Chapter 49 Graham Nichol Economic evaluations of medical technologies assess the effectiveness and cost of the technologies so that physicians, policy makers, and the general public can decide which technologies offer sufficient value for the money. The cost-effectiveness of health care interventions including EMS must be demonstrated definitively if claims of their public health benefit are to have scientific credibility [1]. Since some experts question the merits of interventions to improve resuscitation care [2], while others endorse such interventions [3], we believe that economic evaluations of EMS provide critical information to inform public policy. Many important outcomes must be considered when evaluating the effectiveness of an intervention. A key outcome consideration is cost (“destitution” in the framework of the “six Ds of outcome”). Although it can be intellectually difficult to consider cost as a health care constraint, the reality is that even when it comes to health care, all resources are finite and selecting the most cost-effective intervention is an important decision. This chapter will discuss conducting economic evaluation of health interventions in the out-of-hospital setting and will describe a methodology for determining the cost of an EMS intervention to the community it serves that was developed by the EMS Cost Analysis Project (EMSCAP), sponsored by the National Highway Traffic Safety Administration (NHTSA) [4]. Although EMS research is an emerging field, some projects have worked to establish effectiveness, such as the Ontario Prehospital Life Support Study (OPALS) [5–7]. Interventions such as treatment of non-traumatic cardiac arrest [8–12] and use of a formalized system of care for severe trauma [13–18] are known to be effective. However, little is known about the cost-effectiveness of most EMS interventions. A structured literature review found that from 2003 to 2013 there were only 60 published economic evaluations of EMS interventions. Only 14 of these evaluations were considered full economic evaluations. Further, using a published checklist for evaluating the quality of an economic evaluation [19], the authors found that most of these studies were of poor quality [20]. They also determined that there were inconsistencies in how EMS costs were measured, indicating the need for a standardized approach to calculating the cost of EMS. In general, there are four types of cost analyses that are full economic evaluations. The term full economic evaluation means that the costs and the consequences of two or more interventions are compared. The primary difference between the four types of full economic evaluations is how the outcome is measured. A cost-benefit analysis measures the outcome, or the effect of an intervention, in dollars. For example, Riediger and Fleischmann-Sperber estimated that the annual cost for their EMS system was $8.3 million and that the outcome from providing EMS care was $44.3 million in socioeconomic cost savings to the community [21]. Cost-effectiveness analysis measures a common effect, such as lives saved, between two interventions and reports the result in terms of effect per unit of cost. The effect is measured in natural units such as the amount of disability or health care resources consumed. A common example is the reporting of cost per life saved. For example, Forrer et al. assessed the cost-effectiveness of implementing a police automated external defibrillator program and estimated the cost per life saved ranged from $23,542 to $70,342 and the cost per year of life saved ranged from $1,582 to $16,060 [22]. In a cost-utility analysis the effect is measured in quality-adjusted life-years. For example, Nichol et al. found that the mean incremental cost per quality-adjusted life-year for lay responder defibrillation was $46,700 (95% confidence interval (CI) $23,100 to $68,600) [23]. Finally, a cost-minimization analysis compares two equivalent treatments and determines which has the lowest cost. De Wing et al. used this method and found that burn patients transported by helicopter who could have also been safely transported by ground ambulance had a sevenfold to eightfold increase in transportation charges (assumed to be the actual cost, which is not always a valid assumption in health care research – see later) compared to burn patients transported by ground ambulance [24]. Extensive literature can be found on how to conduct economic analyses in health care settings. A key factor in ensuring external validity is that standardized guidelines be followed. This allows comparisons to be made across studies and between systems. The Panel on Cost-Effectiveness in Health and Medicine published guidelines for standardizing economic analyses in health care [25]. These guidelines recommend that the costs and consequences of an intervention always be considered. However, calculating EMS system costs is complicated and is not specifically addressed in existing textbooks apart from the first edition of this book. In addition, a comparison of the existing cost-analysis literature in EMS found that there was no standard approach to calculating EMS system costs [26]. NHTSA-sponsored EMSCAP project created a standardized guideline for what to include when calculating the cost of EMS (Table 49.1) [26].This guideline accounts for all the costs of the EMS system regardless of who pays for them. Thus, this approach determines the cost of the EMS system from the community’s perspective. Table 49.1 EMS cost framework components (listed alphabetically) [26]
Economic evaluation of EMS-related interventions
Introduction
State of cost analysis research in EMS
Types of cost analyses
Conducting a full economic evaluation
Category
Description
Administrative overhead
Include the cost of all of the following;
Quality assurance of system
Occupational safety (e.g. fit testing, vaccinations)
Occupational health services
Janitorial
Laundry
Water, sewer, and electric utilities
Billing, collections
Insurance
Liability
Workers’ compensation
Vehicle
Assets/building
Secretarial
Legal
Human resources
Regulatory compliance
Office equipment, consumable and durable
Personnel recruitment
Accreditation (Commission on Accreditation of Ambulance Services, etc.)
Travel
Accounting and auditing
Bystander response
Bystander response to medical
emergencies (e.g. community CPR
defibrillation or first aid) Include the cost of all of the following:
Training (e.g. instructor, location, equipment)
Equipment
Retraining
Communications
Include the cost of all of the following:
Public safety answering point equipment and facilities
Dispatch center software (e.g. computer aided dispatch system), equipment and facilities
In-vehicle communication devices Portable/wireless devices, including radios and cell telephones
Medical oversight/hospital communication devices EMS communication infrastructure (e.g. trunk system, telephone system, or satellite [but not cell telephone towers, etc. because these are sunk costs])
For each include the cost of:
Acquisition
Operation
Maintenance
Replacement
Equipment
Any equipment necessary to train, provide, maintain, or administer the EMS system (e.g. personal protective equipment, computers used for dispatch, etc). There are two types of equipment: durable (i.e. used multiple times) and consumable (i.e. used only once and discarded). This should include the cost of:
1. Durable equipment
Acquisition
Operation
Maintenance
Replacement
2. Consumables
Acquisition
Replacement (including caused by expiration)
Human resources
All personnel involved in organized EMS response, whether paid or unpaid, including any labor costs associated with any of the listed cost categories (e.g. field providers, dispatchers, maintenance, billing, training personal, etc.).
This should include the cost of:
Salaries
Benefits
Overtime
Training (overtime pay, stipend, etc.)
Information systems
This could include but is not limited to medical record systems and billing systems.
This should include the cost of:
Acquisition
Operation
Maintenance
Replacement
Medical oversight
A physician may be employed by the EMS agency, in which case the cost may be accounted for in human resources; otherwise, estimate cost, not simply charges; also consider that administrative overhead may be borne by other entities but should be accounted for (e.g. malpractice insurance, travel, communication equipment).
Include the cost of all of the following:
Quality assurance/quality improvement of out-of-hospital emergency care
Direct medical oversight
Indirect medical oversight
Physical plant
Any buildings necessary to train, provide, maintain, or administer the EMS system. This should include the cost of:
Acquisition
Operation
Maintenance
Replacement
Training
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
Economic evaluation of EMS-related interventions
Source: Lerner 2007 [26]. Reproduced with permission of Elsevier.