341 All Over the Road: A Systematic Review of Mobile Integrated Health, Community Paramedicine Programs

Abstract

Mobile Integrated Health Community Paramedicine (MIHCP) expands the scope of EMS clinicians to provide patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce ED usage. Prior MIHCP reviews have been limited in breadth or focused on characterizing interventions. This systematic review aims to characterize the outcomes and methodology that programs used to evaluate their effectiveness. We searched Pubmed, Embase, CINAHL, and Scopus databases for peer-reviewed literature related to MIHCP programs from January 1, 2000, through July 2020. We included all full-text English studies whose program met the National Association of Emergency Medical Technicians (NAEMT) definition, had an MIH- CP-related intervention and measured outcome, and was implemented through emergency medical services. We excluded all non-English papers, abstract-only, and incomplete studies. We identified 22 studies in our literature review. Study populations ranged from 14 to 2315 subjects and lasted from 4 to 48 months. There were three randomized controlled trials, 13 cohort studies (8 retrospective, 5 prospective), three case series, and three cross-sectional studies. Of the 13 cohort studies, 8 used a pre-post control, 2 statistically matched controls, 1 non-statistically matched control, 1 combined statistically matched and pre-post controls, and 1 did not feature a control. Case series and cross-sectional studies did not feature controls. 14 studies included ED usage as an outcome, measured by: ED visits (9), hospital admissions (8), ED length of stay (3), ED visits avoided (2), readmission rate (3), and ED transport rate (5). 12 studies included at least one Center for Medicare & Medicaid Innovation (CMMI) healthcare utilization core outcome. 4 studies reported cost-related outcomes, measured by: ambulance transport savings (2), ED visit savings (2), hospital admissions savings (1), and cost per quality adjusted life year increase (1). Three studies used at least one NAEMT core cost outcome. The NAEMT laid out a uniform set of measures (eg. health care utilization and cost) for MIHCP to optimize resource utilization and achievement of the triple aim. No individual study reported all CMMI healthcare utilization core outcomes nor NAEMT cost core outcomes. Our review of MIHCP studies revealed significant heterogeneity in study designs, control groups, and outcome measurements. Importantly, 6/22 (27%) studies used appropriate controls, while the rest were subject to selection bias, and only 9/22 (41%) were prospective, leaving the others more subject to information bias. Future MIHCP studies should focus on appropriate study designs to reduce bias and report core outcome measures to improve consistency across investigations and adherence to national organizations' recommendations.