Apart from the Medical Complaints, Why do Patients Use Emergency Medical Services? Results of a Patient Survey

Abstract

Introduction Many countries face an increased use of emergency medical services (EMS) with a decreasing percentage of life-threatening complaints. Though there is a broad discussion among experts about the cause, patients' self-perceived, non-medical reasons for using EMS remain largely unknown.

Methods The written survey included EMS patients who had≥1 case of prehospital emergency care in 2016. Four German health insurance companies sent out postal questionnaires to 1312 insured patients. The response rate was 20%; 254 questionnaires were eligible for descriptive and interferential analyses (t-tests, chi2-tests, logistic models).

Results The majority of respondents indicated that their EMS use was due to an emergency or someone else’s decision (≥84%; multiple checks allowed); 56% gave need for a quick transport as a reason. Other frequently stated reasons addressed the health care system (e. g., complaints outside of physicians’ opening hours) and insecurity/anxiety about one’s state of health (>45% of the respondents). “Social factors” were similarly important (e. g., 42% affirming, “No one could give me a ride to the emergency department or doctor’s office.”). Every fifth person had contact with other emergency care providers prior to EMS use. Respondents negating an emergency as a reason were less likely to confirm wanting immediate medical care on site or quick transports compared to those affirming an emergency. Patients using EMS at night more often denied having an emergency compared to patients with access to care during the day.

Conclusion The study identified a bundle of reasons leading to EMS use apart from medical complaints. Attempts for needs-oriented EMS use should essentially include optimization of the health care and social support system and measures to reduce patients’ insecurity.

Introduction

Many countries worldwide face an increased use of emergency medical services (EMS; ^{1 2 3 4 5} ) with a decreasing percentage of life-threatening complaints ^{6 7 8} . In Germany, the number of urgent EMS uses increased by estimated 63% within 10 years (own calculation based on German “Notfallrettung”, excluding EMS’ unqualified patient-transports; contrasting years 2006/2007 to 2016/2017; ² , p. 60). A study for the federal state of Bavaria demonstrated that demographic changes explain only a fraction of the increased demand ⁹ . An estimated 15% of all German EMS cases documented by paramedics ¹⁰ or 16% of all cases involving emergency physicians in the federal state Baden-Wuerttemberg ( 11 ; excl. sepsis) are time-critical so-called “tracer diagnoses” (cf. ¹² ). About 34% of all EMS cases documented by paramedics are considered prone to ambulatory care (with NACA-Score≤II) and 76% as not life threatening (NACA-Score≤III ¹⁰ ). In another German study, about 52% of all cases covered by emergency physicians are not considered life threatening (NACA-Score≤III). The percentage for those cases increased significantly over time (34% in 1984 to 52% in 2004 with NACA score≤III) ⁷ . Evidently, increased EMS demand results in a need for more employees and equipment, leading to higher costs for EMS providers and health insurance companies covering those cases. To date, it is still unknown how increasing EMS use affects the quality of prehospital care. Yet, studies for emergency departments (ED) have shown that avoidable overcrowding – to which EMS partly contribute – may lower quality of care for patients with more severe needs in the ED ^{13 14 15} .

Consequentially, one core question arises frequently: Why do patients use emergency medical services, apart from their medical complaints? The majority of studies focus on why people use emergency/urgent care services in general and emergency departments (ED) in particular (e. g., ¹⁶ ). This leaves questions as to how strongly identified reasons contribute especially to EMS use or if additional reasons can be found. It is also likely that reasons vary from one country to another, as emergency medical services, health care systems and cultural contexts differ ¹⁷ . German studies highlight the following reasons for increased utilization of emergency care:

• subjective, patient-related factors (e. g., lack of knowledge about alternative options, increasing sense of entitlement) ^{18 19} ,

• challenges in the health care system (e. g., waiting lists for appointments) ^{20 21 22 23 24 25} and

• challenges in other supportive systems (e. g., waiting lists for psychological appointments) ²⁶ .

German patients strongly decide for themselves which mode of emergency care they choose and when ²⁷ . German emergency care splits into two pathways:

1. With minor, not deferrable health problems, people are usually supposed to

   1. seek outpatient care of physicians offering consultation hours for emergencies in their regular doctor’s office

   2. or (especially outside of regular opening-hours) in specific offices of outpatient emergency services. They can also call 116117 by phone for home-visits. The general practitioners (GP) or specialists working for those services are then acting as “doctors on call” (“Ärztlicher Bereitschaftsdienst”). They usually rotate, as they spend the majority of their time with regular, non-emergency care in ambulatory offices.

2. With more severe health problems that might need resources or competencies within a hospital, people are supposed to dial 112 or to go directly to the ED. Due to compulsory health insurance and usually just a small fee (e. g., 10 Euros per EMS use or hospital day), the barrier is rather low to use EMS and the usually subsequent hospital care. If a person calls 112, the emergency medical dispatchers have very few options other than to dispatch vehicle(s). German EMS offer emergency care and non-emergency transports. The latter require physicians’ or psychotherapists’ prescription; they are usually planned using a different phone number but reaching the same dispatch centre. Throughout this paper, the focus is on EMS’ prehospital emergency care by paramedics and/or emergency physicians – in contrast to non-emergency medical transports (German: “Krankentransporte”).

Especially for countries with similar scant gatekeeping, it is important to understand the patients’ motives and the circumstances that triggered the utilization of EMS. This may help to develop solutions that the majority of the public accepts and supports. Hence, the present paper focuses results on the questions:

• Apart from medical/health related circumstances, which patient-reported reasons triggered the EMS use?

• Among those users who negated an emergency, what were their key factors for using EMS?

Methods

The postal survey of EMS patients is part of the project “Integrated emergency care: A focus on emergency medical services” (German abbreviation: “Inno_RD”). As a systematic search did not detect any suitable instruments on subjective reasons for EMS use, we developed a questionnaire that also contains perceived health and quality of life. Complementing Andersenʼs Behavioral Model of Health Services Use (originally developed to explain and predict use of health services) ²⁸ to emergency medical services supported the systemization of potential reasons for EMS use. In Germany, EMS and health care system are separated legally and organizationally, but may influence one another. The complemented model integrates this potential interaction between both systems ( Fig. 1 ).

Fig. 1.

Exemplary items of the questionnaire (in italics) based on Andersenʼs Behavioral Model of Health Services Use ²⁸ extended to the use of emergency medical services.

Following a pretest (n=43), the data collection took place from Oct. 16 ^th until Dec. 2 ^nd of 2018. Four collaborating German statutory health insurance companies (BMW BKK, Schwenninger BKK, BKK VerbundPlus, Bosch BKK) sent out the questionnaire to 1.312 of their insureds, if they

1. were 18 years or older and lived in Germany at the date of the survey,

2. had an EMS use including vehicles indicating prehospital emergency care (including ground and aerial rescue; in German: “Notarztwagen”, “Notarzteinsatzfahrzeug”, “Rettungswagen” or “Primärtransport – Luft”)

3. by the German Red Cross

4. in selected “model regions” within the federal states of Bavaria and Baden-Wuerttemberg

5. in the year 2016.

The selection strategy excluded patients who had non-emergency medical transports, died, lived abroad (on the start date of the survey) and those who opted out of their health insurance company since their last (index) EMS use in 2016. The specific selection was due to the broader aim of the research project to match the patients’ survey response with the data of their health insurance and the respective EMS provider of specific “model regions”. In Germany, dispatch centers are obliged to choose the EMS provider that is closest to the site of emergency. The Red Cross covers most of the prehospital emergency care in the two chosen federal states. Respondents were asked to recall their last EMS use in Germany in 2016 – independent from the federal state.

The selected insureds did not receive any reminder or incentives.

The results base on descriptive and interferential analysis with IBM SPSS Statistics Version 25 and 26 (IBM Corporation, Armonk, NY, USA) and Microsoft Excel 2016, using pairwise deletion. We rounded percentages to whole numbers. For subgroup analyses, independent-samples t-tests and Fisher’s exact test with their corresponding effect size (Cohen’s d; Cramér’s V) were calculated. We accepted an α≤5%. Two logistic models compared patients confirming vs. negating the reason “I had an emergency.”

Three variables used for sub-group analyses or logistic regressions derive out of the respondents’ health claims data which was available for all patients: 1.) Age (interval-scaled based on the year of the EMS use [2016] minus the year of birth), 2.) Gender, 3.) Weekday of the EMS use (based on patients’ last EMS case in 2016).

Respondents gave fully informed consent to the linkage and storage of their data. State Data Protection Commissioners of Bavaria, Baden-Wuerttemberg and Saxony-Anhalt, Data Protection Officers of the respective health insurance funds and the Board of Medical Ethics of Magdeburg University (65/18) approved of consent forms and data protection procedures. We wrote this paper in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement ²⁹ .

Results

The response rate was 20% (n=259). 254 questionnaires were eligible for analysis (since≥50% of the quantitative items filled; see full questionnaire in appendix with 20 quantitative and 3 qualitative questions). According to the health claims data, during their last EMS use in 2016 the majority of the respondents were residents in Bavaria and Baden-Wuerttemberg. The prehospital care took place in (at least) 12 out of 16 states in Germany (n=95 with information on site of emergency).

Reasons for EMS Use

89% of all respondents affirm an emergency as a reason for the EMS use (see n for each item in Fig. 2 ). The second common reason is that others had decided to call EMS (84% “yes”). About half of the respondents affirm reasons addressing core services of EMS providers: 56% wanting fast transports to the hospital or ED; 47% wanting instant medical care on site.

Fig. 2.

Answers on the question “Why else did you use the emergency medical service?” (sorted in descending order; n min=189, n max=227; vertical numbers are given for easy cross-reference in text).

Half of the respondents also affirm one or more reasons that are due to the health care system (considering items #6, #10, #18 and #19 displayed in Fig. 2 ; n=119 out of max. 227 persons answering at least one item of the complete question set displayed in Fig. 2 ). The most common health-care related reason is: “My complaints occurred outside of the opening hours of a GP or specialist” (48% “yes, was a reason”; n=200).

About every second person states insecurity (53% insecure about own health); approximately every third patient is anxious (38% with great fears). The worry to become an emergency soon was reason for 26%. Approximately 44% of the respondents affirm social reasons (considering the items # 8, # 16 and #17; n=100 out of max. 227 persons answering at least one item of the complete question set).

22% affirm “I had hoped for too long that my health would improve without needing a doctor (for the first time or again)”. In another section, 246 persons answered to “Retrospectively, if you think of all the health problems you ever had: How many additional times should or would you have wanted to call the emergency medical service?” 16.% concede that they should have called more often; the mean amount of additional calls is 0.4 (SD 1.4; maximum=15).

Another question asked “In connection to the cause and directly prior to using the emergency medical service, did you have contact with the following…?”, listing offices of outpatient emergency services, doctors on call, the emergency department of a hospital or a contact person at the phone number 116117. 6–9% of the respondents had prior contact to such providers (with min. 6% for doctors on call and max. 9% for offices of outpatient emergency services; with varying n=227–242). Altogether, 21% of the respondents (answering any part of the question block) had prior contact to one or more providers.

Factors for Using EMS in (Non-)Emergency Cases

Those 227 persons answering the item “I had an emergency” (options: yes, was a reason; no was not a reason; see Fig. 2 ) could be divided into two groups:

1. group “Emergency was not a reason” (n=25) versus

2. group “Emergency was a reason” (n=202).

Crosstabs on the other items displayed in Fig. 2 reveal: If respondents negated an emergency as a cause, they were less likely (4%) to confirm “I wanted a quick transport to the hospital/the emergency department” than those confirming an emergency as a reason (62%; n total=195; Cramér’s V=0.38; see Table 1 ). Group no. 1 was also less likely to confirm, “I wanted immediate medical care on site” (8 versus 53%; total n=191; V=0.30). The associations between the two compared groups and all other items of Fig. 2 were either not significant (items # 2 and 15–19) or only showed low effects (V<0.3 for items #3, 5–6, 8–14; p≤0.05).

Table 1 Significant association between different variables and negating vs. confirming an emergency (percentages rounded).

Item # according to Fig. 2	Variable	Group 1 (Negating emergency)	Group 2 (Confirming emergency)	p-value	Cramér’s V
	Sociodemographic
	Age (metric; n=227)	47.5 mean (SD 21.4; median: 50)	56.1 mean (SD 20.4; median: 58)	0.05	–
	Gender (n=226)	17% ♀ 5% ♂	84% ♀ 95% ♂	0.01	0,18
	Motives and surrounding factors (sorted by Cramér’s V in descending order)
#4	“I wanted a quick transport to the hospital/the emergency department” (n=195); % for: “yes, was a reason”	4%	62%	<0.001	0.38
#7	“I wanted immediate medical care on site” (n=191); % for: “yes, was a reason”	8%	53%	<0.001	0.30
#10	“The time to an appointment at the general practitioner or specialist was unacceptable.” (n=190); % for: “yes, was a reason”	4%	42%	<0.001	0.26
#11	“I had great fears.” (n=188); % for: “yes, was a reason”	4%	42%	<0.001	0.26
#3	“The emergency medical service/the emergency physician was the quickest one available.” (n=194); % for: “yes, was a reason”	29%	67%	<0.001	0.26
#13	“I absolutely/necessarily wanted an emergency physician.” (n=186); % for: “yes, was a reason”	4%	34%	0.01	0.22
#5	“I was insecure how my health might be.” (n=196); % for: “yes, was a reason”	25%	57%	0.02	0.21
#9	“The emergency medical service was uncomplicated to use.” (n=191); % for: “yes, was a reason”	13%	43%	0.01	0.20
#6	“My complaints occurred outside of the opening hours of a general practitioner or specialist.” (n=194); % for: “yes, was a reason”	21%	50%	0.07	0.19
#14	“I was afraid to soon become an emergency.” (n=190); % for: “yes, was a reason”	4%	30%	0.01	0.19
#12	“I did not know who else to turn to.“ (n=184); % for: “yes, was a reason”	13%	36%	0.02	0.17
#8	“No one could give me a ride to the emergency department or doctor’s office.” (n=195); % for: “yes, was a reason”	21%	44%	0.03	0.16
	Self-reported EMS use during night (n=218); % for: use between approx. 6 p.m. and 5:59 a.m.	58%	37%	0.05	0.14

There is only a low effect that group no. 1 is more likely to report an EMS use between approx. 6 p.m. and 5:59 a.m. (group 1: 58% versus group 2: 37% during night; n=218; V=0.14; p=0.05).

There is no significant difference between group 1 and 2 in

• the amount of prior self-reported EMS uses (p=0.74; d=0.07; n=212),

• whether the patient called the ambulance him-/herself or not (p=0.49; V=0.08; n=225),

• whether the patient had contact to other emergency care providers directly prior to the EMS use (p=0.43; V=0.07; n=222) or

• whether the EMS use took place on the weekend (p=0.82; V=0.02; n=227).

The latter is also not significant if EMS use on the weekends (Saturday/Sunday) is contrasted to working days excluding Wednesdays and Fridays (as in Germany both of these working days are frequently with shortened opening-hours for GPs and specialists (p=0.60; V=0.06)).

We calculated logistic models to predict why people use EMS in cases they do not judge as emergency.

Model #1

Due to theoretical considerations, the first model bases on all variables depicted in Table 1 , except those that maintain time pressure, respectively wishes for “quick” and “immediate” services (items # 3, 4 and 7): Those omitted items may be in non-predictive association with the answers on the statement “I had an emergency”. Subjective time pressure might rather be an outcome of a subjective emergency judgement and, thus, not a predictor. Wanting an emergency physician (item # 13) can also be considered a consequence of self-perceived emergency. With all remaining variables entered blockwise, only self-reported EMS use during night is a significant predictor for negating an emergency as a reason (OR: 3.81 [CI: 1.33; 10.93]; n=169; see Table 2 ).

Table 2 Predictors for negating an emergency as a reason for EMS use (significant results in bold; B=Regression Coefficient; OR=Odds Ratio; CI=Confidence Intervals; slashes, if model excludes an item a priori).

Nagelkerke’s R²; corected R²	Modell 1 (n=169)			Modell 2 (n=169)
	0.37; 0.33			0.29; 0.25
	B	Sig.	OR [95% CI]	B	Sig.	OR [95% CI]
Age	−0.02	0.21	0.98 [0.96; 1.01]
Gender (reference: men)	1.01	0.01	2.75 [0.83; 9.14]
#10 Time to appointment unacceptable (reference: yes)	2.31	0.08	10.03 [0.73; 137.43]	2.92	0.02	18.61 [1.57; 220.13]
#11 great fears (reference: yes)	2.14	0.06	8.51 [0.93; 78.14]
#5 insecure about health (reference: yes)	0.81	0.22	2.24 [0.63; 8.01]
#9 uncomplicated use (reference: yes)	0.82	0.38	2.28 [0.36; 14.33]
#6 outside of opening hours (reference: yes)	−0.05	0.95	0.95 [0.22; 4.14]	0.76	0.25	2.13 [0.59; 7.63]
#14 afraid to become emergency (reference: yes)	0.84	0.48	2.31 [0.22; 23.86]
#12 did not know who else to turn to (reference: yes)	−1.04	0.33	0.35 [0.43; 2.86]
#8 no one could give ride (reference: yes)	0.37	0.63	1.40 [0.36; 5.45]	0.74	0.26	2.10 [0.58; 7.60]
Time of EMS use (reference: daytime)	1.34	0.01	3.81 [1.33; 10.93]	1.57	0.003	4.80 [1.73; 13.36]
#19 insufficiently or badly treated (reference: yes)				−0.62	0.61	0.54 [0.51; 5.67]
#18 call number 116 117 not reachable or available (reference: yes)				19.08	0.10	193728374.57 [0.00; ]
#17 no one could care at home (reference: yes)				0.87	0.57	2.39 [0.12; 47.16]
#16 no time to go to doctor earlier (reference: yes)				−1.91	0.13	0.15 [0.13; 1.74]
#2 others have decided (reference: yes)				−0.97	0.26	0.38 [0.70; 2.07]
Constant	−13.46	0.00	0.00	−44.40	0.10	0.00

Model #2

The second model focuses on external surrounding conditions triggering EMS use. Based on the modified Andersen’s model ( Fig. 1 ), we included family and community based “enabling resources’” (items # 2, 8, 16, 17), items for ”environment/health care system” (items #6, 10, 18 and item “EMS use at night”) and a variable for prior “health care use” (item # 19). Again, EMS use at night increases the chance of negating an emergency (OR 4.80 [CI: 1.73; 13.36]). Additionally, patients negating that the time to an appointment at a GP or specialist was unacceptable are more likely to negate an emergency as a reason for EMS use (OR 18.61 [CI: 1.57; 220.13]).

Adding the personal variables age and gender to Model #2 results in significance for the same two items (with Nagelkerkes R²=0.33; n=169).

Discussion

In an international rapid review, Coster et al. ¹⁶ identified six domains why people use emergency and urgent care services:

1. “Confidence in Primary Care and Access to Appointments”

2. “Perceived Urgency Anxiety and the Value of Reassurance From Emergency-based Services”

3. “Perceived Need for EMS or Hospital Care, Treatment, or Investigations”

4. “Being Advised to Attend ED by Family Friends or Healthcare Professionals”

5. “Convenience in Terms of Location, Not Having to Make Appointment, and Opening Hours”

6. “Individual Patient Factors (e. g.,, Costs and Transport)”( 16 , p. 1142–1144)

German studies with qualitative interviews of patients with low-acuity visits to the ED confirmed the two motives: “convenience” and “health anxiety”, ¹⁹ equaling Coster et al.’s domain #5 and 2. Reasons were also the substitution of late appointments or unavailable GPs or specialists ^{25 30} .

According to our analysis for EMS patients, Coster et al.’s domains apply in the following order of importance: As 89% of the respondents confirmed the reason “I had an emergency”, the perceived “urgency” (domain 2 ) and “need” (domain 3 ) seem to be equally important. “Advice by others” (domain 4 ) seems to be the next important reason, as 85% confirmed that their EMS use was due to someone else’s decision to call. The section “anxiety” within the domain no. 2 seems to be slightly more important than “access to care” (domain no. 1 ).

Coster et al. focus their domain “individual patient factors” (domain 6 ) on costs and transport options. Our questionnaire did not contain whether people lacked means of transportation, but 42% affirmed the reason that no one was able to give them a ride to the ED or doctor’s office. Using a quantitative method and having the questionnaire sent out by their health insurance company (that – in theory – could refuse reimbursement of unnecessary EMS use), social desirability bias on cost related questions seemed likely. Thus, in the questionnaire, we omitted the question whether the EMS was the cheapest option to reach the hospital. Relating to Coster et al.’s “transport options”, the results showed that 44% of the respondents negated to want a quick ride to the hospital. Forty percent of the respondents confirmed the statement “The emergency medical service was uncomplicated to use” in context of the domain “convenience” (no. 5 ).

New domains deriving from this study might be “ promptness of the service ”, as 56% of the respondents confirmed a fast transport and 47% an instant care on site as a reason. In the future, studies could investigate, whether a new domain “ care on site/home visit ” remains important for EMS in particular, even if more people knew about alternative options of home visits by others, e. g., ambulatory care doctors/nurses. As at least 44% of the respondents stated social reasons, a new domain “ social factors ” might be useful. This would acknowledge that social factors are important determinants for health and the utilization of health care and EMS (cf. ^{28 31 32} ). Our results show that one cannot generally judge the public as using EMS too often or quickly. Therefore, “ delayed own decision ” ought to be an additional domain. Though seldom stated, the domain ” effects of prior health care use ” should be considered, as it may include aspects like previous insufficient medical care, side effects of medications and other avoidable emergency conditions.

It remains contradictory that 89% of all respondents confirmed an emergency as a reason while 26% worried to become an emergency soon. The percentage (84%) of people answering that someone else’s call was reason for the EMS use seems plausible in combination with the high amount of third party calling in their index case (89%) reported in a previous paper ³³ . As it is very likely that not every patient had relevant impairments and only 17% reported unconsciousness, one may assume that the patients’ wish had at least some impact on third party calling. This is strengthened by the fact that patients affirming someone else’s decision as a reason were not significantly more often negating an emergency. Nonetheless, the presented results, as well as studies from other countries, give nudges to conduct more research on how a dispatcher can balance between the patient’s and the callerʼs perspectives ^{4 34} .

Knowledge about alternatives and referrals of other providers might influence the usage of emergency medical services. Depending on the source, either a majority (e. g., 78% ³⁵ ) or a minority (e. g., 37% ²¹ ) of the German public knows about the service of the “doctors on call“ or its phone number. According to the presented results, those services are involved prior to every 5 ^th EMS use. Roughly every 10 ^th person denied an emergency as a reason and items show that more than every third person was not interested in a quick transport or treatment on site. Thus, from a patient’s point of view, there is not always the need for prompt dispositions by dispatchers, quick decisions or care by paramedics or emergency physicians, as well as short driving times. This offers a chance that – in situations that are not life-threatening – longer, more detailed assessments will increase the quality of the disposition or the decision which other (e. g., health care) provider to refer to. Less focus on time-based quality measures for low acuity cases may also support road safety for EMS personnel and patients alike.

The quota of emergency physicians’ involvement is higher than the subjective wish for it: Thirty-one percent of the respondents confirmed the reason “I absolutely/necessarily wanted an emergency physician.”, while the quota of emergency physicians’ involvement per EMS case is approx. 60% (according to the involved vehicles manned with emergency physicians recorded in the health claims data which is available for all respondents). Another German-wide study also including EMS use that was not billable estimate that approx. 41% of all prehospital emergency care cases involve emergency physicians ² . Yet, there is a need to expand the research on how strongly the subjective assessment of the emergency should affect disposition and further care.

A current German legal draft aims at increasing EMS care on site without transportation to the hospital. As 44% of our respondents negated wanting a quick transport to the hospital and 47% affirmed wanting care on site, some of the 95% of patients transported to the hospital could be open to care on site only. However, up to half of the users, those interested in a quick transport, might not well accept the objective to reduce transports. Surveys in other countries reveal hesitation towards alternate transport destinations for low acuity conditions (e. g., ³⁶ ).

The results that people have higher chances of negating an emergency, if they have EMS uses at night could be an indicator that some patients lack alternatives to EMS use for low acuity cases at night (or do not know about them). In Germany, non-medical ambulance transports are usually limited to daytime. To reduce dispositions of highly qualified staff and expensive equipment at night for subjective non-emergency cases future studies could investigate how strongly any or all of those measures should be implemented:

• The provision of non-medical transports at night,

• The increase and promotion of other types of care for minor emergencies or

• The promotion of health literacy in general.

So far, quality assurance of EMS strongly focuses on achieved rescue times and life-threatening conditions ^{6 37 38} . The current results on the wide variety of reasons to call may encourage patient involvement in developing quality indicators that matter to a larger number of users.

Limitations

To the best of our knowledge – after using English and German search terms (for example emergency medical service* AND reason* OR motive*) on pubmed and google scholar as well as snowballing techniques from papers found – , this is the first study to elaborate patients’ subjective reasons for real instances of EMS use, using a theory-based, systematical approach and enabling to compare a wide range of possible reasons according to their impact/importance.

The results represented EMS use in (at least) 12 out of 16 German federal states. Nonetheless, they overrepresented southern federal states and patients with statutory health insurance, lacking those with private insurance (which equal about 11% of all persons insured in Germany ³⁹ ). According to results published in a previous paper ³³ , there is a high plausibility that the vast majority of the respondents were able to recall their EMS use, even though it took place two years ago: For example, self-reported complaints versus diagnosed ICD codes (during inpatient care accompanying the EMS use) correspond well. Patients also reported that their EMS use was a rare event (median/modus: 2 EMS uses per life). Studies show “vivid memories for emotional events”, which further increases the likeliness of a good recall ability for the broad, not too detailed questions related to their rare and probably emotional EMS use ( 40 , p.1). Nonetheless, future studies would do well to interview as soon as possible during or after the EMS use, which could also help include some of the medium-term fatal courses and increase response rates. Further testing, shortening of the questionnaire and sending out reminders might also help increase the latter. Yet, the response rate might also be limited by cultural factors as studies from Germany tend to achieve lower response rates than e. g., North American studies ⁴¹ .

To keep the questionnaire as short as possible, the study did not differentiate how strongly the motives for the index EMS use are determined by underlying, more consistent reasons such as the respondents’ social structures and prior experiences (cf. ²⁸ ). Altogether, the questionnaire may be considered a starting point for further validations, taking into account it will need several different questionnaires and a bundle of studies to cover the complete list of possible reasons for EMS use. In general, the approach to adapt Andersenʼs model proved useful to detect reasons not yet reported in the general literature on the utilization of emergency services.

Conclusion

The study identified a variety of subjective reasons for EMS use beyond pure medical need. Some of them are not yet widely reported in other sources, e. g., “ promptness of the service ” and “ delayed own decision ”. Measures to optimize EMS use and care will always have to take into account the contributing or even triggering effect of the health care and social system. Improving health literacy could help ease anxiety and fears which are also common reasons. Up to half of the users might not well accept the political objective to reduce transports to the hospital. It could be beneficial to conduct more research on the interactions between patients, callers and dispatchers. The discrepancy between the patients’ reasons and the present quality assurance measures highlights the need to increase patients’ involvement in further development of quality assurance in EMS.

Funding Statement

Funding This work was funded by the German Innovation Fund of the Joint Federal Committee (G-BA) [grant number 01VSF17032]