Injury, Int. J.

Care Injured 43 (2012) 1843–1849

Contents lists available at SciVerse ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

The cost-effectiveness of physician staffed Helicopter Emergency Medical Service

(HEMS) transport to a major trauma centre in NSW, Australia
Colman Taylor a,b,*, Stephen Jan a, Kate Curtis a,c,d, Alex Tzannes d,e, Qiang Li a, Cameron Palmer g,h,
Cara Dickson d, John Myburgh a,d,f
a
The George Institute for Global Health, Australia
b
Sydney Medical School, The University of Sydney, Australia
c
Sydney Nursing School, University of Sydney, Australia
d
St George Hospital, Australia
e
The Ambulance Service of NSW, Australia
f
University of NSW, Faculty of Medicine, Australia
g
Trauma Service, The Royal Children’s Hospital Melbourne, Australia
h
Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background and context: Helicopter Emergency Medical Services (HEMS) are highly resource-intensive
Accepted 19 July 2012 facilities that are well established as part of trauma systems in many high-income countries. We
evaluated the cost-effectiveness of a physician-staffed HEMS intervention in combination with treatment
Keywords: at a major trauma centre versus ground ambulance or indirect transport (via a referral hospital) in New
Helicopter Emergency Medical Services South Wales (NSW), Australia.
Primary scene response Methods: Cost and effectiveness estimates were derived from a cohort of trauma patients arriving at St
Cost-effectiveness
George Hospital in NSW, Australia during an 11-year period. Adjusted estimates of in-hospital mortality
Health economics
Trauma care
were derived using logistic regression and adjusted hospital costs were estimated through a general
Trauma system linear model incorporating a gamma distribution and log link. These estimates along with other
assumptions were incorporated into a Markov model with an annual cycle length to estimate a cost per
life saved and a cost per life-year saved at one year and over a patient’s lifetime respectively in three
patient groups (all patients; patients with serious injury [Injury Severity Score > 12]; patients with
traumatic brain injury [TBI]).
Results: Results showed HEMS to be more costly but more effective at reducing in-hospital mortality
leading to a cost per life saved of $1,566,379, $533,781 and $519,787 in all patients, patients with serious
injury and patients with TBI respectively. When modelled over a patient’s lifetime, the improved
mortality associated with HEMS led to a cost per life year saved of $96,524, $50,035 and $49,159 in the
three patient groups respectively. Sensitivity analyses revealed a higher probability of HEMS being cost-
effective in patients with serious injury and TBI.
Conclusion: Our investigation confirms a HEMS intervention is associated with improved mortality in
trauma patients, especially in patients with serious injury and TBI. The improved benefit of HEMS in
patients with serious injury and TBI leads to improved estimated cost-effectiveness.
ß 2012 Elsevier Ltd. All rights reserved.

Background and context
Helicopter Emergency Medical Services (HEMS) are an estab-
lished component of many health systems, particularly in high-
income countries. Their use may be broadly grouped into two
* Corresponding author at: P.O. Box M201, Missenden Rd, Camperdown, NSW
2050, Australia. Tel.: +61 2 9657 0300.
E-mail address: ctaylor@georgeinstitute.org.au (C. Taylor).
response types, primary responses (direct to the scene of an
incident) and secondary inter-facility transfers (of trauma and
other critically ill patients). In primary scene responses, HEMS have
several potential advantages for trauma patients over usual care
provided by ground transport networks. These include access to
areas where road infrastructure is limited, faster transport to
hospital in rural areas1 and faster access to definitive care through
the provision of advanced interventions (such as endotracheal
intubation or fluid resuscitation) by a physician or trained
paramedic at the scene. It is hypothesised that the advantages

0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2012.07.184
1844 C. Taylor et al. / Injury, Int. J. Care Injured 43 (2012) 1843–1849
provided by HEMS in primary scene responses may improve the
chances of survival for seriously injured trauma patients in
comparison to care provided by ground ambulance networks.
Previous systematic reviews2,3 and annotated reviews4–8
suggest that HEMS may improve trauma patient mortality in
comparison to patients transported by ground ambulance.
However, clear differences between studies exist in the context
in which the HEMS operates, the staffing of HEMS and ground
ambulance comparators, the patient population used as well as the
methods used in the evaluation.
As a healthcare intervention, HEMS are an expensive alternative
compared to ground transport and any potential benefits provided
by HEMS need to be considered in context of the associated costs.
Few studies have evaluated the cost-effectiveness of HEMS in
trauma and due to regional variability previous results are likely to
be system specific.9
In the New South Wales (NSW), Australia, HEMS operate under
unique geographical conditions which include large distances
servicing a sparse population. In this environment, the predomi-
nant staffing model for HEMS is physicians trained in specialties
such as emergency medicine and anaesthesia with qualified
paramedics.10 Despite results supporting the use of physician-
staffed models of trauma care11,12 (which are predominantly
delivered via HEMS), the benefit and value of physician staffed
HEMS in NSW is unknown. In the context of scarce resources and
competing alternatives for government funding there is an
imperative to investigate the cost-effectiveness of physician-
staffed HEMS primary scene responses to trauma.
Setting
In NSW, eight HEMS currently operate from various locations
around the state, performing primary scene responses and
secondary inter-facility transfers as part of the NSW state trauma
plan.10 In the Sydney metropolitan area, HEMS physicians and
paramedics can also travel via road to incidents in close proximity
to the base of operations. Patients meeting major trauma criteria13
are transported to designated major trauma centres which have
the full spectrum of care available including surgery, radiology,
intensive care and rehabilitation.14 St George Hospital is a
designated major trauma hospital located in south eastern Sydney
that receives trauma patients from its catchment area transported
by the following modes: paramedic-crewed ground ambulance;
physician-staffed HEMS or ground ambulance (90% via HEMS);
fixed-wing aircraft; international retrievals; other transport modes
such as private vehicles and walk-ins.
HEMS +
treatment at
major
trauma
centre
Paents meeng
SGH trauma
criteria
Non-HEMS +
treatment at
major
trauma
centre
Fig. 1. Patient event pathways in model.
Aim
The aim of this health economic investigation was to evaluate
the cost-effectiveness of direct physician-staffed transport
(termed ‘HEMS’) from the scene to a level one trauma centre,
for adult trauma patients versus a ground transport or indirect
transport (via a referral hospital) alternative (termed ‘non-HEMS’).
Methods
This study was approved by the South Eastern Sydney and
Illawarra Area Health Service Human Resources Ethics Committee.
The evaluation was undertaken from the perspective of the health
care funder. A Markov model incorporating two health states (alive
or dead) and an annual cycle length was developed. Fig. 1 describes
the patient event pathway model; patients surviving the index-
hospitalisation were modelled over their lifetime.
The Injury Severity Score (ISS) is an anatomical scoring system
that provides an overall score for patients with multiple injuries
(range: 1–75, with higher scores associated with higher mortality).
ISS combines the Abbreviated Injury Scale injury scores (AIS;
range: 1–6), which are assigned across six body regions. The
Trauma Score (TS) combines the patient’s initial Glasgow Coma
Score (GCS), capillary refill and respiratory effort (range: 1–16,
with lower scores associated with higher mortality).
Based on previous research that suggests a HEMS intervention
is associated with a higher probability of survival following serious
injury(s)15 or traumatic brain injury (TBI),16 we calculated
estimates in all patients meeting St George Hospital trauma triage
criteria (Model #1; Appendix I shows trauma criteria) as well as
patient subgroups with serious injury (Model #2) and traumatic
brain injury (TBI) (Model #3). Serious injury was defined according
to the NSW definition of major trauma which included an ISS
greater than 12.14
Study sample
Model event probabilities were derived from trauma patients
arriving at St George Hospital during a reference period of 11 years
from January 2000 to December 2010. Patients were included in
the cohort if they sustained any form of trauma during the
reference period and met the St George Hospital trauma triage
activation criteria (Appendix I). ISS values calculated using
different AIS versions were adjusted using AIS mapping tools.17
The following patients were excluded from the analysis: paediatric
patients (16 years), patients who arrived at St George Hospital
greater than 24 h after their injury, patients not arriving by
Survive
Survive
injuries
Die
Die
Survive
Survive
injuries Die
Die
 C. Taylor et al. / Injury, Int. J. Care Injured 43 (2012) 1843–1849
ambulance or helicopter and patients who were transported from
outside the St George Hospital catchment area (including
5 regional hospitals which is reflective of where primary scene
responses transferred to St George Hospital emanate from).
For this evaluation, a HEMS patient included patients receiving
a physician intervention pre-hospital and then being directly
transported (from the scene by road or HEMS) to St George
Hospital. HEMS patients were retrospectively identified by the
transport mode on arrival at hospital as well as ambulance case
sheet numbers. A non-HEMS patient included patients arriving at
hospital via a paramedic-staffed ground ambulance or via a referral
hospital (including regional hospitals and urban non-designated
trauma centres).
Estimating effectiveness
As part of a sequential analysis we estimated the adjusted
probability of survival until hospital discharge for HEMS and non-
HEMS patients. Given the imbalance in patient illness severity
between the HEMS and non-HEMS patient groups, we calculated
adjusted estimates of in-hospital mortality using logistic regres-
sion. Based on clinical judgement and previous research,2 the
following covariates were used in the final model: age (4 levels),
sex, year of arrival to hospital (11 levels), mechanism of injury (5
categories), use of endotracheal intubation pre-hospital, scene
Trauma Score, TBI, serious injury (ISS > 12 in Model #1; ISS used as
continuous variable in Models #2 and #3), rural status, admission
to ICU, emergency operation performed. TBI was defined as an
anatomical injury to the head (AIS codes beginning with 1 coded to
the ISS head region) with an AIS score  3. Patients were
considered ‘rural’ if the postcode of injury was greater than 1 h
estimated travel time via road. Emergency operation was defined
as patients being transferred directly from the emergency
department to the operating room.
All co-variates were entered into the model along with the
patient group variable (HEMS and non-HEMS). Model discrimina-
tion was tested through the receiver operating characteristic [ROC]
area and calibration through the Hosmer–Lemeshow (H–L)
statistic.
To model survival over a lifetime we incorporated the estimated
probability of in-hospital mortality for HEMS and non-HEMS
patients into a Markov model with an annual probability of death.
In Model #1 we used the probability of death published by the
Australian Bureau of Statistics18 (based on the average age of the
cohort) that assumes that patients have a normal life expectancy
beyond the index hospitalisation. In Models #2 and #3 we adjusted
the probability of death for the higher risk of death following
traumatic brain injury19 (SMR: 1.51; 95% CI: 1.25–1.78).
Estimating costs
Treatment costs were estimated in four phases of
care: treatment in a referral hospital, transport to a trauma
centre, treatment during the index hospitalisation and treatment
following discharge.
Treatment costs during the index hospitalisation were calcu-
lated on a per patient basis and averaged whereas estimates were
sourced for the other phases of care. To adjust for differential
timing all cost information was adjusted to 2010 equivalent values
using the health specific consumer price index published by the
Australian Bureau of Statistics.20
To estimate index hospitalisation costs, medical record
numbers and dates of admission from the trauma data were
provided to the St George Hospital Casemix Unit, with a report
query template to ensure the same data recovery. These units
record the actual costs (including emergency department, theatre,
1845
intensive care, allied health and rehabilitation) incurred by each
patient in a state-wide uniform database (Trendstar Decision
Support System1). Patient costing, including overheads
(e.g. staffing, floor space) was conducted in accordance with
2008–2009 NSW Program and Product Data Collection Stan-
dards.21 For patients who were discharged from emergency
department (and therefore patient level costs were unavailable)
we applied the average cost of an emergency department
presentation ($396 [2009 AUD]).22 Costs for hospital separations
that crossed financial years were excluded from the analysis due to
inappropriate allocation of DRG cost weights.
To calculate a unit cost of the index hospital treatment for
HEMS and non-HEMS patients we estimated a predicted cost using
a generalised linear model, incorporating a gamma distribution
and log link.23 Total cost was adjusted for differences in patient
case mix between transport groups using the same covariates
identified in the analysis of effectiveness. Residuals were examined
to assess model fit and identify potential outliers, with sensitivity
analyses performed excluding any identified outliers to assess
their impact on the predicted costs.
To incorporate pre-hospital transport costs, we utilised the
average cost estimate per case for emergency road missions ($546
per case [2006 AUD]) and helicopter missions published by the
Independent pricing and Regulatory Tribunal of NSW ($5786 per
case [2006 AUD]).24 For the HEMS transport group we calculated
an adjusted cost according to the proportion of patients arriving via
ground and HEMS. In the non-HEMS transport group, we adjusted
the transport cost according to the proportion of inter-hospital
transfers and the transport mode utilised during inter-hospital
transfer.
To estimate cost of treatment at a referral hospital, we applied
the standard cost of an emergency department presentation ($396
[2009 AUD]).22 To account for transport to the referral hospital we
added the average cost of ground transport as estimated above.
This is based on the assumption that patients arriving via a referral
hospital (within 24 h post injury) would have been transferred to
the referral hospital via ground transport and would have spent the
majority of their time in the referral hospital Emergency
Department before being transferred to St George Hospital.
Post discharge, we assumed an average rate of annual patient
healthcare expenditure over a lifetime for survivors in Model #1,
based on the Australian Institute of Health and Welfare Report
(estimated government contribution: $3617 per annum [2009
AUD]).25 For patients with serious injury or TBI (Models #2 and #3)
we assumed an annual health expenditure that was five-fold
higher per year over a lifetime based on the government
contribution to the financial cost of traumatic brain injury in
Australia (estimated government contribution: $18,008 per
annum [2009 AUD]).26
Sensitivity analyses
We undertook multiple one and two-way sensitivity analyses
to assess the effect of varying key assumptions across plausible
ranges. Age at injury was varied across the inter-quartile range of
the patient cohort. Index hospitalisation costs were varied across
the 95% CI of the point estimate and unadjusted costs was also
tested. We also tested the effect of higher ongoing treatment costs
for serious injury and traumatic brain injury survivors based on the
government contribution to spinal cord injury costs in Australia
(estimated government contribution: $51,499 per annum [2009
AUD]).26 In terms of the survival probabilities incorporated into the
models, we varied values across the 95% CI of the point estimates.
We also tested the effect on survival estimates of excluding
patients estimated to be dead on arrival, excluding inter-hospital
transfers and omitting variables from the model that may have
1846 C. Taylor et al. / Injury, Int. J. Care Injured 43 (2012) 1843–1849

been associated with the intervention (endotracheal intubation; Table 2

ICU admission; emergency operation performed). Finally, we
performed probabilistic sensitivity analyses on the three cost-
effectiveness models using Monte Carlo Simulations incorporating
gamma distributions for costs and beta distributions for probabili-
ties.27
Estimating cost-effectiveness
We derived two estimates of cost-effectiveness from our cost
and effect assumptions, the incremental cost per life saved at one
year and the incremental cost per life year saved over a patient’s
lifetime. Estimates were derived for the whole patient group
(Model #1) as well as the pre-specified patient sub-groups (Models
#2 and #3). Future costs and benefits were discounted at a rate of
5%.28 To represent the uncertainty in the estimates, we derived
cost-effectiveness acceptability curves (CEAC) for each of the three
models.27
Results
Study sample
Table 1 shows a total of 13,992 patients were included in the
original cohort. After exclusions 10,180 patients with complete
records remained (a priori exclusions n = 3546 patients; incom-
plete records n = 266). The final cohort included 1869 seriously
injured patients (18.4%) and 1067 patients with traumatic brain
injury (10.5%). Three hundred and ninety one patients (3.8%) were
included in the HEMS group and 9789 patients (96.2%) in the non-
HEMS group. Unadjusted in-hospital mortality was 2.9% and 6.1%
for non-HEMS and HEMS patients respectively. A summary of the
baseline characteristics of the HEMS and non-HEMS groups for the
pre-specified patient groups is provided in Appendix II.
After imputation of emergency department (ED) costs (for
patients discharged directly from the ED), cost data were available
in 88% of the final patient cohort (N = 8940). Cost data were
missing due to unavailability of records (11%; N = 1107) and cross
over between financial years (1%, N = 133). The unadjusted cost of
the index hospitalisation was $8717 and $28,118 for non-HEMS
and HEMS patients respectively.
Estimated costs
Table 2 reports the modelled one-year and life time
treatment costs for HEMS and non-HEMS transport groups for
One year and lifetime treatment costs for HEMS and non-HEMS patients.
HEMS Non-HEMS
One year
All patients $47,230 $29,650
Seriously injured patients $66,335 $47,714
TBI patients $66,326 $42,560
Life time
All patients $100,584 $82,371
Seriously injured patients $313,784 $285,901
TBI patients $312,765 $276,861
all patients, seriously injured patients and head injured patients.
One year treatment costs were predominantly influenced by the
cost of the index hospitalisation. Residuals produced from
estimating index hospitalisation costs in the a priori patient
groups indicated good model fit and the removal of potential
outliers from the models did not substantially affect the
estimates (<10% change in predicted costs). Costs were
uniformly higher for patients in the HEMS group compared to
patients in the non-HEMS group.
Estimated effectiveness and cost-effectiveness
All models showed that adjusted probability of in-hospital
survival in the HEMS group was significantly higher than
patients in the non-HEMS group (p < 0.05). Removing covariates
thought to be associated with the intervention led to more
accurate survival estimates in both sub-group patient models
without affecting model discrimination and calibration, and
therefore these estimates were utilised in the base case cost-
effectiveness estimates for Models #2 and #3. After adjustment
for patient imbalance between groups, the odds of in-hospital
death in the non-HEMS group were between 3.2 and 3.8 times
higher compared to the odds of death in the non-HEMS group
(all patients: 3.80 [95% CI: 1.85–7.83; p = 0.0003]; patients with
serious injury: 3.00 [95% CI: 1.45–6.21; p = 0.0031]; patients
with TBI: 3.20 [95% CI: 1.23–8.34; p = 0.0173]). All models
revealed excellent discrimination (AUC: 0.97 [all patients]; 0.90
[serious injury]; 0.91 [TBI]) and calibration (H–L p-value: 0.40
[all patients]; 0.73 [serious injury]; 0.96 [TBI]). As shown in
Table 3, the improved survival in the HEMS group translated
into a cost per life saved at one year between $519,787 and
$1,566,379. The survival difference led to an additional 0.2–0.7
life years per patient across the a priori patient groups and a cost
per life year saved between $49,159 and $96,524.

Table 1
Study sample characteristics.

Initial cohort

N 13,992
Excluded [N; %] 3812 (27.2%)

Final cohort All patients Serious injury TBI

N 10,180 1869 1067

Died [N; %] 309 (3.0%) 288 (15.4%) 211 (19.8%)
Unadjusted cost of index hospitalisation $23,257 $32,553 $30,740
HEMS
N 391 182 84
Died [N; %] 24 (6.1%) 23 (12.6%) 15 (17.9%)
Unadjusted cost of index hospitalisation $28,118 $50,075 $59,513
Non-HEMS
N 9789 1687 983
Inter-hospital [N; %] 502 (5.1%) 283 (16.8%) 195 (19.8%)
Died [N; %] 285 (2.9%) 265 (15.7%) 196 (19.9%)
Unadjusted cost of index hospitalisation $8716.99 $30,607 $28,348
 C. Taylor et al. / Injury, Int. J. Care Injured 43 (2012) 1843–1849 1847

Table 3
Incremental cost per life saved at one year and cost per life year saved.

% 1-year survival HEMS % 1-year survival non-HEMS Net lives saved per 100 transports Cost per life saved

All patients 94.71 93.59 1.12 $1,566,379

Seriously injured patients 93.20 89.71 3.49 $533,781
TBI patients 92.82 88.25 4.57 $519,787

Mean life expectancy HEMS Mean life expectancy non-HEMS Mean life year gain per patient Cost per life year saved

All patients 16.43 16.24 0.19 $96,524

Seriously injured patients 15.39 14.83 0.56 $50,035
TBI patients 15.33 14.60 0.73 $49,159

Sensitivity analysis results showed a higher likelihood of HEMS being cost effective in patients
with serious injury and traumatic brain injury.
One and two-way sensitivity analyses revealed the incremental
cost effectiveness ratios (ICERs) for cost per life year saved were Discussion
sensitive to a number of input assumptions in Model #1 and less
sensitive in Models #2 and #3. For patients in Model #1 ICERs In NSW, physician-staffed Helicopter Emergency Medical
ranged from $48,169 to $242,463 with a high discount rate (10%), Services (HEMS) are an expensive resource with undefined health
unadjusted costs and a two-way analysis of the upper estimates of economic benefits. Our results show a HEMS intervention
95% CI for in-hospital mortality (for both groups) producing higher combined with treatment at a major trauma centre is associated
ICERs. In Models #2 and #3 ICER estimates ranged from $32,645 to with improved mortality leading to an estimated cost per life saved
$82,516 and $33,105 to $81,640 respectively. These models were between $519,787 and $1,566,379 and an estimated cost per life
sensitive to the same inputs as Model #1 as well as higher ongoing year saved between $49,159 and $96,524. The estimated cost-
treatment costs. In all models the ICER estimates were not effectiveness of HEMS improved in patients with more serious
sensitive to excluding patients who were estimated to be ‘dead on injuries and in patients with traumatic brain injury.
arrival’. Excluding inter-hospital transfers from the analysis led to This evaluation was a novel assessment of the value provided by
a much higher ICER in Model #1 (OR for death in non-HEMS versus HEMS in NSW in primary scene responses. The hospital selected for
HEMS: 2.3 [95% CI: 1.0–5.2]; $242,463 per life year saved) and this investigation is classified in the highest tier of trauma hospital
similar ICERs in Models #2 (OR: 3.6 [95% CI: 1.4–9.2]; $50,657 per in NSW and has a large urban and rural catchment area which is
life year saved) and #3 (OR: 4.3 [95% CI: 1.2–15.2]; $45,360 per life broadly representative of many high-income trauma systems. Our
year saved). effectiveness estimates were sourced from registry data which are
Fig. 2 shows the results of the probabilistic sensitivity analysis, prospectively collected and comprehensively capture patients
displaying the likelihood of the ICER for cost per life year saved meeting hospital trauma criteria. We also utilised individual
being below increasing willingness to pay thresholds. Results patient cost data from hospital accounting systems which captured

0.9

0.8
Probability of being cost-effecve

0.7

0.6

0.5

0.4 ALL PATIENTS

SERIOUS INJURY
0.3
TBI
0.2

0.1

0
$4,000.00
$8,000.00
$12,000.00
$16,000.00
$20,000.00
$24,000.00
$28,000.00
$32,000.00
$36,000.00
$40,000.00
$44,000.00
$48,000.00
$52,000.00
$56,000.00
$60,000.00
$64,000.00
$68,000.00
$72,000.00
$76,000.00
$80,000.00
$84,000.00
$88,000.00
$92,000.00
$96,000.00
$100,000.00
$-

Willingness to pay per life-year saved

Fig. 2. Cost effectiveness acceptability curves for cost per life-year saved in all patients, patients with serious injury and patients with traumatic brain injury.
1848 C. Taylor et al. / Injury, Int. J. Care Injured 43 (2012) 1843–1849
the true cost of the index hospitalisation. To evaluate the
cost-effectiveness of a HEMS intervention we used an a priori
statistical analysis plan which included a comparison of relevant
health care strategies29 and robust outcomes.
However, due to the differences in emergency medicine
organisation and funding arrangements between regions, our
results are likely to have limited generalisability outside Australia.
Our estimates of the index hospitalisation cost and mortality in
both groups relied on the robustness of our modelling approach.
Covariates were selected based on clinical judgement and previous
research.2 Removing covariates which were potentially associated
with a HEMS intervention (such as ICU admission) did improve the
accuracy of estimates in our sub-group models but the overall
effect was not substantially different. In order to capture
uncertainty we utilised the full 95% confidence intervals of the
cost and effect estimates in our probabilistic sensitivity analysis.
Beyond in-hospital survival, our estimates of life years saved
depended on the age related probability of death for the general
population in both groups. This assumes conservatively that there
is no ongoing effect of HEMS transport beyond the index
hospitalisation.
Despite data being collected prospectively, our analysis is
retrospective in nature and therefore the possibility of unobserved
confounding cannot be excluded. A recent article highlighted the
utility of propensity score matching in examining the benefit of
HEMS,30 which resulted in lower estimated absolute risk reduction
attributable to HEMS compared to traditional logistic regression.
As our study utilised logistic regression, the benefit attributable to
HEMS may have been overestimated although our estimates of
HEMS benefit were similar to previous literature.2,31 In defining
comparators we used a tasking agency perspective, where usual
care (termed non-HEMS) included ether direct transport via
ground to St George Hospital or ground transport to a regional
hospital followed by inter-hospital transfer to St George Hospital.
In this scenario, we hypothesised that the true benefit of HEMS was
its ability to bypass regional hospitals in rural areas. By using these
definitions we may have introduced a selection bias (where a
comparable non-HEMS patient may have died before reaching St
George Hospital), however inter-hospital transfer numbers were
small and removing inter-hospital transfers did not substantially
affect the cost-effectiveness estimates in Models #2 and #3.
Despite the above limitations of our analysis, this investigation
is one of few methodologically rigorous economic evaluations of
HEMS9 and the results add to a paucity of economic literature in
the field of out-of-hospital emergency care.32 A previous evalua-
tion of HEMS from the perspective of the service provider in the US
found a HEMS intervention in trauma patients led to cost per life
year saved of $2454 USD33 (2010 AUD $4444). Our study adopted
a broader perspective, including the ongoing medical cost of
survivors (as is appropriate in the Australian context34), and found
a higher level of costs. A more recent study found a HEMS
intervention led to a cost per quality adjusted life year saved of
s28,32735 (2010 AUD $59,140) in seriously injured patients.
Although our study did not adjust for quality of life, the cost-
effectiveness of HEMS in seriously injured patients is similar.
The cost-effectiveness of HEMS transport appears to improve
with increasing injury severity and in patients with traumatic
brain injury. This is consistent with other studies demonstrating
benefit associated with HEMS.15,36 Our estimates showed HEMS
are cost-effective in these populations despite survivors incurring
higher ongoing treatment costs.26 Previous studies have shown
that HEMS are poorly targeted to the patients that can benefit most
due to the difficulty in assessing injury severity on-scene as well as
a desire to keep under-triage to a minimum.37 The difference in
cost-effectiveness in all patients versus the two specific subgroups
(seriously injured and TBI) reflects the importance of accurate
dispatch criteria, to ensure HEMS are well targeted. A previous
review highlighted a paucity of evidence supporting current
dispatch criteria31 and given the potential improvements in cost-
effectiveness, our results support the need for further attention in
this area.
To judge the acceptability of our cost-effectiveness estimates,
our results can be viewed in the context of the value of human life
and society’s willingness to pay to avoid fatalities. A previous
report38 reviewed the value of a statistical life (VSL) from 17
Australian and 227 international studies. A meta-analysis was
undertaken of the higher quality studies yielding an average VSL of
$6.0 million (2010 AUD $6.7m). The report also found the average
value of a statistical life year (VALY) in Australia to be $124,095
(2010 AUD $138,767). More recently, a stated choice experiment
was used to estimate the value of risk reduction (VRR) in car
occupants in NSW,39 finding participants were willing to pay
between $6.3 and $6.4 million (2010 AUD $6.9–7.0m) to avoid
fatalities. Evidence from overseas has also confirmed individuals
are willing to pay for a HEMS.40,41 Put into the context of such
findings, our ratios appear within the range of acceptable values.
Conclusion
There have been many evaluations of the benefit of HEMS in
trauma, both in NSW and internationally. However, few evalua-
tions have estimated the cost-effectiveness of HEMS relative to
ground or indirect transport (via a referral hospital). Our
evaluation shows that a HEMS intervention is associated with
reduced in-hospital mortality. When modelled over a lifetime, this
association leads to reasonable cost-effectiveness estimates, in the
context of a single funder health care system, particularly in
patients with serious injuries and traumatic brain injury. These
data highlight the importance of further research into appropriate
patient selection for a HEMS intervention.
Conflict of interest statement
Co-authors Curtis, Tzannes, Dickson and Myburgh and all paid
employees of the NSW Department of Health, which funds
Helicopter Emergency Medical Services. The primary author (C.
Taylor) has a paid part-time position with Novartis Pharmaceu-
ticals.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.injury.2012.07.184.
References
1. Sheperd M, Trethewy C, Kennedy J, Davis L. Helicopter use in rural trauma.
Emergency Medicine Australasia 2008;20:494–9.
2. Butler DP, Anwar I, Willet K. Is it the H or the EMS in HEMS that has an impact on
trauma patient mortality? A systematic review of the evidence. Emergency
Medicine Journal 2010;27:692–701.
3. Ringburg AN, Thomas SH, Steyerberg EW, van Lieshout EMM, Patka P, Schipper
IB. Lives saved by helicopter emergency medical services: an overview of
literature. Air Medical Journal 2009;28(6):298–302.
4. Thomas SH. Helicopter emergency medical services transport outcomes litera-
ture: annotated review of articles published 2000–2003. Prehospital Emergency
Care 2004;8(3):322–33.
5. Thomas SH. Helicopter EMS transport outcomes literature: annotated review of
articles published 2004–2006. Prehospital Emergency Care 2007;11(4):477–88.
6. Thomas SH, Biddenger PD. Helicopter trauma transport: an overview of recent
outcomes and triage literature. Current Opinion in Anaesthesiology 2003;16:
153–8.
7. Thomas SH, Cheema F, Cumming M, Wedel SK, Thomson D. Nontrauma heli-
copter emergency medical services transport: annotated review of selected
outcomes-related literature. Prehospital Emergency Care 2002;6(2):242–55.
 C. Taylor et al. / Injury, Int. J. Care Injured 43 (2012) 1843–1849
8. Thomas SH, Cheema F, Wedel SK, Thomson D. Trauma helicopter emergency
medical services transport: annotated review of selected outcomes-related
literature. Prehospital Emergency Care 2002;6(3):359–71.
9. Taylor CB, Stevenson M, Jan S, Middleton PM, Fitzharris M, Myburgh J. A
systematic review of the cost and benefit of helicopter emergency medical
services. Injury 2010;41:10–20.
10. Taylor CB, Stevenson M, Jan S, Liu B, Tall G, Middleton PM, et al. An investigation
into the cost, coverage and activities of Helicopter Emergency Medical
Services in the state of New South Wales, Australia. Injury 2011;42:
1088–94.
11. Botker MT, Bakke SA, Christensen EF. A systematic review of controlled studies:
do physicians increase survival with prehospital treatment? Scandinavian
Journal of Trauma Resuscitation and Emergency Medicine 2009:17.
12. Garner AA. The role of physician staffing of helicopter emergency medical
services in prehospital trauma response. Emergency Medicine Australas
2004;16(4):318–23.
13. Ambulance Service of New South Wales. Protocol T1 – pre-hospital management
of major trauma. 2008.
14. NSW Health. Selected specialty and statewide service plans – NSW trauma services.
2011http://www.health.nsw.gov.au/pubs/2009/pdf/trauma_report.pdf.
15. Frankema SP, Ringburg AN, Steyerberg EW, Edwards MJ, Schipper IB,
van Vugt AB. Beneficial effect of helicopter emergency medical services on
survival of severely injured patients. British Journal of Surgery 2004;91(11):
1520–6.
16. Davis DP, Peay J, Serrano JA, Buono C, Vilke GM, Sise MJ, et al. The impact of
aeromedical response to patients with moderate to severe traumatic brain
injury. Annals of Emergency Medicine 2005;46(2):115–22.
17. Palmer CS, Franklyn M, Read-Allsopp C, McLellan S, Niggemeyer L. Develop-
ment and validation of a complementary map to enhance the existing 1998 to
2008 Abbreviated Injury Scale map. Scandinavian Journal of Trauma Resuscita-
tion & Emergency Medicine 2011;19:29.
18. Australian Bureau of Statistics. ABS life tables. 2011http://www.abs.gov.au/.
19. Harrison-Felix CL, Whiteneck GG, Jha A, DeVivo MJ, Hammond FM, Hart DM.
Mortality over four decades after traumatic brain injury rehabilitation: a
retrospective cohort study. Archives of Physical Medicine and Rehabilitation
2009;90(9):1506–13.
20. Australian Bureau of Statistics. Consumer price index Australia. 2011http://
www.abs.gov.au/.
21. NSW Health Department. NSW program and product data collection standards
incorporating subacute and non-acute and national minimum dataset for mental
health establishments data collection requirements. North Sydney: NSW Health
Department; 2006–2009.
22. NSW Health. NSW costs of care standards. Inter-Goverment & Funding Strategies
Branch; 2010http://www.health.nsw.gov.au/policies/owner/igfsm.html.
23. Manning WG, Mullahy J. Estimating log models: to transform or not to
transform? Journal of Health Economics 2001;20(4):461–94.
24. Independent Pricing and Regulatory Tribunal of New South Wales. Report to
the Minister for Health on Revenue and Charging Structure. Review of
financial aspects of the ambulance service in NSW. 2005http://www.sfaq.i-
part.nsw.gov.au/files/Review%20of%20Financial%20Aspects%20of%20the%2
0Ambulance%20Service%20of%20NSW%20-%20November%202005.pdf.PDF.
25. Australian Institute of Health and Welfare. Health expenditure Australia 2008–
09. Health and welfare expenditure series, 2010http://www.aihw.gov.au/publi-
cation-detail/?id=6442472450.
1849
26. Access Economics. The economic cost of spinal cord injury and traumatic brain
injury in Australia. Report prepared for the Victorian Neurotrauma Initiative;
2009, http://www.tac.vic.gov.au/upload/vni/The%20economic%20cost%20of%
20spinal%20cord%20injury%20and%20traumatic%20brain%20injury%20in%20
Australia.pdf.
27. Claxton K, Sculpher M, McCabe C, Briggs A, Akehurst R, Buxton M, et al.
Probabilistic sensitivity analysis for NICE technology assessment: not an op-
tional extra. Health Economics 2005;14(4):339–47.
28. Australian Government Department of Health Aging. Guidelines for preparing
submissions to the Pharamceutical Benefits Advisory Committee (version 4.3).
Canberra: Australian Government Department of Health Aging; 2008.
29. Drummond MF, Richardson WS, O’Brien BJ, Levine M, Heyland D. Users’ guides
to the medical literature XIII. How to use an article on economic analysis of
clinical practice. A. Are the results of the study valid?. Evidence-Based Medicine
Working Group. JAMA 1997;277(19):1552–7.
30. Galvagno SM, Elliot RH, Nabeel Zafar S, Millin MG, Efron DT, Koenig GJ, et al.
Association between helicopter vs ground emergency medical services and
survival for adults with major trauma. JAMA 2012;307(15):8.
31. Ringburg AN, de Ronde G, Thomas SH, van Lieshout EMM, Patka P, Schipper IB.
Validity of Helicopter Emergency Medical Services dispatch criteria for trau-
matic injuries: a systematic review. Prehospital Emergency Care 2009;
13(1):2009.
32. Lerner EB, Maio RF, Garrison HG, Spaite DW, Nichol G. Economic value of out-of-
hospital emergency care: a structured literature review. Annals of Emergency
Medicine 2006;47(6):515–24.
33. Gearhart PA, Wuerz R, Localio AR. Cost-effectiveness analysis of helicopter EMS
for trauma patients. Annals of Emergency Medicine 1997;30(4):500–6.
34. Meltzer D. Accounting for future costs in medical cost-effectiveness analysis.
Journal of Health Economics 1997;16(1):33–64.
35. Ringburg AN, Polinder S, Meulman TJ, Steyerberg EW, van Lieshout EMM, Patka
P, et al. Cost-effectiveness and quality-of-life analysis of physician-staffed
helicopter emergency medical services. British Journal of Surgery 2009;96:
1365–70.
36. Davis DP, Ochs M, Hoyt DB, Bailey D, Marshall LK, Rosen P. Paramedic-admin-
istered neuromuscular blockade improves prehospital intubation success in
severely head-injured patients. Journal of Trauma-Injury Infection & Critical Care
2003;55(4):713–9.
37. Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF. Helicopter scene
transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
J Trauma 2006;60(6):1257–65.
38. Access Economics. The health of nations: the value of a statistical life. Report
prepared for the office of the Australian Safety and Compensation Council.
Canberra; 2007, http://www.safeworkaustralia.gov.au/AboutSafeWork
Australia/WhatWeDo/Publications/Documents/330/TheHealthOfNations_Value_
StatisticalLife_2008_PDF.pdf.
39. Hensher DA, Rose JM, de Dios Ortuzar J, Rizzi LI. Estimating the willingness to
pay and value of risk reduction for car occupants in the road environment.
Transportation Research Part A 2009;43:692–707.
40. Olsen JA, Donaldson C. Helicopters, hearts and hips: using willingness to pay to
set priorities for public sector health care programmes. Social Science & Medicine
1998;46(1):1–12.
41. Ringburg AN, Buljac M, Stolk EA, van Lieshout EMM, van Beeck F, Patka P, et al.
Willingness to pay for lives saved by Helicopter Emergency Medical Services.
Prehospital Emergency Care 2009;13(1):37–43.