Review Of: Weaver M, Moore C, Patterson D, et al. Medical necessity in emergency medical services transports. Am J Med Qual. 27 December 2011. Epub ahead of print.
The Science: This is cross-sectional study of 10 years of data collected from the National Hospital Ambulatory Medical Care Survey on medically unnecessary EMS transports to emergency departments (EDs). The goal was to evaluate the prevalence of these transports, identify trends and determine whether insurance status was a predictor of unnecessary transports.
The investigators found an increase in medically unnecessary transports from 1997 to 2007: 13% to 17% over the time period. They also found that insurance status was not a predictor of these transports, either. They concluded that there may be opportunities for alternative strategies for select patients seeking EMS care.
Medic Marshall: I applaud the authors of this study for attempting to determine the prevalence of unnecessary medical transports by EMS. By the looks of this study, it only continues to grow—especially because the number of ED visits are steadily climbing, for which EMS comprises about 15% of ED visits. The transports unfortunately put an undue burden on EMS organizations and demand an already dwindling pool of resources, which makes it more difficult for these transports to be reimbursed as well.
However, I think this study needs to be interpreted with some caution. Although the samples were drawn from a national representative database, it’s difficult to actually determine the rate of medically unnecessary transports.
Furthermore, it’s difficult to determine what other factors may influence the numbers, such as EMS documentation and justification for transport, skill and comfort level of EMS providers to not transport patients, organizational policy, and guidelines regarding the transport or non-transport of certain patient populations. In addition, changes in reimbursement by insurance companies and Medicare/Medicaid have put added pressure on EMS organizations to increase the number of transports (which may include medically unnecessary transports).
So I’m a little hesitant to agree with the conclusion that alternative destinations may be an answer to reducing the number of medically unnecessary transports. I believe further evaluation is needed regarding what the effects of organizational policy and medical guidelines are on EMS providers to transport patients to EDs in the first place. Or perhaps EMS needs to start adopting new strategies to prevent the medical emergencies from occurring in the first place.
Doc Wesley: Like many studies of this kind, the devil is in the details. I agree with Marshall that the authors undertook a tremendous challenge by examining the largest existing database on hospital visits. Although the percentage of “unnecessary” transports rose over the period examined, their results were significantly lower than previously published studies that only measured visits to a few select institutions.
Another surprising finding was that there was no relationship between insurance status and the rate of unnecessary EMS transports. This directly conflicts other studies that have linked uninsured status with higher rates of unnecessary transports. The best finding of this study was the most common diagnosis for those felt to not warrant EMS transport. These included substance abuse, urinary track infection, backache and gastroenteritis.
An important factor that this study failed to examine was the level of EMS that transported the patients. BLS services would be significantly less likely to implement alternate destination policies without access to appropriate on-scene evaluation by an ALS provider.
Although there continues to be debate over the ability of ALS providers to perform screening exams for alternate destination, this study does indicate that programs interested in exploring such a program would be best served by initially addressing the most common reason for unnecessary transport.
The purpose of this study was to generate national estimates of the prevalence of medically unnecessary emergency medical services (EMS) transports to emergency departments (EDs) over time and to identify characteristics that may be associated with medically unnecessary transports. A previously published algorithm was applied to operationalize medical necessity based on ED diagnosis to 10 years of data from the National Hospital Ambulatory Medical Care Survey. The trend over time was reported using descriptive statistics weighted to produce national estimates. Nationally, the proportion of EMS transports that were medically unnecessary increased from 13% to 17% over the 10-year study period. Individual demographic characteristics, including insurance status, were not predictive of inappropriate utilization. EMS transports for medically unnecessary complaints increased from 1997 to 2007. Our findings from a nationally representative sample highlight the opportunity for alternative patient delivery strategies for select patients seeking EMS services.