You are on page 1of 14

Using data relating to a currently operating public emergency ambulance

system, the authors endeavor to estimate the nature of the demand for
such service. Despite certain limitations in the data, it has been
possible to develop a model that explains variations and accurately
predicts the result and type of public emergencies to be handled
by the public system in a year.

AN ANALYSIS OF THE DEMAND FOR EMERGENCY


AMBULANCE SERVICE IN AN URBAN AREA
Carole A. Aldrich, M.S.; John C. Hisserich, M.P.H.; Lester B. Lave, Ph.D.

Introduction of such a catastrophic nature as to leave


ALTHOUGH true medical emergencies few alternatives. Many of the demands
are rare events for a given family, en such a system are, of course, for less
they occur frequently in a sizable city. medically threatening conditions. Most
Residents expect prompt, competent treat- calls do, however, involve cases whose
ment of these emergencies. Medical emer- associated anxiety or pain is sufficient to
warrant immediate response.
gencies arise from automobile accidents, The over-all task for a city is one of
poisonings, heart attacks, and a number determining the nature of the demand
of other accidents and sudden illnesses. for treatment of medical emergencies
In true emergencies, time is a crucial and emergency-like incidents. Ideally, it
factor in treatment; protection from would be desirable to be able to predict
shock and further injury is important. the type and frequency of occurrences
A number of other medical condi- for given areas. With this information, it
tions arise which, though less severe, would be possible to determine the role
are emergency-like in their sudden onset of an emergency medical system and
and aura of anxiety. Such conditions each of its components. In particular, the
may be resolved by first-aid, by a information could be used to optimize
family physician's care, or in the event the location of ambulances and emer-
that these are unavailable, in an emer- gency treatment facilities as well as the
gency treatment facility. Due to a training of ambulance attendants and of
variety of circumstances, the growing the equipment carried in ambulances.*
volume of these non-emergency demands This paper represents an attempt to
is placing an increasing strain on all solve one part of the problem. Using
components of the emergency system. data collected on a currently operating
In most communities, a public emer- public emergency ambulance system, we
gency ambulance system of some type is have attempted to estimate the nature
set up to respond to calls for medical of the demand for the service. Our re-
assistance. The bulk of a community's sults are limited and must be qualified.
true, life-threatening medical emergen-
cies are generally handled by this sys- * See
Andrews (1969), Jacobs and Mc-
tem, since real emergencies are usually Laughlin (1967), and King and Sox (1967).

156 VOL. 61, NO. 6. A.J.P.H.


EMERGENCY AMBULANCE SERVICE

While the predominant number of true, The billing procedures for this fee sys-
life- or function-threatening, medical tem were not fully operational during
emergencies are handled by the public 1967; hence, its impact on demand was
system, the vast majority of emergency. somewhat attenuated.
like conditions, which represent latent Finally, Los Angeles is a sizable city
demands on the public system, are of great diversity. We investigated 632
handled by other means. Therefore, rela- census tracts which exhibited vast differ-
tively minor changes in the nature of ences in size, income, employment, and
the public system might lead to quite demographic characteristics. Population
significant changes in the demand for it. per census tract ranges from 0 to 10,108
Also, we were unable to obtain data on with a mean of 3,920; the size of the
a number of factors, such as weather, tracts ranges from 63 to 7,842 acres.
that might be important. White population per census tract has a
In spite of these problems, we were mean of 82.4 per cent with a standard
able to develop a model which explains deviation of 6.8 per cent; population
virtually all of the variation among aged over 65 has a mean of 10.5 per
census tracts in the demand for publicly cent with a standard deviation of 6.8
dispatched ambulances. Given socio- per cent. The median age across census
economic data about a census tract, we tracts for men is 32.7 and for women
can predict with great accuracy the num- 34.9, while the range goes from 8.9
ber and type of medical emergencies years to 60 years. Median income shows
that the public system will be called upon even more variation since it has a mean
to handle during the course of a year. of $7,148 and standard deviation of
$2,928 with a ,range from $2,345 to
The Los Angeles Public $35,000. As another measure of income,
Ambulance System the percentage of families whose income
was less than $4,000, averaged 5.7 per
Los Angeles is an appropriate case cent with a standard deviation of 3.3 per
study since the public system differs cent. Finally, employment per census
among the areas of the city. During the tract ranged from 0 to 46,543 with a
period of this study, three modes of mean of 1,308.
service were utilized. In the western and Two possibly important factors which
harbor areas, the city contracts with could not be studied were the effects of
private ambulance services to respond to weather and the training of ambulance
public calls and transports the victim to a attendants. A climate of greater ex-
specified contract hospital emergency tremes than that found in Los Angeles
room. The San Fernando Valley section could be expected to produce a different
of the city is served by ambulances of mix of injuries and a seasonal shift in
the Los Angeles Fire Department. The the nature and level of demand. The
balance of the city, including the down- level of ambulance attendant training is
town area, is served by ambulances of relatively good throughout the city. The
the Los Angeles Central Receiving Hos- effects on demand of very poor attendants
pital Department. Some changes took or considerably more skilled personnel
place in the public system over the such as registered nurses or physicians
period of study. For most of the first could not be evaluated.
three years, no charge was made for am-
bulance service. Late in the third year, a Data
fee system was instituted which stipu-
lated that all people transported to a hos- Records of public ambulance trips
pital were to be charged for this service. were collected from the files of the Los

JUNE. 1971 1157


Angeles Central Receiving Hospital, acteristics of the census tract, the type
where data from the entire city are of public service, and the availability of
stored. Tickets, which are filled out by alternative sources of care. The functions
ambulance attendants, include informa- are estimated by least squares regression
tion on the time required to respond to analysis. We regard the linearity of the
a call, the nature of the emergency, and model as a reasonable approach to a
its location. The information was coded much more complicated specification. The
by census tract, year, and type of inci- assumption of linearity over the relevant
dent according to the following classifi- range is supported by the high per-
cation: automobile accidents, other ac- centage of variance explained and the
cidents, suspected cardiacs, possible similarity of the parameter estimates to
poisonings, other illnesses, and dry runs. a priori expectations.
Not all calls involved transportation to We expected that demand would be
an emergency room; in some cases, the highest in tracts with a concentration
attendant rendered first-aid and left the of people of low socioeconomic status.*
patient at the scene. Dry runs refer only These people may use the emergency
to those cases in which the attendant system even in the absence of real emer-
could not locate the victim or found that gencies because they generally do not
the situation had been handled before he have a regular physician. Low socio-
arrived. A 4 per cent sample of public economic status is defined in terms of in-
ambulance trips for the years 1964-1967 come (families whose 1959 income was
was collected. Each observation was less than $4,000), race, unemployment,
weighted to reproduce the original data. age (people over 65), employment in low-
A total of approximately 14,000 trips status jobs, and crowded living condi-
was tabulated. tions (a high number of people per hous-
Data describing the socioeconomic ing unit). It is assumed that areas with
characteristics of the area were derived high mobility will generate more calls
from 1960 census records. The data than low mobility areas, as new residents
describe the population by age, sex, in- are unlikely to be aware of private medi-
come, education, occupation, employ- cal care facilities. Areas with a high pro-
ment, marital status, and racial charac- portion of commercial land and high em-
teristics. The tract itself is described by ployment within the tract are likely to
various land use variables, including generate calls due to the large inflow of
number of housing units, and by em- people who might be injured while away
ployment within the tract. from home. It seems plausible that many
incidents which would be treated by a
The Model family physician or with first-aid be-
come demands on the public system
The model focuses on the per capita when the individual is away from home.
demand for public ambulance service. Finally, the presence of a freeway within
Although a geographical unit (such as a tract is likely to increase the traffic
a census tract) is the relevant focus from volume and generate more frequent auto-,
a policy viewpoint, geographical units mobile accidents.
complicate the analysis. The explanatory An indication of the efficiency of an
power of a census tract model is made ambulance service is the average re-
artificially high by the natural associa- sponse time (the elapsed time between
tion between calls and population. There the receipt of a request for an ambulance
are also statistical reasons for preferring and its arrival on the scene). This time
the per capita model. is determined by the dispatch procedure,.
Our model specifies demand as a * See Alpert, et al. (1969), Lavenhar, et al.
linear function of socioeconomic char- (1968), and Weinerman, et al. (1966).

158 VOL. 61, NO. 6, A.J.P.H.


EMERGENCY AMBULANCE SERVICE

the availability of an ambulance, and prevailed in 1967. Nearly a decade


travel time to the scene. elapsed between the census data collected
A long response time could lead in 1959 and the ambulance demand data
people to choose an alternative means of gathered in 1967. There are some indica-
transportation. Although most users are tions that the data are a reasonable de-
probably not aware of average response scription, e.g., the results appear to be
time, many, such as the police, have had stable over the period 1964 to 1967.
direct experience and have a feeling for Nonetheless, we express some reserva-
whether or not the ambulance arrived tions about the socioeconomic data and
promptly. A variable indicating mean suggest that these data be analyzed
ambulance travel time for each census again when the 1970 census is available.
tract was included in the analysis as a Data were collected on alternative
partial indication of this factor. No data sources of medical care. These data in-
were available to indicate the total re- cluded the number of physicians prac-
sponse time. ticing in a tract, the distance to the near-
Within the Los Angeles system, al- est hospital with an emergency room set
ternate dispatch procedures are em- up to handle medical emergencies, and
ployed and an attempt was made to the distance to the nearest contract
isolate their effect on demand. In most emergency hospital. The distance data
areas of Los Angeles, calls are screened have the undesirable characteristic of
by a registered nurse, who makes a de- giving a zero distance when a hospital is
cision as to whether the call warrants an located in a census tract. For hospitals
ambulance. However, in the area where located close to an accident, the distance
firemen handle dispatching, essentially measure tends to be only a remote ap-
no screening takes place. Unfortunately, proximation to the notion of how con-
the screening factor is confounded with venient it is to get to the hospital. It was
other aspects of the service. Thus, it is not surprising that the distance variables
impossible to isolate the effect of screen- contributed nothing to the analysis and
ing. so were dropped. Similarly, data on the
Total demand for public ambulance number of physicians whose offices were
service is categorized by type of inci- in the tract did not add to the analysis.
dent. By knowing whether incidents are There are approximately 75,000 calls
automobile accidents, other kinds of ac- each year which are answered by public
cidents, cardiac cases, or other types of ambulances. Since our data cover four
illness, one can make changes in the years (1964 to 1967), it was impossible
type of equipment carried in ambulances to collect 300,000 records. Given limi-
and the type of training given to drivers. tations on time and expense, only a 4 per
These categories are analyzed with sub- cent sample could be taken. While this
sets of the variables used to predict total sample is quite an adequate representa-
demand. Table 1 presents a list of the tion of the total demand for all four
variables used in the analysis. years, it begins to have large sampling
Data Problems variation when analyzing disaggregate
categories, such as demand by type of in-
Before presenting the results of the cident or by year.
analysis, some problems in the data Some notion of sampling variation
should be noted. The most significant can be gained by assuming that calls
problem concerns the socioeconomic data. come from a random process which
Since Los Angeles is a rapidly changing generates 36 calls per 1,000 people per
city, data from the 1960 census are not year. The average census tract will gen-
likely to be perfect descriptions of what erate 141 calls, but the random nature

JUNE. 1971 1159


Table 1-List of variables
Standard
Variable Mean deviation Description
Total demand* 144 241 Number of calls per capita (X 1,000) by pub-
lic ambulances in this census tract during
1964-1967
Auto accidents 38 52 Number of calls arising from automobile
accidents
Other accidents 30 82 Number of calls arising from accidents other
than auto
Cardiac 7 6 Number of calls involving heart attacks
Poison 5 4 Number of calls involving poison
Other illness 49 116 Number of calls involving an illness other
than heart attack or poison
Dry runs 14 19 Calls where the driver could not locate the
patient or where the incident was handled
before the ambulance arrived
2. Housing density .382 .129 Number of housing units per capita in tract
3. Recently moved .151 .075 Percentage of individuals who moved into the
tract during the two years before the census
was taken
4. White population .824 .290 Percentage of population which is white
5. % over 65 .105 .066 Percentage of the population older than 65
6. % single females .190 .084 Percentage of the population who are females
(over 14) who are unmarried, separated,
divorced, or widowed
7. % single males .113 .058 Percentage of the population who are males
(over 14) who are unmarried, separated,
divorced, or widowed
8. % poor families .057 .033 Percentage of the population whose famnily
income is less than $4,000
9. % males unemployed .019 .014 Percentage of population who are unemployed
males
10. % males employed .262 .049 Percentage of population who are working
males
11. % females in labor force .158 .059 Percentage of population who are females re-
porting either that they are employed or are
looking for a job
12. Total employment .576 2.833 Total persons employed in census tract divided
by number of people residing in tract
13. % children .251 .111 Percentage of population aged under 15
14. % single white males .139 .095 Percentage of population who are white males
who are unmarried, separated, divorced, or
widowed
* When each year's demand is divided by population and the years are pooled, the result is 36 (mean) and 28
(standard deviation).

1160 VOL. 61. NO. 6, A.J.P.H.


EMERGENCY AMBULANCE SERVICE

Table 1-Continued
Standard
Variable Mean deviation Descriptioni
15. % married whites .466 .074 Percentage of population who are white and
married
16. % male farmers .009 .027 Percentage of working males (who reside in
tract) who are employed as farmers
17. % male managers .513 .090 Percentage of working males (who reside in
tract) who are employed as managers, clerks,
salesmen, craftsmen, farm, or other laborers
18. % male household .084 .057 Percentage of working males (who reside in
tract) who are employed as household work-
ers or in other service
19. % female professional .912 .074 Percentage of working females (who reside in
tract) who are employed as professional,
manager, clerk, craftsmen, operative, in
household service, or in other service
20. % female farmers .034 .040 Percentage of working females (who reside in
tract) who are employed as farmers or farm
managers
21. % female laborers .005 .010 Percentage of working females (who reside in
tract) who are employed as general laborers
22. Acres/capita .156 .825 Total tract acreage divided by tract population
23. % commercial land .077 .092 Percentage of tract acreage in commercial use
24. % industrial land .039 .080 Percentage of tract acreage in industrial use
25. '% transportation land .012 .051 Percentage of tract acreage in transportation
use
26. Freeway .316 .465 A variable taking on a value of 1 if a freeway
runs through the census tract (and 0 other-
wvise)
27. Response time 1.004 .297 The average time (in minutesX.1) between
when an ambulance was called and when
it arrived
28. Area #1 .028 .045 San Fernando Valley (served by LAFD) who
do not screen incoming calls) X.1
29. Area #2 .002 .014 Baldwin Hills (served by a contract ambulanice
company) X.1
30. Area #3 .005 .021 Canyon area (sparsely populated, served by
contract ambulance company) X.1
31. Area #4 .002 .015 Westchester (area served by contract ambu-
lance company) X.1
32. Area #5 .005 .022 Harbor (area served by contract amnbulance
company) X.1
37. Area # 2 in 1967 .001 .(11

JUNE. 1971 1161


Table 2-Sampling variation
Probability of Expected calls Standard Coefficient
Category occurrence* per area* deviation* of variation*
Total calls:
per year (within a census tract) .036 141 11.6 8
per 4 years (within a census tract) .144 565 22.1 4
per year (within larger area) .143 561 22.0 4
Automobile accidents
per 4 years (within a census tract) .038 149 11.9 8
Other accidents
per 4 years (within a census tract) .030 118 10.7 9
Cardiac
per 4 years (within a census tract) .007 26 5.1 20
per 4 years (within larger area) .028 110 10.3 9
Poisonings
per 4 years (within a census tract) .005 20 4.5 23
per 4 years (within larger area) .020 78 8.7 11
Cardiacs and poisonings
per 4 years (within a census tract) .012 47 6.8 14
Other illness
per 4 years (within a census tract) .049 192 13.5 7
Dry runs
per 4 years (within a census tract) .014 55 7.4 13
* Probability of occurrence is the probability, per capita, of a call being phoned in under the specified condi.
tions. (p).
Expected calls per area is the number of calls phoned in from an area, on average (np) we assume that all
census tracts have population 3,920.
Standard Deviation about the number of expected calls ([np(l-p)]1/2; sampling variation means that we might
expect to observe np+2[np(l-p)]1/2 calls actually being phoned in from the given area.
Coefficient of Variation; the standard deviation divided by the mean; (100[np(I-p)]1/2/np). Note that aggre.
gating years together, census tracts together, or both, greatly reduces the coefficient of variation.

of the process means that from 118 to model with both sets of data and tended
164 calls can be expected in any year. to find similar estimates.
This sampling variation is sufficiently An important problem with the am-
large that it is difficult to estimate the de- bulance call data is that during the
mand model. Sampling variation for the second half of 1967, the private am-
various categories are shown in Table 2. bulance company which was responsible
For those categories where the coefficient for one section of the city failed to re-
of variation is 8 or greater, sampling port all of its calls. Thus, there is an
variation is likely to obscure estimation. underestimate of the demand for am-
To circumvent this problem, we ag- bulance service for this period in this
gregated census tracts together to get part of the city. The area in question is
157 areas (each comprising about four only a small portion of the city. There-
census tracts). This pooling of data has fore, the results of the four year analysis
a significant effect in reducing sampling were quite similar to the results obtained
variation. For example, the coefficient from analyzing 1964-66 and 1967
of variation for cardiac calls falls from separately. We also formulated a model
20 for census tract data to 9 for the which allowed for the underestimation
larger area data. We estimated the in this one area during 1967; it con-

1162 VOL. 61. NO. 6. A.J.P.H.


EMERGENCY AMBULANCE SERVICE

firmed a significant amount of under- data, we refit the 1964-67 relations and
reporting. found similar results. We extended the
We attempted to estimate the effect of analysis with the aggregated data by
charging for public ambulance service. analyzing cardiac and poison categories
From 1964 to the second half of 1966, separately. Finally, we took data for
there was no charge for using public am- each year for the 157 areas and pooled it
bulance service. During the last months to get 628 (4X 157) sample points with
of 1966, a charge of $15 was instituted which to examine changes in demand
for cases where the victim was trans- over time. Since these analyses replicate
ported to a hospital. Collection of this one another, we have presented only a
fee began in 1967. Unfortunately, our few of the estimated relations in
data do not note whether a victim was Table 3.
transported to the hospital; there is The model explains total demand with
casual evidence that the proportion of a high degree of accuracy: the co-
cases which involved transportation to efficient of determination (R2) when
the hospital fell in 1967, but there is no adjusted for lost degrees of freedom is
quantitative evidence. .927, indicating that 92.7 per cent of the
Finally, we want to stress that the rele- variation is explained by the regression.
vant question for analysis is the nature The F statistic is 275 with 31 and 600
of demand for all emergency medical degrees of freedom (F must be greater
care. Public ambulance service is a small than 1.70 for a level of confidence of
part of this demand. Our data were not .99). The regressions explaining sub-
such that we could attack the larger categories are nearly as good since the
problem and so we are forced to assume lowest coefficient of determination (for
that the characteristics of other ways of dry runs) is .598. In all of the regres-
handling medical emergencies did not sions reported, the F statistic implies that
change over this period.* one can be confident at extremely high
Results levels (considerably beyond .99) that
A number of similar models were esti- the regressions explain a significant
mated, using least squares regression amount of variation in the dependent
analysis. First, we added all four years variables. One might further note that R2
and estimated a demand relation for each rises with the mean of the dependent
category, combining the cardiac-poison variable across regressions. We con-
cases. To look at underreporting bias, we cluded that this result follows from
fit separate relations for 1964-66 and sampling variation, as discussed above.
1967 separately. To lessen the im- The regression coefficients and their
portance of sampling error, we aggre- t statistics (the coefficient divided by its
gated the 632 census tracts into 157 con- standard error) are presented in Table 3.
tiguous areas. Using these "aggregated" Each coefficient indicates the marginal
effect of a variable, other factors held
* Excluded variables, such as the character-
constant. For example, in the first re-
istics of emergency medical care outside the gression, a one percentage point increase
public system, will not bias the estimated
parameters if they are uncorrelated with the in- in the proportion of the population which
cluded variables. Since we couldn't get data is white will decrease ambulance calls per
on the characteristics of these other ways of capita by .1 per cent. This effect might
handling medical emergencies, we must assume seem small, but one must realize that in-
that they did not change over time or that come, housing density, and many other
they changed in such a way that the change
is uncorrelated with the included explanatory factors are being held constant. Thus,
variables. whites call the public ambulance system

JUNE. 1971 1163


Table 3-The total demand for public ambulances
Total* Pooledt
Demand Years
R2 .927 .904
Degrees of freedom 600 592
1. Constant term 161 (3.14) -1 (-.07)
2. Housing density -534 (-6.30) -43 (-1.74)
3. Recently moved 593 (5.74) 151 (5.40)
4. White population -98 (-5.09) -19 (-4.64)
5. % over 65 838 (7.19) 131 (4.82)
6. % Single females -455 (-2.45) -120 (-2.77)
7. % Single males 929 (4.92) 206 (4.91)
8. % Poor families 705 (4.12) 160 (3.35)
9. % Males unemployed 1,563 (4.61) 346 (3.11)
10. % Employed males 1,324 (10.88) 216 (5.58)
11. F. in labor force -143 (-1.17) -164 (-6.82)
12. Total employment 49 (37.24) 9 (14.13)
13. I% Children 519 (3.46) 14 (.62)
14. % Single white M. 428 (3.79) -27 ( 4 1.38)
15. % Married whites 125 (1.01) -26 (-1.39)
16. % M. farmers -417 (-2.46) -56 (-1.38)
17. % M. managers 179 (3.01) 17 (1.16)
18. % M. household -44 (-.50) 106 (4.08)
19. % F. professional -180 (-3.00) -6 (-.28)
20. % F. farmers 1,313 (4.60) 34 (.21)
21. % F. laborers 220 (.72) -209 (-2.08)
22. Acres/capita 36 (2.66) 12 (2.69)
23. % Comm. land 170 (3.03) 11 (.87)
24. % Indust. land -129 (-3.07) 11 (1.33)
25. % Trans. land -137 (-2.36) -1 (-.11)
26. Freeway 7 (1.22) -1 (-.26)
27. Response time -13 (-1.23) -1 (-.78)
28. Area #1 104 (1.07) 39 (2.34)
29. Area #2 -161 (-.77) -64 (-1.93)
30. Area #3 -41 (-.28) 13 (.53)
31. Area #4 27 (.13) -35 (-.43)
32. Area #5 258 (1.75) -4 (-.15)
33. 1964 -35 (-3.46)
34. 1965 -28 (-2.75)
35. 1966 5 (.52)
36. 1967 0
37. Area #2 in 1967 -104 (-2.78)
* Total ambulance calls per capita for each census tract (X 1,000) summed over 1964-7.
+ Totals calls per capita for 157 areas, all years pooled ( X 1,000) .
+ The figure in parentheses is the t statistics.

less than nonwhites even when they are hypothesized, that the disadvantaged use
poor and are living in slum neighbor- the public ambulance system more often.
hoods. Demand increases with housing density,*
For the first regression, the set of nonwhite population, low income, male
variables indicating low socioeconomic * Housing units per capita; the inverse of
status are all significant and indicate, as housing density is actually used in the analysis.

1164 VOL. 61, NO. 6. A.J.P.H.


EMERGENCY AMBULANCE SERVICE

unemployment, and females in the labor schedule in 1966 had its most immediate
force. We also note that additional em- impact in eliminating calls from the few
ployment within the census tract in- industrial firms who continued to take
creases demand. advantage of the free service for many
The fact that we have estimated a minor illnesses and injuries. Similarly,
multivariate regression means that great land devoted to transportation generates
care must be taken in interpreting many fewer calls than residential land. Trans-
of the estimated coefficients. For ex- portation acreage is devoted to airports,
ample, we include measures of the pro- train yards, and docks which have little
portion of children and of the aged, but public traffic and which are often served
must exclude the proportion of people by special ambulance services.
aged 14-65 in the estimation. This
means that the other two coefficients are Automobile Accidents
relative to the excluded category. Thus, Nearly all automobile accidents involv-
the positive coefficients for children and ing injury result in a call for a public am-
the aged mean that these groups gener- bulance. Thus, in predicting the number of
ate more calls than those aged 14-65. In calls for public ambulances to handle
particular, the aged generate more calls automobile accidents, one is really pre-
than either of the other groups. Similarly, dicting the number (and location) of
relative to married people, single women automobile accidents involving injury.
(including those separated, divorced, and This job is quite different from that of
widowed) generate fewer calls while predicting the demand for public am-
single men (including those separated, bulances to handle illness.*
divorced, and widowed) generate more Socioeconomic variables are not as
calls. Whites generate fewer calls than powerful in this analysis as in the other
nonwhites; in addition, as with the total categories. Housing density has a nega-
population, single white women generate tive effect, while acreage per capita and
fewer calls than married white people land devoted to transportation have posi-
while single white males generate more. tive effects. The results suggest the
Some of the less populated recreational hypothesis that serious automobile acci-
areas within the city seem to generate dents tend to occur either on freeways or
more demand, primarily from auto ac- suburban and rural roads, rather than
cidents. As a consequence, the first land in urban areas.
use variable indicates that demand rises
as acreage per capita increases. Rela- The positive coefficients for total em-
tive to residential land, commercial land ployment within the tract and for the
generates more calls per acre; as the per- percentage of land devoted to commer-
centage of land devoted to commercial cial activity indicate that these are good
use rises, demand increases. Commercial surrogates for high traffic volume.
areas have considerably more pedestrian The sociological variables of im-
and auto traffic with a consequently portance are difficult to interpret. One
greater opportunity for injury or illness would hypothesize that the percentage of
to occur on a public street. Industrial single males would have a positive effect,
land generates fewer calls than residen- but the opposite result occurred in this
tial land. Industrial settings are now rela- study. The negative effect of a high per-
tively safe due to the influence of Work- centage of children is understandable,
mens' Compensation laws and many in- because children tend to reside in tracts
dustrial firms have set up procedures to with neither freeways nor rural roads.
handle accidents without calling the The positive influence of female employ-
public system. The imposition of the fee * See King (1968).

JUNE, 1971 1165


-, -
--- 1- 1- 1- - 1- 1- 1- 1- 1-1 - - 1- 1- 1- - -, - - - -, -, - - - - --- X
Ln 0 'O 0 L5 r1- 0 > 01
t t - ef 0%
D c
O %O C I _00O cC : 0% C
0C1-
0 Ci c - O= "
t-
,Co t- Cn d Cl4 s (Z C 0 _4 Lf C r CC C _ n1 CO

II~~~~~
_I ~C
-- d _ I-CS_I4%CS _I-S_ _ CD n _I _I I - CD = CD _n
_IN %
0
g-__4 CLIP 4 _ r_ _ I I I _ _ -
C cC 1 Ic
ITCl~~ -

t- CSl
_I 0% m 00 I"Ctl
CS t _I
d CJ -tl _I -e 4 .! OR C- - Co _1 _IC>

0nLHX %00 dn
%O ON0 0U: eCo r t- -e ol
Ctsn IU 103 oc
oq 0 CD oo o c CD. oo CDo
W Lo
r-i 00r-4sC4
sbt C14O-_-P- CtC

a
en cs _I_ CiL
0_ _ _ Cl I _I
Cl_

\0r- O- 00I as tD4 COt 10 Id,


C-I % C% Co Ft 0 00z CN %O

g on Ch o 1 n to ~t-_ eAlrq uq:t CO (Ds t- "- _sN m Rt CS- 0.4 M 04 m C9

< 4~II
Clo4 U_
~~~~~~~~
O~~~~~~~~~% c6IO0v
t-I C>J L6 r-
OOOO*t
6 C% _1s' 4c6 4
C1 @t
C6 t-0_>OC ci{0 Ic0CDeS_
C8 c4 16 'C

oo Z
Q~~~~~~t C v00 00 N 0 t- U)CS r- t- ko Co 00LO t- t C,4 O 00 m m t- C e 00 CO4 CSt
8~~~~~~~~C cD CS u r- _ _-4 0 %C r_ % _ Clin
~~~~ m Co r- P- LO ". Ci
LO
i r- " 00 CO | ~ ~ | le Cc{ r--C ;
r- r- Co I | ~ ~ON
P-
^ ~
~~~~~ M COt- r-- t- r-- r-- r-

4-)

O CO O J2o
Z -. > H H o X ~C~
X ON S Co m m le C9 C) %C Xee
l e P- m F 9
@ Z-

PSo t- llzCh1O _ t- CS4 00- t- _d 1DCD_ C) CSI0


Cs Ch Cs 00 t- m t-
_I C

4) Z
ocn L0Mes
Cs i_ SOs iN su e11 sc-1111- Co
zl t- Cl8 - | ,,_ ,,,_
0 ;m~~~~~~~L No e 00 Co C ON 00 LO 00 C14 ON t- t- dt
o .-%0-%'~.fCC X o
00 On t- o ~c u t Oc Oc kc t- eP 00 O-

Cs Cd m
0 = ct
"I
_q w m m t- % r- r- M C% _ t- C4 M -It dz M r-z rI I- le - I t-0 C

~ ',-, ',,
r-4
r-4N
| e
C_IIP.4C1 ,

7 Fe
1'~7 ? Co I I
*Co
' I U

>~~~~~~~ > _ _ C _ _

Y e O-| b ~~0
0~~ e St C -- h CZ
t- IC b Ie es
-I C'4 'w Ln

:o o <,, W 88Se e .Co V-e 8888


CdvX
_CO >ooo_C! *b o U o o o t U o .oiC

- -_I _ Cl Cl C. C. CC Co Cl Cl Cl Cl

1166 VOL. NO. %we


61. alw1w.
W%Fft. %fly A. A.J.P.H.
EMERGENCY AMBULANCE SERVICE

ment probably coincides with central city One would hypothesize that socio-
residence. economic data would predict public am-
The coefficient of determination of bulance demands arising from cardiac
.671 is lower than that for total acci- cases quite well. Males over age 45 are
dents, although still quite significant. more prone to coronary attacks and the
poor would tend to rely more heavily on
Other Accidents the public system in this type of case.
This category included injuries result- Difficulties arise, however, in this anal-
ing from fights, falls, and other miscel- ysis because of a small sample of such
laneous accidents. One would suspect that cases.
males are particularly likely to be in- The positive effects of low density
volved in this category. These injuries housing and the Fire Department re-
probably involve broken bones and sponse area probably reflect to some de-
hemorrhage and are likely to involve a gree a reliance by the suburban San
call for a public ambulance. Falls and Fernando Valley dwellers on the Fire
similar accidents are more likely to occur Department for quick response to heart
among children and the elderly than in attacks. The percentage of the popula-
the population at large; they are also tion over 65 has, as expected, a positive
more likely to occur in areas such as effect.
slums. Fights generally involve young Many cardiac calls involve employed
men. males at work. In fact, total employment
The results tend to support these and females in the labor force are the
hypotheses. The coefficients of all vari- only variables that are statistically sig-
ables indicating low income neighbor- nificant. Surprisingly, the data do not
hoods are of the expected sign and, with suggest that particular kinds of employ-
the exception of unemployment, are sig- ment are more likely to generate heart
nificant. Children and the elderly are re- attack calls than others, although the re-
lated to higher demand rates, along with sults indicate that unemployed males are
single males. Surprisingly, employed less likely to have heart attacks than em-
males have a larger and more significant ployed males. Despite the weakness of
effect on demand than do unemployed the individual variables due to collinear-
males. Single women have almost no ity, the R2 is .731, which is quite re-
effect. The land use variables indicate spectable.
that these accidents occur more fre- As with the cardiac category, the
quently in residential areas than else- sample size for poisoning cases was quite
where. low, thereby reducing the predictive
ability. The fact that children are a
Sickness: Cardiac and Poison strongly positive influence certainly co-
Cardiacs and poison cases were an- incides with expectations. The positive
alyzed using the aggregated areas. An at- effects of low income variables probably
tempt was made to analyze the two reflect a greater reliance on the public
categories together; however, the obvi- system due to decreased alternatives.
ous differences in the kinds of indi- Children are much less likely than adults
viduals likely to be victims of these types to be transported by ambulance when an
of emergencies complicated interpreta- emergency occurs because they can more
tion of the aggregate estimate. Thus, we easily be fitted into a priivate car. Low
used the aggregated data (each observa- socioeconomic status families have fewer
tion represents calls from four census private autos available, especially during
tracts over four years) to estimate each working hours when children are liable
category separately. to get into difficulty. It is possible that

JUNE. 1971 1167


the negative effect of unemployed males lance calls increase. Perhaps the ex-
and the positive effect of employed males planation is that these males are away
indicate this decreased availability of al- from home and unable to provide trans-
ternatives, i.e., if the man is home with portation to a physician.
some type of vehicle, he will transport Land use variables show that com-
the child to the hospital. mercial property generates many calls,
while industrial and transportation land
Sickness: Other generates fewer calls than residential
Illness with some acute distress symp- land. As indicated earlier, industrial firms
toms is an extremely common event; a handle their calls outside the public sys-
very small percentage of these cases tem and areas devoted to transportation
come into the public system. In general, generate few calls.
these cases will go to the family physi-
cian unless he cannot be reached or is Dry Runs
otherwise unavailable. Stable, high-in- A dry run occurs when the ambulance
come families are more likely to handle driver either cannot locate the patient, or
these cases through a private physician; when he sees that the situation is being
transient, recently moved people, or handled without any need for him. Area
older people are more likely to call the number one is extremely significant. This
public system for assistance. In this is the area where no screening of calls
study, this category included a number is done; thus, as one would expect, auto-
of cases of drunkenness and unconscious matically dispatching an ambulance for
individuals found to have no evidence of every call leads ambulances to go on
trauma. more dry runs than in areas where the
The results showing that older people dispatcher must be satisfied that a medi-
are likely to generate calls accords with cal emergency is involved. The influence
our expectations. The negative effect of of income variables in this equation is
children probably indicates that families not clear, probably due to collinearity
with small children are likely to have among the explanatory variables (the
access to a physician and so not rely on San Fernando Valley area is of a uni-
the public system. People who have re- formly higher income level than the un-
cently moved are likely to call the pub- screened areas).
lic system when such an emergency
occurs, as are people of low income. The The Effect of Price
reason for both is that neither of these In order to isolate the effect of the
groups is likely to have readily available charge added in 1967, the data were
alternatives, such as a family physician. regrouped so that each point represented
Similarly, whites call the public system the total calls from four census tracts for
less often than nonwhites. Single females a given year. All four years were pooled
exert a substantial negative influence and a variable was added to allow for
while single males have substantial posi- under-reporting in one area in 1967.
tive effect. Single females are more likely There were significant increases in de-
to have a regular physician and the high mand from 1964 to 1966 (the 1964-65
demand generated by single men prob- increase is 23 per cent and the 1965-66
ably reflects the many downtown habitues increase is 11 per cent) - Demand actually
who are high utilizers. The factor for fell from 1966 to 1967 (by 1.7 per cent)
total employment in a tract has a posi- which is a significant departure from the
tive effect, again indicating highly com- trend and from our expectations, since
mercial areas. As the percentage of males Los Angeles continued to grow. Am-
in the labor force increases (whether they bulance demand in Los Angeles has been
are employed or unemployed), ambu- growing over time; this growth was

1168 VOL. 61, NO. 6, A.J.P.H.


EMERGENCY AMBULANCE SERVICE

slowed through the $15 charge. Addi- Types of Families that Use an Emergency
tional data are needed before the precise Clinic." Medical Care 7:55, 1969.
effect of the charge can be estimated. It 2. Andrews, R. B.: "Criteria Selection in
seems plausible that there might be a Emergency Medical System Analysis." EMS
lag between the institution of the charge Working Paper No. 1, 1969 (EMS-69-1-W).
and its effect on demand; people may not Paper presented at Annual Meeting,
Western Section Operations Research So-
be aware of it for some time. ciety of America, February 1969.
3. Jacobs, A. R. and McLaughlin, C. P.:
Conclusion "Analyzing the Role of the Helicopter in
The demand for public ambulances Emergency Medical Care for a Community."
appears to be highly predictable, using a Medical Care 5:343, 1967.
4. King, B. G.: "Estimating Community Re-
simple linear model employing socio- quirements for the Emergency Care of
economic variables, quality of service Highway Accident Victims." A.J.P.H. 58:
variables, and land use variables. Low-in- 1422, 1968.
come families and nonwhites tend to use 5. King, B. G. and Sox, E. D.: "An Emergency
the public ambulance system more often Medical Service System-Analysis of Work-
load." Publ. Mth. Rep. 82:995, 1967.
than others. Areas with elderly people or 6. Lavenhar, M. A., Ratner, R. S., and Weiner-
children also generate many calls. Esti- man, E. R.: "Social Class and Medical
mates of demand are stable over time Care: Indices of Nonurgency in Use of
and tend to be similar across type of in- Hospital Emergency Services." Medical
cident giving rise to the call. Care 6:368, 1968.
7. Weinerman, E. R., Ratner, R. S., Robbins,
REFERENCES A., and Lavenhar, M. A.: "Yale Studies in
Ambulatory Medical Care: V. Determinants
1. Alpert, J. J., Kosa, J., Haggerty, R J., of use of Hospital Emergency Services."
Robertson, L., and Haggerty, M. C.: 'The A.J.P.H. 56:1037, 1966.

Miss Aldrich is a doctoral candidate, Graduate School of Industrial Admin-


istration, Carnegie-Mellon University, Pittsburgh, Pennsylvania 15213. Mr.
Hisserich is a doctoral candidate in Health Services Administration, School of
Public Health, University of California, Los Angeles 90024. Dr. Lave is Professor
of Economics, Graduate School of Industrial Administration, Carnegie-Mellon
University, Pittsburgh, Pennsylvania 15213.
This paper was submitted for publication in April, 1970.
The authors are listed in alphabetical order. Mr. Hisserich formulated the
general nature of the problem and collected the data; Miss Aldrich and Dr.
Lave suggested the statistical methodology, performed the analysis and drafted
the paper. The work of Mr. Hisserich and Miss Aldrich was supported by the
Emergency Medical Systems Project. Dr. Lave's work and the computer time
were supported by PHS Grant No. RO1 HS 00069 from the National Center
for Health Services Research and Development.
Miss Aldrich is a doctoral candidate, Graduate School of Industrial Admin-
istration, Carnegie-Mellon University, Pittsburgh, Pennsylvania, 15213. Mr.
Hisserich is a doctoral candidate in Health Services Administration, School
of Public Health, University of California, Los Angeles, 90024. Dr. Lave is
Professor of Economics, Graduate School of Industrial Administration, Carnegie-
Mellon University, Pittsburgh, Pennsylvania, 15213.
The Emergency Medical Systems Project at UCLA is funded by the U. S.
Department of Transportation, National Highway Safety Bureau (contract No.
FH-11-6849).
The statements contained in this paper should not be interpreted as repre-
senting the official opinions or policies of the U. S. Department of Transporta-
tion, U. S. Public Health Service, University of California, or Carnegie-Mellon
University.
The authors are indebted to Robert Andrews, Eugene Durbin, and Phillip
Enterline for suggestions and criticism; any remaining errors are those of the
authors.