Research Project
48 Healthcare Quarterly Vol.20 No.2 2017
Abstract The Economic Value of Community� Paramedicine Programs Study� was a randomized controlled trial in two Eastern Ontario communities – one urban and one rural – to deter- mine whether community� paramedicine services (the intervention through home visits) would have a positive economic impact through influencing self-perceived quality� of life and determining a monetized value. A total of 200 clients who were high-users of healthcare services and had one or more of five chronic diseases (congestive heart failure, chronic obstructive pulmonary� disease, hy�perten- sion, stroke and diabetes) were recruited in early� 2015. These participants were randomly� assigned to either the interven- tion group (receiving community� paramedicine services for 12 months) or the control group (receiving conventional treatment). Study� results suggest that although quality� of life scores decreased for all groups, those receiving commu- nity� paramedicine services demonstrated significantly� less reduction in their scores. Suggestions to further increase cost efficiency� of this novel service are given.
Introduction The concept is proving effective. The practice of community paramedicine (CP) has arisen from grass roots innovation to meet community needs by local paramedic services leveraging their skills and knowledge to address non-emergent client
presentations. In contrast to the traditional stabilize and trans- port clients to emergency rooms for assessment and manage- ment, medics are additionally focussing on preventative measures to support clients to live in their home as long as possible.
As O’Meara et al. (2016) notes, CP has appeared as a solution to many of the healthcare system’s vexing issues as a result of increasingly higher education for paramedics and growing acceptance by other providers and clients that this profession has much to offer beyond its traditional role charac- terized by expediency. Paramedics have evolved from being ambulance attendants to part of the primary healthcare team through increasingly robust entry-level education programs as well as continuing didactic and clinical training programs. This expanded skill and knowledge set has enabled paramedics to evolve beyond conventional practice and more fully collaborate with physicians, nurses and other allied health professionals.
The major issues community paramedics are addressing are complex, while well elaborated in the healthcare literature (Health Quality Ontario 2012). These include:
• With 5% of the Canadian population consuming 50–67% of resources, the need has evolved to change the health and wellness profile of this group of citizens.
• In addition to increasingly scarce resources, the healthcare system remains fragmented and the literature additionally
Conserving Quality of Life through Community Paramedics Christopher Ashton, Denise Duffie and Jeffrey Millar
CARE IN THE COMMUNITY
Healthcare Quarterly Vol.20 No.2 2017 49
points to the need to not only streamline processes within healthcare as well as integrating with social service supports to address underlying determinants.
• With one in five people with congestive heart failure and chronic obstructive lung disease presenting with readmis- sion to hospital within 30 days of discharge, the rate of progress in supporting the transition from hospital to home needs to be accelerated.
In the context of Canada’s well-developed public health- care system, these issues are vexatious; it follows that innova- tive approaches are needed and be geared to promoting the wellness of people in their homes. Chronic disease is largely mediated by social determinants of health (SDHs) (PHAC 2011). Social determinants are those factors affecting people’s health as a result of societal, community and family pressures that positively or negatively affect health. CP, in addition to providing primary assessment, treatment, prevention and management, as well as a healthcare navigation function to address health and social conditions, operates in the realm of SDHs by meeting people where they are, at home.
This window into people’s lives allows CPs a view beyond what is seen in clinics and offers much insight into how daily living can be better supported and potentially raise the health profile of those dealing with chronic disease and multimor- bidities. Although numerous models of CP have been reported (Bigham et al. 2013), the commonality of these models has been their tailored response to local needs. In some cases, they are well defined and protocol driven such as extended paramedic practitioners in the UK (Mason et al. 2007, Dixon et al. 2009) and in others they are fluid and operate in multiple locales in response to specific needs and care gaps such as the CP programs in Renfrew County, Ontario (O’Meara et al. 2016).
Viewing this service as one that increases community resil- ience, the Canadian Safety and Security Program sponsored a two-year, multiple-location randomized controlled trial (RCT) to assess the economic impact of CP. One year was allotted for the field phase with the remainder for planning, education and analysis. Of the various models for CP, that of regular home visitation supplemented by response to CP requests for in-home service as undertaken in Renfrew’s Aging at Home program was chosen as best poised to address the needs of high healthcare system utilizers (Canadian Safety and Security Program 2014; O’Meara et al. 2016). This study was also in response to literature calls for further evidence regarding this practice, as well as exploring its potential in urban as well as rural environments.
The Aging at Home program has evolved to be effective and sustainable in Renfrew over the past decade. Working in close collaboration with other local healthcare and social service agencies, paramedics service clients broadly within
their existing scope of practice under the Ontario Provincial paramedic medical oversight model. With primary or advanced paramedic training supplemented by additional training, CPs in this program now have a proven safe (Mason et al 2007) skill set suited to managing chronic disease. A list of skills and competencies is provided in Box 1.
Methods In addition to the rural setting in Renfrew, this study included new CP service provision and participation in the urban areas of Hastings County, Ontario. Paramedics from the Quinte Emergency Medical Services detachment in Belleville received the same supplemental training and were coached by the Renfrew CP prior to commencing home-based practice.
A total of 200 eligible clients (120 for Hastings and 80 for Renfrew) were recruited in early 2015 and randomly assigned to either the inter vention group (receiving communit y
Christopher Ashton et al. Conserving Quality� of Life through Community� Paramedics
BOX 1. Key skills for community paramedics
• Level of responsiveness • Fall risk assessment • Level of awareness • Fall risk prevention • Glasgow Coma Scale • Safe home mobility assessment • Pupillary response • Post fall assessment • Skin condition • Get up and go assessment • Temperature • Mini mental health assessment (Dementia) • Heart rate, rhythm, quality • Mental health status assessment (Coping) • Electrocardiography (ECG) interpretation • Urinary catheterization • 12-Lead interpretation • Urine dip test • Lung sounds • Advanced wound care • Respiratory rate, regularity, quality • Antibiotic therapy • Blood glucometry • Foot assessment and foot care • Venipuncture (draw and catheterize) • Influenza vaccinations • History assessment • Dealing with death and dying (patient attachment) • Medication compliance • Patient interview (building and maintaining rapport) • Health literacy and education • i-STAT blood analysis • Intramuscular injections • Mental health crisis intervention • Emergency advanced life support (ALS) care • Subcutaneous injections
50 Healthcare Quarterly Vol.20 No.2 2017
paramedicine services) or the control group (receiving conven- tional treatment). All of these clients had used a Paramedic Service ambulance to go to a hospital emergency room (ER) three times or more in the preceding year, and had one or more of the following chronic conditions: chronic obstruc- tive pulmonary disorder, congestive heart failure, diabetes, hypertension or stroke.
Clinica l acumen on the part of the project Steering Committee, as well as the literature, recognized the progres- sivit y of these chronic diseases and that CPs would be working with a challenging study group. Agborsangya et al. (2012) speak to the highly positive association between chronic disease and especially multimorbidity with ER and hospital utilization. In their cross-sectional questionnaire survey conducted in Alberta, multimorbidity was associated with a clinically important reduction in self-reported quality of life scores and twice the likelihood of being hospitalized or having an ED visit.
Given t h is prog re ssiv it y of d isea se a nd u su a l c a re pathways already entrenched in our study group, our notion was that over the course of 12 months, CP would be consid- ered successful should it show a decrease in the trajectory of disease progression in the intervention compared to the control group. To explore this, a three-year retrospective analysis was undertaken to plot all participants’ utiliza- tion of paramedic, ER and hospital admissions. Among the intervention and control groups through the f ield phase, a comparative interruption in this utilization trajectory was postulated to inform the success of the trial. This inter- rupted trajectory is well demonstrated by the Renfrew group in Figure 1.
Due consideration was given to basic concepts and measure- ment tools for best determining the possible economic value generated by CP in this study. Within the past decade of Canadian healthcare, it has become popular to consider healthcare service as a value-laden proposition and measure its effectiveness in that context. The previous view taken upon healthcare as mainly a cost to societies to be minimized while
maintaining quality through increased efficiencies has given rise to:
“often conflicting goals, including access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfac- tion. Lack of clarity about goals has led to divergent approaches, gaming of the system, and slow progress in performance improvement (Porter 2010).”
Value, a product of measuring outcomes relative to costs, encompasses efficiency. Therefore, any healthcare trial which seeks to determine value of an intervention will inherently incorporate the inf luence of efficiency; the question remains as to how to define value in healthcare from this perspective. Cost of this intervention, community paramedicine services, were readily derived through determining the cost of the CP service.
Value in this project was measured for those patient groups with predominantly one of five chronic diseases, that is, conges- tive heart failure, chronic obstructive pulmonary disease, hypertension, stroke and diabetes for the summary aggre- gate. Client participants in this study were all high-intensity users of 911, ERs and hospital admissions. Porter (2010) states “Providers tend to measure only what they directly control in a particular intervention and what is easily measured, rather than what matters for outcomes.” He further purports “For any condition or population, multiple outcomes collectively define success. The complexity of medicine means that competing outcomes (e.g., near-term safety versus long-term functionality) must often be weighed against each other.”
For this project, we have defined value through the use of quality-adjusted life year (QALY). The term quality of life is highly subjective and varies considerably across nations and cultures; any instrument used to measure this must take into account local preferences for health (e.g., heart disease consid- ered worse to have than arthritis in the UK) as well as be valid and reliable across various disease states. For all reasons discussed to this point, the measurement instrument chosen was the EuroQol Group’s EQ 5D 3L. As there to date has not been a Canada-wide valuation of preference indices chosen, we chose the United States indices as our closest comparison.
The 2012 Symposium Proceedings for Patient-Reported Outcomes Measurement in Alberta (IHE 2012): Potential of the EQ-5D introduces the instrument as:
“The EQ-5D (‘EuroQol – five dimensions, three levels’) is a patient-reported outcomes measure that captures five dimensions of health-related quality of life: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. It is appealing as a standard- ized health outcomes measure for Alberta because, as
Conserving Quality� of Life through Community� Paramedics Christopher Ashton et al.
FIGURE 1. Paramedic service transports to hospital
P er
ce nt
ag e
0
20
40
60
80
100
Period (February 1 to January 31) 2012–2013 2013–2014 2014–2015 2015–2016
Renfrew intervention Renfrew control
Healthcare Quarterly Vol.20 No.2 2017 51
a generic measure, it is applicable to a wide range of health conditions and can be used as a research tool at both the population health and program levels, and has potential as a clinical monitoring tool. It is designed for completion by the patient, is quick and easy to use and adaptable for use in surveys, face-to-face interviews or the clinical setting. It is commonly used around the world in clinical, population health, health economics and research applications.”
Speaking to the current context of healthcare and research we are in, the Symposium acknowledges a strong rationale for obtaining patient-reported outcome measures:
“the goal of a patient-centered healthcare system is to improve the health and functioning of patients … Moreover, self-care is an important part of healthcare, so obtaining some level of measurement of patient health and health behaviors will be important for the overall evaluation of health and healthcare.”
CP, as a primary care provider, acts at the interface of the patients and numerous other elements of the primary care system working toward seamless delivery of healthcare. It has been postulated that community paramedics (CPs) can stimulate use of underutilized, relatively inexpensive communit y-based ser vices (Mason 2008). Because CPs generally have a broad knowledge of health conditions and associated service providers, it is also thought that client utilization of community services becomes more integrated and efficient.
Results The initial 200-person sample was recruited according to the designated inclusion criteria with Hastings-Quinte Paramedic Service recruiting 120 (60 each in intervention and control groups) and Renfrew County Paramedic Service recruiting 80 (40 each in intervention and control groups). The Hastings- Quinte region was the designated urban area so all recruiting was executed in the cities of Belleville and Trenton in Quinte West. Renfrew County was the designated rural area and all recruiting was executed across the entire county.
Table 1 summarizes the challenges of recruiting sufficient participants from a target population characterized by chronic illness – the numbers of potential participants deceased signifi- cantly by the time the study began or could not be reached to determine their participation interest. This latter challenge was particularly acute in Hastings-Quinte, whereas Renfrew County also experienced recruitment challenges from potential participants moving to long-term care (LTC) or outside the study area.
As demonstrated in Table 2, both communities suffered significant losses in their sample groups during the field phase period (from February 1, 2015 to January 31, 2016). For instance, each community lost at least 10% of the starting sample to death and Hastings-Quinte lost 9.5% of their sample to transfer to LTC. Renfrew County experienced significant sample losses to withdrawals (13.7%), reasons for which are unknown, and was unable to reach 18.7% of the sample (mostly in the control group) because of the inability to reach them at the study’s conclusion. Data loss in this regard was mitigated by the researchers’ ability to determine whether death was the reason for study exit.
Paramedic service transports for clients to ER were gathered for three years prior to study commencement and followed through the field phase. Results implied that there was signifi- cant escalation of the specific target population’s healthcare service needs over the course of three retrospective years. This pattern is quite pronounced in both communities and suggests
Christopher Ashton et al. Conserving Quality� of Life through Community� Paramedics
TABLE 1. Summary of sample recruitment from a master list of eligible participants
Sample disposition category Hastings-Quinte Renfrew Total
Total number of eligible clients (met criteria)
485 233 718
Deceased (at time of recruitment)
18 26 44
Moved to long-term care or outside study area
2 55 57
Declined to participate 5 30 35
Unable to contact 340 42 382
Recruited into study 120 80 200
TABLE 2. Disposition of sample for Hastings-Quinte and Renfrew county study groups
Status
Renfrew Hastings–Quinte
Total Control Int. Total Control Int.
Deceased 9 5 4 18 10 8
Moved 7 3 4 3 2 1
Hospitalized 2 0 2 5 1 4
Nursing home 0 0 0 12 5 7
Not reached 15 12 3 0 0 0
Withdrew 11 0 11 1 0 1
Discharged 1 0 1 0 0 0
Complete 35 20 15 87 42 45
Totals 80 40 40 126 60 66
Int. = intervention.
AU: Table details and text numbers do not match (some highlighted; e.g. Hastings–
Quinte total = 120 or 126?). Please double-check all the numbers in tables & the
various mentions in the text and confirm any changes that need to be made
52 Healthcare Quarterly Vol.20 No.2 2017
that significant chronic disease progression was taking place in the period leading up to the study’s field phase.
Cost-utility analysis was performed through comparing entry and exit study EuroQols among the control and inter- vention group, individually and for the aggregate. We used the EuroQol 5D 3L, usage of which was granted by the EuroQol Group. As mentioned previously, there are f ive domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) which are scored one, two or three. EQ 5D 3L indices range from 1 through zero to −0.6. One (1) is perfect health, diminishing to zero (0) which is death, and indices below zero represent states worse than death.
Aggregate scoring demonstrating the change in EQs is shown in Table 3.
As shown, the average self-reported quality of life scores decreased for all groups, intervention and control, through the 12-month field phase. Given our notion that our study popula- tion was dealing with progressive, chronic disease(s), these results are not surprising. Nonetheless, it is significant to note that the rate of decrease in EQ 5Ds is less for both intervention groups (0.084 for Renfrew and 0.075 for Hastings) compared to the controls. This would imply that regardless of other outcomes, the community paramedicine intervention conserved quality of life compared to groups receiving usual care.
Economic impact of CP through conserving quality of life was monetized through conversion to QALYs and considera- tion of the cost of the intervention. Per client marginal costs for one year’s CP service through this study was calculated to be $5,675 for Renfrew and $5,731 for Hastings. On that basis, cost to realize a QALY through this community paramedicine intervention was $67,560 for Renfrew and $76,413 for Hastings.
Discussion The National Institute for Health and Care Excellence (NICE, or the Institute) provides guidance to the National Health Service in England on the clinical and cost effectiveness of selected new and established technologies. According to NICE, the expression for health effects should be in QALYs. The EQ 5D is their preferred measure for health-related quality of life in adults.
On admission to the study, participant EQ 5D scores averaged 0.56 This mean score is less than 0.79 which has been proposed as being consistent with a much higher use of health- care resources (Agborsangaya et al. 2014). Given the extent of chronic disease, multimorbidities and age of our partici- pants, decreased quality of life because of disease progression as expressed through EuroQols was anticipated.
While it may seem that the change in EQ 5D scores was small for both study locations, the lessened rate of increase for the intervention groups of 0.084 and 0.075 can be consid- ered clinically significant. It has been reported that any change in EQ 5D scores greater than 0.03 should be considered as significant (Agborsangaya et al. 2014).
Economic impact as expressed through cost per QALYs are higher than those which NICE would consider an attractive inter- vention. NICE guidelines suggest that a new technology costs less than £20,000–£30,000. This study showed a significantly higher cost than the NICE guidelines. We also reaffirm our notion that a gain of QALYs would be highly challenging in this sample of participants with advanced and progressive chronic disease.
Calculations were dependent on a predetermined number of participants recruited to the study. Given the research roles assigned to the paramedics and learning curve of a new service now managing clients with significant morbidities, we believe that CPs could follow a larger clientele which would reduce the cost per QALY significantly. Leveraging technology through providing clients with remote patient monitoring followed by CPs has also been suggested to decrease costs to an attractive rate by increasing the number of clients that individual CPs could follow.
Conclusions This article reports on one of the few RCTs undertaken regarding CP. Among its unique features, the participant group presented a great challenge for the caregivers in attempting to conserve quality of life and reduce utilization of acute care facilities as well as LTC institutions. Where other studies have concentrated on the use of medics in the home to address acute issues and attempt to provide local care rather than transport to ERs, our study focussed on regular visitation and monitoring to alleviate the trajectory of chronic disease.
While it would have been a major success to have demon- strated a more attractive cost per QALY through this study and analysis, nonetheless it was shown that this type of CP did significantly conserve quality of life. Through assigning a greater clientele rather than a fixed number to community paramedics as was done in this study, it is most likely that costs of the service to achieve benefits in quality of life would decrease.
Additionally, leveraging technology through remote patient monitoring has been shown to allow paramedics to care for more patients in their home. Further work in this regard would illuminate the possibilities.
TABLE 3. EuroQol changes for Renfrew and Hastings
County Group
Change in EuroQols
ValSet Average Total %
Renfrew Intervention −1.673 −0.076 −13.42
Renfrew Control −4.148 −0.160 −33.62
Hastings-Quinte Intervention −0.948 −0.020 −3.87
Hastings-Quinte Control −4.738 −0.095 −15.67
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Healthcare Quarterly Vol.20 No.2 2017 53
References Agborsangaya, C., M. Lahtinen, T. Cooke and J. Johnson. 2014. “Comparing the EQ-5D 3L and 5L: Measurement Properties and Association with Chronic Conditions and Multimorbidity in the General Population.” Health and Quality of Life Outcomes 12: 74.
Bigham, B., S. Kennedy, I. Drennan and L. Morrison. 2013. “Expanding Paramedic Scope of Practice in the Community: A Systematic Review of the Literature.” Prehospital Emergency Care 17: 361–72.
Canadian Safety and Security Program. 2014. Project Charter. Hastings- Quinte EMS – Economic Value of Community Paramedicine Programs. CSSP-2014-CP-2017.
Dixon, S., S. Mason, E. Knowles, B. Colwell, J. Wardrope, H. Snooks et al. 2009. “Is it Cost Effective to Introduce Paramedic Practitioners for Older People to the Ambulance Service? Results of a Cluster Randomized Controlled Trial.” Emergency Medicine Journal 26: 446–51.
Health Quality Ontario. 2012. QMonitor. 2012 Report on Ontario’s Health System. Retrieved June 28, 2017. <www.hqontario.ca/portals/0/ Documents/pr/qmonitor-full-report-2012-en.pdf>.
Institute of Health Economics (IHE). 2012. Patient Reported Outcomes Measurement in Alberta. Potential of the EQ-5D. Retrieved June 28, 2017. <http://www.ihe.ca/publications/patient-reported-outcomes-measurement- in-alberta-potential-of-the-eq-5d-ndash-symposium-proceedings>.
Mason, S., E. Knowles, B. Colwell, S. Dixon, J. Wardrope, R. Gorringe et al. 2007. “Effectiveness of Paramedic Practitioners in Attending 999
Calls from Elderly People in the Community: Cluster Randomised Controlled Trial.” BMJ 335(7626): 919–22.
National Institute for Health and Care Excellence (NICE). 2013. Guide to the Methods of Technology Appraisal 2013. Retrieved June 28, 2017. <https://www.nice.org.uk/process/pmg9/chapter/foreword>.
O’Meara, P., C. Stirling, M. Ruest and A. Martin. 2016. “Community Paramedicine Model of Care: An Observational, Ethnographic Case Study.” BMC Health Services Research 16: 39.
Porter, M. 2010. “What is Value in Health Care?” New England Journal of Medicine 363: 2477–81.
Public Health Agency of Canada (PHAC). 2011. “What Determines Health?” Retrieved June 28, 2017. <www.phac-aspc.gc.ca/ph-sp/ determinants/index-eng.php>.
About the Authors Christopher Ashton is executive vice president of HarbourFront Health Group Inc., a research-intensive healthcare consulting firm.
Denise Duffie is president of HarbourFront Health Group Inc., a research-intensive healthcare consulting firm.
Jeffrey� Millar is a paramedic with the Renfrew Paramedic Service and is A/Commander Community Paramedicine.
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