The Robert Wood Johnson Foundation’s Role in the 1970s EMS Systems Movement – Part B

This Biot is a continuation from SEMP Biot #262 Part A, available at: http://www.semp.us/biots/biot_262.html.

Did The RWJF’s venture into emergency medical care accomplish what it set out to do? The RWJF commissioned the RAND (henceforth, Rand) Corporation, the National Academy of Sciences, and personality Digby Diehl to evaluate the program because of David Roger’s belief that “before new solutions would be absorbed into the mainstream of American life, a better educated and more sophisticated public would ask for objective evidence that demonstrations launched under Foundation funding were actually helping to reduce the problems at which they were directed.” He also was sensitive to the Peterson Report of 1970, which said: “Foundations apparently find the process of conceiving or making grants more satisfying and more worthy of their time and resources than evaluating success or failure of these grants, what was learned by them, and the extent to which the results were disseminated to an interested public.” (12)

A committee of the National Academy of Sciences “composed of experts in all facets of planning and operating emergency medical service systems, which advised us on the programs, did on-site reviews of all 44 regions,” wrote Rogers. The report was glowing; however, the report contains an inherent conflict of interest because the NAS participated in administering the EMS program with RWJF. The RWJF asking the NAS to evaluate the EMS program contradicts the values stated above by Rogers. Indeed, Rogers made the statement that “the National Academy of Sciences report suggests a continuing commitment to the program [with] over 75 percent of the regions” having financially self-sustaining programs and broad public acceptance and support. (13) This statement is not confirmed by other reports at the time that indicated relatively poor acceptance of financial responsibility for EMS programs when states and regions were asked to fund them when federal categorical grant funds were terminated. (See, for example, the May 8, 1984 Government Accountability Office (GAO) report titled “States Use Added Flexibility Offered by the Preventive Health and Health Services Block Grants” HRD-84-41, available at www.gao.gov.)

The Rand Corporation study apparently was not glowing, judging from Rogers’ plain-spoken remarks in the RWJF 1978 Annual Report. The Rand study, according to Rogers, “was planned and funded shortly after the start of the program. The Rand study of a sample of preselected sites was designed to assess the effect of full regionalization of emergency services on access to services, on speed of treatment, transfer to appropriate hospitals, and communication between hospitals and personnel in emergency vehicles. We also hoped to get some information on the lifesaving capability of such programs.

“When planning the Rand Corporation study, the Foundation was early in its development, and our lack of experience in service programs and evaluation alike led us to make several fundamental errors. First, our goals for full regionalization were unrealistically high. Second, the time frame for the conduct of the study was wrong—we started too early and the two-year period of the evaluation was too short. Third, the appeal of the program seemed so great and its advantages so obvious to us, that we expected good data from all programs. Thus only seven of the 44 sites were selected for the Rand study. Although we made participation in the evaluation a precondition of the

grants, neither the grantees nor we were aware how difficult and time consuming it would be to gather data from the multiple groups and organizations comprising regional emergency medical service [sic] systems. This resulted in three of the seven sites having such incomplete data that they were excluded from the final analysis. In retrospect, we expected too much, we looked too soon, and sites were too few in number to obtain solid answers to the questions of most compelling interest to us.” (14)

For example, Rand was unable to determine whether regionalization as measured by any rigorous criterion such as cross-country ambulance runs, or assignment of hospital destination based on matching a patient’s problems with institutional capacity, because this matching process “simply did not occur.” Thus, Rand could not make an assessment as to whether such coordinated services could make a difference as RWJF staff members predicted they would.

Amazingly, the Rand study found that “access to emergency care prior to launching the program was not as deficient as thought. Despite the complex nature of arrangements regarding notification of emergencies, dispatch of ambulances and the like, people seemed to be getting to care more promptly than was commonly supposed.” The attentive reader will note that this finding contradicts the surveys supposedly conducted by RWJF staff members, according to Robert Wood Johnson’s biographer, noted earlier in the eighth paragraph of this Biot.

The most important finding of the entire Rand study, according to Rogers, was the critical importance of the kind and extent of medical training of those who staff ambulances.” The Rand study, noted Rogers, showed that physicians in the hospital needed highly trained paramedics with whom physicians could communicate to administer definitive care in the ambulance during the critical moments between the medical catastrophe and arrival at the hospital. “There was far less communication with emergency medical technicians, who receive less training and can stabilize patients but not give definite care.” In San Bernardino County, California, physicians prescribed treatment for 65 percent of severe cases en route when a paramedic and an EMT were in the ambulance together, but in only 7 percent of such cases when the lesser-trained EMT was aboard alone.” Indeed, he went on, prenotification that a patient was coming into the hospital “increases the changes that the patient will be seen by a physician, that the physician will be present in the emergency room when the patient arrives, and sharply cuts the delay in treatment—from 27.3 minutes to 10.7 minutes in the region examined.” A pictorial of this entire process is available in the two hour debut of “Emergency!” which is now available on DVD. (See also SEMP Biot #258 at http://www.semp.us/biots/biot_258.html)

But, Rogers asked, do regionalize EMS programs save more lives? The data was “soft, anecdotal, and provided by the regions themselves,” but “pointed in the right direction,” noted Rogers. For example, data from the city of Newark, New Jersey, comparing deaths in control areas in which the coordinated system was not in place with those in which it was, suggest that deaths from accidents and those produced by motor vehicles were significantly decreased [Rogers provides no data here. Ed.] In Newark the program was able to drop the response time from notification to on-site management of emergencies by almost 50 percent. Bits and pieces of data from other areas—Florida, East Lansing, Peoria, and other regions—also suggest greater lifesaving capacity when coordinated systems are in place, but the data lack rigor and control [and thus are invalid. Ed.]

Seattle, Washington, seemed to provide a bright spot in the gloom. Of 301 individuals with cardiac arrest who were treated by EMTs, 6 percent were discharged alive from the hospital [in what condition, we aren’t told]. In contrast, of 569 receiving treatment from paramedics, 20 percent survived to hospital discharge [in what condition, we aren’t told].

“The findings suggest that paramedic services have a small but measurable effect on the community’s cardiac mortality rate: a drop of 1.3 percent if managed by EMTs; a drop of 8.4 percent if a paramedic is in attendance.” The root cause of this difference was that paramedics could provide definitive treatment (e.g., defibrillation).

James C. Butler and Susan G. Fowler in 2000 attempted to locate the 44 original RWJF EMS program grantees to learn the current status of emergency medical services. The results of the survey, which I was unable to locate, show that “emergency medical services, many of them highly sophisticated, are functioning well, and that 911 and EMS have become part of the fabric of the nation’s health care system.” (15) Digby provides additional anecdotal stories in irritating journalist jargon, e.g., “The 911 call came in at 5:30 pm on Sunday, August 16, 1998—an accident on busy Interstate 10...The bridge would make reaching the victims difficult…The Acadian Ambulance communications center dispatched an Air Med helicopter, a paramedic…” and on and on. His interviews with Blair Sadler, David Boyd, and others, however, were very helpful in tracing the history of The Robert Wood Johnson Foundation’s contribution to the EMS movement.

In summary, the fledgling Robert Wood Johnson Foundation, provided $15 million between 1974 and 1978 in private foundation monies to 44 grantees to develop regional EMS systems. The results of the investment were less than hoped for, according to at least one truly independent evaluation ( Rand), and RWJF staff members acknowledged a degree of naiveté and zealotry in undertaking so vast a program as engineering societal EMS systems.

Some takeaways from Biots #262 and #263 are:

1. Access to emergency care prior to launching the RWJF EMS program was not as deficient as thought. Despite the complex nature of arrangements regarding notification of emergencies, dispatch of ambulances and the like, people seemed to be getting to care more promptly than was commonly supposed.

2. RWJF grantee performance data collection was suboptimal, rendering assessment of outcomes of interest extremely difficult.

3. Emergency medical care is so taken for granted today, its origins are barely remembered.

4. The Robert Wood Johnson Foundation, a private foundation, was exemplary in providing funds to America’s communities to try to better health care delivery.

5. Because The Robert Wood Johnson Foundation EMS program and federal categorical grant monies were infusing into the country at the same time, determining RWJF’s contribution to EMS systems as currently known and understood remains problematic.

6. Many of the problems first encountered during the RWJF grant period (e.g., lack of data) have emerged again in the 1990s and 2000s as economically-stressed local governments question the value of EMS systems, and researchers bemoan the persistent

paucity of data to support the validity and safety of administering prehospital medicine when hospitals are so close by most of the time (except in rural or wilderness areas). (See also SEMP Biot #258 at http://www.semp.us/biots/biot_258.html.)

Sources:

(continued from Biot #262)

12. David Rogers: “The President’s Statement.” The Robert Wood Johnson Foundation Annual Report 1978. Princeton, NJ.: The Robert Wood Johnson Foundation, 1978. Available at: http://www.rwjf.org/files/publications/annual/AnnualReport1978.pdf. Accessed September 13, 2005.

13. Ibid. p. 19.

14. Ibid. p. 16.

15. Digby Diehl: The Emergency Medical Services Program” In “To Improve Health and Health Care – Volume III The Robert Wood Johnson Foundation Anthology.” 2000, Editor’s Introduction. Available online at: http://www.rwjf.org/files/publications/books/2000/chapter_10.html. Accessed September 13, 2005.