Patients Refusing Prehospital Transport Are Increasingly Likely to Be Geriatric

Objective. Elderly patients are becoming an increasingly larger proportion of our population, and there is a paucity of data regarding the epidemiology of geriatric patients refusing transport. Treatment refusal rates range from 5% to 15% in many studies. This study sought to test the hypothesis that geriatric patients constituted an increasing proportion of those persons refusing prehospital transport. Methods. This study was a retrospective analysis of data from a query of a large urban EMS service. Results. There were a total of 22,347 adult transport refusals recorded during the 16-month study period. Multivariate logistic regression incorporating covariates for sex, race, season, chief complaint, metropolitan region, and whether any treatment occurred prior to transport refusal confirmed the increasing likelihood of Period 2 patients being geriatric, as compared with Period 1 (OR 1.24, 95% CI 1.14–1.35, Wald P < .001). Conclusion. This data shows that despite controlling for these covariates, patients refusing transport in the second period of this study were nearly 25% more likely to be geriatric as compared to those in the initial 8 months of the study.


Introduction
Emergency medical services (EMSs) are the system that is responsible for the prehospital treatment and transportation. When EMS is activated, they appropriately respond by arriving to give on the scene care. Of course, patients then have the right to receiving treatment and transportation or refuse one or both, against the advice of the treating paramedic (AMA). Treatment refusal rates range from 5% and 15%, in many studies [1][2][3]. Refusal of care or transport may happen for many reasons such as the patient not feeling they need further care and financial restraints. There may be negative outcomes associated with refusing treatment/transport, such as a subsequent Emergency Department (ED) visit, hospital admission, or even death.
Despite an increased emphasis on geriatric care, the health status of this age range is still meager. Elderly patients are becoming an increasingly larger proportion of our population, and there is a paucity of data regarding the epidemiology of geriatric patients refusing transport. This would be an alarming trend if found and would then require further study to look at the etiology of the refusal. This study sought to test the hypothesis that geriatric patients constituted an increasing proportion of those persons refusing prehospital transport.

Methods
This study was a retrospective analysis of data from a query of a large urban EMS service associated with the Oklahoma City, OK, and Tulsa, OK, metropolitan areas. The study includes all EMS interactions from January 1, 2010, to May 31, 2011, with patients who were at least 18 years old. There were no exclusions for gender, race, or diagnoses. The data includes EMS vehicle region (Eastern or Western), month and year of EMS interaction, response outcome (treated at the scene, patient refused care, care transferred), chief complaint, gender, age in years, and race. No patient identifiers such as encounter number, medical record number, or name were included.
All adult transport refusals over 16 months were included, with the study timeline of 16 months divided into the first 8 months (Period 1) and the second 8 months (Period 2). Periods 1 and 2 patients were assessed with univariate categorical analysis for proportions with chi-square testing. Next, multivariate logistic regression was used to determine association between the study period and geriatric status (age 65 or older), after adjustment for covariates such as sex, chief complaint, metropolitan region (of the two areas served by the study EMS service), race, season, and whether any treatment occurred prior to transport refusal. Analyses were conducted with STATA 11 MP (StataCorp, College Station, TX); P was set at 0.05 for all analyses and 95% confidence intervals (CIs) were calculated for odds ratios (ORs).

Results
There were a total of 22,347 adult transport refusals recorded during the 16-month study period.  Table 2 provides a breakdown of all EMS responses by chief complaint, with trauma being the most common. The number and percentage of patients refusing transport within each individual age group is found in Table 3. The finding of increased likelihood of geriatric status in those patients refusing transport was also present when the 16-month dataset was analyzed for overall trend during the 16 individual months of the study (OR 1.02, 95% CI 1.01-1.03, P < .001). Of the 22,347 transport refusals, no treatment was given before transport refusal in 19,552 instances (9,218 versus

Discussion
Prior anecdotal evidence suggests an increasing prevalence of geriatric patients refusing EMS transport [1][2][3]. The data from this study strengthens the validity of this claim. However, the etiology and impact of this trend remains unclear. Patient sex, race, seasonal variations, and chief complaint all offer a plausible potential impact on transport refusal rates. Yet, this data shows that despite controlling for these covariates, patients refusing transport in the second period of this study were nearly 25% more likely to be geriatric as compared to those in the initial 8 months of the study. Although comparing subsequent individual months has obvious limitations, this trend remained true when dividing and analyzing the total 16-month study period into 16 individual time periods (2% increase in geriatric likelihood over each month during the study period). This rate of increase is rather alarming and warrants further investigation. One possible explanation for this observed increase could be financial constraints. The continued rise in cost of ambulance transport and hospital care combined with fixed income levels of many geriatric patients may be serving as a barrier to patient willingness to be transported. This study did not account for the financial means of those individuals who refused transport. A follow-up study seeking to elicit the cause of this increased refusal rate among the geriatric population would be both interesting and potentially impactful on the development of new strategies to improve appropriate EMS utilization by the elderly. In conclusion, the data from this study demonstrated a nearly 25% increased likelihood of geriatric patients to refuse EMS transport from the first 8-month period to the second 8-month period when controlling for covariates. Further investigation into the characterization and impact of this trend is warranted.