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RESEARCH: Suzanne Mason, Emma Knowles, Brigitte Colwell, Simon Dixon, Jim Wardrope, Robert Gorringe, Helen Snooks, Julie Perrin, and Jon Nicholl Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial BMJ 2007; 335: 919 [Abstract] [Full text]

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Older people who fall are more likely to fall again

Philippa A Logan, John RF. Gladman, Kate Robertson   (11 October 2007)

What are we getting for our money?

Daniel S. Sutton   (5 December 2007)

Older people who fall are more likely to fall again 11 October 2007
Philippa A Logan, Research Occupational Therapist University of Nottingham, NG7 2UH, John RF. Gladman, Kate Robertson Send response to journal: Re: Older people who fall are more likely to fall again	Whilst we welcome the development of services that improve satisfaction and which reduce unnecessary visits to Emergency Departments (ED), if falls are common, and falls prevention is possible, then being seen by a paramedic instead of ED or being referred to falls prevention teams means that these fallers may not get into evidence based services, such as demonstrated in the PROFET (Close et al., 1999) study, which picked up fallers from the ED. Thus, patients may be satisfied, the ED may be cleared, but preventable falls may still continue to occur and the old people affected may be unaware that there are effective interventions they are being denied. In collaboration with our local rehabilitation and ambulance services, we are evaluating in a RCT the application of falls prevention to this group of patients who fall, call an ambulance but who are not transported to hospital. Close, J., Ellis, M., Hooper, R., Glucksman, E., Jackson, S., & Swift, C. (1999). Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. The Lancet, 353(9147), 93-97. Competing interests: None declared
What are we getting for our money? 5 December 2007
Daniel S. Sutton, Master's Queen's University 178 Patricia Ave, Toronto, ON M2M 1J5 Send response to journal: Re: What are we getting for our money?	The article on ER services by Mason, et al. (1) found that the use of paramedic practitioners for minor acute conditions in the elderly was effective at reducing the need for hospitalization and improving patient satisfaction. Subsequently, in his editorial, Wollard stated that, for an investment of 24,250 pounds, the use of paramedic practitioners would save the NHS (National Health Service) 72,000 pounds per practitioner per year (2). Despite their positive findings, there still remains a question to be asked about what we are getting for our money. While paramedic practitioners most likely will provide significant cost savings, benefits in patient satisfaction, and a reduction in ER demand for the elderly population, there are no benefits in terms of health outcomes or mortality. According to the EQ-5D there was no significant difference in health outcomes between those treated by the normal service when compared to those treated with the paramedic practitioners (1). Granted that, despite not reporting the p-value, this finding is accurate; one must ask whether or not the investment required to run the paramedic practitioner program is justifiable, even when it does not improve health outcomes? For similar investments in fall/injury prevention programs we could affect greater long term cost savings, patient satisfaction, reduction in ER demand, and additionally improve the health of seniors. For instance, Stay on Your Feet is a community based fall prevention program that has been proven to be cost effective (3). The program, estimated to cost 781,829 (AUD), resulted in a net benefit of 5.4 million (AUD) in direct hospitalization savings and 16.9 million (AUD) for indirect savings. In other words this program has a benefit to cost ratio of up to 20:6:1. If only hospitalization savings are taken into account, there is still a benefit to cost ratio of 6:3:1. Community programs, like Stay on Your Feet can achieve theses results because they target everyone regardless of their individual risk. Therefore, a large percentage of the population who would’ve otherwise been injured from falls would no longer be at risk. Seniors also benefit from things like a decrease in the severity of falls, decreased morbidity from diseases, and a general improvement in their quality of life. In contrast, paramedic practitioners target only the elderly that have already been injured. This type of program will never be able to achieve the magnitude of health benefits obtained by community prevention programs. When considering where to spend resources in an already strained health care system, one must consider the following: Of the two types of interventions, paramedic practitioners and community fall prevention programs, which one will bring about the best results for the least amount of money spent? It is clear that community prevention programs can bring about a greater of array of benefits than paramedic practitioners, and they are also very cost-effective. References. 1.Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, et al.: Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ 2007, 335: 919-924. 2.Wollard M: Paramedic Practitioners and Emergency Admissions. BMJ 2007, 335:893-894. 3. Beard J, Rowell D, Scott D, et al.: Economic analysis of a community based-falls prevention program. Public Health 2006, 120:742-751. Competing interests: None declared