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New study shows that one third of patients with diabetes attended by an ambulance for severe hypoglycaemia transported to hospital

EMAS - A&E 5A new study has been published in Primary Care Diabetes on ‘Severe hypoglycaemia requiring emergency medical assistance by ambulance services in the East Midlands: a retrospective study’. Hypoglycaemia or low blood sugar is important because this may be linked to greater risk of death.

The study involved a new collaboration between the University of Leicester Cardiovascular and Diabetes group (Professors Kamlesh Khunti and Melanie Davies), University of Bristol (Harriet Fisher),  University of Queensland, Australia (Sanjoy Paul),University of Lincoln and East Midlands Ambulance Service NHS Trust (Mohammad Iqbal, Professor Niro Siriwardena).

The study aimed to report the characteristics, treatment and provider costs for people with diabetes requiring an emergency ambulance for severe hypoglycaemia and involved an analysis of routinely collected data on 90,435 emergency calls collected over four months by the East Midlands Ambulance Trust, UK.

There were 523 (0.6%) ambulance attendances for severe hypoglycaemia, with an incidence of 2.76 per 100 patient years: 28% of events occurred at night and 32% of those attended were transported to hospital. Those patients with a higher respiratory rate, indicating difficulty breathing, were more likely to be transported to hospital, whereas patients on treatment with insulin and those with higher blood glucose after treatment of hypoglycaemia were less likely to be transported to hospital.

Median ambulance costs were higher at £176 for individuals not transported to hospital whereas those transported cost £92 reflecting the greater time ambulance staff spent with patients who were enabled to remain at home.

The research team are planning further studies investigating longer term outcomes of prehospital care for hypoglycaemia as part of CaHRU’s Prehospital and Emergency Quality and Outcomes (PEQO) programme.

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The impact of New Public Management in the Ambulance Service

The use of performance indicators has been a feature of public policy for over three decades. They were first introduced by the EMAS - PTS 7Conservative Government to tackle perceived inefficiencies in the UK public sector. The answer lay in the New Public Management (NPM) reforms, which imported private sector techniques into the public sector to achieve better value-for-money. Consequently, NPM viewed the relationship between public service providers and users through the prism of a producer-consumer dichotomy, with the emphasis on producing quantifiable outputs. While the NPM reforms were introduced by the Conservatives, they were continued apace by New Labour, who wanted to avoid being too closely-identified with ‘producer’ interests, as Labour had traditionally been.  New Labour, through their emphasis on greater competition and choice, wanted to provide public services that were sensitive to ‘consumer’ needs.

Until April 2011, ambulance service quality has mainly been measured in terms of response times. These response time targets were: for Category A high-emergency calls, 75 per cent of calls to arrive at the scene in less than eight minutes and 95 per cent to arrive within 19 minutes; for serious but not life-threatening Category B calls, an ambulance to arrive within 19 minutes 95 per cent of the time; and Category C calls, which are neither serious nor life-threatening, where the target response time is negotiated locally.

The Category B response time targets were abolished by the Department of Health from 1 April 2011, and a set of Clinical Quality Indicators (CQIs) were introduced to complement the Category A eight-minute response time target. From June 2012, the Category A target was sub-divided into Red 1 and Red 2 calls. The former covers the most time-critical incidents and includes patients with cardiac arrest, breathing difficulties and obstructed airways. Red 2 calls are still serious but less time-critical and include patients suffering from strokes and fits. Some Category B and all existing Category C calls became the new Category C ‘Green calls’, and these were sub-divided into four groups: two serious, but non-threatening and two non-life-threatening groups.

The politically-important Category A eight-minute response time target has focused service delivery priorities on improving outcomes for life-threatening conditions and meets public expectations for a rapid response from the ambulance service. Research evidence suggests that timely interventions significantly improve survival outcomes among patients suffering from Out-of-Hospital Cardiac Arrests (OHCAs), but this condition typically accounts for only 1-2 per cent of the pre-hospital population. Cardiac arrests are part of a ‘first hour quintet’ of conditions, which also includes severe trauma, chest pain, stroke and respiratory distress, where early treatment and shorter pre-hospital times can improve survival outcomes.  Even this quintet of potentially life-threatening conditions only represents 15-20 per cent of pre-hospital calls. Indeed, many ambulance service users do not present with life-threatening conditions at all.

By focusing on such a small proportion of the pre-hospital population, the Category A eight-minute target has led to a number of unintended consequences, not least of which has been the mismatch between resources and patients’ needs. For instance, some ambulance services concentrated vehicles in urban areas, where it was easier to achieve a faster response time, thus creating a potential spatial mismatch between resources and need. There have also been reports of gaming, when staff are under pressure to record the ‘right’ answer, even when response times are longer than eight minutes. Security of tenure for Chief Executives of ambulance services in England depends critically on meeting the eight-minute target, so it was inevitable that resources were channelled into meeting it.[1]  The prioritisation of the Category A target may have led some ambulance services to regard a sub-eight-minute response as a success, even if the patient outcome was poor, and interpreting a response time of more than eight minutes that led to a good patient outcome as a failure.

The target culture in ambulance services may have created tensions between ambulance service managers and frontline clinicians, with diverging priorities between the two. Previous studies have suggested that managers’ key focus may be on meeting external targets while frontline ambulance clinicians are more concerned with delivering high quality care to patients.[2,3] A recent Health Foundation-funded quality improvement project in England, the Ambulance Service Cardiovascular Quality Initiative (ASCQI), which includes a collaboration between East Midlands Ambulance Service NHS Trust, the University of Lincoln, the National Ambulance Research Steering Group and the National Ambulance Services Clinical Quality Group is seeking to investigate the issue of culture in more detail.

The National Institute for Health Research (NIHR)-funded programme for applied health research, Prehospital Outcomes for Evidence-Based Evaluation (PhOEBE), is currently attempting to generate more meaningful measures of prehospital outcomes. The programme aims to achieve this by systematically reviewing the international evidence base relating to prehospital outcomes and linking Hospital Episode Statistics (HES) and Office of National Statistics (ONS) mortality data to risk-adjustment measures of ambulance service care.

While the introduction of CQIs to supplement the response time targets represents progress, there is still an ongoing need to generate a broader range of meaningful outcome measures that better capture the often-complex nature of patients’ experiences of the ambulance service. In generating new quality and outcome measures, there is always a risk of over-complication. Therefore, the new quality and outcome measures need to be sufficiently meaningful without being overly-complex. The PhOEBE programme should make a valuable contribution to this debate.

Viet-Hai Phung, CaHRU

 

1.   Bevan G, Hamblin R. Hitting and missing targets by ambulance services for emergency calls: effects of different systems of performance measurement within the UK. J R Stat Soc Ser A Stat Soc 2009:172: 161-190.

2.   Wankhade P. Performance measurement and the UK emergency ambulance service: Unintended consequences of the ambulance response time targets. International Journal of Public Sector Management 2011:24: 384-402.

3.   Wankhade P. Different cultures of management and their relationships with organizational performance: evidence from the UK ambulance service. Public Money and Management 2012:32: 381-388.

 

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How well do newer Z drug sleeping tablets work?

A new study from the CaHRU was published online this December 2012. The full paper is available from the link below:

Huedo-Medina T, Kirsch I, Middlemass J, Klonizakis M, Siriwardena AN.  Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. British Medical Journal 2012; 345: e8343 doi: 10.1136/bmj.e8343.

BMJ paper

Newer (Z drug or non-benzodiazepine) sleeping tablets are known to have short term benefits for treatment of insomnia but their effectiveness has been questioned because of publication and reporting bias reported in previous meta-analyses. Publication bias is due to positive trials being more likely to be published and reporting bias is where positive results are more likely to be published in papers. The placebo response contributes a large part of the effect of drugs like antidepressants but we know little about the extent of the placebo response to hypnotics.

This review of data submitted to the FDA showed that Z drugs decreased the time to fall asleep both subjectively and measured in a sleep lab. There was little demonstrable effect on other outcomes, partly because most studies tended not to measure these outcomes such as sleep quality, sleep efficiency, waking during the night after going to sleep, although these outcomes are often more important to patients than time to fall asleep.

There is a lot of debate currently about the lack of data from pharmaceutical industry (‘pharma’) trials to undertake independent analyses. The FDA data provide all pharma data prior to drug approval and are a helpful way of independently evaluating drug effects and side effects. Pharma trials tend to be more positive than non-pharma trials so the effects of studies submitted tend to be an overestimate of the effects of the drugs. Most of the pharma trials included in this meta-analysis were of short duration (up to 30 days) and in people with primary insomnia, not linked to depression or pain.

The drugs had more effect with larger doses, which is not surprising, but also had more effect in younger or female patients and regardless of type of drug, which is more surprising.  The drug effect and the placebo response were small and, but the two together produced to a reasonably large response. Around half the effect of the drug was a placebo response, which means the placebo response is important in this type of treatment.

Psychological treatments for insomnia work as well as sleeping tablets in the short term and better in the longer term so focusing on increasing access to these treatments, for example through Resources for Effective Sleep Treatment, would benefit people with sleep problems.

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SAFER 2 (Support and Assessment for Fall Emergency Referrals) trial protocol published

The SAFER 2 study is a randomised controlled trial of the clinical and cost effectiveness of new protocols for emergency ambulance personnel to assess and refer older people who fall to appropriate community based care.  The protocol for the study, led by Prof Helen Snooks at Swansea University and including Prof. Niro Siriwardena of the CaHRU and East Midlands Ambulance Service NHS Trust as a collaborator, has recently been published in BMJ Open:

Snooks H, Anthony R, Chatters R, Cheung WY, Dale J, Donohoe R, Gaze S, Halter M, Koniotou M, Logan L, Lyons R, Mason S,  Nicholl J, Phillips C, Phillips J, Russell I, Siriwardena AN, Wani M, Watkins A, Whitfield R, Wilson L. Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care. BMJ Open 2012;2: e002169. doi:10.1136/bmjopen-2012-002169

The study measured the costs and benefits of a novel protocol implemented by emergency ambulance paramedics caring for older people who had fallen, allowing the paramedic to assess and refer appropriate patients to a community based falls service. The study involved ambulance services in London,Wales,East Midlands. Stations were randomly allocated to implement the new protocol (intervention) or continue to provide care according to their standard practice (control).

Paramedics based at the stations selected for the intervention group received additional training, protocols and clinical support to enable them to assess older people and decide whether they need to be taken to the Emergency Department (ED) immediately, or whether they could benefit from being left at home, with a referral to a community falls service. The study compared costs, processes and outcomes of care (particularly subsequent 999 calls and ED attendances for falls) at 1 and 6 months for patients aged 65 or over who had fallen together with other quantitative and qualitative data.

The study was recently been completed and, currently in the final data collection phase, is due to be published next year.

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Improvement science and methods seminar series: experimental methods in health research

The latest seminar in the ‘improvement science and methods’ seminar series covered non-randomised experimental designs and was given by director of CaHRU, Niro Siriwardena.

The seminar included discussion of pre-experimental (uncontrolled before-and-after) designs and quasi-experimental designs such as time series, interrupted time series and non-randomised control group designs, including the advantages and disadvantages of these methods for quality improvement and complex interventions.

Presentation: ‘Experimental methods in health research’

A chapter on ‘Experimental methods in health research’ by Professor Siriwardena is also included in the recently published second edition of ‘Researching Health’, a textbook for health researchers.  The book includes qualitative and quantitative methods employed in researching health, contemporary issues such as research ethics, comparative research and the use of mixed methods, and how to disseminate health research.