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Dept. of Economics (Web page)
Karlstad University
SE-651 88 Karlstad Sweden
Phone: +46-54-700-10-00
Karlstad University Working Paper in Economics
# 2013 / 2
Time is money, but how much?
The monetary value of response time for Thai ambulance emergency services
Dr. Henrik Jaldell a
, Dr. Lebnak P b
, Dr. Anurak A. b
, Ms. Krongkan B., Ms. Khanisthar P. b
a
Department of Economics, Karlstad University
b
Emergency Medical Institute Thailand, EMIT
2
Time is money, but how much?
The monetary value of response time for Thai ambulance emergency services
Dr. Henrik Jaldell
Karlstad University
Department of Economics
S-651 88 Karlstad
Sweden
henrik.jaldell@kau.se
Phone: +46547001369
Fax: +46547001799
Dr. Lebnak P., Dr. Anurak A., Ms. Krongkan B., Ms. Khanisthar P.
Emergency Medical Institute Thailand, EMIT,
Bangkok, Thailand
Abstract:
The monetary values for how much ambulance emergency services are calculated for two different
time factors, response time, which is the time from when a call is received by the EMS call-taking
centre until the response team arrives at the emergency scene, and operational time, which is the
time from alarm to the accident scene and to the hospital. The study is performed in three steps.
First, marginal effects of reduced fatalities and injuries for a minute change of the time factors are
calculated using logistic regressions. Second, monetary values are chosen for fatalities and injuries;
third, the marginal effects and the monetary values are put together to find a value per minute. The
values are found to be 5.5 million Thai Baht per minute for fatality, 326,000 Baht per minute for
severe injury, and 2,100 Baht per minute for slight injury. The total value of fatality, severe injury
and slight injury for a one-minute improvement for each dispatch, summarized over one year, is 1.6
billion Thai Baht using response time. The resulting total values could be used on the benefit side in
an economic cost-benefit analysis of investments, such as new technology, which could reduce the
response and operational times.
Keywords:
Response time, cost-benefit, medicine, emergency, EMS
JEL codes:
D61, I31, R53,
Acknowledgement:
Financial support from Swedish Ministry of Foreign Affairs is acknowledged. Many thanks to Anders
Edberg, Ericsson (Thailand), without whom this project would not have been possible.
3
1. Introduction
The success of all emergency responses is dependent on the time taken to get to the place where
someone is lying ill or where a traffic accident has occurred. The faster the response the better the
outcome will be. Hence, it is reasonable to say that all efforts should be made to decrease the time
factor in the alarm chain from calling to taking the call, to dispatching, to getting ready to leave, to
driving to the injured or accident, to taking care of the injured or suppressing the fire, and to getting
the injured to hospital. On the other hand, should all efforts be made solely to decrease the time
factor? Such efforts are costly and there are other health matters that could be invested in: better
ambulances with more technical equipment, more training of the staff, better hospitals, provision of
self-help equipment etc. The economical way of dealing with this problem of the public sector is to
perform cost-benefit analyses. If benefits outweigh costs, in monetary terms, then an investment
should be made since it can be said to increase welfare in society. If costs outweigh benefits, the
investment should not be made.
The purpose of this study is to find a monetary value for the time factor of the emergency responses
in Thailand. It is not a cost-benefit analysis, since it only considers the benefit side of the time factor.
Notwithstanding, the results of the study could be used in a cost-benefit analysis. For example, if the
Thai emergency sector intends to invest in new alarm technology that could save 1 minute in
response time for all responses, how much will such an investment lead to in benefits measured in
economic welfare terms?
As noted by Blanchard et al. (2012), there are only a few studies on the relation between the
response time of emergency medical service (EMS) and the saving of lives. When it comes to cardiac
arrest, reducing ambulance response time has been shown to increase survival rate (Pons et al.
2005; Pell et al. 2001; O’Keefe et al. 2011). Gonzales et al. (2009) found increased EMS pre-hospital
time to be associated with higher mortality rates. Using fire and rescue services, which have shorter
response times than traditional ambulances for health care responses, has been found to increase
survival rate (Mattsson and Juås 1997; Jaldell 2004; Sund et al. 2011). However, there are also
studies that have concluded that there is no relation between the response time and outcome of the
patient (Blackwell et al. 2002; Blackwell et al. 2009; Pons and Markovchick 2002).
There are five motivations behind this paper. The first is that, as noted above, there is not much
research done on the effect of the response time. The second is that most of the studies mentioned
have taken up one health problem (cardiac arrest), while from a planning perspective there are of
course many more reasons for having ambulance services. Furthermore, most of the analyses have
evaluated the 8-minute response time goal for American ALS units responding to life-threatening
events, for example, by comparing the survival rate below or above the 8-minute response time
using non-continuous measures of response time. This analysis focuses instead on a continuous
measure of the response time. The third is that this study examines not only the relation between
response time and mortality, but also the effect of the illness condition for non-mortality cases. The
fourth is that the number of observations in this study is over a million, compared to hundreds or
thousands in the papers mentioned above. The fifth is that the analysis done does not stop at the
outcome of the patient, but instead takes on an economic perspective, where the purpose is to find
a monetary value for the total benefits of reducing the response time. This value could be used in a
4
cost-benefit analysis for evaluating investments in new alarm technology that would speed-up the
response time.1
To find the monetary value of the time factor for emergency responses in Thailand, the analysis is
performed in two steps. The first step is to analyze the emergency response data from the call-
taking and dispatch centre database of the Emergency Medical Institute of Thailand. The data used is
for 19 months (from March 2009 to September 2010) with 1,160,391 emergency response records
representing 73 % of all emergency response cases in Thailand during this time period. In the
statistical analysis a logistic regression analysis is used to find the relation, expressed as marginal
effects, between an independent variable and dependent variables. The dependent variables are
fatality, severe injury and slight injury. The independent variable is the response time or the
operational time, i.e. the time factor of the emergency response. Holding other independent
variables and risk factors constant, the marginal effect describes the increase or decrease in the time
factor for a one minute change and how this will affect the risk of fatality, severe injury and slight
injury.
Using results from a Thai cost-of-illness study (Thanirananon et al. 2008) the total value of fatality,
severe injury and slight injury for a one-minute improvement for each dispatch summarized over
one year is 1.6 billion Thai Baht for response time, where response time is the time from when a call
is received by the EMS call-taking centre until the response team arrives at the emergency scene. For
operational time, it is 800 million Thai Baht, where operational time is the time from when a call is
received by the EMS call-taking centre until the patient is admitted to a hospital emergency room.
The above values for a one-minute improvement to the time factor for one year are calculated using
the provinces included in the Narenthorn database. The number of emergency response cases in
these provinces represents 73 % of the total number of the emergency responses in Thailand during
the study period. Therefore, if we were to extrapolate the loss values for the whole of Thailand the
value would be 2.2 billion Thai Baht for response time and 1.1 billion million Thai Baht for
operational time. These figures represent the positive welfare effect, for one year, of reducing the
emergency responses in Thailand by one minute on average.
Assuming, for example, that an investment could be made in a new call taking and dispatch system
with a technology life of 20 years, which could decrease the response time and operational time by
one minute, the present value of the benefits of such an investment will be between 12.8 and 25.6
billion Thai Baht, assuming a social discount rate of 6 %.
Section 2 describes the Thai emergency system and section 3 contains the data used. The model and
the results are presented in sections 4 and 5, respectively. Section 6 concludes the study with a
discussion and conclusion.
1
No similar cost-benefit study has been found and there have been very few economic studies of out-of-
hospital emergency care (see Lerner et al. 2006).
5
2. Emergency System in Thailand
Currently, the emergency call number “1669” is being used as the emergency medical contact
number in Thailand. The system has been installed in each province at the main hospital or the
provincial health office. The call taker asks the caller for information and tries to understand the
symptoms or other relevant information. He/she then gives the caller some essential medical
suggestions and advice, such as first-aid, and then asks for further information about the location
and situation to be able to make a decision about the next step. A dispatcher controls the resources
by using different EMS-levels including the first response unit (FR), the basic life support unit (BLS)
and the advanced life support unit (ALS). He/she also addresses their suitability to operate at the
scene of the problem and their capacity to aid the patient. The FR-unit is able to assess and give
primary care to the emergency patient, e.g. first-aid and simple procedures. The BLS-unit has more
capability to take care of the emergency patient than the first response unit, e.g. basic medical
operation, oxygen giving and non-invasive emergency care. The ALS-unit has the capability to
provide care similar to the emergency unit in a hospital, e.g. CPR (Cardiopulmonary resuscitation)
with defibrillator, ventilation support, intravenous infusion, intravenous injection and invasive
treatments. The important role of the call taking and dispatch system is to receive the correct
information quickly, to evaluate the situation and to supply personnel, vehicles, equipment, etc,
which can support the emergency case in the best way possible and reach the location of the
incident rapidly, especially to assist an emergency patient who could be severely injured or die if the
assistance is delayed. There are 12 million emergency cases per year, 30% of which are for critical or
emergency patients, i.e. those who need the emergency services to prevent life threatening
situations. Of the total amount of emergency cases, approx. 60,000 emergency patients died
outside hospitals. If Thailand had an efficient emergency medical service, 15 – 20% of emergency
patients, or 9,000-12,000 people would be saved per year.
6
3. Data
Definition of response time and operational time
The emergency operation system can be described as having the operational flow shown in figure 1.
Figure 1: Emergency Medical Time
T0 – T1 is the time from when the person who sees or is involved in the incident makes a decision to
call the emergency number 1669 in order to request for medical assistance. This time cannot be
measured accurately because the caller cannot always accurately recall or measure the time (in
minutes) from seeing or being involved in the incident to the time of calling the emergency medical
service. T1 - T2 is the time between the caller making a phone call to the emergency services (1669)
and the call-taker answering the call, which is usually 5-10 seconds. In the case of a call taker being
unavailable, the communication supplier for the emergency operation will generally place the
emergency phone call into a queuing system; the call is connected as soon as the next free call taker
is available. T2 – T3 is the time from the call taker collecting data from the caller to when he/she
makes a decision to dispatch the appropriate emergency operation unit to the scene of the incident.
The necessary data is the location, the patient’s details, symptoms, the safety of the location, etc.
The duration might be between 15 seconds and several minutes depending on the severity and
complexity of the incident. T3 – T4 is the time from when the commander informs and dispatches
7
the emergency operation unit, until the unit vehicle leaves from its base. Normally, this will depend
upon the technology of the communication system used for transferring the entire case data to the
emergency operation unit. Also, it will depend upon the call procedure for the unit staff and the
distance between the base and their vehicle. Several emergency units are specified to move out of
the base within 1 minute after being informed of the incident, but this has not been implemented
officially, and cannot be considered as the standard service as of yet.
T4 – T5 is the time taken for the vehicle to move from the base to the incident location. T5 – T6 is
the time from arriving at the location until reaching the patient. This might differ; for example, for a
traffic accident it may take less than 15 seconds. Alternatively, if the incident is in a skyscraper in the
city centre, it will take longer (e.g. 5 minutes) to arrive at the patient’s side. T6 – T7 is the time it
takes to deliver medical care at the location, which will most likely be different from case to case.
For example, for a patient involved in a traffic accident, it will be more advantageous if he/she can
arrive at a hospital rapidly and receive medical care in the operating room as fast as possible (Scoop
and Run). On the other hand, if the patient has cardiac arrest symptoms, it will be more
advantageous if he/she can receive the necessary invasive care at the location until the situation is
stabilized, and then he/she can be transferred to the hospital (Stay and Play). T7 – T8 is the time
taken to transfer the patient to the hospital. This may differ depending on the urgency. The
decision to take the patient to the hospital will be taken by the unit leader and confirmed by the
commander, who receives the report of the emergency patient from the operation unit before
arriving at the hospital.
In this study response time and operational time are defined as:
Response Time: the response time is the time from when the call taker receives the phone call until
the operational unit arrives at the scene site. (T2-T5)
Operational time: the time from when the call taker receives the phone call to the operational unit
transfer of the patient to the hospital. (T2-T8)
The Emergency Medical Institute of Thailand (EMIT) creates the monitoring and implementation
report by extracting relevant data and information from the online-dispatch system called the
“Narenthorn Emergency Medical Database”. The local agencies report data through this system in
order to obtain financial reimbursement for the emergency medical operations they have
successfully performed. The reports in the system include basic information on the dispatch centre,
location and notification, but also time information and information about the injury. The
information consists of the time the information is received, the command time, the vehicle dispatch
time, the scene arrival time, the scene departure time, the hospital arrival time, the base returning
time, the total response time, the distance (in kilometres) and the type of operation unit.
The information on accident or emergency injury is categorized into 12 items, and for disaster into 6
items. There is also categorized information of the injury based on seriousness levels, type of
operation unit and operational staff. The reports also include information on the preliminary
operation results on scene categorized by the type of treatment and identified by the referral, for
example, death and no treatment, heart attack, onsite treatment, etc. The hospital treatment
consists of admission time, treatment duration, treatment result, referrals, continuous treatment,
death, etc.
8
The Narenthorn database has been used nationwide, except for eight provinces, and covers the
regions with about 3/4 of the population of Thailand.2
For the period studied here, 2009 – 2010,
there are 1,489,800 reports, or 73.2% of total reports, which are generated through the system.
However, there are problems with the reports from October 1, 2009 to March 31, 2010. Some
obviously contain wrong time data, for instance, a response time of over 248 minutes and an
operational time of 314 minutes3
, so in total only 1,186,067 reports are used in the analysis.
Descriptive statistics
Treatment results have been categorized into three levels: slight injury, severe injury and fatality.
Slight injury means all patients who receive medical care on scene or at the hospital. Recovery is
allowed to take place at home before or after the rescue services arrive at the scene or after the
patients have received emergency care. Severe injury means patients who receive medical care, and
are admitted to a hospital, and when there is no death before or after the rescue arrives on the
scene, or after the patients receive emergency care. Fatality means patients who die before or after
the rescue services arrive at the scene, or after the patients receive emergency care, and includes
death at the hospital.
Cause of incident is divided into four groups: physical trauma, medical emergency, traffic accident
and others. Physical trauma includes a fall and collapse, fall from a height, building collapse, physical
assault, trauma from an external object, trauma from an animal, fire, electrocution, burns, bombing,
natural hazards, and hazmat. Medical emergency includes drowning, suicide and medical
emergency, while traffic accident includes motor vehicle collision. The number of dispatches for
each incident group with regard to EMS-level and treatment result is found in tables 1a- 1c. Medical
emergency is the most frequent cause of incident, followed by traffic accidents. ALS-units are more
often dispatched to medical emergencies than BLS- and FR-units, while BLS-units are more often
dispatched to traffic accidents. It can be seen that ALS-units are dispatched to a higher degree to
more serious injuries, followed by BLS-units and FR-units. In tables 2a-2b the response and
operational times are reported for different EMS-levels and treatment results. ALS-units also have
the longest response times followed by BLS-units and FR-units. However, the operational time is
similar for all three units.
2
The provinces not included are Bangkok, NongKhai, NongBualamphu, Udonthani, Kalasin, Khonkaen,
Mahasalakham and Roiet.
3
The maximum time is chosen according to mean + one standard deviation.
9
Table 1. Number of dispatches for each EMS-level and treatment results.
a. Total EMS LEVEL
EMERGENCY ALS BLS FR
n n n n
Medical emergency 670,313 56.5% 117,560 64.4% 139,085 53.7% 413,668 55.5%
Traffic accident 358,173 30.2% 47,523 26.1% 83,237 32.1% 227,413 30.5%
Physical trauma 128,410 10.8% 13,491 7.4% 29,370 11.3% 85,549 11.5%
Other 29,171 2.5% 3,845 2.1% 7,227 2.8% 18,099 2.4%
Total 1,186,067 100.0% 182,419 100.0% 258,919 100.0% 744,729 100.0%
b. Treatment results
EMERGENCY Total FATALITY SEVERE SLIGHT
n n % n % n %
Medical emergency 670,622 56.5% 12,476 58.7% 180,126 62.0% 462,082 56.3%
Traffic accident 358,435 30.2% 6,915 32.6% 71,393 24.6% 247,374 30.1%
Physical trauma 128,478 10.8% 1,694 8.0% 26,814 9.2% 95,392 11.6%
Other 29,207 2.5% 151 0.7% 11,971 4.1% 16,119 2.0%
Total 1,186,742 100.0% 21,236 100.0% 290,304 100.0% 820,967 100.0%
FATALITY=worst of injuries, SEVERE=worst of injuries, SLIGHT=worst of injuries.
c.
EMS LEVEL Total FATALITY SEVERE SLIGHT
ALS 182,419 15.4% 14,647 69.0% 94,046 32.4% 62,994 7.7%
BLS 258,919 21.8% 2,372 11.2% 67,376 23.2% 173,196 21.1%
FR 744,729 62.8% 4,205 19.8% 128,814 44.4% 584,275 71.2%
Total 1,186,067 100.0% 21,224 100.0% 290,236 100.0% 820,465 100.0%
FATALITY=If fatality was worst of injuries, SEVERE=If severe injury was worst of injuries, SLIGHT=If slight injury was worst of injuries.
Table 2. Percent of each treatment and response and operational time in minutes for each
emergency group and for each EMS-level.
a.
EMERGENCY FATALITY
%
SEVERE
%
SLIGHT
%
Response
time
Median
Response
time
Mean
Response
time
Std
Operational
time
Median
Operational
time
Mean
Operational
time
Std
Medical
emergency 1.9% 26.9% 68.9%
9 37.6 206.5 26 66.3 241.0
Traffic accident 1.9% 19.9% 69.0% 7 38.4 221.5 19 67.3 260.9
Physical trauma 1.3% 20.9% 74.2% 7 36.7 210.5 23 65.0 244.5
Other 0.5% 41.0% 55.2% 9 37.9 208.7 29 69.8 247.7
Total 1.8% 24.5% 69.2% 8 37.8 211.6 24 66.6 247.7
b.
EMS LEVEL FATALITY
%
SEVERE
%
SLIGHT
%
Response
time
Median
Response
time
Mean
Response
time
Std
Operational
time
Median
Operational
time
Mean
Operational
time
Std
ALS 8.0% 51.6% 34.5% 12 36.6 191.4 25 61.9 225.9
BLS 0.9% 26.0% 66.9% 9 30.2 177.3 23 61.5 224.6
FR 0.6% 17.3% 78.4% 7 40.7 226.8 24 69.5 260.2
Total 1.8% 24.5% 69.2% 8 37.8 211.6 24 66.6 247.7
10
In figure 2 we can see the relation between the response time variable and the percent of death and
severe injury for all cases and for each emergency type. The risk of fatality increases by up to a
response time of 20-25 minutes, but after 25-30 minutes the curves seem to be quite horizontal and
thus the risk of dying is no longer increasing.
Figure 2. Proportion of fatalities related to response time.
For severe injuries the relations have about the same shapes (not shown here). There is an increased
risk of a severe injury for shorter response times, but after about 30 minutes (shorter for traffic
accidents) a longer response time no longer leads to an increased risk of a severe injury.
3.2 Monetary value of emergency injury or accident
The purpose of an economic cost-benefit analysis, CBA, is to measure the welfare impacts of public
investments. If the benefits of the investment are larger than the costs, measured in monetary units,
then welfare can be increased by investing in the project. Therefore, in this analysis we need figures
in Thai Baht for saving lives and reducing injuries.
There are two main methods of finding such monetary values: the cost-of-illness (COI) method and
the willingness to pay (WTP) approach. WTP is based on the idea that people can assess the risk of
having an accident, and that they will pay for reducing or minimizing that risk (see e.g. Viscusi and
Aldy, 2003; Bellavance et al., 2009; Lindhjem et al. 2011). The monetary value is derived either from
questions asked of people (stated preference technique) or by studying people’s behaviour, e.g. how
much they pay when buying risk reducing protection or how high a wage they want for accepting a
job with a higher risk (revealed preferences).
11
When it comes to estimating the value of a statistical life, VSL, there have been only a few studies
that cover Thailand. Vassanadumrongdee and Matsuoka (2005), using surveys in Bangkok with 1,080
questionnaires (680 for the air pollution sample and 400 for the traffic accident sample), employed
the stated preference technique contingent valuation to estimate VSL in the context of air pollution
and traffic accidents. For both risk contexts they used the same reductions in risk level with
reductions of 30/1000000 and 60/1000000. The income adjusted VSL was found to be 59 million
Baht for the smaller risk reduction and 38 million Baht for the larger for air pollution, and 61 million
Baht for the smaller risk reduction and 38 million Baht for the larger for traffic accidents. Chestnut et
al. (1998) tried to find a VSL for air pollution in Bangkok. They referred to studies done in other
countries and used a benefit transfer to calculate a value of US $0.80 to $2.78 million. Gibson et al.
(2006) calculated a VSL of US $0.25 million for landmine clearance in rural Thailand using the
contingent valuation method. Miller (2000) compared the VSL of transport between different
countries, by means of benefit transfer using countries’ different GDP levels, to calculate “best
estimates” for each country. The “best estimate” for Thailand was US $0.38 million.4
The above studies only calculate values of a statistical life. However, we are also interested here in
the monetary value of severe injury and slight injury. For our monetary values results from a study
by Pichai Thanirananon et al. (2008), which employed a cost-of-illness method to calculate the cost
of traffic accidents in Thailand in 2004, has been used. The cost-of-illness method is a way to
calculate the consequences of accidents in monetary values (see e.g. Tarricone, 2006; Larg and
Moss, 2011). That is, it is the sum of emergency costs, hospital costs, productivity loss etc.
Thanirananon et al. focused on five regional hospitals which had a department for providing service
data on the injuries caused by traffic accidents. The loss value was categorized into 3 groups as
follows: 1) The human cost group (loss of productivity, quality of life, medical costs, emergency
medical service costs, long-term costs, etc) 2) The damaged property cost group (vehicle and other
properties damages). 3) The crash cost group (management expenditure of insurance companies,
police, courts, rescue services and the delay of transportation). The loss value for 2004 was also
recalculated to values for fatality of 63,317 million Baht, for severe injury 58,963 million Baht and for
slight injury 1,299 million Baht for 2011 by adjusting for inflation (increasing by 25 %).
4
Another question is whether the same value should be used for different injuries; some studies have found
different values depending on the context (e.g. Savage, 1993; Jones-Lee and Loomes, 1995; Hammitt and Liu,
2004; Carlsson et al., 2010). However, this problem has not been taken into account in this study.
12
4. The Model
We have chosen logistic regressions because of the structure with binary dependent variables. The
problem is choosing how to find a model that both best fits the data and performs well in calculating
the marginal effects of a change in response time that is true for all dispatches. For an example of
how this can be discussed, let us look at the relation between response time and deaths in traffic
accidents in figure 2. Since there seems to be no change in deaths after about 25 minutes, one
choice of model is to restrict the data to only those dispatches where the response time is less than
or equal to 25 minutes. The problem with such a model is that it will predict a much higher
proportion of deaths above 25 minutes than is reasonable according to the data. Consider figure 2
where we can see that about 5.5 % deaths is reasonable for a response time of 40 minutes.
However, a logistic regression model that is restricted to less than 25 minutes would predict this to
be about 40 %. Another suggestion is to choose something like a moving average logistic regression
model, where the first model includes only data for 1 to 5 minutes, the second from 2 to 6 minutes,
the third from 3 to 7 minutes and so forth. Predictions and marginal effects are then calculated for 3
minutes for the first model, 4 minutes for the second model and so forth. Such a model fits the data
much better, but is not very general of course since it has different parameter values for each
minute of response time. Yet another alternative is to try to include as many data points as possible.
This is used here and all response times including median time + one standard deviation are
included. All three models are shown in figures 3 (predictions of proportions of deaths) and 4
(marginal effects).
What we are after is a value for a change of one minute in response time for an average dispatch.
Here, we use the model with the median + 1 standard deviation for response time included, even if
it does not fit the data perfectly. However, choosing one of the other two models would result in
much too high a marginal effect for an average dispatch. The models thus contain response times up
to 249 minutes and operational times up to 313 minutes. Since the relation between the outcome
and the response time seems to be somewhat different, depending on the case of the emergency,
we have chosen to perform different statistical analyses for each case of emergency (traffic
accidents, medical emergency, physical trauma and others).
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0 5 10 15 20 25 30
Proportiondead
Response time, min
Pred value moving average
Pred value response time
<=249min
Pred value response time
<=25 min
Figure 3. Relation between response time and predicted proportion of deaths using different models.
13
-0.003
-0.002
-0.001
0
0.001
0.002
0.003
0.004
0.005
0.006
0.007
0 5 10 15 20 25 30
Proportiondead
Response time, min
Marg eff moving average
Marg eff response time
<=249 min
Marg eff response time
<=25 min
Figure 4. Relation between response time and marginal effect for proportion of deaths using different
models.
14
5. Results
Since the dependent variables have been set to be binary, logit regression analyses have been used
to find out the relation between the independent variables, response time and operational time, and
the dependent variable. The parameter estimates for the independent variables are recalculated
into marginal effects, which show how much the risk of fatality, severe injury and slight injury
changes when the time variable is changed by one minute.
The analyses have thus proceeded in three steps. First, logistic regression models have been used to
find parameter estimates for how the time variables affect the three injury types (equation 1).
Equation 1 has been estimated for each injury and emergency type, and for response and
operational time respectively, that is 3*4*2=24 models have been estimated.
*
*
( ) Prob( 1)
1
TIME
TIME
e
E Y Y
e
 
 


  

(1)
Second, since the model is nonlinear the parameter estimates have been recalculated into marginal
effects (equation 2). The marginal effects are evaluated at the median response and operational
time.5
*
* 2
( )
Marginal effect=
(1 )
TIME
TIME
E Y e
TIME e
 
 




 
(2)
The marginal effects for response time are presented in table 3. They are higher for severe injury
than for fatalities, meaning that a marginal decrease of response time leads to more people saved
from severe injury than from fatality. For fatality the marginal effect is highest for traffic accidents,
while for severe injury it is highest for others followed by medical emergency. For slight injuries the
marginal effects are negative and will therefore not be used in the next step. For operational time
(not showed here) the marginal effects are lower than for response time, indicating that there is a
decreasing marginal value of time, since operational time is longer than response time.
Third, the marginal effects have been recalculated into number of persons affected by a minute
change in response and operational time in one year (equation 3), as presented in table 4 and 5. If
the marginal effect is not statistically significant or negative, the value is set to zero.
*
* 2
( )
Marginal effect in one year= * *
(1 )
TIME
TIME
E Y e
n n
TIME e
 
 




 
, (3)
where n is equal to total number of responses in one year for each emergency type. A one-minute
change would save most people from fatality when it comes to traffic accidents. For severe injuries a
one-minute change would save most in the treatment group others, followed by medical
emergency.
Fourth, the monetary values have been summed up in Thai baht, ฿, for one year, for each
emergency type and totally for all emergency responses. Using the monetary values of lives and
5
Normally marginal effects are evaluated at the sample means of the data or the sample averages of the
individual marginal effects are used (Greene 2008). However, since the median in the sample used here better
describes the typical response and operation time than the mean value does, the median has been used here.
15
injuries, we can calculate a total value per EMS type. The results are shown in table 6. For both
response time and operational time the most important treatment type is medical emergency,
followed by traffic accident. The values for operational time are lower than the values for response
time, reflecting the decreasing marginal value of time. However, the ratio between response and
operational time differs for the different emergency types. The relative difference is smallest for
traffic accident and largest for others, and about 1/2 for the total emergencies. Different ambulance
types have different marginal benefit values per minute. For response time, ALS has a value of 1130
Baht per minute, BLS a value of 644 baht per minute and FR a value of 445 baht per minute.
Table 3. Marginal effects and P(.) >0 results for response time evaluated at median response time
(=8 min).
Injury type /
emergency type
Physical Trauma Medical
Emergency
Traffic Accident Others
Fatality 0.0001473
(0.000)
0.0001912
(0.000)
0.0002861
(0.000)
0.0000287
(0.309)
Severe injury
0.0027129
(0.000)
0.0040699
(0.000)
0.0017932
(0.000)
0.0047531
(0.000)
Slight injury
-0.0004476
(0.000)
-0.0002977
(0.000)
-0.001437
(0.000)
-0.0003409
(0.000)
Table 4. Deaths and injuries saved per year calculated given marginal effect per minute for
response time.
Injury type / emergency type
Physical Trauma Medical
Emergency
Traffic
Accident
Others
Fatality 11.9 15.5 23.2 2.2
Severe injury 220.0 330.0 145.4 398.3
Slight injury 0 0 0 0
Number of dispatches 81101 423356 226215 18424
Table 5. Deaths and injuries saved per year calculated given marginal effect per minute for
operational time.
Injury type / emergency type
Physical Trauma Medical
Emergency
Traffic Accident Others
Fatality 8.8 8.7 17.0 -
Severe injury 88.5 109.8 51.4 136.5
Sligth injury 0 0 0 0
Number of dispatches 81101 423356 226215 18424
Table 6. Monetary value per minute and year.
Baht/Year/Minute/
emergency type
Physical Trauma Medical
Emergency
Traffic Accident Others Total
Response time
(at median 8 minutes)
฿ 135,401,000 ฿ 987,186,000 ฿ 484,352,000 ฿ 27,349,000 ฿ 1,634,289,000
Operational time
(at median 24 minutes)
฿ 76,177,000 ฿ 427,974,000 ฿ 304,957,000 ฿ 9,370,000 ฿ 818,477,000
The loss values for a one-minute improvement in the time factor for one year are calculated using
the provinces in the Narenthorn database. Eight provinces, including Bangkok, are not included in
the Narenthorn database. The number of emergency response cases in these provinces represents
16
26.8% of the total number of the emergency responses in Thailand during the period considered
here. Therefore, if we were to extrapolate the loss values for the whole of Thailand we should,
therefore, increase the total loss value by dividing the study result with 73.2%.
The result of such an extrapolation for a response time is 2,232,600,000 Thai Baht and for an
operational time 1,118,100,000 Thai Baht. These figures represent the positive welfare effect, for
one year, of reducing the emergency responses in Thailand by one minute on average.
17
6. Discussion and conclusion
This study shows that using a logistic regression analysis makes it possible to find a correlation
between response time and the severeness of injury. The correlation indicates that a faster response
time results in fewer fatalities and milder severeness of injury. Furthermore, the time factor is most
important for medical emergency, followed by traffic accidents and physical trauma. The results also
show that the more advanced the ambulance that is used the more important the response time is.
For operational time the correlation has the same sign, but it is not as strong as for response time,
which seems reasonable since there should be a decreasing marginal utility of time.
One limitation of the study is that the emergency response data cannot categorize permanent
disability as a final outcome; thus, the additional loss value of disability is excluded in the analysis,
and the loss value for those cases is covered under the category severe injury.
The planned investment thought of here is a better alarm system which could reduce the time from
accident or injury to dispatch of ambulance, and result in a one-minute decrease in response time. In
comparison, a study in Canada showed that the introduction of base paging reduced the call-
response interval by 30 seconds (Jermyn 2000). Considering operational time, Spaite et al. (1993)
listed several observed problems on-scene, for example with communication, equipment and
uncooperative patients. Most of the time was concerned primarily with logistics and not with
medical care, and operation problems occurred in more than 40 % of the dispatches. Another way to
decrease time is to enforce a single alarm number in Thailand (as in the EU, 112, or North America,
911) instead of the different numbers to police, fire and rescue services and emergency response,
together with dialling directly to hospitals for ambulances. Thus, there seems to be possibilities for
increased effectiveness. However, high speed driving could perhaps be the solution to faster
response time in rural areas (Petzäll et al. 2011), but probably not in populated areas; and using
lights and sirens when driving ambulances has both pros and cons such as high risk of crashes
(Lemonick, 2009; see also Salvucci et al., 2004).
Assume that an investment could be made, one which could decrease the response time and
operational time by one minute: for example, a new call taking and dispatch system with a
technology life of 20 years. Using the results of this study, the present value of the benefits of such
an investment is between 12.8 and 25.6 billion Thai Baht, assuming a social interest rate of 6 %.
18
References
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Time is money, but how much? The Monetary Value of Response Time for Ambulance

  • 1. Dept. of Economics (Web page) Karlstad University SE-651 88 Karlstad Sweden Phone: +46-54-700-10-00 Karlstad University Working Paper in Economics # 2013 / 2 Time is money, but how much? The monetary value of response time for Thai ambulance emergency services Dr. Henrik Jaldell a , Dr. Lebnak P b , Dr. Anurak A. b , Ms. Krongkan B., Ms. Khanisthar P. b a Department of Economics, Karlstad University b Emergency Medical Institute Thailand, EMIT
  • 2. 2 Time is money, but how much? The monetary value of response time for Thai ambulance emergency services Dr. Henrik Jaldell Karlstad University Department of Economics S-651 88 Karlstad Sweden henrik.jaldell@kau.se Phone: +46547001369 Fax: +46547001799 Dr. Lebnak P., Dr. Anurak A., Ms. Krongkan B., Ms. Khanisthar P. Emergency Medical Institute Thailand, EMIT, Bangkok, Thailand Abstract: The monetary values for how much ambulance emergency services are calculated for two different time factors, response time, which is the time from when a call is received by the EMS call-taking centre until the response team arrives at the emergency scene, and operational time, which is the time from alarm to the accident scene and to the hospital. The study is performed in three steps. First, marginal effects of reduced fatalities and injuries for a minute change of the time factors are calculated using logistic regressions. Second, monetary values are chosen for fatalities and injuries; third, the marginal effects and the monetary values are put together to find a value per minute. The values are found to be 5.5 million Thai Baht per minute for fatality, 326,000 Baht per minute for severe injury, and 2,100 Baht per minute for slight injury. The total value of fatality, severe injury and slight injury for a one-minute improvement for each dispatch, summarized over one year, is 1.6 billion Thai Baht using response time. The resulting total values could be used on the benefit side in an economic cost-benefit analysis of investments, such as new technology, which could reduce the response and operational times. Keywords: Response time, cost-benefit, medicine, emergency, EMS JEL codes: D61, I31, R53, Acknowledgement: Financial support from Swedish Ministry of Foreign Affairs is acknowledged. Many thanks to Anders Edberg, Ericsson (Thailand), without whom this project would not have been possible.
  • 3. 3 1. Introduction The success of all emergency responses is dependent on the time taken to get to the place where someone is lying ill or where a traffic accident has occurred. The faster the response the better the outcome will be. Hence, it is reasonable to say that all efforts should be made to decrease the time factor in the alarm chain from calling to taking the call, to dispatching, to getting ready to leave, to driving to the injured or accident, to taking care of the injured or suppressing the fire, and to getting the injured to hospital. On the other hand, should all efforts be made solely to decrease the time factor? Such efforts are costly and there are other health matters that could be invested in: better ambulances with more technical equipment, more training of the staff, better hospitals, provision of self-help equipment etc. The economical way of dealing with this problem of the public sector is to perform cost-benefit analyses. If benefits outweigh costs, in monetary terms, then an investment should be made since it can be said to increase welfare in society. If costs outweigh benefits, the investment should not be made. The purpose of this study is to find a monetary value for the time factor of the emergency responses in Thailand. It is not a cost-benefit analysis, since it only considers the benefit side of the time factor. Notwithstanding, the results of the study could be used in a cost-benefit analysis. For example, if the Thai emergency sector intends to invest in new alarm technology that could save 1 minute in response time for all responses, how much will such an investment lead to in benefits measured in economic welfare terms? As noted by Blanchard et al. (2012), there are only a few studies on the relation between the response time of emergency medical service (EMS) and the saving of lives. When it comes to cardiac arrest, reducing ambulance response time has been shown to increase survival rate (Pons et al. 2005; Pell et al. 2001; O’Keefe et al. 2011). Gonzales et al. (2009) found increased EMS pre-hospital time to be associated with higher mortality rates. Using fire and rescue services, which have shorter response times than traditional ambulances for health care responses, has been found to increase survival rate (Mattsson and Juås 1997; Jaldell 2004; Sund et al. 2011). However, there are also studies that have concluded that there is no relation between the response time and outcome of the patient (Blackwell et al. 2002; Blackwell et al. 2009; Pons and Markovchick 2002). There are five motivations behind this paper. The first is that, as noted above, there is not much research done on the effect of the response time. The second is that most of the studies mentioned have taken up one health problem (cardiac arrest), while from a planning perspective there are of course many more reasons for having ambulance services. Furthermore, most of the analyses have evaluated the 8-minute response time goal for American ALS units responding to life-threatening events, for example, by comparing the survival rate below or above the 8-minute response time using non-continuous measures of response time. This analysis focuses instead on a continuous measure of the response time. The third is that this study examines not only the relation between response time and mortality, but also the effect of the illness condition for non-mortality cases. The fourth is that the number of observations in this study is over a million, compared to hundreds or thousands in the papers mentioned above. The fifth is that the analysis done does not stop at the outcome of the patient, but instead takes on an economic perspective, where the purpose is to find a monetary value for the total benefits of reducing the response time. This value could be used in a
  • 4. 4 cost-benefit analysis for evaluating investments in new alarm technology that would speed-up the response time.1 To find the monetary value of the time factor for emergency responses in Thailand, the analysis is performed in two steps. The first step is to analyze the emergency response data from the call- taking and dispatch centre database of the Emergency Medical Institute of Thailand. The data used is for 19 months (from March 2009 to September 2010) with 1,160,391 emergency response records representing 73 % of all emergency response cases in Thailand during this time period. In the statistical analysis a logistic regression analysis is used to find the relation, expressed as marginal effects, between an independent variable and dependent variables. The dependent variables are fatality, severe injury and slight injury. The independent variable is the response time or the operational time, i.e. the time factor of the emergency response. Holding other independent variables and risk factors constant, the marginal effect describes the increase or decrease in the time factor for a one minute change and how this will affect the risk of fatality, severe injury and slight injury. Using results from a Thai cost-of-illness study (Thanirananon et al. 2008) the total value of fatality, severe injury and slight injury for a one-minute improvement for each dispatch summarized over one year is 1.6 billion Thai Baht for response time, where response time is the time from when a call is received by the EMS call-taking centre until the response team arrives at the emergency scene. For operational time, it is 800 million Thai Baht, where operational time is the time from when a call is received by the EMS call-taking centre until the patient is admitted to a hospital emergency room. The above values for a one-minute improvement to the time factor for one year are calculated using the provinces included in the Narenthorn database. The number of emergency response cases in these provinces represents 73 % of the total number of the emergency responses in Thailand during the study period. Therefore, if we were to extrapolate the loss values for the whole of Thailand the value would be 2.2 billion Thai Baht for response time and 1.1 billion million Thai Baht for operational time. These figures represent the positive welfare effect, for one year, of reducing the emergency responses in Thailand by one minute on average. Assuming, for example, that an investment could be made in a new call taking and dispatch system with a technology life of 20 years, which could decrease the response time and operational time by one minute, the present value of the benefits of such an investment will be between 12.8 and 25.6 billion Thai Baht, assuming a social discount rate of 6 %. Section 2 describes the Thai emergency system and section 3 contains the data used. The model and the results are presented in sections 4 and 5, respectively. Section 6 concludes the study with a discussion and conclusion. 1 No similar cost-benefit study has been found and there have been very few economic studies of out-of- hospital emergency care (see Lerner et al. 2006).
  • 5. 5 2. Emergency System in Thailand Currently, the emergency call number “1669” is being used as the emergency medical contact number in Thailand. The system has been installed in each province at the main hospital or the provincial health office. The call taker asks the caller for information and tries to understand the symptoms or other relevant information. He/she then gives the caller some essential medical suggestions and advice, such as first-aid, and then asks for further information about the location and situation to be able to make a decision about the next step. A dispatcher controls the resources by using different EMS-levels including the first response unit (FR), the basic life support unit (BLS) and the advanced life support unit (ALS). He/she also addresses their suitability to operate at the scene of the problem and their capacity to aid the patient. The FR-unit is able to assess and give primary care to the emergency patient, e.g. first-aid and simple procedures. The BLS-unit has more capability to take care of the emergency patient than the first response unit, e.g. basic medical operation, oxygen giving and non-invasive emergency care. The ALS-unit has the capability to provide care similar to the emergency unit in a hospital, e.g. CPR (Cardiopulmonary resuscitation) with defibrillator, ventilation support, intravenous infusion, intravenous injection and invasive treatments. The important role of the call taking and dispatch system is to receive the correct information quickly, to evaluate the situation and to supply personnel, vehicles, equipment, etc, which can support the emergency case in the best way possible and reach the location of the incident rapidly, especially to assist an emergency patient who could be severely injured or die if the assistance is delayed. There are 12 million emergency cases per year, 30% of which are for critical or emergency patients, i.e. those who need the emergency services to prevent life threatening situations. Of the total amount of emergency cases, approx. 60,000 emergency patients died outside hospitals. If Thailand had an efficient emergency medical service, 15 – 20% of emergency patients, or 9,000-12,000 people would be saved per year.
  • 6. 6 3. Data Definition of response time and operational time The emergency operation system can be described as having the operational flow shown in figure 1. Figure 1: Emergency Medical Time T0 – T1 is the time from when the person who sees or is involved in the incident makes a decision to call the emergency number 1669 in order to request for medical assistance. This time cannot be measured accurately because the caller cannot always accurately recall or measure the time (in minutes) from seeing or being involved in the incident to the time of calling the emergency medical service. T1 - T2 is the time between the caller making a phone call to the emergency services (1669) and the call-taker answering the call, which is usually 5-10 seconds. In the case of a call taker being unavailable, the communication supplier for the emergency operation will generally place the emergency phone call into a queuing system; the call is connected as soon as the next free call taker is available. T2 – T3 is the time from the call taker collecting data from the caller to when he/she makes a decision to dispatch the appropriate emergency operation unit to the scene of the incident. The necessary data is the location, the patient’s details, symptoms, the safety of the location, etc. The duration might be between 15 seconds and several minutes depending on the severity and complexity of the incident. T3 – T4 is the time from when the commander informs and dispatches
  • 7. 7 the emergency operation unit, until the unit vehicle leaves from its base. Normally, this will depend upon the technology of the communication system used for transferring the entire case data to the emergency operation unit. Also, it will depend upon the call procedure for the unit staff and the distance between the base and their vehicle. Several emergency units are specified to move out of the base within 1 minute after being informed of the incident, but this has not been implemented officially, and cannot be considered as the standard service as of yet. T4 – T5 is the time taken for the vehicle to move from the base to the incident location. T5 – T6 is the time from arriving at the location until reaching the patient. This might differ; for example, for a traffic accident it may take less than 15 seconds. Alternatively, if the incident is in a skyscraper in the city centre, it will take longer (e.g. 5 minutes) to arrive at the patient’s side. T6 – T7 is the time it takes to deliver medical care at the location, which will most likely be different from case to case. For example, for a patient involved in a traffic accident, it will be more advantageous if he/she can arrive at a hospital rapidly and receive medical care in the operating room as fast as possible (Scoop and Run). On the other hand, if the patient has cardiac arrest symptoms, it will be more advantageous if he/she can receive the necessary invasive care at the location until the situation is stabilized, and then he/she can be transferred to the hospital (Stay and Play). T7 – T8 is the time taken to transfer the patient to the hospital. This may differ depending on the urgency. The decision to take the patient to the hospital will be taken by the unit leader and confirmed by the commander, who receives the report of the emergency patient from the operation unit before arriving at the hospital. In this study response time and operational time are defined as: Response Time: the response time is the time from when the call taker receives the phone call until the operational unit arrives at the scene site. (T2-T5) Operational time: the time from when the call taker receives the phone call to the operational unit transfer of the patient to the hospital. (T2-T8) The Emergency Medical Institute of Thailand (EMIT) creates the monitoring and implementation report by extracting relevant data and information from the online-dispatch system called the “Narenthorn Emergency Medical Database”. The local agencies report data through this system in order to obtain financial reimbursement for the emergency medical operations they have successfully performed. The reports in the system include basic information on the dispatch centre, location and notification, but also time information and information about the injury. The information consists of the time the information is received, the command time, the vehicle dispatch time, the scene arrival time, the scene departure time, the hospital arrival time, the base returning time, the total response time, the distance (in kilometres) and the type of operation unit. The information on accident or emergency injury is categorized into 12 items, and for disaster into 6 items. There is also categorized information of the injury based on seriousness levels, type of operation unit and operational staff. The reports also include information on the preliminary operation results on scene categorized by the type of treatment and identified by the referral, for example, death and no treatment, heart attack, onsite treatment, etc. The hospital treatment consists of admission time, treatment duration, treatment result, referrals, continuous treatment, death, etc.
  • 8. 8 The Narenthorn database has been used nationwide, except for eight provinces, and covers the regions with about 3/4 of the population of Thailand.2 For the period studied here, 2009 – 2010, there are 1,489,800 reports, or 73.2% of total reports, which are generated through the system. However, there are problems with the reports from October 1, 2009 to March 31, 2010. Some obviously contain wrong time data, for instance, a response time of over 248 minutes and an operational time of 314 minutes3 , so in total only 1,186,067 reports are used in the analysis. Descriptive statistics Treatment results have been categorized into three levels: slight injury, severe injury and fatality. Slight injury means all patients who receive medical care on scene or at the hospital. Recovery is allowed to take place at home before or after the rescue services arrive at the scene or after the patients have received emergency care. Severe injury means patients who receive medical care, and are admitted to a hospital, and when there is no death before or after the rescue arrives on the scene, or after the patients receive emergency care. Fatality means patients who die before or after the rescue services arrive at the scene, or after the patients receive emergency care, and includes death at the hospital. Cause of incident is divided into four groups: physical trauma, medical emergency, traffic accident and others. Physical trauma includes a fall and collapse, fall from a height, building collapse, physical assault, trauma from an external object, trauma from an animal, fire, electrocution, burns, bombing, natural hazards, and hazmat. Medical emergency includes drowning, suicide and medical emergency, while traffic accident includes motor vehicle collision. The number of dispatches for each incident group with regard to EMS-level and treatment result is found in tables 1a- 1c. Medical emergency is the most frequent cause of incident, followed by traffic accidents. ALS-units are more often dispatched to medical emergencies than BLS- and FR-units, while BLS-units are more often dispatched to traffic accidents. It can be seen that ALS-units are dispatched to a higher degree to more serious injuries, followed by BLS-units and FR-units. In tables 2a-2b the response and operational times are reported for different EMS-levels and treatment results. ALS-units also have the longest response times followed by BLS-units and FR-units. However, the operational time is similar for all three units. 2 The provinces not included are Bangkok, NongKhai, NongBualamphu, Udonthani, Kalasin, Khonkaen, Mahasalakham and Roiet. 3 The maximum time is chosen according to mean + one standard deviation.
  • 9. 9 Table 1. Number of dispatches for each EMS-level and treatment results. a. Total EMS LEVEL EMERGENCY ALS BLS FR n n n n Medical emergency 670,313 56.5% 117,560 64.4% 139,085 53.7% 413,668 55.5% Traffic accident 358,173 30.2% 47,523 26.1% 83,237 32.1% 227,413 30.5% Physical trauma 128,410 10.8% 13,491 7.4% 29,370 11.3% 85,549 11.5% Other 29,171 2.5% 3,845 2.1% 7,227 2.8% 18,099 2.4% Total 1,186,067 100.0% 182,419 100.0% 258,919 100.0% 744,729 100.0% b. Treatment results EMERGENCY Total FATALITY SEVERE SLIGHT n n % n % n % Medical emergency 670,622 56.5% 12,476 58.7% 180,126 62.0% 462,082 56.3% Traffic accident 358,435 30.2% 6,915 32.6% 71,393 24.6% 247,374 30.1% Physical trauma 128,478 10.8% 1,694 8.0% 26,814 9.2% 95,392 11.6% Other 29,207 2.5% 151 0.7% 11,971 4.1% 16,119 2.0% Total 1,186,742 100.0% 21,236 100.0% 290,304 100.0% 820,967 100.0% FATALITY=worst of injuries, SEVERE=worst of injuries, SLIGHT=worst of injuries. c. EMS LEVEL Total FATALITY SEVERE SLIGHT ALS 182,419 15.4% 14,647 69.0% 94,046 32.4% 62,994 7.7% BLS 258,919 21.8% 2,372 11.2% 67,376 23.2% 173,196 21.1% FR 744,729 62.8% 4,205 19.8% 128,814 44.4% 584,275 71.2% Total 1,186,067 100.0% 21,224 100.0% 290,236 100.0% 820,465 100.0% FATALITY=If fatality was worst of injuries, SEVERE=If severe injury was worst of injuries, SLIGHT=If slight injury was worst of injuries. Table 2. Percent of each treatment and response and operational time in minutes for each emergency group and for each EMS-level. a. EMERGENCY FATALITY % SEVERE % SLIGHT % Response time Median Response time Mean Response time Std Operational time Median Operational time Mean Operational time Std Medical emergency 1.9% 26.9% 68.9% 9 37.6 206.5 26 66.3 241.0 Traffic accident 1.9% 19.9% 69.0% 7 38.4 221.5 19 67.3 260.9 Physical trauma 1.3% 20.9% 74.2% 7 36.7 210.5 23 65.0 244.5 Other 0.5% 41.0% 55.2% 9 37.9 208.7 29 69.8 247.7 Total 1.8% 24.5% 69.2% 8 37.8 211.6 24 66.6 247.7 b. EMS LEVEL FATALITY % SEVERE % SLIGHT % Response time Median Response time Mean Response time Std Operational time Median Operational time Mean Operational time Std ALS 8.0% 51.6% 34.5% 12 36.6 191.4 25 61.9 225.9 BLS 0.9% 26.0% 66.9% 9 30.2 177.3 23 61.5 224.6 FR 0.6% 17.3% 78.4% 7 40.7 226.8 24 69.5 260.2 Total 1.8% 24.5% 69.2% 8 37.8 211.6 24 66.6 247.7
  • 10. 10 In figure 2 we can see the relation between the response time variable and the percent of death and severe injury for all cases and for each emergency type. The risk of fatality increases by up to a response time of 20-25 minutes, but after 25-30 minutes the curves seem to be quite horizontal and thus the risk of dying is no longer increasing. Figure 2. Proportion of fatalities related to response time. For severe injuries the relations have about the same shapes (not shown here). There is an increased risk of a severe injury for shorter response times, but after about 30 minutes (shorter for traffic accidents) a longer response time no longer leads to an increased risk of a severe injury. 3.2 Monetary value of emergency injury or accident The purpose of an economic cost-benefit analysis, CBA, is to measure the welfare impacts of public investments. If the benefits of the investment are larger than the costs, measured in monetary units, then welfare can be increased by investing in the project. Therefore, in this analysis we need figures in Thai Baht for saving lives and reducing injuries. There are two main methods of finding such monetary values: the cost-of-illness (COI) method and the willingness to pay (WTP) approach. WTP is based on the idea that people can assess the risk of having an accident, and that they will pay for reducing or minimizing that risk (see e.g. Viscusi and Aldy, 2003; Bellavance et al., 2009; Lindhjem et al. 2011). The monetary value is derived either from questions asked of people (stated preference technique) or by studying people’s behaviour, e.g. how much they pay when buying risk reducing protection or how high a wage they want for accepting a job with a higher risk (revealed preferences).
  • 11. 11 When it comes to estimating the value of a statistical life, VSL, there have been only a few studies that cover Thailand. Vassanadumrongdee and Matsuoka (2005), using surveys in Bangkok with 1,080 questionnaires (680 for the air pollution sample and 400 for the traffic accident sample), employed the stated preference technique contingent valuation to estimate VSL in the context of air pollution and traffic accidents. For both risk contexts they used the same reductions in risk level with reductions of 30/1000000 and 60/1000000. The income adjusted VSL was found to be 59 million Baht for the smaller risk reduction and 38 million Baht for the larger for air pollution, and 61 million Baht for the smaller risk reduction and 38 million Baht for the larger for traffic accidents. Chestnut et al. (1998) tried to find a VSL for air pollution in Bangkok. They referred to studies done in other countries and used a benefit transfer to calculate a value of US $0.80 to $2.78 million. Gibson et al. (2006) calculated a VSL of US $0.25 million for landmine clearance in rural Thailand using the contingent valuation method. Miller (2000) compared the VSL of transport between different countries, by means of benefit transfer using countries’ different GDP levels, to calculate “best estimates” for each country. The “best estimate” for Thailand was US $0.38 million.4 The above studies only calculate values of a statistical life. However, we are also interested here in the monetary value of severe injury and slight injury. For our monetary values results from a study by Pichai Thanirananon et al. (2008), which employed a cost-of-illness method to calculate the cost of traffic accidents in Thailand in 2004, has been used. The cost-of-illness method is a way to calculate the consequences of accidents in monetary values (see e.g. Tarricone, 2006; Larg and Moss, 2011). That is, it is the sum of emergency costs, hospital costs, productivity loss etc. Thanirananon et al. focused on five regional hospitals which had a department for providing service data on the injuries caused by traffic accidents. The loss value was categorized into 3 groups as follows: 1) The human cost group (loss of productivity, quality of life, medical costs, emergency medical service costs, long-term costs, etc) 2) The damaged property cost group (vehicle and other properties damages). 3) The crash cost group (management expenditure of insurance companies, police, courts, rescue services and the delay of transportation). The loss value for 2004 was also recalculated to values for fatality of 63,317 million Baht, for severe injury 58,963 million Baht and for slight injury 1,299 million Baht for 2011 by adjusting for inflation (increasing by 25 %). 4 Another question is whether the same value should be used for different injuries; some studies have found different values depending on the context (e.g. Savage, 1993; Jones-Lee and Loomes, 1995; Hammitt and Liu, 2004; Carlsson et al., 2010). However, this problem has not been taken into account in this study.
  • 12. 12 4. The Model We have chosen logistic regressions because of the structure with binary dependent variables. The problem is choosing how to find a model that both best fits the data and performs well in calculating the marginal effects of a change in response time that is true for all dispatches. For an example of how this can be discussed, let us look at the relation between response time and deaths in traffic accidents in figure 2. Since there seems to be no change in deaths after about 25 minutes, one choice of model is to restrict the data to only those dispatches where the response time is less than or equal to 25 minutes. The problem with such a model is that it will predict a much higher proportion of deaths above 25 minutes than is reasonable according to the data. Consider figure 2 where we can see that about 5.5 % deaths is reasonable for a response time of 40 minutes. However, a logistic regression model that is restricted to less than 25 minutes would predict this to be about 40 %. Another suggestion is to choose something like a moving average logistic regression model, where the first model includes only data for 1 to 5 minutes, the second from 2 to 6 minutes, the third from 3 to 7 minutes and so forth. Predictions and marginal effects are then calculated for 3 minutes for the first model, 4 minutes for the second model and so forth. Such a model fits the data much better, but is not very general of course since it has different parameter values for each minute of response time. Yet another alternative is to try to include as many data points as possible. This is used here and all response times including median time + one standard deviation are included. All three models are shown in figures 3 (predictions of proportions of deaths) and 4 (marginal effects). What we are after is a value for a change of one minute in response time for an average dispatch. Here, we use the model with the median + 1 standard deviation for response time included, even if it does not fit the data perfectly. However, choosing one of the other two models would result in much too high a marginal effect for an average dispatch. The models thus contain response times up to 249 minutes and operational times up to 313 minutes. Since the relation between the outcome and the response time seems to be somewhat different, depending on the case of the emergency, we have chosen to perform different statistical analyses for each case of emergency (traffic accidents, medical emergency, physical trauma and others). 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0 5 10 15 20 25 30 Proportiondead Response time, min Pred value moving average Pred value response time <=249min Pred value response time <=25 min Figure 3. Relation between response time and predicted proportion of deaths using different models.
  • 13. 13 -0.003 -0.002 -0.001 0 0.001 0.002 0.003 0.004 0.005 0.006 0.007 0 5 10 15 20 25 30 Proportiondead Response time, min Marg eff moving average Marg eff response time <=249 min Marg eff response time <=25 min Figure 4. Relation between response time and marginal effect for proportion of deaths using different models.
  • 14. 14 5. Results Since the dependent variables have been set to be binary, logit regression analyses have been used to find out the relation between the independent variables, response time and operational time, and the dependent variable. The parameter estimates for the independent variables are recalculated into marginal effects, which show how much the risk of fatality, severe injury and slight injury changes when the time variable is changed by one minute. The analyses have thus proceeded in three steps. First, logistic regression models have been used to find parameter estimates for how the time variables affect the three injury types (equation 1). Equation 1 has been estimated for each injury and emergency type, and for response and operational time respectively, that is 3*4*2=24 models have been estimated. * * ( ) Prob( 1) 1 TIME TIME e E Y Y e           (1) Second, since the model is nonlinear the parameter estimates have been recalculated into marginal effects (equation 2). The marginal effects are evaluated at the median response and operational time.5 * * 2 ( ) Marginal effect= (1 ) TIME TIME E Y e TIME e           (2) The marginal effects for response time are presented in table 3. They are higher for severe injury than for fatalities, meaning that a marginal decrease of response time leads to more people saved from severe injury than from fatality. For fatality the marginal effect is highest for traffic accidents, while for severe injury it is highest for others followed by medical emergency. For slight injuries the marginal effects are negative and will therefore not be used in the next step. For operational time (not showed here) the marginal effects are lower than for response time, indicating that there is a decreasing marginal value of time, since operational time is longer than response time. Third, the marginal effects have been recalculated into number of persons affected by a minute change in response and operational time in one year (equation 3), as presented in table 4 and 5. If the marginal effect is not statistically significant or negative, the value is set to zero. * * 2 ( ) Marginal effect in one year= * * (1 ) TIME TIME E Y e n n TIME e           , (3) where n is equal to total number of responses in one year for each emergency type. A one-minute change would save most people from fatality when it comes to traffic accidents. For severe injuries a one-minute change would save most in the treatment group others, followed by medical emergency. Fourth, the monetary values have been summed up in Thai baht, ฿, for one year, for each emergency type and totally for all emergency responses. Using the monetary values of lives and 5 Normally marginal effects are evaluated at the sample means of the data or the sample averages of the individual marginal effects are used (Greene 2008). However, since the median in the sample used here better describes the typical response and operation time than the mean value does, the median has been used here.
  • 15. 15 injuries, we can calculate a total value per EMS type. The results are shown in table 6. For both response time and operational time the most important treatment type is medical emergency, followed by traffic accident. The values for operational time are lower than the values for response time, reflecting the decreasing marginal value of time. However, the ratio between response and operational time differs for the different emergency types. The relative difference is smallest for traffic accident and largest for others, and about 1/2 for the total emergencies. Different ambulance types have different marginal benefit values per minute. For response time, ALS has a value of 1130 Baht per minute, BLS a value of 644 baht per minute and FR a value of 445 baht per minute. Table 3. Marginal effects and P(.) >0 results for response time evaluated at median response time (=8 min). Injury type / emergency type Physical Trauma Medical Emergency Traffic Accident Others Fatality 0.0001473 (0.000) 0.0001912 (0.000) 0.0002861 (0.000) 0.0000287 (0.309) Severe injury 0.0027129 (0.000) 0.0040699 (0.000) 0.0017932 (0.000) 0.0047531 (0.000) Slight injury -0.0004476 (0.000) -0.0002977 (0.000) -0.001437 (0.000) -0.0003409 (0.000) Table 4. Deaths and injuries saved per year calculated given marginal effect per minute for response time. Injury type / emergency type Physical Trauma Medical Emergency Traffic Accident Others Fatality 11.9 15.5 23.2 2.2 Severe injury 220.0 330.0 145.4 398.3 Slight injury 0 0 0 0 Number of dispatches 81101 423356 226215 18424 Table 5. Deaths and injuries saved per year calculated given marginal effect per minute for operational time. Injury type / emergency type Physical Trauma Medical Emergency Traffic Accident Others Fatality 8.8 8.7 17.0 - Severe injury 88.5 109.8 51.4 136.5 Sligth injury 0 0 0 0 Number of dispatches 81101 423356 226215 18424 Table 6. Monetary value per minute and year. Baht/Year/Minute/ emergency type Physical Trauma Medical Emergency Traffic Accident Others Total Response time (at median 8 minutes) ฿ 135,401,000 ฿ 987,186,000 ฿ 484,352,000 ฿ 27,349,000 ฿ 1,634,289,000 Operational time (at median 24 minutes) ฿ 76,177,000 ฿ 427,974,000 ฿ 304,957,000 ฿ 9,370,000 ฿ 818,477,000 The loss values for a one-minute improvement in the time factor for one year are calculated using the provinces in the Narenthorn database. Eight provinces, including Bangkok, are not included in the Narenthorn database. The number of emergency response cases in these provinces represents
  • 16. 16 26.8% of the total number of the emergency responses in Thailand during the period considered here. Therefore, if we were to extrapolate the loss values for the whole of Thailand we should, therefore, increase the total loss value by dividing the study result with 73.2%. The result of such an extrapolation for a response time is 2,232,600,000 Thai Baht and for an operational time 1,118,100,000 Thai Baht. These figures represent the positive welfare effect, for one year, of reducing the emergency responses in Thailand by one minute on average.
  • 17. 17 6. Discussion and conclusion This study shows that using a logistic regression analysis makes it possible to find a correlation between response time and the severeness of injury. The correlation indicates that a faster response time results in fewer fatalities and milder severeness of injury. Furthermore, the time factor is most important for medical emergency, followed by traffic accidents and physical trauma. The results also show that the more advanced the ambulance that is used the more important the response time is. For operational time the correlation has the same sign, but it is not as strong as for response time, which seems reasonable since there should be a decreasing marginal utility of time. One limitation of the study is that the emergency response data cannot categorize permanent disability as a final outcome; thus, the additional loss value of disability is excluded in the analysis, and the loss value for those cases is covered under the category severe injury. The planned investment thought of here is a better alarm system which could reduce the time from accident or injury to dispatch of ambulance, and result in a one-minute decrease in response time. In comparison, a study in Canada showed that the introduction of base paging reduced the call- response interval by 30 seconds (Jermyn 2000). Considering operational time, Spaite et al. (1993) listed several observed problems on-scene, for example with communication, equipment and uncooperative patients. Most of the time was concerned primarily with logistics and not with medical care, and operation problems occurred in more than 40 % of the dispatches. Another way to decrease time is to enforce a single alarm number in Thailand (as in the EU, 112, or North America, 911) instead of the different numbers to police, fire and rescue services and emergency response, together with dialling directly to hospitals for ambulances. Thus, there seems to be possibilities for increased effectiveness. However, high speed driving could perhaps be the solution to faster response time in rural areas (Petzäll et al. 2011), but probably not in populated areas; and using lights and sirens when driving ambulances has both pros and cons such as high risk of crashes (Lemonick, 2009; see also Salvucci et al., 2004). Assume that an investment could be made, one which could decrease the response time and operational time by one minute: for example, a new call taking and dispatch system with a technology life of 20 years. Using the results of this study, the present value of the benefits of such an investment is between 12.8 and 25.6 billion Thai Baht, assuming a social interest rate of 6 %.
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