Fischer M, Krep H, Wierich D, Heister U, Hoeft A, Edwards S, Castrillo-Riesgo L G, Krafft T
Klinik und Poliklinik für Anästhesiologie und Spezielle Intensivmedizin des Universitätsklinikum Bonn.
Anasthesiol Intensivmed Notfallmed Schmerzther. 2003 Oct;38(10):630-42. doi: 10.1055/s-2003-42507.
Due to rising health care costs there is a need to verify that the treatment by Emergency Medical Services (EMS) systems is efficient and cost effective. The integration of emergency physicians is inherent part of out-of-hospital emergency care and regulated by law in Germany but not in England and the United States of America. Aim of this study therefore was to conduct a cost performance analysis by evaluating the underlying structure, the costs incurred and the achieved performance in two EMS systems with paramedics or emergency physicians on scene.
The study was carried out in West-Birmingham, a part of the West-Midlands-Ambulance-Service (WMAS), and the EMS of Bonn. Pre defined questionnaires, EMS protocols, calculations of purchasing power parity and recent publications concerning out-of-hospital resuscitation (CPR) were used to evaluate the operating costs, to describe the structure and to measure the quality of performance. Significance was assumed at p < 0.01 for CHI(2)- or t-test, respectively.
Birmingham used state of the art technology for dispatch and logistics whereas Bonn trusted in high qualified personnel. In the 1st quarter 1997 the Mainz-Emergency-Evaluation Score could be achieved before (MEES A) and after preclinical treatment (MEES B) in 3502 and 3422 patients in Birmingham and Bonn, respectively. In Birmingham 7.5 % and in Bonn 17 % of all patients could be improved by the EMS treatment, respectively (p < 0.01). Looking at severely ill patients (MEES A < 22) the EMS in West-Birmingham achieved an improvement in 27.9 % of these patients with an averaged change in MEES of 0.9 +/- 1.7 points in all of them. In contrast the Bonn EMS improved the status in 47.8 % of these patients and MEES A could be improved considerably by 2.3 +/- 3.4 points (p < 0.01). Pharmacological treatment was less frequently used in Birmingham than in Bonn (12.9 % vs. 32.4 %, respectively; p < 0.01). At equal incidences of CPR attempts discharge rate after CPR was only 4 % in WMAS compared to 14.7 % in Bonn-North (p < 0.01). Per inhabitant and year total costs amounted to 10.43 euro for the EMS system in Birmingham, which is 42 % less than in Bonn. Unit hour utilisation reached 0.6 in Birmingham and only 0.33 in Bonn. In severely ill patients the improvement of MEES A by 0.1 points cost per inhabitant and year 1.16 euro in Birmingham and only 0.65 euro in Bonn. The survival of one patient after CPR was calculated to 0.7 euro in Birmingham and 0.17 euro in Bonn.
The provider of the EMS in West-Birmingham--WMAS--organised a reliable system with high efficiency concerning unit hour utilisation and response time reliability. In the EMS of Bonn, in contrast, the complex therapy by the emergency physicians improved MEES considerably and increased probability of survival after CPR at a higher level of efficiency. Further investigations however are necessary to evaluate the presented parameter of efficiency.
由于医疗保健成本不断上升，有必要验证紧急医疗服务（EMS）系统的治疗是否高效且具有成本效益。急诊医生的整合是院外急救护理的固有组成部分，在德国受法律监管，但在英国和美国并非如此。因此，本研究的目的是通过评估两个现场配备护理人员或急诊医生的EMS系统的基础结构、产生的成本和取得的绩效，进行成本效益分析。
该研究在西米德兰兹救护车服务（WMAS）的一部分西伯明翰以及波恩的EMS进行。使用预先定义的问卷、EMS协议、购买力平价计算以及近期关于院外复苏（CPR）的出版物来评估运营成本、描述结构并衡量绩效质量。卡方检验或t检验的p值分别小于0.01时具有统计学意义。
伯明翰在调度和物流方面采用了先进技术，而波恩则依赖高素质人员。1997年第一季度，伯明翰和波恩分别有3502例和3422例患者在临床前治疗前（MEES A）和治疗后（MEES B）达到美因茨急诊评估评分。所有患者中，伯明翰有7.5%、波恩有17%通过EMS治疗得到改善（p < 0.01）。对于重症患者（MEES A < 22），西伯明翰的EMS使其中27.9%的患者病情得到改善，所有患者的MEES平均变化为0.9 ± 1.7分。相比之下，波恩的EMS使这些患者中的47.8%病情得到改善，MEES A显著提高了2.3 ± 3.4分（p < 0.01）。伯明翰使用药物治疗的频率低于波恩（分别为12.9%和32.4%；p < 0.01）。在CPR尝试发生率相同的情况下，WMAS的CPR后出院率仅为4%，而波恩北部为14.7%（p < 0.01）。伯明翰的EMS系统人均每年总成本为10.43欧元，比波恩低42%。伯明翰的单位小时利用率达到0.6，而波恩仅为0.33。在重症患者中，伯明翰使MEES A提高0.1分的人均每年成本为1.16欧元，而波恩仅为0.65欧元。计算得出，伯明翰CPR后一名患者的生存成本为0.7欧元，波恩为0.17欧元。
西伯明翰的EMS提供商——WMAS——组织了一个可靠的系统，在单位小时利用率和响应时间可靠性方面效率很高。相比之下，波恩的EMS中急诊医生的综合治疗显著改善了MEES，并在更高的效率水平上提高了CPR后的生存概率。然而，需要进一步研究来评估所呈现的效率参数。
