Ambulances

Changes to the content of the costing manual that were made to align with the new health economic guidelines included incorporating a new typology of costs and consequently updating the roadmap for costing studies. The roadmap describes the steps that are needed to conduct a costing study [4 (link)]. It serves as a starting point for conducting costing studies and connects the health economic guidelines to the costing manual.
Reference prices for health care consumption, which are average unit costs, constitute a frequently used part of the costing manual. Reference prices were recalculated using recent information on costs, volume and prices for various types of health care services. Reference prices were updated using various techniques (summarized in Table 1), depending on data availability. If possible, bottom-up microcosting was used to calculate reference prices, as this is the gold standard for calculating cost prices [5 (link)]. When bottom-up microcosting data was not available, grosscosting methods were applied to calculate reference prices. Bottom-up microcosting studies, identifying and valuating resource use per individual patient, were used to calculate references prices for hospital care [Tan, S.S., et al. Reference unit prices for surgery, neurology and paediatrics. Submitted for publication]. Reference prices for emergency care, ambulances, blood products, daycare treatment in mental health care and rehabilitation were calculated using top-down grosscosting, for which data on costs and volumes were derived from health care providers. Data on expenditures and volumes derived from national health care database were used to calculate reference prices using top-down grosscosting, for primary care physicians, paramedical care, elderly care, home care, mental health care and health care for disabled patients [6 ]. Finally, tariffs were used to value diagnostic procedures [7 ]. For contacts with independent psychotherapists and psychiatrists, ambulatory consultation in a general institution and inpatients days in mental health care tariffs were used [8 ]. Relevant stakeholders were consulted to validate the updated reference prices. Updated informal care costs were derived from the website of the Central Administration Office (CAK). Productivity costs should be valued using the friction cost method based on the Dutch health economic guidelines. The friction period is equal to the average duration of a job vacancy plus an additional four weeks. The average duration of job vacancies was calculated with the following formula: 365 / (the number of filled vacancies in one year / the number of vacancies at a moment in that same year). The number of vacancies was derived from the website of Statistics Netherlands. Wage levels were also derived from the Statistics Netherlands website.

In Denmark, the 1-1-2 emergency number is used for all emergencies, including those that require police-, fire- and health-related responses. All 1-1-2 calls are answered by the police or fire brigade. In mid-2011, five regional EMCCs were introduced in Denmark to provide EMD service to the entire country. The assessment and prioritization of citizens with medical problems who called the 1-1-2 number was done previously by the police (or, in part of the capital, by the fire brigade). After determining the caller’s location, the 1-1-2 operator now transfer all health-related calls to the appropriate EMCC where the calls are assessed. The EMCC staff determines the level of emergency and decides on a response using the Danish Index, a criteria-based dispatch protocol for assessing the calls, making decisions about the emergency level and determining the appropriate responses [2 ,3 (link)]. The Danish Index has 37 main symptom groups that are each subdivided into five levels of emergency; each level of emergency contains a number of more specific symptoms. The five levels of emergency are as follows: A: life-threatening or potentially life-threatening condition, immediate response required; B: urgent, but not life-threatening condition; C: non-urgent condition that needs an ambulance; D: non-urgent supine patient transport; and E: other service or advice/instruction including taxi transportation (no ambulances are dispatched for emergency level E calls). The Danish Index also suggests supplementary questions to ask the caller and advice for lay bystanders and for health care professionals. 1-1-2 calls that are answered by an EMCC are assigned a Danish Index criteria code that corresponds to the level of emergency, main symptom and specific subgroup symptom.

Is an emergency care delivered by a professional provider at the scene and during transportation and/or emergency transportation to the health facility by ambulance but outside the walls of the hospital [32 (link), 33 (link)].

The “ResISSSTE Cerebro” program includes seven urban healthcare facilities located in Mexico City and one in each of the neighboring states of Morelos and Hidalgo. According to the World Stroke Organization global stroke services guidelines and action plan (9 (link)), seven facilities are cataloged as essential stroke centers (ESC). Thus they offer access to non-contrast computed tomography (NCCT), clinical evaluation, and potentially IVT (according to IVT criteria cited below). At ESC, there is no personnel with expertise in AS treatment. The eighth facility is an advanced stroke center (ASC) capable of providing advanced stroke services on a 24/7 basis, including multidisciplinary stroke expertise, multimodal imaging, and acute reperfusion therapies for ischemic stroke.
Since its approval in 2019, the program has operated as a modified hub-and-spoke model. It receives funding from the Mexican government through the ISSSTE healthcare system and has access to ambulance services available 24/7. It also includes a stroke telemedicine network to facilitate the evaluation and care of potential patients.
As mentioned above, the program's functioning is mainly based on the hub-and-spoke model but with certain adequations to the Mexican Healthcare system. For example, most hub-and-spoke models function by offering daytime AS treatment at local centers, and the patients in need of treatment out-of-hours and on weekends are treated at hub hospitals. But, in the “ResISSSTE Cerebro” program, all centers provide AS treatment regardless of time or day, with the only difference being that advanced modalities of treatment (EVT and IVT guided by perfusion imaging up to 9 h after the onset of symptoms) are available only at the ASC. Similarly, the drip-and-ship model, as initially conceived, assumes that all centers within a network can diagnose LVO, thus allowing emergency medical services (EMS) to move patients to the closest hospital and only transfer to a thrombectomy-ready hospital for those patients with confirmed LVO. The drip-and-ship model was only partially implemented in our program due to constrained access to ambulances and human and technological infrastructure to perform advanced imaging in stroke patients at the ESC. Our model also accommodates that most of the patients in Mexico arrive at a hospital by their means (for example, the family car or public transportation), with few coming by EMS; therefore, prenotification is uncommon. Consequently, by concentrating the human and technological resources in a single center, the “ResISSSTE Cerebro” program can deliver advanced AS treatment 24/7 while preserving the capability of ESC to provide telemedicine supervised IVT also 24/7.
The stroke telemedicine network utilizes an instant messaging app that includes all the emergency room staff of all shifts grouped by each ESC. Each group, in turn, has all the stroke team members located at the ASC. Emergency room physicians are in charge of all initial evaluations and are responsible for alerting the stroke team and carrying out their instructions regarding treatment. At the same time, they order the NCCT and arrange for a possible transfer to the ASC. The ESC prenotifies all transfers to ASC. The protocol is known by all the staff at the emergency rooms of the ESC, and a print or electronic copy is available for consultation at the office of the head of the emergency department. Figure 1 depicts the pathway for patients initially arriving at ESC, and Figure 2 is that of patients coming directly to the ASC. All the ESCs are staffed 24/7 with emergency physicians, residents (emergency medicine is a 3-year residency program in Mexico), and radiologists. At the ASC, the staff comprises emergency physicians and emergency medicine residents, radiologists, neuroradiologists, clinical neurologists and clinical neurology residents, neurosurgeons and neurosurgery residents, and interventional neurologists and interventional neurology residents.