Cost As A Barrier To Ambulance Access - National Heart Foundation

Cost as a barrier to ambulance access:
Overview of the evidence
December 2011

For further information regarding this report, contact:
Christopher Poulter
Policy Officer
Heart Foundation
(03) 9090 2038
christopher.poulter@heartfoundation.org.au
2

Key Messages
Those who are not covered for an ambulance or live within non-universal ambulance
coverage states/territories, are significantly less likely to intend to call Triple Zero
(000), if they thought they were having a heart attack.
ACS patients who have not travelled to hospital by ambulance and who identify with
being ‘worried about the cost of an ambulance,’ are significantly less likely to intend
to call Triple Zero (000) the next time they experience similar symptoms.
Universal ambulance coverage in the longer term, appears to:
- Foster greater ambulance use in patients who need it most (i.e. urgent cases)
- Not significantly increase ambulance use for non-urgent presentations to hospital
Introduction
E
vidence demonstrates that travelling to hospital by
ambulance is strongly associated with shorter prehospital
delay times for suspected heart attack, thereby
reducing time to definitive treatment. The ‘barriers’ to accessing
an ambulance are both individual and systembased.
Doubt, denial and embarrassment are well-known
individual barriers which the Heart Foundation is addressing
through the ‘Will you recognise your heart attack?’
social marketing campaign. System barriers, such as cost
of an ambulance, restrict access to ambulance services
for some people.
In May 2010, the Heart Foundation released a discussion paper, titled universal ambulance cover.
The development and release of the discussion paper followed Heart Foundation research which
showed 7% of people (nationally) would delay calling Triple Zero (000) for a suspected heart attack
based purely on the cost of an ambulance. 1 A thorough stakeholder consultation process followed
the discussion paper’s release. One of the key recommendations arising from the discussion paper
consultation was to further explore the impact of cost on ambulance access. In response to this
strong recommendation, the Heart Foundation has undertaken further analysis to better understand
the extent to which cost is a barrier for some people accessing an ambulance for time-critical emergencies,
such as heart attack. This report highlights new data analysis encompassing:
Intention to call Triple Zero (000)
Trends in ambulance use and demand
Factors contributing to non-ambulance use for acute coronary syndrome (ACS) patients
3
1. Heart Foundation. Warning Signs baseline survey 2008

Intention to call Triple Zero (000)
The Heart Foundation’s ‘Heart Watch’ national consumer
survey conducted quarterly, explores people’s
attitudes and behaviours relating to cardiovascular
disease. Heart Watch is based on a sample of Australian
adults (35-65yrs) across all states and territories.
The below analysis of ‘Heart Watch’ is from a
12-month period (Jan-Dec 2010) with a sample of
over 11,000 people. The margin of error was 0.9%,
meaning that with 95% confidence, the results hold
true at the Australian population level, plus or minus
the error margin (e.g. 50% ±0.9%).
Tables 1.0 - 1.2 relate to intention to call Triple Zero (000). The analysis is broken down by:
Respondents with ambulance cover;
Respondents without ambulance cover; and
Respondents from states and territories with and without universal ambulance access.
Table 1.0
In your experience, do you agree or disagree with each of these reasons
for hesitating to call an ambulance?
‘It’s too expensive to call for an ambulance’
All respondents in NSW, VIC, WA, SA, NT and ACT:
All respondents in NSW, VIC, WA, SA, NT and ACT that DO NOT have cover:
All respondents in QLD and TAS:
Strongly agree/
agree*
19.9%
43.5%
7.7%
Table 1.1
‘What do you think you would do if you thought you were suffering from
a heart attack?’
All respondents in NSW, VIC, WA, SA, NT and ACT:
All respondents in NSW, VIC, WA, SA, NT and ACT that DO NOT have cover:
All respondents in QLD and TAS:
Call Triple Zero
(000)*
74.6%
67.3%
83.7%
Table 1.2
‘Suppose you were experiencing severe chest pain that kept on getting
worse and nausea, would you call an ambulance/Triple Zero (000)?’
All respondents with cover:
All respondents that DO NOT have cover:
Yes*
69.0%
53.3%
National sample: 11,633 *Result is statistically significant (p=0.00) * 95% confidence interval= ± 0.9%
Tables 1.0-1.2 demonstrate ambulance cost significantly influences a proportion of the population’s
intention to call Triple Zero (000) for a suspected heart attack. Cost is a significant factor for people
residing outside of those jurisdictions with universal ambulance access (outside of QLD & TAS) and/
or without some form of ambulance cover, with 43.5% of respondents in that category indicating it is
too expensive to call an ambulance.
4

Trends in ambulance use and demand
Within Australia; Queensland and Tasmania are the only
jurisdictions to have adopted a universal ambulance
cover model. All other state/territory jurisdictions have a
‘fee for service’ model in place along with limited cover
for certain population groups (i.e. pension/healthcare
card holders). The following analysis compares arrival at
ED by ambulance for Queensland and Tasmania, with all
other States and Territories.
Analysis of 4-year hospital arrival by ambulance with ED triage category data, shows significantly
higher rates of ambulance use within Queensland and Tasmania for patients who are classified as
triage category 1 (Resuscitation) and category 2 (Emergency), compared to all other states and territories
(see graph 1 & 2). 2 The difference is greatest for triage category 2 (Emergency), which is the
category that the majority of suspected acute coronary syndrome patients are classified as when presenting
to hospital. Although not definitive, this analysis suggests that patients are more likely to engage
the ambulance service when they need it most, when universal access is provided.
Arrival at hospital (ED) by ambulance, with
Australian Triage Scale category 1 and 2 (2006 - 2010)
Graph 1: ATS category 1: Resuscitation*
92
90
%
88
86
84
82
80
2006/07 2007/08 2008/09 2009/10
QLD TAS All other S/Ts (ave)
Graph 2: ATS category 2: Emergency*
*Result is statistically
significant (p

Trends in ambulance use and demand (cont.)
Conversely, there is no significant difference in ambulance usage within Queensland and Tasmania
compared to all other states and territories for patients classified in lower-acuity triage categories
4 (semi-urgent) and 5 (non-urgent) (see graph 4 & 5). When universal ambulance cover was
introduced within Queensland in July 2003, there was a total increase of 13% in ambulance responses
within the first 12 months. 3 However, the AIHW analysis for lower acuity presentations,
supports the experience observed within Queensland over the last few years, where consumer
education on appropriate ambulance use, along with the progressive implementation of various
demand management strategies (which are now considered common practice across jurisdictions),
have resulted in a steady and consistent decrease in non-urgent ambulance demand. It is clear
that the lasting impact of universal ambulance cover upon ambulance use has been greatest
among those incidents that are deemed time-critical emergencies such as heart attack.
Arrival at hospital (ED) by ambulance, with
Australian Triage Scale category 4 and 5 (2006 - 2010)
Graph 3: ATS category 4: Semi-urgent
20
18
%
16
14
12
10
2006/07 2007/08 2008/09 2009/10
QLD TAS All other S/Ts (ave)
Graph 4: ATS category 5: Non-urgent
10
8
%
6
4
2
0
2006/07 2007/08 2008/09 2009/10
QLD TAS All other S/Ts (ave)
6
3. Queensland Ambulance Service. Audit Report 2007. Queensland State Government.

Factors contributing to non-ambulance use for ACS patients
A sample of patients (n=135) from South Australia, Victoria
and New South Wales who presented to hospital with
suspected ACS and who did not use an ambulance, were
surveyed on the key factors that led to their decision to
not engage the ambulance service.³ Analysis of the ‘nonambulance
use’ patient survey reveals 20% of all patients
surveyed, identified being ‘worried about the cost of an
ambulance’ as a key reason for not travelling to hospital
by ambulance. Furthermore, 23% identified being a ‘non-ambulance member’ was a key reason
for not travelling to hospital by ambulance.
Graph 5: Reasons for deciding not to travel to hospital by ambulance
50
45
45.2
40
37
35
%
30
25
20
20
23
21.5
15.6
25.9
15
10
5
7.4
3.7
0
Doubt seriousness Worried about
of condit ion cost of ambulance
Non-ambulance
member
Want ed t o drive
self t o hospit al
Didn't want t o Belief ambulance Family member
burden ambulance would t ake t oo insist ed t aking me
long
The hospit al is
nearby
Ot her
Reason
n=135
Respondents who were ‘worried about the cost of an ambulance’
Table 1.3 Table 1.4
‘Worried about cost of an ambulance’ by
Private Health Insurance status (%)*
‘Worried about cost of an ambulance’ by intention to
use ambulance next time for similar symptoms (%)*
Private Health Insurance
No Private Health Insurance
3.7
30.3
Would you use an ambulance next
time for similar symptoms?
Yes
No
14.3
31.3
*Result is statistically significant (p=0.00)
*Result is statistically significant (p=0.04)
Further analysis of the ‘non-ambulance use’ patient survey shows those respondents who indicated
they were ‘worried about cost of an ambulance,’ were:
Significantly less likely to have private health insurance (see table 1.3); and
Significantly less likely to indicate they would call an ambulance if they were to experienced
similar symptoms in the future (see table 1.4)
7

Conclusion
The role paramedics and ambulance services play in the early detection and management of acute
coronary syndrome (particularly STEMI) is becoming increasingly vital. As reperfusion system strategies
are continually implemented throughout Australia, it will be more important for patients to ’enter
the system’ by calling Triple Zero (000), in order to receive the best possible care.
Within Australia, approx. 50% of all patients
who present to hospital with chest pain arrive
by ambulance. 4 The information presented in
this document suggests that for some people,
the cost of an ambulance is a critical factor
in determining whether they would call an
ambulance or not. Cost is an important issue
that can influences access to a range of
health services, including ambulance. Definitive
research linking non-ambulance use
(due to cost) with inferior clinical outcomes
(and mortality) would present the most compelling
case for universal ambulance cover.
Unfortunately, clinical datasets across ambulance and hospital services are not currently linked,
which makes it difficult to assess the impact of cost as a barrier to ambulance use upon health outcomes.
The Heart Foundation is continuing to explore the benefits and efficacy of a universal ambulance
access model, underpinned by the overarching objective of reducing patient delay to calling
Triple Zero (000) for heart attack, with the vision to ultimately reduce death and disability from heart
disease.
Acknowledgments
Heart Foundation, Data & Evaluation Unit, Melbourne
Lyell McEwin Hospital, ED, Adelaide
John Hunter Hospital, ED, Newcastle
Nepean Cardiac Rehabilitation Service
St Vincent’s Hospital, CCU, Melbourne
8
4. Heart Foundation .’Warning Signs’ Emergency Department presentations data., 2009 - 2011