint. The inference is that paramedics in the U.S. are unable to accurately and safely determine those patients who don't require ambulance transport. Specifically, the authors wanted to look at patients who call 9-1-1 requesting transport and are turned away because the paramedic determines it is not medically necessary.
First, how often did these paramedics encourage follow up with an ED or their primary physician despite not being transported? I don't believe the study was capable of determining this, and this is important when looking at the capability of paramedics determining "medical necessity" (more on this later.) The problem is that meta-analysis does not account for those who suffered irreparable harm or injury as a result of paramedics turning patients away.
The second issue I have is whether medical necessity equals medical transport. For the sake of argument, let's assume it does. But the issue of medical necessity is a problem for this study. The authors point to a strong discordance between physicians and what constitutes "medical necessity." How can paramedics be held accountable to determine medical necessity if physicians can't agree on a definition?
The authors claim it's possible for paramedics to do so if a standard reference were created. Unfortunately one hasn't been. This brings up another question: What are paramedics saying to their patients who request transport but ultimately aren't transported? Is it something like, "You don't need to go to the hospital. Just follow up with your primary physician" or "What would you like us to do for you other than transport you?" It's scary to think about. Yet sadly, I personally know of paramedics who do this.
Although I can't offer a strong opinion on the value of this study, I definitely think more research is needed on this topic. I would also suggest EMS organizations adopt strong quality assurance/improvement programs to address topics that fall within the high acuity/high frequency category. If what this paper is implying is true, EMS still has a long way to go in its development.
BloggersHappy Medic andMedic 999 discussed the differences between U.S. and U.K. medics' abilities to determine non-transport of patients during their international EMS exchange, dubbed "The Project."