EMERGENCY RESPONSE SERVICES: Background and Motivation 3

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911 systems have several advantages in reducing response times. First, they save time in the placement of the telephone call, since citizens are unlikely to have memorized the telephone number for the relevant agency. Further, the personnel who receive the first telephone call are trained to handle emergencies, as opposed to standard telephone operators or directory assistance personnel. Even when the appropriate agency is reached, decentralized call centers without 911 tend to assign telephone duties to personnel who also have other responsibilities. Specialization might be important for learning the details of a geographical area as well as for developing the skills required to gather information from emergency callers. However, there is potentially a cost to centralization in the cases where 911 is provided at a central location without Enhanced 911 capabilities, since workers may not be as familiar with addresses and geography when they are responsible for larger areas. More info

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EMERGENCY RESPONSE SERVICES: Background and Motivation 2

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While the scope and particular details of many systems vary, 911 systems operate according to the following standard procedure:

• 911 is dialed by an individual in an emergency

• Call is answered by a Public Service Answering Point (PSAP) operator

• A trained 911 call-taker evaluates the caller’s emergency and gathers necessary information (location, severity, etc…)

• Call-taker communicates with the appropriate emergency service agencies for dispatch to the emergency

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EMERGENCY RESPONSE SERVICES: Background and Motivation

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The goal of this section is to motivate our empirical analysis of emergency response systems through a description of the background and institutions of pre-hospital care. To do so, we review the operation of the emergency medical response system (in most communities, a 911 system), focusing in particular on potential productivity benefits. We further discuss the interaction between pre-hospital and in-hospital emergency care. Finally, we describe the factors which lead to heterogeneity in the adoption of 911.

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EMERGENCY RESPONSE SERVICES: Introduction 6

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We further explore the salience of hospital incentives to adopt advanced technologies through a preliminary analysis of the determinants of a hospital’s share of ambulance-transported cardiac patients in a given county. We find evidence that a hospital’s “market share” is sensitive both to its overall level of emrgency room technology as well as its level of cardiac-specific technology. In addition, increases in the level of technology by rival hospitals (other hospitals in the same county) have a negative impact on hospital market share.

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EMERGENCY RESPONSE SERVICES: Introduction 5

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In addition, we document that in Pennsylvania, many patients reside in counties which do not include a hospital with certain high-level cardiac-specific technologies (such as a cardiac catheterization laboratory); as a consequence, these patients are not treated by hospitals with high-level cardiac technology in response to a cardiac emergency. It is interesting to observe that, in contrast to the general population, nearly all of the cardiac patients in our sample have some form of insurance (almost 99%). Instead, it seems to be the availability of medical technology in nearby hospitals which most significantly limits the access of patients to high levels of cardiac care in emergency situations.

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EMERGENCY RESPONSE SERVICES: Introduction 4

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Our findings regarding the relationship between 911 and mortality are more subtle. First, we are unable to establish a direct reduced-form statistical relationship between the level of 911 in a given county and patient mortality. Of course, this may be due to the fact that the overall mortality rate is relatively low (approximately 7%) and only a small portion of our sample resides in counties with no 911 technology (approximately 20%), making it difficult to infer the impact of the technology level on the mortality rate. However, our analysis of the impact of 911 on response time suggests an alternative strategy: we use the adoption of 911 as an instrument for an individual’s response time in the patient mortality regressions. In particular, we show that 911 technology affects response time, and we can assume that 911 adoption is unrelated to the severity of a particular patient. Our preliminary instrumental variables analysis of the effect of response time on mortality finds that shorter response times do indeed reduce mortality. While this analysis is still exploratory, we believe that the use of county-level infrastructure as an instrument for individual-level services is a potentially fruitful approach for further exploration.

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EMERGENCY RESPONSE SERVICES: Introduction 3

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Our analysis focuses on relatively simple, reduced-form procedures. We begin by exploring the sources of heterogeneity in the allocation of 911 services to different localities. We find that 911 is allocated not only according to factors which might increase their technical efficiency (such as the number of residents per county), but also according to a county’s political orientation. In particular, communities with more conservative voting patterns are less likely to adopt advanced 911 systems. Although we do not perform a formal cost-benefit analysis, these results suggest that public policies concerning 911 systems can potentially increase the efficiency of the diffusion process. For example, some of the barriers to adoption include the lack of incentives and information faced by county government officials, problems which could potentially be remedied at relatively low cost.

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EMERGENCY RESPONSE SERVICES: Introduction 2

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The principal aim of this paper is to evaluate the determinants and implications of differences in the pre-hospital and in-hospital emergency services adopted in a given community. To accomplish this goal, we evaluate the incentives to adopt emergency response systems and in-hospital technology, as well as the productivity gains from these investments. We focus in particular on the productivity and adoption of Basic and Enhanced 911 services, services which entail investments in information technology and telecommunications equipment.

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EMERGENCY RESPONSE SERVICES: Introduction

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Emergency response services, provided through 911 calling and ambulance services, serve as the first line of contact between patients suffering from emergency conditions and the local health care infrastructure. Together with the emergency rooms in hospitals, emergency response services play an important role in the health care outcomes for a number of emergency indications. For example, in the case of out-of-hospital cardiac arrest, the time lapse between collapse and the initiation of CPR and defibrillation is claimed to be an important determinant of the probability of survival.1 As well, the emergency response system plays a critical role in selecting which hospital receives each emergency patient, where hospitals may differ in their quality and in the technologies available for emergency care. The patient benefits from emergency response services thus arise not only from the direct provision of medical and transportation services, but also through the system’s role in allocating patients to the hospital facilities which are most appropriate for their particular medical condition. Furthermore, emergency response systems may have indirect effects on patients through their influence on the choices made by hospitals. Emergency response systems affect the incentives of hospitals to adopt certain technologies, such as gaining “trauma center” certification and introducing capabilities for the provision of cardiac care, since these choices can potentially influence the allocation of emergency patients to hospitals.

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