Emergency Medicine

Study raises doubts about the usefulness of emergency department diagnosis as a criteria for medically unnecessary EMS transports

Emergency medical services (EMS) systems respond to thousands of calls for help each day to transport people to a hospital emergency department (ED). Yet, the patient's condition (ED diagnosis), a marker used to determine the medical necessity of transport, did not warrant ambulance transport in 13 percent of transports that occurred in 2002. ED diagnosis is one criterion (along with signs and symptoms such as heart rate and chest pain) that EMS and ED staff use when reviewing transport decisions and when constructing new decision protocols. However, a new study raises considerable doubts about the usefulness of ED diagnosis as a criterion for determining medically unnecessary EMS transports.

Overall, researchers found only fair agreement among physicians about which diagnoses constituted unnecessary EMS transport. Three emergency physicians and two family medicine physicians evaluated 913 diagnostic codes, and rated each code as either medically necessary, uncertain, or medically unnecessary. The percentage of codes classified as medically unnecessary varied across physicians and ranged from a low of 25 percent to a high of 65 percent. Ranges for the uncertain and medically necessary categories ranged from 18 to 46 percent and 14 to 48 percent, respectively.

Family medicine-trained physicians agreed more with one another than did emergency physicians. Agreement was observably better among physicians with more experience.

Among family medicine physicians, agreement ranged from poor for diagnoses associated with conditions of the perinatal period to substantial for diagnoses associated with the digestive system. Among emergency physicians, agreement ranged from poor for neoplasm-related diagnoses to fair for diseases of the circulatory system. The study authors, who were supported in part by the Agency for Healthcare Research and Quality (T32 HS00032), call for more research with a larger sample of physicians.

See "Use of ED diagnosis to determine medical necessity of EMS transports," by P. Daniel Patterson, Ph.D., M.P.H., E.M.T.-B., Charity G. Moore, Ph.D., M.S.P.H., Jane H. Brice, M.D., M.P.H., and Elizabeth G. Baxley, M.D., in the October/December 2006 Prehospital Emergency Care 10, pp. 488-493.

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