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Guo B, Corabian P, Yan C, et al. Community Paramedicine: Program Characteristics and Evaluation [Internet]. Edmonton (AB): Institute of Health Economics; 2017 Sep.
This section is to address the following question:
The literature search identified four systematic reviews (for details, see Appendix E, Table E.1).
The systematic reviews by Hill et al.24 and Evans et al.1 focused on emergency care practitioners (ECP) within the United Kingdom context. The systematic review by Tohira et al.29 focused on the impact of community paramedicine on ambulance transportation to the emergency department. The review by Bigham et al.30 identified 11 studies published between 2000 and 2011 that measured outcomes of various community paramedicine programs. However, this review did not perform any formal critical appraisal of the methodological quality of included studies using a validated quality appraisal tool, which is a key component of a systematic review.
Overall, these reviews found that a number of studies of high methodological quality described care processes (diagnosis, investigations instigated, and treatment initiated) provided by ECPs to be equivalent to or better than that provided by practitioners with traditional roles. Pre-hospital ECPs provided “added value” by treating more patients at the scene, thereby reducing unnecessary referral to the emergency department. However, the appropriateness of the decision of the new pre-hospital practitioner and patient safety were not well supported by the available evidence.
The characteristics of the included studies are summarized in Appendix E. Of the 20 selected primary studies, four were conducted in Canada,17, 31–33 one in Australia,34 13 in the United Kingdom,27, 35–39, 26, 40, 41–45 and two in the United States.5, 46 Two studies reported on a cluster randomized controlled trial,27, 35 and all other studies are observational studies using different methods to collect data.
Most studies included all age groups, while some studies only included elderly patients (for example, over 60 years of age) or pediatric patients. Care provider populations also varied in terms of age, professional experience, and certifications (for example, EMTs, paramedics, nurses). ECPs were most frequently studied, and the majority of studies on ECPs were conducted in the United Kingdom.
The outcome measures reported in the included studies are presented below in Table 3.
Reported outcome measures.
The results of the methodological quality appraisal using the Downs and Black checklist are presented in Appendix C. The median score using the Downs and Black checklist was 15 (range from 11 to 22).
Most studies addressed a clearly defined question using an adequate methodology and reported outcomes clearly. However, the included studies suffer from several methodological limitations. For example, the majority of studies did not report important potential confounding factors such as patient characteristics or adjust outcome measures for these confounders. Most studies had inadequate follow-up or accounting for patients who were not assessed or treated by paramedics. In some studies, there was a lack of control group or comparison data. These methodological limitations have to be taken into account when interpreting the study outcomes.
One study conducted in Australia examined the impact of an extended care paramedic model (see Appendix E, Table E.2).34 The objective of this study was to explore the introduction of a rapid response team as outlined in the South Australian Palliative Care Services Plan for 2009–2016. Though the plan originally identified the service as being provided by nurse practitioners, the partnership model implemented utilized extended care paramedics for the provision of out-of-hours emergency care to palliative patients. Data were collected from across the metropolitan area of Adelaide. During the 118 days of the trial, there were 40 paramedic visits, which equates to visits on 10 days per month. About 78.5% of the patients requiring this service were registered with a specialist palliative care service. Satisfaction from patients, caregivers, and the extended care paramedics was high. The authors concluded that this partnership model has enabled an emergency out-of-hours service to be provided between the specialist palliative care and ambulance services. Furthermore, early data reveals that 90% of unnecessary and unwanted admissions to hospitals have been avoided in the palliative care population.
Four studies reported community paramedicine programs in Nova Scotia,17, 31 Alberta,32 and Ontario33 (see Appendix E, Table E.3).
The longitudinal study by Martin-Misener et al. examined the impact of a nurse practitioner-paramedic-family physician model of care on patients and the healthcare system in the geographically remote area of the Long and Brier Islands in Nova Scotia.17 The study sample included 86 Caucasian residents at Year 1, 85 at Year 2, and 50 at Year 3. There were no significant differences between participants over the three time periods in terms of age, gender, number of children or family members living with the participant, education level, location of family physician, or identification of someone they could talk to about their illness.
The study of this innovative model of care with a 3-year follow-up showed a reduction of patient visits to the emergency department and general practitioners, reduction in healthcare costs (medication prescription and travel cost), increase in patient access to healthcare services (including access to nurse practitioners and paramedics, and health promotion and disease prevention programs/services), and a high level of patient acceptance and satisfaction with the healthcare services they received. There were no statistically significant differences over time in total Psychosocial Adjustment to Illness Scale (PAIS) scores over time.
For detailed reporting on the cost and cost-effectiveness results for this study, please see the economic analysis in section 7.
Another study conducted in Halifax, Nova Scotia examined the impact of extended care paramedics involved in long-term care calls.31 In this study, data were collected from consecutive calls to 15 participating long-term care facilities for three months. Dispatch determinants, transport rates, and relapse rates were compared for long-term care patients attended by extended care or emergency paramedics. The involvement of extended care paramedics in end-of-life care was identified.
Of 238 eligible calls, 140 (59%) were attended by an extended care paramedic (intervention group) and 98 (41%) by emergency paramedics (control group). Although the top three determinants were the same in each group, the overall distribution of dispatch determinants and acuity differed. The study showed a significant reduction of transfers to an emergency department (extended care paramedic: 6% versus control: 79%) and an increase in patient numbers not transferred to an emergency department (extended care paramedic: 70% versus control: 21%). In the extended care paramedic group, 6 out of 98 (6%) patients not transported to an emergency department triggered a 911 call within 48 hours for a related clinical reason, although none of the patients not transported by emergency paramedics relapsed.
Although this study showed reduced rates of transport to an emergency department with a low rate of relapse, the authors suggested that future study is needed to determine the appropriate populations for extended care paramedics and to analyze the appropriateness and safety of those patients who were not transported to an emergency department.
A recent study conducted in Alberta examined the impact and clinical outcomes of a pre-hospital T&R/ATR protocol on patients with uncomplicated supraventricular tachycardia (SVT).32 Data were linked from the AHS EMS electronic patient care record database for the city of Calgary to the Regional Emergency Department Information System. All SVT patients treated by EMS between 1 September 2010 and 30 September 2012 were identified.
There were 229 confirmed SVT patient encounters. The T&R protocol was used in 75 events; 10 of these (13%; 95% CI [7.4, 23]) led to an EMS re-presentation within 72 hours, and 4 (5%; 95% CI [2.1, 13]) led to presentation at an emergency department. All re-presentations were attributed to a single individual. After excluding 15 records that were incomplete due to limitations in the electronic patient care record database platform, 43 of 60 (72%) T&R encounters met all protocol criteria for T&R.
The T&R protocol evaluated in this study applied to a significant proportion of patients presenting to EMS with SVT. Risk of re-presentation following this protocol was low, and paramedic protocol adherence was reasonable. The T&R protocol appears to be a viable option for uncomplicated SVT in the pre-hospital setting.
A retrospective case series study conducted in Ontario evaluated the impact of an “aging at home” program that uses an integrated healthcare team involving community paramedics on 911 calls.33 Data were collected from a chart review of clients participating in the program located in a rural community between 1 January 2010 and 30 April 2011. Each record was evaluated for the presenting problem and whether transport to a local emergency department was initiated by using 911.
Of the 129 client interactions by community paramedics and personal support workers, 13 chief complaint categories were determined and 15 incidents resulted in emergency department visits by using 911, suggesting that the contributions of community paramedics in an aging at home program can contribute to a reduction in 911 activations without compromising the health of the clients. The authors concluded that the use of community paramedics in an integrated healthcare team aimed at supporting clients living at home demonstrates a negative correlation in the use of 911 calls.
Thirteen selected studies examined the safety and/or clinical effectiveness of ECPs within the United Kingdom’s healthcare systems (see Appendix E, Table E.4). One cluster randomized controlled trial was reported in two publications.27, 35 No individual patient randomized controlled trial was found, and all other included studies were observational studies.
The ECPs evaluated in these studies varied in terms of the care provider (nurses or paramedics with additional training), target population, care provided (assessment, diagnosis, treatment, education, or follow-up), setting (urban, rural/remote, patient’s home, or long-term care facilities), and outcome measures. All patients were adults except for one study that included only pediatric patients.
In all included studies, the scope of the ECPs was tailored to the needs of the local communities (urban or rural settings), and all care providers received additional training beyond the scope of practice for a locally identified paramedic. Competencies with extended roles of paramedics included the assessment of minor acute and chronic diseases/conditions or injuries, provision of non-traditional pathways to facilitate further assessment, treatment, and follow-up, and provision of on-site health promotion education and surveillance of chronic diseases/conditions (see Table 2 above, in section 5).
The most frequently reported outcome measure was transfer to an emergency department, followed by discharge at the scene, and subsequent attendance at a healthcare service.
The cluster randomized controlled trial involved 3,018 elderly patients who were older than 60 years of age, with 1,549 patients in the intervention group and 1,469 patients in the control group. One study, Mason et al. (2007), reported the safety and efficacy outcomes of all 3,018 participants,27 and another study, Mason et al. (2008) analyzed a subgroup of 2,025 patients from the original sample of 3,018 patients and assessed and reported the safety outcomes, in particular.35
Mason et al. (2007) found no significant difference in 28-day mortality between the intervention and control groups (RR 0.87, 95% CI [0.63, 1.21]).27
Mason et al. (2008) found that 219 (10.9%) had an unplanned emergency department visit within seven days; 162 (74.0%) of these re-presented with a condition related to their initial episode. The independent raters agreed on suboptimal care 83.4% of the time. There were 16 agreed upon episodes related to suboptimal care (0.80%). No significant differences were found between the intervention and control groups in relation to re-presentation at a hospital within seven days for a related condition, or in relation to rates of assessed suboptimal care.
Overall, patients in the intervention group were less likely to attend an emergency department (RR 0.72, 95% CI [0.68, 0.75]) or require hospital admission (RR 0.87, 95% CI [0.81, 0.94]) within 28 days, and they experienced a shorter total episode time (235 versus 278 minutes, 95% CI for difference [−60, −25 minutes]).
Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (RR 1.16, 95% CI [1.09, 1.23]).
Mason et al. (2007) concluded that paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.27 In addition, Mason et al. (2008) suggested that appropriately trained paramedics with extended skills treating older people with minor acute conditions in the community are as safe as standard EMS transfer and treatment within the emergency department.35
Evidence from other observational studies suggests the following:
However, some studies also found the following:
Two studies evaluated community paramedicine programs implemented in the United States (see Appendix E, Table E.5).5, 46
One historical cohort study evaluated the impact of the San Diego Resource Access Program (RAP), an EMS-based case management and referral intervention pilot meant to reduce EMS, emergency department, and inpatient visits.5 The study sample consisted of adults with 10 or more EMS transports within 12 months and others reported by pre-hospital personnel with significant recent increases in transports. Between the pre- and post-periods, EMS encounters declined by 37.6% from 736 to 459 (P= 0.001), resulting in a 32.1% decrease in EMS charges from $689,743 to $468,394 (P= 0.004). The EMS task time and mileage decreased by 39.8% and 47.5%, respectively, accounting for 262 hours (P= 0.008) and 1,940 miles (P=0.006). The number of emergency department encounters at the one participating hospital decreased by 28.1% from 199 to 143, which correlated with a 12.7% decrease in charges from $413,410 to $360,779. The number of inpatient admissions declined by 9.1% from 33 to 30, corresponding to a 5.9% decrease in inpatient charges from $687,306 to $646,881. Hospital length of stay declined 27.9%, from 122 to 88 days. Across all services, total charges declined by $314,406. This pilot study demonstrated that an EMS-based case management and referral program was an effective means of decreasing EMS transports by frequent users, but had only a limited impact on use of hospital services.
The second study describes the development, implementation, and experience of a novel, community-based program that leveraged the existing EMS system to identify rural-dwelling older adults with unmet medical and social needs.46 The program specifically included: geriatrics training for EMS providers; screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; communication of EMS findings to community-based case managers; in-home evaluation by case managers; and referral to community resources for medical and social interventions. The measures used to evaluate the program included patient needs identified by EMS or in-home assessment, referrals provided to patients, and patient satisfaction. EMS screened 1,231 of 1,444 visits to older patients (85%); of those receiving specific screens, 45% had fall-related needs identified, 69% had medication management-related needs, and 20% had depression-related needs. One hundred and seventy-one eligible EMS patients who could be contacted accepted in-home assessment. Of the 153 individuals completing the assessment, 91% had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in a rural community, although many will refuse the services.
In 2014, Ontario researchers Drennan et al. published a protocol for a pragmatic, randomized controlled trial that would compare community paramedics with standard care in patients with diabetes mellitus, heart failure, or chronic obstructive pulmonary disease. The objective of the trial is to determine whether community paramedics conducting regular home visits (including health assessment and evidence-based treatment), in partnership with primary care physicians and other community-based resources, could reduce the rate of hospitalization and emergency department use for patients with these conditions.47 The lead author was contacted for an update on the trial; however, no response has been received as of the end of June 2017.
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