"Generic Prehospital Assessment Form"
EMS Outcomes Research: Defining our Future Todd Hatley, MBA, MHA, REMT-P Assistant Professor, PreMIS – Clinical Research Associate Director Department of Emergency Medicine University of North Carolina – Chapel Hill President, NEMSMA firstname.lastname@example.org www.unc.edu/~thatley Outcomes Research • “What Works” • Do particular treatments or procedures affect outcomes? Reasons • To improve the knowledge base of medicine • To provide accountability • To make marketing decisions Understanding Healthcare Outcomes Research – Kane 1997 Problems • Outcomes may be due to numerous factors • Outcomes do not always point directly to process changes that need to occur • Usually require extra effort and cost to collect • Outcomes are essentially probability statements • Long term project • Outcome may be in distant future Kane, R.L. Understanding Health Care Outcomes Research Donabedian • Structure – training, equipment, • Process – what was done • Outcomes – results of the action Study Designs • Randomized Control Trials – Difficult to coordinate – Costly – Restricted to target group – Rely on random allocation – Trade internal validity for external validity Study Design • Epidemiological approach – Applied to observational data – Inability to be sure that differences are not from unobservable variation – Substantial amount of inference in analysis but easier transition to practice The Algebra of Effectivenss CLINICAL FACTORS Principal diagnosis Severity/extent of principal Complications, Severity/extent diagnosis and iatrogenic Comorbid illness of principal comorbidities illness severity/extent diagnosis Acute clinical Acute clinical Physical stability stability Physical functional functional status status Age, sex Survival Patient Factors Treatment Outcomes + effectiveness + Random events ----> Patient attitudes and Health-related preferences quality of life Resource use Health-related quality of life Cultural, Psychological, ethnic, and cognitive, socioeconomic psychosocial attributes, beliefs, functioning and behaviors NON-CLINICAL FACTORS Satisfaction Lisa Iezzoni - Risk Adjustment for Measuring Healthcare Outcomes. Outcome Measures • Generic Measures – comprehensive measures that assess the overall effects on health status • Condition Specific – focus on symptoms and signs that reflect the status of a given medical condition • Satisfaction – the patient’s response to his/her evaluation of the healthcare providers performance Outcome Measures Measurement Scale High n tio ct ep fe lity ng rc Ef sa tio s pe Z om at ct bi ni e eg e iv l na Fu pt N E ff Di nc so m ve r Sy le Pe k Ro iti or s Objective W Po fe Health Status f Li Y o lity Psychological ) a ,Y Qu Physical X Q( Social Low High X tion e ep tiv s rc jec Pe ub S Health Domains Low Testa, MA and Simonson DC, NEJM, 334;835-840, 1996 Generic Outcome Measures • Unidimensional – Index of ADL – Comprehensive Older Person’s Evaluation – Self-rating anxiety scale – Self-rating depression scale – Mental status questionnaire – Social Health Battery Generic Outcome Measures • Multidimensional – 36 item Short Form Health Survey – Sickness Impact Profile – Nottingham Health Profile – Duke-UNC Health Profile – Dartmouth COOP Charts Generic Outcomes Measures • Four D’s – Death – Disease – Disability – Discomfort Condition Specific Measures • Symptoms • Signs • Test Satisfaction • Group Health Association of America Consumer Satisfaction Survey – Assessment of Health Plans • Picker/Common Wealth Survey – Assessment of Hospital Satisfaction • Patient Satisfaction Scale – Assessment of patient’s perception of physician Risk Adjustment • “..Effort to create a level playing field.” • Many factors can influence outcome of care. • Some refer to as case-mix adjustment Classes of Risk Adjusters • Severity • Co-morbidity – Heart disease – Diabetic • Demographics – Age (young, old) – Sex – Race and Ethnicity Measurement Outcome = f (baseline, patient clinical characteristics, patient demographics/psychosocial characteristics, treatment, setting) Conceptual Model Treatment •Specific Medication Clinical Factors •Diet •Cardiac Output •Exercise •Severity •Case Management •Duration •Etiology •Co-morbidity •Prior Status Outcomes •Cardiac Output •Symptoms Patient Factors •Function •Age •Gender •Complications •Occupation •Quality of life •Employment/work loss How do we assess the effects of care provided in the out-of-hospital environment? Callaham M. Quantifying the scanty science of prehospital emergency care. Ann Emerg Med. 1997;30:785-790. Where’s the evidence • Prehospital fluids • Response time 90% 8:59 • Epinephrine • Atropine • Lidocaine • Amiodarone • Ventilator rates “Measuring Morbidity Outcomes in EMS” workshop NHTSA 1994 EMSOP Objectives and Goals • Identify conditions that should take precedence on EMS outcomes research; • Determine the appropriate risk adjustment measures for the priority conditions identified; • Determine the appropriate outcome measures for the priority conditions identified; • Identify stakeholders and constituencies important for EMS outcomes research; • Develop a research dissemination plan. • (Identify Datasets that are available.) The Episode of Care Model EMERGENT PREHOSPITAL ED SUBSPECIALTY INPATIENT FOLLOW-UP CARE CARE CARE CARE CARE Precipitating Event Care complete “Units of Service” The Episode of Care Model Prehospital Emergency Emergent Inpatient Follow-up Care Department Subspecialty Care Care Care Care RA T OUT RA T OUT RA T OUT RA T OUT RA T OUT RA = Risk Adjustment Precipitating Event T= Therapeutic Intervention(s) Long-Term Outcomes OUT = Outcome Measures Prehospital Unit of Service Model for EMS Outcomes Research Prehospital Emergency Emergent Impatient Follow-up Care Department Subspecialty Care Care Care Care Prehospital Care Assessment Scene Treatment Patient Removal Transport Interval Interval Interval Interval Precipitating Risk Intervention(s) Intervention(s) Outcome Event Adjustment Measures Measurements Core Risk Adjustment Measures (RAMs) • Age • Final level of responsiveness • Sex (at time of transfer of care) • Race & Ethnicity • Initial Glascow Coma Scale • Initial vital signs • GCS before and after • Vitals before and after major intervention intervention • Final GCS • Final vital signs (at time of • Event to treatment interval transfer of care) • Prehospital treatment interval • Initial level of consciousness • EMS provider impression of • Level of responsiveness presenting condition before and after an intervention RAMs Requiring Linkage • Principle Diagnosis ( Primary ICD-9 Code) • Patient Co-Morbidity (Secondary ICD-9 Codes) Core Outcome Measure • Medically Meaningful • Readily available in the prehospital environment • Used in other healthcare settings • Agreed to by EMSOP and consultants Generic EMS Outcome Measures • Six D’s – Death (Survival) – Disease (Impaired Physiology) – Disability – Discomfort – Destitution (Cost) – Dissatisfaction Death • Should be evaluated in the following settings: – Prehospital interval – Emergency Department interval – After hospitalization before discharge • Disposition should also be considered – Treat/release at scene – Treated/released from ED – Treated in the ED and admitted to hospital – Discharged alive from hospital Disability • None recommended • Lack of validation • Not routinely obtained on emergency patients Discomfort • Most relevant • May be the area of greatest impact Patient Satisfaction • Indicator of quality care • Can be used to assess the performance at the organization, unit and individual level • No generic model has been developed for EMS Cost • Cost-effectiveness analysis – Measured in natural units such as disability • Cost-benefit analysis – Measured by cost • Cost-utility analysis – Measured in quality adjusted life years EMSOP Priority Conditions • Adults • Pediatrics – Minor trauma – Minor trauma – Respiratory Distress – Major trauma – Chest Pain – Respiratory distress – Major Trauma – Airway obstruction – Airway Obstruction – Respiratory arrest – Cardiac Arrest – Cardiac arrest Minor/Major Trauma Condition Specific Measures • Risk adjuster • Outcome – RTS – TRISS – GCS – FIM (Functional – ASI Independence Measure, – ISS not applicable to minor trauma)* – NISS – SF-36 (Medical Outcomes Short Form 36 item)* – SIP (Sickness Impact Profile) Respiratory Distress Condition Specific Measures • Risk Adjusters • Outcome Measures – PEFR (Peak – No outcomes measure Expiratory Flow Rate) could be used for all – Oxygen saturation patients – Dyspnea scale – Oxygen saturation • Visual analogue – PEFR – Dyspnea scale Maybe we need to redefine our mission “Saving Lives” vs. “Relieving Discomfort” Research Needed • Studies to substantiate or refute the appropriateness of the previous measures; • Studies to determine the feasibility and reliability of using outcomes measure among all levels of prehospital provider; • Studies to determine if feasibility and reliability vary based on condition and/or core risk adjustment measures. CPR-Only Survivors of Out-of-Hospital Cardiac Arrest: Implications for Out-of-Hospital Care and Cardiac Arrest Research Methodology Valerie De Maio ANNALS OF EMERGENCY MEDICINE 3 7 : 6 JUNE 2001 Performance Measures Major/Minor Trauma: 90% of pts with moderate or greater pain will have a decrease in the NRS Chest pain: 90% of patients will have decrease of chest pain upon arrival at ED Respiratory Distress: 90% of patients will have decreases of the VASD upon arrival at ED Pediatric Seizures: 90% of pts will not be actively seizing on ED arrival Cardiac Arrest: 20% W/VF discharged alive and N intact RA/AO: 90% adequately ventilated on arrival to ED My Bias • Evidence Based practice – OPALS • Performance Improvement – Six sigma improvement – Statistical process control • Benchmarking – Sharing of Best practices Questions References • Understanding Health Care Outcomes Research by Robert l. Kane, Aspen Publishing , 1997. • NHTSA Outcomes Research Final Report • Donabedian • Harvard Course Healthcare Outcomes Design