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Use of ED diagnosis to determine medical necessity of EMS transports

P Daniel Patterson1, Charity G Moore, Jane H Brice

  • 1Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA. dpatterson@schsr.unc.edu

Prehospital Emergency Care
|September 26, 2006
PubMed

Insights

Physician agreement on medical necessity for emergency transports was fair, with significant variation by specialty and diagnosis. Further criteria development is needed for consistent evaluation of emergency medical services.

Area of Science:

  • Medical research
  • Health services research

Background:

  • Emergency medical services (EMS) transports are sometimes questioned for medical necessity.
  • Emergency department (ED) diagnoses are proposed as a sole criterion for determining necessity.

Purpose of the Study:

  • To assess interrater agreement among physicians when classifying EMS transports as medically unnecessary based solely on ED diagnoses.
  • To identify factors influencing agreement in medical necessity determinations.

Main Methods:

  • Nine hundred thirteen International Classification of Diseases, Ninth Revision (ICD-9) codes were reviewed by emergency and family medicine physicians.
  • Agreement was measured using kappa statistics, analyzing overall, interrater, and category-specific concordance.
  • Experience level and specialty were examined for their impact on agreement.

Main Results:

  • Physicians deemed 25%-65% of diagnoses as medically unnecessary.
  • Overall agreement was fair (kappa = 0.31), with higher agreement among family medicine physicians (kappa = 0.52) than emergency physicians (kappa = 0.22).
  • Agreement varied by disease category, highest for symptoms (kappa = 0.40) and lowest for blood disorders (kappa = -0.17); experienced physicians showed better agreement.

Conclusions:

  • The utility of ED diagnoses alone for determining medical necessity is questionable.
  • Further refinement and validation of criteria, such as Neely Conference criteria, are required.
  • Investigating inter-specialty judgment differences is crucial for medical director professions.
Abstract

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