Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States M. Kit Delgado, MD, MS, Kristan.

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Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States M. Kit Delgado, MD, MS, Kristan L. Staudenmayer, MD, MS, N. Ewen Wang, MD, David A. Spain, MD, Sharada Weir, PhD, Douglas K. Owens, MD, MS, Jeremy D. Goldhaber-Fiebert, PhD Annals of Emergency Medicine Volume 62, Issue 4, Pages 351-364.e19 (October 2013) DOI: 10.1016/j.annemergmed.2013.02.025 Copyright © 2013 American College of Emergency Physicians Terms and Conditions

Figure 1 Model structure. The model calculates the difference in the costs and outcomes related to the decision of choosing helicopter EMS as opposed to ground EMS for the scene transport of an injured patient to a US trauma center. Event probabilities and their associated costs conditional on strategy chosen (helicopter versus ground) and injury severity are presented in Table 1. A Markov model was used to calculate remaining patient life expectancy and lifetime health care expenditures for the cohort of patients who survive to be discharged from the hospital. Annals of Emergency Medicine 2013 62, 351-364.e19DOI: (10.1016/j.annemergmed.2013.02.025) Copyright © 2013 American College of Emergency Physicians Terms and Conditions

Figure 2 Relationship between relative reduction in mortality and the cost-effectiveness of helicopter EMS. A, Base case analysis. The plotted line represents the cost-effectiveness of helicopter EMS relative to ground EMS as a function of the assumed mortality reduction provided by helicopter EMS, given the base case assumptions described in Table 1. B, Effect of overtriage rate on cost-effectiveness of helicopter EMS. According to analysis of national data, 36% of patients transported by helicopter EMS have only minor injuries. The 2 dotted lines demonstrate how the cost-effectiveness of helicopter EMS changes according to the highest and lowest regional overtriage rates observed in national data. C, Effect of difference in disability outcomes on cost-effectiveness of helicopter EMS. In our base case, we assume no difference in disability outcomes. The 2 dotted lines demonstrate how the cost-effectiveness of helicopter EMS changes according to whether helicopter EMS is associated with worse or better disability outcomes as measured by the SF-6D quality of life scale during the course of a lifetime. ICER, incremental cost-effectiveness ratio. Annals of Emergency Medicine 2013 62, 351-364.e19DOI: (10.1016/j.annemergmed.2013.02.025) Copyright © 2013 American College of Emergency Physicians Terms and Conditions

Figure 3 Effect of the variation in the added cost of helicopter EMS on the threshold mortality reduction needed to be cost-effective. According to the Medicare Fee Schedule, we assume that the helicopter EMS costs about $5,700 more than ground EMS transport for patients located 55 miles from a trauma center (our base case assumption). The plotted lines demonstrate how the cost-effectiveness of helicopter EMS would change according to the assumed relative mortality reduction and the regional variation in the added cost of helicopter EMS over ground EMS. Annals of Emergency Medicine 2013 62, 351-364.e19DOI: (10.1016/j.annemergmed.2013.02.025) Copyright © 2013 American College of Emergency Physicians Terms and Conditions

Figure 4 Probabilistic sensitivity analysis of the incremental cost-effectiveness ratio of helicopter EMS versus ground EMS for trauma scene transport according to the size of the relative mortality reduction from helicopter EMS. A threshold mortality reduction of greater than 26% (RR 0.74) is needed for helicopter EMS to be cost-effective in greater than 95% of simulations if society is willing to pay $100,000 per QALY gained. This is a higher threshold mortality reduction than the threshold of 15% (RR 0.85) that was determined with base-case assumptions. The threshold of 15% (RR 0.85) was cost-effective in 51% of simulations if society is willing to pay $100,000 per QALY gained. Annals of Emergency Medicine 2013 62, 351-364.e19DOI: (10.1016/j.annemergmed.2013.02.025) Copyright © 2013 American College of Emergency Physicians Terms and Conditions