Reducing 9-1-1 Emergency Medical Service Calls By Implementing A Community Paramedicine Program For Vulnerable Older Adults In Public Housing In Canada: A Multi-Site Cluster Randomized Controlled Trial

摘要

Objective: Older adults account for 38–48% of emergency medical service (EMS) calls, have more chronic diseases, and those with low income have lower quality of life. Mobile integrated health and community paramedicine may help address these health inequalities and reduce EMS calls. This study examines the effectiveness of the Community Paramedicine at Clinic (CP@clinic) program in decreasing EMS calls and improving health outcomes in low-income older adults. Methods: This was an open-label, pragmatic, cluster-randomized controlled trial conducted within subsidized public housing buildings for older adults in 5 paramedic services across Ontario, Canada. A total of 30 apartment buildings were eligible (>50 units, >60% of units occupied by older adults, unique postal code, available match for pairing). Paired buildings were randomly allocated to intervention (CP@clinic for one year) or control (usual care) via computer-generated randomization. The CP@clinic intervention is a community-based, paramedic-led, health promotion and disease prevention program held weekly in building common rooms. CP@clinic includes risk assessment with validated tools, decision support, health promotion, referrals to resources, and reports back to family doctors. All residents could participate, but only older adults (55 years and older) were included in analyses. The primary outcome was building-level EMS calls from paramedic service databases. Secondary outcomes were individual-level changes in chronic disease risk factors and quality-adjusted-life-years (QALYs). Data were analyzed using Generalized Estimating Equations to account for clustering by sites. Results: Intention-to-treat analysis showed no significant difference in EMS calls (mean difference = ?0.37/100 apartment units/month, 95%CI: ?0.98 to 0.24). Sensitivity analysis excluding data from 2 building pairs with eligibility changes after intervention initiation revealed a significant difference in EMS calls in favor of the intervention buildings (mean difference = ?0.90/100 apartment units/month, 95%CI: ?1.54 to ?0.26). At the individual level, there was a significant QALY increase (mean difference = 0.06, 95%CI: 0.02 to 0.10) and blood pressure decrease (systolic mean change = 3.65?mmHg, 95%CI: 2.37 to 4.94; diastolic mean change = 2.03?mmHg, 95%CI: 1.00 to 3.06). Conclusions: CP@clinic showed a significant decrease in EMS calls, decrease in BP, and improvement in QALYs among older adults in subsidizing public housing, suggesting this simple program should be replicated in other communities with public housing. Trial Registration: Clinicaltrials.gov, Registration no. NCT02152891.