The Economic Impact of Community Paramedics Within Emergency Medical Services: A Systematic Review.

BACKGROUND AND OBJECTIVE: Globally, emergency medical services (EMSs) report that their demand is dominated by non-emergency (such as urgent and primary care) requests. Appropriately managing these is a major challenge for EMSs, with one mechanism employed being specialist community paramedics. This review guides policy by evaluating the economic impact of specialist community paramedic models from a healthcare system perspective. METHODS: A multidisciplinary team (health economics, emergency care, paramedicine, nursing) was formed, and a protocol registered on PROSPERO (CRD42023397840) and published open access. Eligible studies included experimental and analytical observational study designs of economic evaluation outcomes of patients requesting EMSs via an emergency telephone line ('000', '111', '999', '911' or equivalent) responded to by specialist community paramedics, compared to patients attended by usual care (i.e. standard paramedics). A three-stage systematic search was performed, including Peer Review of Electronic Search Strategies (PRESS) and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Two independent reviewers extracted and verified 51 unique characteristics from 11 studies, costs were inflated and converted, and outcomes were synthesised with comparisons by model, population, education and reliability of findings. RESULTS: Eleven studies (n = 7136 intervention group) met the criteria. These included one cost-utility analysis (measuring both costs and consequences), four costing studies (measuring cost only) and six cohort studies (measuring consequences only). Quality was measured using Joanna Briggs Institute tools, and was moderate for ten studies, and low for one. Models included autonomous paramedics (six studies, n = 4132 intervention), physician oversight (three studies, n = 932 intervention) and/or special populations (five studies, n = 3004 intervention). Twenty-one outcomes were reported. Models unanimously reduced emergency department (ED) transportation by 14-78% (higher quality studies reduced emergency department transportation by 50-54%, n = 2639 intervention, p < 0.001), and costs were reduced by AU$338-1227 per attendance in four studies (n = 2962). One study performed an economic evaluation (n = 1549), finding both that the costs were reduced by AU$454 per attendance (although not statistically significant), and consequently that the intervention dominated with a > 95% chance of the model being cost effective at the UK incremental cost-effectiveness ratio threshold. CONCLUSIONS: Community paramedic roles within EMSs reduced ED transportation by approximately half. However, the rate was highly variable owing to structural (such as local policies) and stochastic (such as the patient's medical condition) factors. As models unanimously reduced ED transportation-a major contributor to costs-they in turn lead to net healthcare system savings, provided there is sufficient demand to outweigh model costs and generate net savings. However, all models shift costs from EDs to EMSs, and therefore appropriate redistribution of benefits may be necessary to incentivise EMS investment. Policymakers for EMSs could consider negotiating with their health department, local ED or insurers to introduce a rebate for successful community paramedic non-ED-transportations. Following this, geographical areas with suitable non-emergency demand could be identified, and community paramedic models introduced and tested with a prospective economic evaluation or, where this is not feasible, with sufficient data collection to enable a post hoc analysis.

Economic evaluation of the "paramedics and palliative care: bringing vital services to Canadians" program compared to the status quo.

OBJECTIVE: Based on programs implemented in 2011-2013 in three Canadian provinces to improve the support paramedics provide to people receiving palliative care, the Canadian Partnership Against Cancer and Healthcare Excellence Canada provided support and funding from 2018 to 2022 to spread this approach in Canada. The study objectives were to conduct an economic evaluation of "the Program" compared to the status quo. METHODS: A probabilistic decision analytic model was used to compare the expected costs, the quality-adjusted life years (QALYs) and the return on investment associated with the Program compared to the status quo from a publicly funded healthcare payer perspective. Effectiveness data and Program costs, expressed in 2022 Canadian dollars, from each jurisdiction were supplemented with literature data. Probabilistic sensitivity analyses varying key model assumptions were conducted. RESULTS: Analyses of 5416 9-1-1 calls from five jurisdictions where paramedics provided support to people with palliative care needs between April 1, 2020 and March 31, 2022 indicated that 60% of the 9-1-1 calls under the Program enabled people to avoid transport to the emergency department and receive palliative care at home. Treating people at home saved paramedics an average of 31 min (range from 15 to 67). The Program was associated with cost savings of $2773 (95% confidence interval [CI] $1539-$4352) and an additional 0.00069 QALYs (95% CI 0.00024-0.00137) per 9-1-1 palliative care call. The Program return on investment was $4.6 for every $1 invested. Threshold analyses indicated that in order to be cost saving, 33% of 9-1-1 calls should be treated at home under the Program, the Program should generate a minimum of 97 calls per year with each call costing no more than $2773. CONCLUSION: The Program was cost-effective in the majority of the scenarios examined. These results support the implementation of paramedic-based palliative care at home programs in Canada.

RéSUMé: OBJECTIFS: En fonction des programmes mis en œuvre en 2011-2013 dans trois provinces canadiennes pour améliorer le soutien que les ambulanciers paramédicaux fournissent aux personnes recevant des soins palliatifs. le Partenariat canadien contre le cancer et Excellence des soins de santé Canada a fourni un soutien et du financement de 2018 à 2022 pour diffuser cette approche au Canada. Les objectifs de l'étude étaient d'effectuer une évaluation économique du « programme ¼ par rapport au statu quo. MéTHODES: Un modèle probabiliste d'analyse décisionnelle a été utilisé pour comparer les coûts prévus, les années de vie ajustées en fonction de la qualité (AVAQ) et le rendement du capital investi associés au Programme par rapport au statu quo du point de vue des payeurs de soins de santé financés par l'État. Les données sur l'efficacité et les coûts du Programme, exprimés en dollars canadiens de 2022, de chaque administration ont été complétées par des données documentaires. Des analyses probabilistes de sensibilité ont été effectuées en fonction de diverses hypothèses clés du modèle. RéSULTATS: Des analyses de 5416 appels 9-1-1 provenant de cinq administrations où des ambulanciers paramédicaux ont fourni du soutien aux personnes ayant des besoins en soins palliatifs entre le 1er avril 2020 et le 31 mars 2022 ont indiqué que 60 % des 9Les appels 1-1 dans le cadre du Programme ont permis aux gens d'éviter le transport vers les urgences et de recevoir des soins palliatifs à domicile. Le traitement à domicile a permis aux ambulanciers paramédicaux d'économiser en moyenne 31 minutes (de 15 à 67 minutes). Le programme a permis de réaliser des économies de 2 773 $ (intervalle de confiance [IC] de 95 %, de 1 539 $ à 4 352 $) et de 0,00069 AVAQ supplémentaires (IC à 95 %, de 0,00024 à 0,00137) par appel de soins palliatifs 9-1-1. Le rendement du capital investi du Programme était de 4,6 $ pour chaque dollar investi. Les analyses des seuils ont indiqué que pour réaliser des économies, 33 % des appels 9-1-1 devraient être traités à domicile dans le cadre du Programme, le Programme devrait générer un minimum de 97 appels par année, chaque appel ne dépassant pas 2773 $. CONCLUSION: Le Programme a été rentable dans la majorité des scénarios examinés. Ces résultats appuient la mise en œuvre de programmes de soins palliatifs paramédicaux à domicile au Canada.

The allied health rural generalist pathway: a cost consequence analysis.

INTRODUCTION: Rural and remote health workforces face longstanding challenges in Australia. Little is known about the economic effectiveness of workforce initiatives to increase recruitment and retention. A two-level allied health rural generalist pathway was introduced as a workforce strategy in regional local health networks (LHNs) in South Australia in 2019. This research measured the resources and outcomes of the pathway following its introduction. METHODS: A multi-phase, mixed-methods study was conducted with a 3-year follow-up period (2019-2022). A cost-consequence analysis was conducted as part of this study. Resources measured included tuition, time for quarantined study, supervision and support, and program manager salary. Outcomes measured included length of tenure, turnover data, career progression, service development time, confidence and competence. RESULTS: Fifteen allied health professional trainees participated in the pathway between 2019 and 2022 and seven completed during this time. Trainees participated for between 3 and 42 months. The average total cost of supporting a level 1 trainee was $34,875 and level 2 was $70,469. The total return on investment within the evaluation period was $317,610 for the level 1 program and $58,680 for the level 2 program. All seven completing trainees continued to work in regional LHNs at the 6-month follow-up phase and confidence and competence to work as a rural generalist increased. CONCLUSION: This research found that the allied health rural generalist pathway has the potential to generate multiple positive outcomes for a relatively small investment and is therefore likely to be a cost-effective workforce initiative.

The impact of COVID-19 on patient safety attendant use.

ABSTRACT: Patient safety attendants (PSAs) provide constant direct observation to patients who have cognitive impairments or thoughts. Some estimates report that an acute care hospital in the United States may spend more than $1 million annually on PSAs, an expenditure often not reimbursed. With no national defined standards to regulate or monitor PSA use, this study sought to determine the impact of COVID-19 on a PSA reduction program in a large Midwestern healthcare system.

Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics.

OBJECTIVE: Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. METHODS: A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. RESULTS: One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. CONCLUSIONS: Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.

How does medical scribes' work inform development of speech-based clinical documentation technologies? A systematic review.

OBJECTIVE: Use of medical scribes reduces clinician burnout by sharing the burden of clinical documentation. However, medical scribes are cost-prohibitive for most settings, prompting a growing interest in developing ambient, speech-based technologies capable of automatically generating clinical documentation based on patient-provider conversation. Through a systematic review, we aimed to develop a thorough understanding of the work performed by medical scribes in order to inform the design of such technologies. MATERIALS AND METHODS: Relevant articles retrieved by searching in multiple literature databases. We conducted the screening process following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) in guidelines, and then analyzed the data using qualitative methods to identify recurring themes. RESULTS: The literature search returned 854 results, 65 of which met the inclusion criteria. We found that there is significant variation in scribe expectations and responsibilities across healthcare organizations; scribes also frequently adapt their work based on the provider's style and preferences. Further, scribes' job extends far beyond capturing conversation in the exam room; they also actively interact with patients and the care team and integrate data from other sources such as prior charts and lab test results. DISCUSSION: The results of this study provide several implications for designing technologies that can generate clinical documentation based on naturalistic conversations taking place in the exam room. First, a one-size-fits-all solution will be unlikely to work because of the significant variation in scribe work. Second, technology designers need to be aware of the limited role that their solution can fulfill. Third, to produce comprehensive clinical documentation, such technologies will likely have to incorporate information beyond the exam room conversation. Finally, issues of patient consent and privacy have yet to be adequately addressed, which could become paramount barriers to implementing such technologies in realistic clinical settings. CONCLUSIONS: Medical scribes perform complex and delicate work. Further research is needed to better understand their roles in a clinical setting in order to inform the development of speech-based clinical documentation technologies.

Initial single centre experiences of a radiographer advanced practitioner led nephrostomy exchange programme.

INTRODUCTION: To evaluate the technical success, radiation dose, complications and costs from the introduction of a radiographer-led nephrostomy exchange service. METHODS: Post-graduate qualified interventional radiographers with several years' experience in performing other interventional procedures began performing nephrostomy exchanges. Training was provided by an interventional radiologist. Each radiographer performed ten procedures under direct supervision followed by independent practice with remote supervision. Each radiographer was then responsible for the radiological report, discharge, re-referral for further exchange and, where indicated, sending urine samples for culture and sensitivity. Data extraction included the time interval between exchanges, radiation dose/screening time and complications. RESULTS: Thirty-eight long-term nephrostomy patients had their histories interrogated back to the time of the initial insertion. The mean (range) age at nephrostomy insertion was 67 (35-93) years and 65% were male. Indications for nephrostomy were prostatic or gynaecological malignancy, ureteric injury, bulky lymphoma and post-transplant ureteric stricture. A total of 170 nephrostomy exchanges were performed with no statistically significant differences in the radiation dose, fluoroscopy time nor complication rates between consultants and radiographers. There was, however, a statistically significant reduction in the time interval between nephrostomy exchanges for the radiographer group (P = 0.022). CONCLUSION: Interventional radiographers can provide a safe, technically successful nephrostomy exchange program with radiation doses equivalent to radiologists. This is a cost-effective solution to the capacity issues faced in many departments, whilst providing career progression, job satisfaction and possibly improved care. IMPLICATIONS FOR PRACTICE: Radiographer-led interventional services should be considered by other institutions as a means of providing effective nephrostomy exchanges.

Barriers to and solutions for addressing insufficient professional interpreter use in primary healthcare.

BACKGROUND: The aim of this nationwide study was to investigate barriers to adequate professional interpreter use and to describe existing initiatives and identify key factors for successful interpreter policies in primary care, using Switzerland as a case study. METHODS: Adult and paediatric primary care providers were invited to participate in an online cross-sectional questionnaire-based study. All accredited regional interpreter agencies were contacted first by email and, in the absence of a reply, by mail and then by phone. Local as well as the national health authorities were asked about existing policies. RESULTS: 599 primary care physicians participated. Among other reasons, physicians identified cumbersome organization (58.7%), absent financial coverage (53.7%) and lack of knowledge on how to arrange interpreter interventions (44%) as main barriers. The odds of organising professional interpreters were 6.6-times higher with full financial coverage. Some agencies confirmed difficulties providing professional interpreters for certain languages at a timely manner. Degrees of coverage of professional interpreter costs (full coverage to none) and organization varied between regions resulting in different levels of unmet needs. CONCLUSIONS: Professional interpreter use can be improved through the following points: increase awareness and knowledge of primary care providers on interpreter use and organization, ensure financial coverage, as well as address organizational aspects. Examples of successful interventions exist.

Does Introducing Public Funding for Allied Health Psychotherapy Lead to Reductions in Private Insurance Claims? Lessons for Canada from the Australian Experience.

OBJECTIVE: Provincial and territorial governments are considering how best to improve access to psychotherapy from the current patchwork of programmes. To achieve the best value for money, new funding needs to reach a wider population rather than simply replacing services funded through insurance benefits. We considered lessons for Canada from the relative uptake of private insurance and public funding for allied health psychotherapy in Australia. METHOD: We analysed published administrative claims data from 2003-2004 to 2014-2015 on Australian privately insured psychologist services, publicly insured psychotherapy under the 'Better Access' initiative, and public grant funding for psychotherapy through the 'Access to Allied Psychological Services' programme. Utilisation was compared to the prevalence of mental disorders and treatment rates in the 2007 National Survey of Mental Health and Wellbeing. RESULTS: The introduction of public funding for psychotherapy led to a 52.1% reduction in private insurance claims. Costs per session were more than double under private insurance and likely contributed to individuals with private coverage choosing to instead access public programmes. However, despite substantial community unmet need, we estimate just 0.4% of the population made private insurance claims in the 2006-2007 period. By contrast, from its introduction, growth in the utilisation of Better Access quickly dwarfed other programmes and led to significantly increased community access to treatment. CONCLUSIONS: Although insurance in Canada is sponsored by employers, psychology claims also appear surprisingly low, and unmet need similarly high. Careful consideration will be needed in designing publicly funded psychotherapy programmes to prepare for the high demand while minimizing reductions in private insurance claims.

Medical Interpreters in Outpatient Practice.

This article provides an overview of the federal requirements related to providing interpreter services for non-English-speaking patients in outpatient practice. Antidiscrimination provisions in federal law require health programs and clinicians receiving federal financial assistance to take reasonable steps to provide meaningful access to individuals with limited English proficiency who are eligible for or likely to be encountered in their health programs or activities. Federal financial assistance includes grants, contracts, loans, tax credits and subsidies, as well as payments through Medicaid, the Children's Health Insurance Program, and most Medicare programs. The only exception is providers whose only federal assistance is through Medicare Part B, an exception that applies to a very small percentage of practicing physicians. All required language assistance services must be free and provided by qualified translators and interpreters. Interpreters must meet specified qualifications and ideally be certified. Although the cost of interpreter services can be considerable, ranging from $45-$150/hour for in-person interpreters, to $1.25-$3.00/minute for telephone interpreters, and $1.95-$3.49/minute for video remote interpreting, it may be reimbursed or covered by a patient's Medicaid or other federally funded medical insurance. Failure to use qualified interpreters can have serious negative consequences for both practitioners and patients. In one study, 1 of every 40 malpractice claims were related, all or in part, to failure to provide appropriate interpreter services. Most importantly, however, the use of qualified interpreters results in better and more efficient patient care.

Community Paramedicine Applied in a Rural Community.

RESEARCH OBJECTIVE: Abbeville County Emergency Management Services (ACEMS) began a community paramedicine (CP) program to utilize trained paramedics to serve patients who frequently use the emergency department (ED) and have 1 or more of the following diagnoses: hypertension, diabetes, chronic heart failure, asthma, and chronic obstructive pulmonary disease. The objective of this study was to determine if the CP program reduced ED visits in Abbeville while improving patient outcomes. DESIGN: A pre/posttest with a comparison group study design was used to evaluate the CP program. The study population had 193 patients (68 enrollees and 125 comparisons) who resided in Abbeville County, South Carolina. Frequent users of the ED were recruited and enrolled in the program by Abbeville Area Medical Center (AAMC) staff starting in October 2013. Records from both AAMC and ACEMS were examined to determine the impact of the CP program. RESULTS: Hypertensive patients decreased an average of 7.2 mmHg (P < .0001) in systolic blood pressure and 4.0 mmHg (p < .0001) in diastolic blood pressure. Diabetic patients decreased blood glucose by an average of 33.7 mmol/L (p = .0013). Following enrollment into the program, CP participants decreased ED visits by 58.7% and inpatient visits by 68.8%. Conversely, the comparison group increased ED visits by 4.0% and inpatient visits by 187.5%. CONCLUSIONS: The CP program demonstrated a meaningful difference in the health of participants while reducing their health care utilization. CP patients reduced their ED and inpatient use, required less intensive care, had better health outcomes, and reduced health expenses to the community.

Availability of breastfeeding peer support in the United Kingdom: A cross-sectional study.

Peer support is recommended by the World Health Organization for the initiation and continuation of breastfeeding, and this recommendation is included in United Kingdom (U.K.) guidance. There is a lack of information about how, when, and where breastfeeding peer support was provided in the U.K. We aimed to generate an overview of how peer support is delivered in the U.K. and to gain an understanding of challenges for implementation. We surveyed all U.K. infant feeding coordinators (n = 696) who were part of U.K.-based National Infant Feeding Networks, covering 177 National Health Service (NHS) organisations. We received 136 responses (individual response rate 19.5%), covering 102 U.K. NHS organisations (organisational response rate 58%). We also searched NHS organisation websites to obtain data on the presence of breastfeeding peer support. Breastfeeding peer support was available in 56% of areas. However, coverage within areas was variable. The provision of training and ongoing supervision, and peer-supporter roles, varied significantly between services. Around one third of respondents felt that breastfeeding peer-support services were not well integrated with NHS health services. Financial issues were commonly reported to have a negative impact on service provision. One quarter of respondents stated that breastfeeding peer support was not accessed by mothers from poorer social backgrounds. Overall, there was marked variation in the provision of peer-support services for breastfeeding in the U.K. A more robust evidence base is urgently needed to inform guidance on the structure and provision of breastfeeding peer-support services.

Utilizing Respiratory Therapists to Reduce Costs of Care.

INTRODUCTION: Changes to the reimbursement of respiratory care services over the past 26 years make it imperative that respiratory therapists (RTs) demonstrate cost savings to establish their value. Therefore, this systematic review evaluated the cost-related impacts from utilizing RTs to deliver care when compared to other care providers. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to guide the search process. The study addressed articles across all age groups and care settings that compared the cost of care provided by RTs to a comparison group. Studies were excluded if they were not written in English, described care provided outside of the United States, did not provide quantitative data, or lacked a comparison group. RESULTS: A total of 4,120 articles emerged from the search process, of which 60 qualified for a full text review. Cost savings were evaluated for the 28 articles included in this review, noting the study design, the specific respiratory care practice, use of protocols, clinical setting, and age group. The most frequently studied topic was mechanical ventilation, which along with disease management represented by the most randomized, controlled trials for the study design. The clinical practice area notably absent was home care. CONCLUSIONS: Although cost comparisons across studies could not be made due to the inconsistent manner in which data were reported, evidence demonstrated that care provided by RTs yielded both direct and indirect cost reductions, which were achieved through protocol utilization, specialized expertise, and autonomous decision making. The care provided was consistent with care provided by other disciplines. It is critical for the respiratory care profession to highlight key clinical practice areas for future research, to establish uniform reporting measures for outcomes, and to foster the development of future respiratory care researchers to affirm the value that respiratory therapists add to patient care.

Evaluating the Value of the Respiratory Therapist: Where Is the Evidence? Focus on the Barnes-Jewish Hospital Experience.

Currently, >20 million people in the United States have asthma, and approximately 15 million adults have been diagnosed with COPD, with approximately the same number not yet having been diagnosed with this condition. Moreover, the overall burden of respiratory diseases is still increasing, in part due to environmental factors, such as air pollution. At the same time, the number of patients requiring hospitalization as well as the number of individuals admitted to ICUs from emergency departments has been on the rise over the last decade. Because of the cost to the health-care system, the burden of respiratory diseases, hospitalizations, and ICU admissions also falls on society; it is paid for with tax dollars, higher health insurance rates, and lost productivity. Respiratory therapists (RTs) are in a unique position to influence health-care delivery in a number of settings that include acutely ill hospitalized patients and those with chronic conditions in ambulatory settings. Clinical studies have demonstrated the value of RTs in specific areas, including the performance of medical procedures, the development and implementation of protocols aimed at weaning patients from mechanical ventilation and providing lung-protective ventilation, optimal delivery of in-patient respiratory treatments, the application of disease management programs for COPD, and as part of rapid response teams. However, due to increasing scrutiny of health-care expenditures and limited resources, there is a growing need to document the impact of health-care providers in terms of clinical outcomes. As a profession, RTs should continue to describe the impact they have on patient outcomes and the value they bring to our health-care system. Promoting such investigative outcomes research, along with enhancing the professional aspects of the field of respiratory care, will ensure that the value of RTs does not go unappreciated.

Support and Assessment for Fall Emergency Referrals (SAFER) 2: a cluster randomised trial and systematic review of clinical effectiveness and cost-effectiveness of new protocols for emergency ambulance paramedics to assess older people following a fall with referral to community-based care when appropriate.

BACKGROUND: Emergency calls are frequently made to ambulance services for older people who have fallen, but ambulance crews often leave patients at the scene without any ongoing care. We evaluated a new clinical protocol which allowed paramedics to assess older people who had fallen and, if appropriate, refer them to community-based falls services. OBJECTIVES: To compare outcomes, processes and costs of care between intervention and control groups; and to understand factors which facilitate or hinder use. DESIGN: Cluster randomised controlled trial. PARTICIPANTS: Participating paramedics at three ambulance services in England and Wales were based at stations randomised to intervention or control arms. Participants were aged 65 years and over, attended by a study paramedic for a fall-related emergency service call, and resident in the trial catchment areas. INTERVENTIONS: Intervention paramedics received a clinical protocol with referral pathway, training and support to change practice. Control paramedics continued practice as normal. OUTCOMES: The primary outcome comprised subsequent emergency health-care contacts (emergency admissions, emergency department attendances, emergency service calls) or death at 1 month and 6 months. Secondary outcomes included pathway of care, ambulance service operational indicators, self-reported outcomes and costs of care. Those assessing outcomes remained blinded to group allocation. RESULTS: Across sites, 3073 eligible patients attended by 105 paramedics from 14 ambulance stations were randomly allocated to the intervention group, and 2841 eligible patients attended by 110 paramedics from 11 stations were randomly allocated to the control group. After excluding dissenting and unmatched patients, 2391 intervention group patients and 2264 control group patients were included in primary outcome analyses. We did not find an effect on our overall primary outcome at 1 month or 6 months. However, further emergency service calls were reduced at both 1 month and 6 months; a smaller proportion of patients had made further emergency service calls at 1 month (18.5% vs. 21.8%) and the rate per patient-day at risk at 6 months was lower in the intervention group (0.013 vs. 0.017). Rate of conveyance to emergency department at index incident was similar between groups. Eight per cent of trial eligible patients in the intervention arm were referred to falls services by attending paramedics, compared with 1% in the control arm. The proportion of patients left at scene without further care was lower in the intervention group than in the control group (22.6% vs. 30.3%). We found no differences in duration of episode of care or job cycle. No adverse events were reported. Mean cost of the intervention was £17.30 per patient. There were no significant differences in mean resource utilisation, utilities at 1 month or 6 months or quality-adjusted life-years. In total, 58 patients, 25 paramedics and 31 stakeholders participated in focus groups or interviews. Patients were very satisfied with assessments carried out by paramedics. Paramedics reported that the intervention had increased their confidence to leave patients at home, but barriers to referral included patients' social situations and autonomy. CONCLUSIONS: Findings indicate that this new pathway may be introduced by ambulance services at modest cost, without risk of harm and with some reductions in further emergency calls. However, we did not find evidence of improved health outcomes or reductions in overall NHS emergency workload. Further research is necessary to understand issues in implementation, the costs and benefits of e-trials and the performance of the modified Falls Efficacy Scale. TRIAL REGISTRATION: Current Controlled Trials ISRCTN60481756 and PROSPERO CRD42013006418. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 13. See the NIHR Journals Library website for further project information.

Task-shifting alcohol interventions for HIV+ persons in Kenya: a cost-benefit analysis.

BACKGROUND: Among HIV+ patients, alcohol use is a highly prevalent risk factor for both HIV transmission and poor adherence to HIV treatment. The large-scale implementation of effective interventions for treating alcohol problems remains a challenge in low-income countries with generalized HIV epidemics. It is essential to consider an intervention's cost-effectiveness in dollars-per-health-outcome, and the long-term economic impact -or "return on investment" in monetary terms. METHODS: We conducted a cost-benefit analysis, measuring economic return on investment, of a task-shifted cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use in a modeled cohort of 13,440 outpatients in Kenya. In our base-case, we estimated the costs and economic benefits from a societal perspective across a six-year time horizon, with a 3% annual discount rate. Costs included all costs associated with training and administering task-shifted CBT therapy. Benefits included the economic impact of lowered HIV incidence as well as the improvements in household and labor-force productivity. We conducted univariate and multivariate probabilistic sensitivity analyses to test the robustness of our results. RESULTS: Under the base case, total costs for CBT rollout was $554,000, the value of benefits were $628,000, and the benefit-to-cost ratio was 1.13. Sensitivity analyses showed that under most assumptions, the benefit-to-cost ratio remained above unity indicating that the intervention was cost-saving (i.e., had positive return on investment). The duration of the treatment effect most effected the results in sensitivity analyses. CONCLUSIONS: CBT can be effectively and economically task-shifted to paraprofessionals in Kenya. The intervention can generate not only reductions in morbidity and mortality, but also economic savings for the health system in the medium and long term. The findings have implications for other countries with generalized HIV epidemics, high prevalence of alcohol consumption, and shortages of mental health professionals. TRIAL REGISTRATION: This paper uses data derived from "Cognitive Behavioral Treatment to Reduce Alcohol Use Among HIV-Infected Kenyans (KHBS)" with ClinicalTrials.gov registration NCT00792519 on 11/17/2008; and preliminary data from "A Stage 2 Cognitive-behavioral Trial: Reduce Alcohol First in Kenya Intervention" ( NCT01503255 , registered on 12/16/2011).

Community Paramedicine Initiative: Transforming Paramedicine in British Columbia.

British Columbia's health care system is facing challenges related to rural access to care and an ever increasing demand for services. These variables are compounded by the anticipated needs of an aging population that can expect to live several of their golden years with a chronic illness. The introduction of community paramedicine in BC allows for a care delivery model that expands the role of qualified paramedics to include the delivery of prevention, health promotion and primary care services in the community. The implementation of the Community Paramedicine Initiative in rural and remote BC highlights a transformational approach to health care delivery empowered by a technology enabled perspective of community needs.

Results of the 2015 Perfusionist Salary Study.

Presently, there exists no published valid and reliable salary study of clinical perfusionists. The objective of the 2015 Perfusionist Salary Study was to gather verifiable employee information to determine current compensation market rates (salary averages) of clinical perfusionists working in the United States. A salary survey was conducted between April 2015 and March 2016. The survey required perfusionists to answer questions about work volume, scheduling, and employer-paid compensation including benefits. Participants were also required to submit a de-identified pay stub to validate the income they reported. Descriptive statistics were calculated for all survey questions (e.g., percentages, means, and ranges). The study procured 481 responses, of which 287 were validated (i.e., respondents provided income verification that matched reported earnings). Variables that were examined within the validated sample population include job title, type of institution of employment, education level, years of experience, and geographic region, among others. Additional forms of compensation which may affect base compensation rates were also calculated including benefits, call time, bonuses, and pay for ancillary services (e.g., extracorporeal membrane oxygenation and ventricular assist device). In conclusion, in 2015, the average salary for all perfusionists is $127,600 with 19 years' experience. This research explores the average salary within subpopulations based on other factors such as position role, employer type, and geography. Information from this study is presented to guide employer compensation programs and suggests the need for further study in consideration of attrition rates and generational changes (i.e., perfusionists reaching retirement age) occurring alongside the present perfusionist staffing shortage affecting many parts of the country.