Emergency Medical ServicesOutcomes Project (EMSOP):An OverviewDTNH22-96H-05245 :Emergency Medical ServicesOutcomes Project (EMSOP):An OverviewDTNH22-96H-05245 Ronald F. Maio DO, MS University of Michigan Department of Emergency Medicine


Gameplan :Gameplan Background Methods Results Application


Origins :Origins NHTSA Uniform Prehospital EMS Data Conference - August 1993 Attendees wanted outcome measures Emphasis on non-mortality NHTSA Morbidity Outcomes Workshop - April 1994


NHTSA Workshop: Outcome Measures :NHTSA Workshop: Outcome Measures Death Disease Disability Discomfort Dissatisfaction Destitution


NHTSA Workshop: Recommendations :NHTSA Workshop: Recommendations 1) Identify priority conditions 2) Improve/standardize risk adjustment 3) Identify outcome measures 4) Support proven evaluation methods 5) Support development of databases 6) Provide info to stakeholders 7) Identify stakeholders/ build support 8) Identify barriers


Priority Conditions:Frequency and Magnitude of EMS Impact :Priority Conditions:Frequency and Magnitude of EMS Impact


EMSOP :EMSOP Support and facilitate outcomes research Focus on emergent acute care Provide a “blueprint” Provide a “toolbox”


EMSOP: Personnel :EMSOP: Personnel PI and Co-PIs Ron Maio, Herb Garrison, Dan Spaite Co-Investigators Jeff Desmond, Mary Ann Gregor Consultant Panel Gene Cayten, John Chew, Ellen MacKenzie, David Miller, Patricia O’Malley, Ian Stiell Technical Consultants Year 1 Steve Joyce, Doug Brown


EMSOP:Vision :EMSOP:Vision


EMSOP:Vision :EMSOP:Vision


EMSOP: Reality :EMSOP: Reality


EMSOP: Reality :EMSOP: Reality


Identifying Priorities :Identifying Priorities Generate an initial list of conditions Compile frequency data Determine magnitude of potential impact Develop summary score and rank


Priority Conditions:Frequency and Magnitude of EMS Impact :Priority Conditions:Frequency and Magnitude of EMS Impact


Development of Pool of Conditions :Development of Pool of Conditions NHTSA Uniform Prehospital EMS Data Elements Amalgam list of illness, injury, signs and symptoms 29 conditions


EMS Frequency DataEMS Data Systems Inc. :EMS Frequency DataEMS Data Systems Inc. Emergency transports: scene to ED 7/1/95 to 6/30/96 Alabama Mississippi Illinois Oklahoma American Medical Response Central California counties


The Next Step :The Next Step How to measure the potential impact of EMS intervention on these conditions?


Determining Impact :Determining Impact Ask opinions Physicians, Administrators, Providers Consider Relevance of outcome category Potential impact


Priority Conditions: < 15 :Priority Conditions: < 15 Condition Freq. Wght. Score Index Minor Trauma 51.34% 9.60 34.30 Major Trauma 7.92% 17.90 25.68 Respiratory Distress 9.96% 14.97 24.40 Airway Obstruction 1.13% 17.91 22.54 Respiratory Arrest 0.44% 16.25 20.60 Cardiac Arrest 0.84% 14.39 19.09 Seizure 14.12% 8.96 18.99


Priority Conditions: > 15 :Priority Conditions: > 15 Condition Freq. Wght. Score Index Minor Trauma 36.10% 10.28 33.39 Respiratory Distress 12.95% 15.34 26.50 Chest Pain 10.24% 14.84 24.07 Major Trauma 3.57% 17.14 21.47 Cardiac Arrest 2.24% 15.85 19.40 Airway Obstruction 0.17% 17.63 19.27 Respiratory Arrest 0.19% 16.30 18.28


< 15 - Weighted Score :< 15 - Weighted Score


> 15 - Weighted Score :> 15 - Weighted Score


The Next Step :The Next Step Identify risk adjustment measures Identify appropriate outcome measures


“Risk Adjustment” :“Risk Adjustment” “…account for pertinent patient characteristics before making inferences about effectiveness or quality of care..” Compare apples to apples


Conceptual Framework :Conceptual Framework The Episode of Care


Identifying RAs and Outcome Measures :Identifying RAs and Outcome Measures Literature review Panel discussion Previous use in Prehospital or other venues Feasibility Focus on “real world” Also considered research arena Recommendations for evaluation


What Have WeAccomplished? :What Have WeAccomplished? Evaluation of methodology Conceptual framework Focus for research and evaluation Priority conditions Importance of non-mortality measures “Toolbox”


What Have WeAccomplished? :What Have WeAccomplished? Maio RF, Garrison HG, Spaite DW, et al: EMSOP I: Prioritizing conditions for outcomes research, Annals of Emergency Medicine 33(4):423-432, 1999. Spaite DW, Maio RF, Garrison HG, et al. EMSOP II: Developing the foundation and conceptual models for out-of-hospital outcomes research. Annals of Emergency Medicine 37(6):657-663, 2001. Garrison HG, Maio RF, Spaite DW, et al. EMSOP III: Risk adjustment measures for out-of-hospital outcomes research. Annals of Emergency Medicine (in press).


What Have WeAccomplished? (cont’d.) :What Have WeAccomplished? (cont’d.) Maio RF, Garrison HG, Spaite DW, et al. EMSOP IV: Pain measurement in out-of-hospital outcomes research. Annals of Emergency Medicine (in press). Spaite DW, Maio RF, Garrison HG, et al. EMSOP V: Establishing the scope and methodological approach to out-of-hospital outcomes and effectiveness research (submitted). McLean SA, Maio RF, Spaite DW, Garrison HG. EMS outcomes research: evaluating the effectiveness of prehospital care. Prehospital Emergency Care 6(2 Suppl):S52-56, 2002. Garrison HG, Maio RF, Spaite DW. Application of measurement tools to pediatric emergency medicine. Ambulatory Pediatrics (in press).


Disappointments :Disappointments Satisfaction measures Cost measures Pediatric measures (infants, special needs) Data sets


Future Applications :Future Applications Acceptance of Priority conditions Tracers Philosophical Issue: Accept importance of non-mortality measure Relieve discomfort vs. save lives


Future Applications:Pain :Future Applications:Pain Is pain a substantial problem among prehospital patients? 1999 NHAMCS 52% no pain measure 20% moderate/ severe pain 14% mild 14% none Conservative estimate: 1 in 5 have substantial pain


The Next Step :The Next Step Evaluate Feasibility Describe the “epidemiology” Monitor/Modify Researchers: identify/develop/evaluate measures conduct observational research conduct interventional research


Challenges :Challenges Access to data Funding Manpower Human use issues Effective dissemination


Summary :Summary The “Age of Accountability” Non-mortality measures important EMSOP provides focus and simple tools Many challenges Get to work now