Cost effectivness of HEMs
Thread Starter
Cost effectivness of HEMs
The costs and benefits of helicopter emergency ambulance services in England and Wales.
This apparently detailed and well researched report into the cost effectiveness of Helicopter Emergency Ambulance services published in 1996 concluded that;
"There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved."
14 years on, do HEMs do any better and if so, how?
Mickjoebill
This apparently detailed and well researched report into the cost effectiveness of Helicopter Emergency Ambulance services published in 1996 concluded that;
"There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved."
14 years on, do HEMs do any better and if so, how?
Mickjoebill
Join Date: Dec 2006
Location: swansea, wales
Age: 66
Posts: 467
Likes: 0
Received 0 Likes
on
0 Posts
Two things come to my mind,
1. We are in a recession
2. Who commissioned this report? I am always suspicious about possible hidden vested interests.
Just my two cents worth, I am a suspicious person by nature! LOL
1. We are in a recession
2. Who commissioned this report? I am always suspicious about possible hidden vested interests.
Just my two cents worth, I am a suspicious person by nature! LOL
Join Date: Jul 2008
Location: BC, Canada
Posts: 88
Likes: 0
Received 0 Likes
on
0 Posts
2. Who commissioned this report? I am always suspicious about possible hidden vested interests.
A more contemporary discussion about HEMS has recently been published by the Emergency Medicine Journal - "Is it the H or the EMS in HEMS that has an impact on trauma patient mortality? A systematic review of the evidence" Butler et al., Emerg Med J 2010;27:692-701.
The article can be downloaded for free by following the link below and selecting your download option from the right of the screen:
http://emj.bmj.com/content/27/9/692.abstract
This is a systematic review (i.e review of published literature rather than de-novo research) which goes through the HEMS debate step by step. Whilst I personally believe there are some methodological flaws to this paper, and I'm not convinced about the results generated by some of the papers they have selected, it is still an interesting read. As usual, no definitive conclusions are drawn and the debate as to the merits of HEMS will continue...
What is clear is that the crux of many arguments as to HEMS effectiveness rest on:
1) the geography of any given country;
2) how you judge effectiveness (?morbidity ?mortality ?return to tax payer status);
3) how you staff your aircraft.
I could go on but I think this post is long enough as it is!
Simon
Further to helisdw's excellent reply, I would recommend reading Ben Goldacre's "Bad Science" book, and ideally the other document mentioned in his (Goldacre's) bibliography about "How to Read an Academic Paper" along with the last study. Helps to sort out the spin from the substance.
14 more years of local, solid financial support for every HEMS unit. 14 more years of local people confirming: "This is what we want".
The HEMS services of England and Wales exist only because of local public support. They were created at local level by local demand, as additional support to the existing ambulance services.
Why do people like to supplement in this way (at an average cost of 50 pence per adult per year) their local ambulance service directly out of their own pockets?
What makes a small but delicious cherry on the icing of a large cake cost effective in the eyes of the consumer?
It does not matter. HEMS gives the people what they want (and choose to pay for)
The HEMS services of England and Wales exist only because of local public support. They were created at local level by local demand, as additional support to the existing ambulance services.
Why do people like to supplement in this way (at an average cost of 50 pence per adult per year) their local ambulance service directly out of their own pockets?
What makes a small but delicious cherry on the icing of a large cake cost effective in the eyes of the consumer?
It does not matter. HEMS gives the people what they want (and choose to pay for)
Bertie,
Nice one.
All I know is, that we came into the lives of hundreds of families in Cornwall during my time there and they were determined never to let us go.
Did we really save the life of that baby that was choking and had turned blue, had stopped breathing and was 30 mins from the nearest hospital?
Or the boy that had drowned in a swimming pool, was resuscitated and in ITU within 6 mins?
That guy pulled from a crumpled car with a ruptured spleen during a blizzard that prevented an ambulance from attending.....
I don't know for sure, but we thought we had and so did the families and the registrars and the ITU nurses and that's the reason it has been publicly funded since 1987.
God bless all who sail in her these day's...
Nice one.
All I know is, that we came into the lives of hundreds of families in Cornwall during my time there and they were determined never to let us go.
Did we really save the life of that baby that was choking and had turned blue, had stopped breathing and was 30 mins from the nearest hospital?
Or the boy that had drowned in a swimming pool, was resuscitated and in ITU within 6 mins?
That guy pulled from a crumpled car with a ruptured spleen during a blizzard that prevented an ambulance from attending.....
I don't know for sure, but we thought we had and so did the families and the registrars and the ITU nurses and that's the reason it has been publicly funded since 1987.
God bless all who sail in her these day's...
Coming into my last of 11 years of HEMS (damn that 60th birthday!) after what has been the most satisfying flying job in 30 years of rotary.
Meeting recovered 'customers' is also a bonus. For example last month I met a 25 year old girl who, in 2005, we had airlifted to A+E after she suffered horrendous injury in a nasty riding accident. She arrested (her heart stopped) during the 10 minute flight. (point to note: both medics can attend a very critical patient in the back of the chopper...in a land ambulance one of them has to drive).
She had fully recovered and was the picture of health and brimming with the positivity of life. She is a champion for the air ambulance and has raised thousands for the charity.
She shyly confided to me that she has a photo of the pilot and the 2 paramedics on the ceiling of her bedroom, above her bed.
Meeting recovered 'customers' is also a bonus. For example last month I met a 25 year old girl who, in 2005, we had airlifted to A+E after she suffered horrendous injury in a nasty riding accident. She arrested (her heart stopped) during the 10 minute flight. (point to note: both medics can attend a very critical patient in the back of the chopper...in a land ambulance one of them has to drive).
She had fully recovered and was the picture of health and brimming with the positivity of life. She is a champion for the air ambulance and has raised thousands for the charity.
She shyly confided to me that she has a photo of the pilot and the 2 paramedics on the ceiling of her bedroom, above her bed.
Avoid imitations
Join Date: Nov 2000
Location: Wandering the FIR and cyberspace often at highly unsociable times
Posts: 14,574
Received 422 Likes
on
222 Posts
She had fully recovered and was the picture of health and brimming with the positivity of life. She is a champion for the air ambulance and has raised thousands for the charity.
She shyly confided to me that she has a photo of the pilot and the 2 paramedics on the ceiling of her bedroom, above her bed.
She shyly confided to me that she has a photo of the pilot and the 2 paramedics on the ceiling of her bedroom, above her bed.
But no, let's not go there....
Helisdw made a good point when citing local geography. Having worked in remote areas of the US we found, that having a helicopter at their disposal, local first responders, would call the helicopter as a means of allowing for continued 1st responder support of their local areas. Using a ground transport would take them out of the local area for six to eight hours. The helicopter would be back in the area in 2 hours without a break in 1st responder coverage.
Whilst I fully empathise with local communities and those on the machines, it is I regret to say a disgrace that after 14 years so much money has been spent, from whatever source, on a new medical innovation with no true peer reviewed audit or evidence of efficacy.
It is hard to think of any other area in medicine where this could apply let alone does apply.
In the early days we had considerable resistance from the ambulance authorities who seemed worried that the evidence would be delivered, forcing them into additional expenditure. As time went on services became more ambulance as opposed to physician orientated which also suppressed research.
We have demonstrated interhospital ITU transfers by helicopter save lives and I believe the same could be done with primary transfers. The result might be more efficient tasking especially in less rural areas, but my post is supposed to be a reflection of an opportunity lost, which increases the risk in the future to at least some services, not a dig at HEMS itself
It is hard to think of any other area in medicine where this could apply let alone does apply.
In the early days we had considerable resistance from the ambulance authorities who seemed worried that the evidence would be delivered, forcing them into additional expenditure. As time went on services became more ambulance as opposed to physician orientated which also suppressed research.
We have demonstrated interhospital ITU transfers by helicopter save lives and I believe the same could be done with primary transfers. The result might be more efficient tasking especially in less rural areas, but my post is supposed to be a reflection of an opportunity lost, which increases the risk in the future to at least some services, not a dig at HEMS itself
Join Date: Jul 2008
Location: BC, Canada
Posts: 88
Likes: 0
Received 0 Likes
on
0 Posts
The examples cited by griffothefog and Bertie Thruster are some of the many anecdotes (and I don't mean that in a derogatory way) that are told about HEMS work. Unfortunately, the scientific evidence base does not conclusively support these findings at the present time - how you measure/judge effectiveness plays a large part in the value you lend to HEMS operations.
As funding follows proven treatments (which in the UK is decided on by NICE), HEMS will never get Government backing whilst it remains an uncertain entity. The cynic in me would say, why should the Government pay for something it gets for free, especially in these times of austerity? I'm fairly sure that if SAR could be funded by local donors, the Government would be delighted in not having to sign a costly contract...
What amazes me about UK HEMS is the overall lack of national organisation. Individual charities have been known to squabble over geographical fund raising boundaries with publicly aired grievances over collecting practices. HEMS operators have sprung up in each county in the UK but are they best placed to serve the local population or are they a product of convenient placement to fit within said geographical boundaries? Why is there no over arching structure on a national basis?
Some may suggest this is just wishful thinking, but you only have to look at the RNLI to see that a charitable organisation can run a hugely successful nation-wide operation. Further more, their annual income generation allows for the funding of an enviable training facility to hone the skills of their staff/volunteers and some advanced technology on their boats. Surely it is not outwith the realms of feasibility for HEMS to emulate this?
Rant over... for now!
Simon
As funding follows proven treatments (which in the UK is decided on by NICE), HEMS will never get Government backing whilst it remains an uncertain entity. The cynic in me would say, why should the Government pay for something it gets for free, especially in these times of austerity? I'm fairly sure that if SAR could be funded by local donors, the Government would be delighted in not having to sign a costly contract...
What amazes me about UK HEMS is the overall lack of national organisation. Individual charities have been known to squabble over geographical fund raising boundaries with publicly aired grievances over collecting practices. HEMS operators have sprung up in each county in the UK but are they best placed to serve the local population or are they a product of convenient placement to fit within said geographical boundaries? Why is there no over arching structure on a national basis?
Some may suggest this is just wishful thinking, but you only have to look at the RNLI to see that a charitable organisation can run a hugely successful nation-wide operation. Further more, their annual income generation allows for the funding of an enviable training facility to hone the skills of their staff/volunteers and some advanced technology on their boats. Surely it is not outwith the realms of feasibility for HEMS to emulate this?
Rant over... for now!
Simon
Well, I spent all day yesterday (Wednesday) at a meeting attended by 115 people, consultants, physicians, paramedics and a few managers from air ambulances from all over the country, reviewing case studies from all areas of the UK.
Very sobering it was, from paediatric incidents to serious RTA's and everything in between, with a range of outcomes. I was astounded by the frankness and honestly shown.
To cover a few of your points above:
- the different air ambulance outfits do talk and learn from what others have done
- Cases are subject to peer review
- different outfits have different capabilities and resources
- sorry guys, your lovely shiny helicopters are just a way to get the people that matter, where they're needed, quickly
Very sobering it was, from paediatric incidents to serious RTA's and everything in between, with a range of outcomes. I was astounded by the frankness and honestly shown.
To cover a few of your points above:
- the different air ambulance outfits do talk and learn from what others have done
- Cases are subject to peer review
- different outfits have different capabilities and resources
- sorry guys, your lovely shiny helicopters are just a way to get the people that matter, where they're needed, quickly
Join Date: Nov 2008
Location: UK
Age: 66
Posts: 919
Likes: 0
Received 0 Likes
on
0 Posts
- sorry guys, your lovely shiny helicopters are just a way to get the people that matter, where they're needed, quickly
If so, we could have lots of smaller, cheaper helicopters all over the country. Now that could be cost effective.
Thread Starter
Well, I spent all day yesterday (Wednesday) at a meeting attended by 115 people, consultants, physicians, paramedics and a few managers from air ambulances from all over the country, reviewing case studies from all areas of the UK.
A databases of cases were patient outcomes were significantly approved by HEMS would help researchers.
Mickjoebill
Join Date: Jul 2008
Location: BC, Canada
Posts: 88
Likes: 0
Received 0 Likes
on
0 Posts
Helinut - I only wish I had the IT skills and imagination to put something like that together!
206 jock - apologies if my previous post came across as disparaging (this wasn't the intention). The UK HEMS charities do an impressive job of fund raising and joint meetings can only serve to help ensure best clinical practice. My point about a national coordinating body was meant as a suggestion to help build on the current success (cost savings, shared governance, etc.).
Regarding your last point:
I'm not sure if that relates to getting medical staff to the patient quickly or getting injured patients to hospital quickly. Perhaps both. In either case, the academic paper (EMJ) alluded to previously looks at both aspects and still doesn't reach a firm conclusion. Whilst I don't doubt that those presenting at the meeting you attended have operational figures and some excellent results/outcomes, the complexity of this area of research means that achieving statistical significance (which is the bottom line for those that hold the purse strings) is very challenging.
As mentioned before, the value of HEMS all comes down to how you quantify its success and is intrinsic to the research challenges highlighted above. I suspect that this will remain the case for some time...
Simon
206 jock - apologies if my previous post came across as disparaging (this wasn't the intention). The UK HEMS charities do an impressive job of fund raising and joint meetings can only serve to help ensure best clinical practice. My point about a national coordinating body was meant as a suggestion to help build on the current success (cost savings, shared governance, etc.).
Regarding your last point:
sorry guys, your lovely shiny helicopters are just a way to get the people that matter, where they're needed, quickly
As mentioned before, the value of HEMS all comes down to how you quantify its success and is intrinsic to the research challenges highlighted above. I suspect that this will remain the case for some time...
Simon
Join Date: Oct 2003
Location: n/a
Posts: 1,425
Likes: 0
Received 0 Likes
on
0 Posts
Talk about trying to do something with old and inconclusive evidence.
A brief (well it is 7am and I'm having breakfast) search of some academic journals for "HEMS Cost Effectiveness" comes out with 400 ish responses. I'll look a bit more later but, for instance....for HEMS in Holland, (not a country noted for its remote terrain or great distances between cities.)
That said the attempts at a meta analysis are thwarted by the great diversity of what HEMS actually IS.
From "A systematic review of the costs and benefits of helicopter emergency medical services" in Injury (Vol 41 Issue 1)
S
A brief (well it is 7am and I'm having breakfast) search of some academic journals for "HEMS Cost Effectiveness" comes out with 400 ish responses. I'll look a bit more later but, for instance....for HEMS in Holland, (not a country noted for its remote terrain or great distances between cities.)
Results:
The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. Over the 4-year study interval, HEMS assistance saved a total of 29 additional lives. No statistically significant differences in quality of life were found between assistance with HEMS or with EMS. Two years after trauma the mean EQ-5D utility score was 0·70 versus 0·71 respectively. The incremental cost–effectiveness ratio for HEMS versus EMS was €28 327 per QALY. The sensitivity analysis showed a cost-effectiveness ratio between €16 000 and €62 000.
Conclusion:
In the Netherlands, the costs of HEMS assistance per QALY remain below the acceptance threshold. HEMS should therefore be considered as cost effective.
Polinder et al in the British Journal of Surgery Society Ltd Vol 96 Issue 11. Published by John Wiley & Sons, Ltd.
The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. Over the 4-year study interval, HEMS assistance saved a total of 29 additional lives. No statistically significant differences in quality of life were found between assistance with HEMS or with EMS. Two years after trauma the mean EQ-5D utility score was 0·70 versus 0·71 respectively. The incremental cost–effectiveness ratio for HEMS versus EMS was €28 327 per QALY. The sensitivity analysis showed a cost-effectiveness ratio between €16 000 and €62 000.
Conclusion:
In the Netherlands, the costs of HEMS assistance per QALY remain below the acceptance threshold. HEMS should therefore be considered as cost effective.
Polinder et al in the British Journal of Surgery Society Ltd Vol 96 Issue 11. Published by John Wiley & Sons, Ltd.
That said the attempts at a meta analysis are thwarted by the great diversity of what HEMS actually IS.
From "A systematic review of the costs and benefits of helicopter emergency medical services" in Injury (Vol 41 Issue 1)
the cost and effectiveness of HEMS varied considerably between studies. Despite generally being more expensive than ground transport, a number of studies found HEMS to be cost-effective. However, given the variation in the intervention design, context and study methods between studies it was not possible to assess the cost–effectiveness of HEMS in general. Given the variation inherent in the health systems in which HEMS operate, synthesis and extrapolation of study findings across differing health environments is difficult. To address economic and clinical evidence in relation to HEMS, future research that is tailored to account for local system factors is required.