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Monday, November 1, 2010

Lack of Data

By Joy Finnegan

In late September the Government Accountability Office (GAO) released the results of a study of the implications of the changes in the air ambulance industry’s size and structure on safety and services. What was the point? Did anybody find this report useful, insightful or helpful?

The GAO looked at how the industry changed in the last decade and the implications for the availability of services, efficient use of air ambulance resources, safety and services provided. They also looked at the relationship between federal and state oversight in the industry.

While conducting the study, the GAO says it analyzed available data and empirically based literature on the industry; visited four air ambulance providers; and interviewed federal and industry officials. They also e-mailed more than 400 air ambulance providers, talked to industry associations, analyzed the Medicare payment data, reviewed NTSB and congressional transcripts, and more.

The GAO says it didn’t make any recommendations in the report. But how could they? The headline of the report is: “Effects of Industry Changes on Services are Unclear.” Throughout the report, the theme is the same or variations on a similar concept—that there is no data or evidence to support many of the claims asserted by the stakeholders asking for the report.

Of course, no one refutes the tremendous growth seen in the industry in the last 10 years. According to the report, from 1999 to 2008, the number of patients transported by helicopter air ambulance increased by 35 percent. The number of air ambulance helicopters almost doubled (88 percent). The consensus of the report is that there is very little agreement within the industry on how this growth has impacted the industry.

One concern among some in the industry, the report says, is that the growth has led to medically unnecessary flights. GAO says some in the industry are proponents of a change in the regulatory framework. Alternatively, GAO reports some in the industry support the existing regulatory framework, saying the growth in the number of helicopters provides flexibility. The report says, “GAO found few data to support either perspective.”

The report notes 32 studies since the ‘70s, spurred by concerns about medically unnecessary use of air ambulances. Basically GAO found that further measurement indices were needed to be able to determine whether patients were over- and under-triaged, that each EMS system has their own criteria for air medical dispatch, and that patterns of air ambulance use and triage protocols have changed considerably in the last 30 years.

“Little evidence exists to link industry growth to safety concerns,” GAO notes. GAO pointed to the February 2009 NTSB public hearing where some participants expressed concerns about helicopter shopping—the practice of calling numerous operators to find one who will agree to take the flight when weather conditions are questionable.

Others at the meeting felt there were situations where calling numerous providers was an appropriate and safe use of resources. Although stopping short of making a recommendation, the report does state, “having information on prior turn downs or aborted missions could help a provider decide whether it is safe to fly.” The report also looked at call jumping, the practice of providers responding to an accident scene without a request and the concern that if two operators respond, there would be an increased risk of collision at the site. But, again, the report simply said, “Beyond anecdotes, we found little evidence of helicopter shopping resulting in unsafe flights or of call jumping.”

Next the GAO looked at the assertion that economic pressures have led to operators using smaller, single-engine helicopters instead of twin-engine helicopters. The report also said there were concerns within the industry that many smaller helicopters do not have climate control and that this could have a bad effect on trauma patients. The report indicated that many doctors were unaware that the helicopter might not have heat or air conditioning and would therefore not be inclined to request one that did, even though requesting climate control would certainly be possible.

The GAO found evidence lacking to suggest recent growth has affected medical outcomes from air transports. They found no studies that compare patient outcomes between states that have multiple providers in the same region, and states with fewer providers and were therefore unable to draw definitive conclusions to support or refute the allegations that the rapid growth has had a negative impact on patient outcomes. The report says they obtained and used available data, adding: “We believe the evidence obtained provides a reasonable basis for our findings.”

Throughout the report, the words and phrases “perspectives differ,” “unclear,” “little evidence,” “unable to validate,” “lack of consensus,” “lack of data,” “lack of empirical evidence,” and “evidence lacking,” appear frequently in regards to the many areas studied.

Reminds me of the old philosophical question, “If a tree falls in the forest and there is no one there to hear it, does it make a sound?” If the data is so vague and lacking, are the results of this study really valid?

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