Exploring the economics of helicopter rescue in Australia

Currently HEMS are used to perform primary scene responses to trauma and secondary interhospital transfers of trauma and patients and other critically ill populations, as well as search and rescue functions. Despite over 30 years of operation in Australia, the use of HEMS remains controversial with issues relating to contract arrangements, staffing, efficacy, safety and cost (which is estimated to be 10 times higher per case than that of ground transport1). In the context of recent high-impact research that showed a link between HEMS and reduced mortality in over 200 000 seriously injured patients in the United States,2 it is timely to shift our focus towards the economic aspects of HEMS in Australia. In doing so, we consider the role of HEMS locally, the benefits HEMS provide in relation to their additional cost, their scope for more efficient reconfiguration and the importance of community preferences.

In Australia, HEMS use a mixture of staffing, provider and funding models. As no comprehensive description exists of the cost, structure and function of HEMS in Australia, we undertook a survey of HEMS in New South Wales for the 2008–09 financial year.3 Our findings showed that the responsibilities of HEMS were largely consistent, involving transport within the regionalised trauma system and local critical care networks, as well as search and rescue. However, the survey highlighted substantial variation in the estimated costs of HEMS, as well as differences in their structure, including providers and staffing, and operations, including population coverage and the number and type of helicopters.

Despite the methodological difficulties, previous studies have been undertaken to assess the value of HEMS in different patient populations and regions. We did a systematic review of the literature, documenting 15 previous economic evaluations of HEMS, of which seven concentrated on trauma populations, four on non-trauma populations and four on non-specific patient populations.4 Although HEMS were costly (up to US$5.6 million per annum), several studies found that HEMS provided an incremental benefit with cost-effectiveness ratios ranging between approximately US$2200 and US$3300 per life-year in trauma patients and between approximately US$7100 and US$12 000 per quality-adjusted life-year in non-trauma patients (US$ value in 2008). Further to this previous research, we examined the cost-effectiveness of a HEMS transportation to a major trauma centre in NSW.5 Consistent with previous research, we found an association between a HEMS intervention and reduced risk of inhospital mortality. When modelled over a lifetime, this effect led to an estimated $97 000 per life-year saved in all patients, $50 000 per life-year saved in patients with serious injury, and $49 000 per life-year saved in patients with traumatic brain injury.

In primary scene responses to trauma, current research relies on an association between a HEMS intervention and reduced patient mortality. Such benefits, when extrapolated over a lifetime, lead to reasonable cost-effectiveness ratios, even when the additional costs of long-term care are incorporated. Because of the large differences in cost-effectiveness that have been observed between patient groups, our results also highlight the cost-effectiveness gains that can be achieved by using accurate triage criteria, which at present are largely non-evidence based. Little is known about the effect of HEMS on functional outcomes, and future research needs to improve our understanding of how HEMS can be designed to optimise long-term quality of life.

Although many HEMS are run by charities, governments also play a significant role. In NSW, HEMS are currently run by private providers and charities under the jurisdiction of the Ambulance Service of NSW. A recent report by the NSW Auditor-General into the aeromedical tender process in NSW found that the cost of switching HEMS contracts to a private provider was three times as high as when they had been run by charities.6 Although the additional cost was potentially offset by improved patient triaging and overall service efficiency, there appears to be no consensus on the providers best placed to run HEMS. From an economic perspective, the use of variant providers may allow a market-based approach to service provision to keep costs to a minimum. Alternately, the use of a single provider (in multiple locations) would allow shared resources and potentially improved efficiency. Recent research has also highlighted safety concerns about HEMS transport,7 and this remains a fundamental consideration in future service reconfiguration.

The recent survey of HEMS in NSW also highlighted inconsistencies in how HEMS are staffed. For primary scene responses, staffing varied between dual paramedic crews and physician/paramedic crews. The benefit of physician staffing in primary scene responses has received considerable attention.8 However, given the variation both within and between states in Australia, there is clearly no consensus on whether HEMS should carry physicians. In the context of the total running cost of HEMS (about $5000 per case1), the cost of different clinical staffing profiles is likely to represent a small proportion. Consequently, it may be optimal to consider staffing profiles in the context of efficiency for the service overall, rather than traditional cost-benefit parameters.

Although potential efficiency improvements in the way in which HEMS are operated may exist, the economics of such services tends not to figure highly in current policy and practice. Historically, charities and not-for-profit organisations have played a fundamental role in the development of HEMS in Australia, which has facilitated services leveraging off the community’s willingness to pay for HEMS. Although there is little research concerning community attitudes to HEMS in Australia, studies from overseas have demonstrated the community’s willingness to support HEMS through increased taxation9 and a preference for supporting HEMS over other health care services such as open-heart operations and joint replacements.10 Indeed, while the proliferation of HEMS charities in Australia may reflect substantial community support for HEMS, the economic implications of this expansion within broader health funding have not been considered in detail.