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Comparing the Air Medical Prehospital Triage Score With Current Practice for Triage of Injured Patients to Helicopter Emergency Medical ServicesA Cost-effectiveness Analysis

Educational Objective To identify whether the current helicopter triage practices for trauma are cost-effective when compared with a more selective Air Medical Prehospital Triage (AMPT) score.
1 Credit CME
Key Points

Question  Is a selective triage strategy more cost-effective than current practices for determining which injured patients should be transported by helicopter vs ground ambulance to a trauma center?

Findings  In a nationally representative cohort using cost-effectiveness modeling, current helicopter triage practices have an incremental cost-effectiveness ratio of $255 333 per quality-adjusted life-year compared with using the Air Medical Prehospital Triage score, which is significantly more than the generally accepted threshold of $100 000 per quality-adjusted life-year for cost-effective medical interventions.

Meaning  Current helicopter triage practices are not cost-effective compared with the Air Medical Prehospital Triage score for determining helicopter vs ground transport for trauma patients.

Abstract

Importance  Little evidence exists to guide helicopter emergency medical services (HEMS) triage, and current practice is inefficient. The Air Medical Prehospital Triage (AMPT) score was developed to identify patients most likely to benefit from HEMS compared with ground EMS. To our knowledge, no studies have evaluated the potential effect on costs and outcomes of a more targeted HEMS triage strategy, such as the AMPT score.

Objective  To evaluate the cost-effectiveness of current practice compared with the AMPT score for HEMS scene triage of trauma patients.

Design, Setting, and Participants  A cost-effectiveness Markov model was developed for the US health care system to compare current practice with the AMPT score as HEMS scene triage strategies from the health care system perspective over a patient lifetime horizon. A base case was estimated using national data of patient characteristics from the National Trauma Databank from 2007 to 2012. Model inputs, including demographic information, health care costs, survival, and utility estimates, were derived from literature and national registries. Triage strategies were modeled as probability of HEMS transport. Multilevel logistic regression was used to evaluate survival probability between HEMS and ground EMS under the triage strategies. Costs considered included transport reimbursements, hospitalization, cost of health care in the first year postinjury, and annual cost of health care after the first year postinjury. Several sensitivity analyses were performed to evaluate robustness of model assumptions.

Main Outcomes and Measures  Incremental cost-effectiveness ratio, with a threshold of $100 000 or less per quality-adjusted life-year defining cost-effectiveness.

Results  The base case had an incremental cost-effectiveness ratio of $255 333 per quality-adjusted life-year for current practice compared with the AMPT score. Assuming 20% of patients have severe injuries and assuming HEMS only benefits these patients, current practice had an incremental cost-effectiveness ratio of $176 686 per quality-adjusted life-year. Probabilistic sensitivity analysis demonstrated that current practice is inferior in 85% of iterations, only becoming favored when the cost-effectiveness threshold is greater than $310 000 per quality-adjusted life-year.

Conclusions and Relevance  Current practice is not cost-effective compared with the AMPT score for HEMS scene triage. The AMPT score was the preferred strategy across a range of model input values in sensitivity analyses. The AMPT score identifies patients most likely to benefit from HEMS while potentially reducing costs to the health care system and should be considered in air medical transport protocols for trauma patients.

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Article Information

Corresponding Author: Joshua B. Brown, MD, MSc, Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (brownjb@upmc.edu).

Accepted for Publication: July 23, 2017.

Published Online: November 1, 2017. doi:10.1001/jamasurg.2017.4485

Author Contributions: Dr Brown had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Brown, Smith, Gestring, Rosengart, Sperry, Weissman.

Acquisition, analysis, or interpretation of data: Brown, Smith, Billiar, Peitzman.

Drafting of the manuscript: Brown, Rosengart.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Brown, Smith, Rosengart.

Administrative, technical, or material support: Brown, Peitzman, Sperry, Weissman.

Study supervision: Smith, Rosengart, Billiar, Sperry, Weissman.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Brown receives support from an institutional T-32 Ruth L. Kischstein National Research Service Award training grant (5-T32-GM-008516-20) from the National Institutes of Health.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Centers for Disease Control and Prevention. Cost of injuries and violence in the United States. http://www.cdc.gov/injury/wisqars/overview/cost_of_injury.html. Accessed July 7, 2016.
2.
Rhee  P, Joseph  B, Pandit  V,  et al.  Increasing trauma deaths in the United States.  Ann Surg. 2014;260(1):13-21.PubMedGoogle ScholarCrossref
3.
Branas  CC, MacKenzie  EJ, Williams  JC,  et al.  Access to trauma centers in the United States.  JAMA. 2005;293(21):2626-2633.PubMedGoogle ScholarCrossref
4.
Delgado  MK, Staudenmayer  KL, Wang  NE,  et al.  Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States.  Ann Emerg Med. 2013;62(4):351-364.e19.PubMedGoogle ScholarCrossref
5.
Economic and Planning Systems. An economic analysis of the US rotary wing air medical transport industry. http://medevacfoundation.org/wp-content/uploads/2014/08/Rotary-Wing-AMT-Economic-Benefit-Study-EPS-082114.pdf. Accessed July 20, 2016.
6.
Medicare Payment Advisory Commission. Mandated report: Medicare payment for ambulance services. Washington, DC: MedPAC; 2013. Medicare and the Health Care Delivery System. http://www.medpac.gov/docs/default-source/reports/chapter-7-mandated-report-medicare-payment-for-ambulance-services-june-2013-report-.pdf?sfvrsn=0. Accessed July 21, 2016.
7.
Brown  JB, Gestring  ML, Guyette  FX,  et al.  Helicopter transport improves survival following injury in the absence of a time-saving advantage.  Surgery. 2016;159(3):947-959.PubMedGoogle ScholarCrossref
8.
Brown  JB, Stassen  NA, Bankey  PE, Sangosanya  AT, Cheng  JD, Gestring  ML.  Helicopters and the civilian trauma system: national utilization patterns demonstrate improved outcomes after traumatic injury.  J Trauma. 2010;69(5):1030-1034.PubMedGoogle ScholarCrossref
9.
Galvagno  SM  Jr, Haut  ER, Zafar  SN,  et al.  Association between helicopter vs ground emergency medical services and survival for adults with major trauma.  JAMA. 2012;307(15):1602-1610.PubMedGoogle ScholarCrossref
10.
Ringburg  AN, de Ronde  G, Thomas  SH, van Lieshout  EM, Patka  P, Schipper  IB.  Validity of helicopter emergency medical services dispatch criteria for traumatic injuries: a systematic review.  Prehosp Emerg Care. 2009;13(1):28-36.PubMedGoogle ScholarCrossref
11.
Ryb  GE, Dischinger  P, Cooper  C, Kufera  JA.  Does helicopter transport improve outcomes independently of emergency medical system time?  J Trauma Acute Care Surg. 2013;74(1):149-154.PubMedGoogle ScholarCrossref
12.
Stewart  KE, Cowan  LD, Thompson  DM, Sacra  JC, Albrecht  R.  Association of direct helicopter versus ground transport and in-hospital mortality in trauma patients: a propensity score analysis.  Acad Emerg Med. 2011;18(11):1208-1216.PubMedGoogle ScholarCrossref
13.
Sullivent  EE, Faul  M, Wald  MM.  Reduced mortality in injured adults transported by helicopter emergency medical services.  Prehosp Emerg Care. 2011;15(3):295-302.PubMedGoogle ScholarCrossref
14.
Thomas  SH, Harrison  TH, Buras  WR, Ahmed  W, Cheema  F, Wedel  SK.  Helicopter transport and blunt trauma mortality: a multicenter trial.  J Trauma. 2002;52(1):136-145.PubMedGoogle Scholar
15.
Sasser  SM, Hunt  RC, Faul  M,  et al; Centers for Disease Control and Prevention (CDC).  Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011.  MMWR Recomm Rep. 2012;61(RR-1):1-20.PubMedGoogle Scholar
16.
Bledsoe  BE, Wesley  AK, Eckstein  M, Dunn  TM, O’Keefe  MF.  Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.  J Trauma. 2006;60(6):1257-1265.PubMedGoogle ScholarCrossref
17.
Brown  JB, Gestring  ML, Guyette  FX,  et al.  Development and validation of the Air Medical Prehospital Triage score for helicopter transport of trauma patients.  Ann Surg. 2016;264(2):378-385.PubMedGoogle ScholarCrossref
18.
Brown  JB, Gestring  ML, Guyette  FX,  et al.  External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport.  J Trauma Acute Care Surg. 2017;82(2):270-279.PubMedGoogle ScholarCrossref
19.
American College of Surgeons.  National Trauma Databank Research Data Set Admission Year 2012. Chicago, IL: American College of Surgeons; 2012.
20.
Mackenzie  EJ, Rivara  FP, Jurkovich  GJ,  et al.  The National Study on Costs and Outcomes of Trauma.  J Trauma. 2007;63(6, suppl):S54-S67, S81-S86.PubMedGoogle ScholarCrossref
21.
Centers for Medicare and Medicaid Services. Ambulance fee schedule public use files. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/afspuf.html. Accessed May 14, 2015.
22.
Eichler  HG, Kong  SX, Gerth  WC, Mavros  P, Jönsson  B.  Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge?  Value Health. 2004;7(5):518-528.PubMedGoogle ScholarCrossref
23.
Neumann  PJ, Cohen  JT, Weinstein  MC.  Updating cost-effectiveness: the curious resilience of the $50,000-per-QALY threshold.  N Engl J Med. 2014;371(9):796-797.PubMedGoogle ScholarCrossref
24.
Blumen  IJ, Lees  D. Air medical safety: your first priority. In: Blumen  IJ, Lemkin  DL, eds.  Principles and Direction of Air Medical Transport. Salt Lake City, UT: Air Medical Physician Association; 2006:519-532.
25.
Levick  N. Transportation safety performance: how does EMS compare with commercial fleets? https://www.nasemso.org/Projects/HITS/documents/TransportComparisons2009poster.pdf. Accessed December 3, 2015.
26.
MacKenzie  EJ, Weir  S, Rivara  FP,  et al.  The value of trauma center care.  J Trauma. 2010;69(1):1-10.PubMedGoogle ScholarCrossref
27.
Arrow Manufacturing Inc. Ambulance sales. http://arrowmfginc.com/for-sale/. Accessed June 1, 2016.
28.
Aircraft Compare. Aircraftcompare.com. http://www.aircraftcompare.com/compare-airplanes/Airplanes/2. Accessed June 1, 2016.
29.
MacKenzie  EJ, Rivara  FP, Jurkovich  GJ,  et al.  A national evaluation of the effect of trauma-center care on mortality.  N Engl J Med. 2006;354(4):366-378.PubMedGoogle ScholarCrossref
30.
Arias  E. United States life tables, 2009. In:  National Center for Health Statistics. Vol 62; No 7. Atlanta, GA: US Centers for Disease Control and Prevention; 2014. https://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_07.pdf. Accessed June 15, 2016.
31.
Gold  MR, Franks  P, McCoy  KI, Fryback  DG.  Toward consistency in cost-utility analyses: using national measures to create condition-specific values.  Med Care. 1998;36(6):778-792.PubMedGoogle ScholarCrossref
32.
Weinstein  MC, Siegel  JE, Gold  MR, Kamlet  MS, Russell  LB.  Recommendations of the Panel on Cost-effectiveness in Health and Medicine.  JAMA. 1996;276(15):1253-1258.PubMedGoogle ScholarCrossref
33.
Lindenauer  PK, Pekow  P, Wang  K, Gutierrez  B, Benjamin  EM.  Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery.  JAMA. 2004;291(17):2092-2099.PubMedGoogle ScholarCrossref
34.
Cameron  CM, Purdie  DM, Kliewer  EV, McClure  RJ.  Long-term mortality following trauma: 10 year follow-up in a population-based sample of injured adults.  J Trauma. 2005;59(3):639-646.PubMedGoogle Scholar
35.
Coinnews Media Group. US inflation calculator. http://www.usinflationcalculator.com/. Accessed June 1, 2016.
36.
Cameron  CM, Purdie  DM, Kliewer  EV, McClure  RJ.  Ten-year health service use outcomes in a population-based cohort of 21,000 injured adults: the Manitoba injury outcome study.  Bull World Health Organ. 2006;84(10):802-810.PubMedGoogle ScholarCrossref
37.
Atlas and Database of Air Medical Services. Air medical civilian fleet by rotor wing make/model. http://www.adamsairmed.org/pubs/rw_make_model_in_ADAMS_multi_year.pdf. Accessed June 1, 2016.
38.
Association of Air Medical Services. Atlas and Database of Air Ambulance Services (ADAMS). http://www.adamsairmed.org. Accessed February 28, 2016.
39.
Cates-Carney  C. Lifesaving flights can come with life-changing bills. http://www.npr.org/sections/health-shots/2016/01/18/460848383/lifesaving-flights-can-come-with-life-changing-bills. Accessed July 15, 2016.
40.
Eavis  P. Air ambulances offer a lifeline, and then a sky-high bill. http://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?_r=0. Accessed July 15, 2016.
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