Showing papers by "Ralph B. D'Agostino published in 1981"

Effectiveness of a prehospital medical control system: an analysis of the interaction between emergency room physician and paramedic.

Abstract: Medical control for paramedics by means of radio and ECG telemetry is costly, time consuming, and of unproved value. We assessed the interaction between emergency room physicians and paramedics during ambulance transport of "seriously ill" cardiac patients (cardiac arrest, acute myocardial infarction, or new onset of crescendo angina pectoris) with paramedics in service. Thirty-five percent of all arrhythmias and 35% of potentially life-threatening arrhythmias were misclassified. Correct treatment was rendered in 74% of the cases, although only 65% were correctly diagnosed (p < 0.01). The principal predictive variable for misdiagnosing or incorrectly treating a patient was the presence of a potentially life-threatening arrhythmia, precisely the condition for which medical control and the paramedic system has the most to offer. Only 39% of patients with life-threatening arrhythmias were correctly diagnosed and correctly treated, whereas 64% of patients without life-threatening arrhythmias were correctly diagnosed and correctly treated (p < 0.001). Mortality reflected correct diagnosis and treatment. In-hospital and overall mortalities were 12% and 33%, respectively, for patients who were correctly diagnosed and treated (p < 0.06), compared with 20% and 43%, respectively, for patients who were incorrectly diagnosed or incorrectly treated (p < 0.04). More rigorous medical control is needed to improve the quality of patient care and outcome and to further integrate the advanced life support program into the health care system.

An analytic method for the evaluation of rural Emergency Medical Service development.

Abstract: An analytic method is presented for assessing the marginal impact of incremental changes in rural Emergency Medical Services (EMS) on cardiac mortality, morbidity, EMS system process and performance, and health care system utilization. The method incorporates a model of the EMS system. This model specifies five sets of interactive variables characterizing EMS system development and effectiveness. The analytic method quantifies the contribution of each of these sets of interactive variables on the outcome variables (cardiac mortality, morbidity, EMS process/performance, and health care system utilization) for three target populations: those who utilize the EMS system, all hospitalized patients with acute ischemic heart disease independent of EMS system use, and the population of all patients dying from acute ischemic heart disease on a communitywide basis. By including in the model those factors unique to rural areas, such as scarcity of fiscal and health care system resources, geographical constraints, and the skewed severity of case mix due to the clinical and socioeconomic conditions found among rural patients, the analytic method is able to quantify and help explain the impact of these factors on the EMS system and the limitations which they impose. The analytic method affords planners and administrators and rational basis for decisions regarding future rural EMS system development through its identification of those system characteristics amenable to change and worth pursuing from a health policy perspective.