Incremental willingness to pay: a theoretical and empirical exposition

Applications of willingness to pay (WTP) have shown the difficultly to discriminate between various options. This reflects the problem of embedding in both its specific sense, of options being nested within one another, and its more-general sense, whereby respondents cannot discriminate between close substitutes or between more-disparate rivals for the same budget. Furthermore, high proportions of reversals between WTP-value and simple preference based rankings of options are often highlighted. Although an incremental WTP approach was devised to encourage more differentiated answers and a higher degree of consistency among respondents, a theoretical basis for this approach has not been elucidated, and there is little evidence to show that this approach might indeed achieve greater consistency between explicit and implicit rankings inferred from WTP values.We address both these issues. Following our theoretical exposition, standard and incremental approaches were compared with explicit ranking in a study assessing preferences for different French emergency care services. 280 persons, representative of the French adult population, were interviewed. Half received the incremental version, the other half the standard version. Results suggest that the incremental approach provides a ranking of options fully in line with explicit ranking. The standard approach was reasonably consistent with explicit ranking but proved unable to differentiate between the five most preferred providers, as predicted by theory. Our findings suggest that the incremental approach provides results which can be used in priority-setting contexts

Aspects médico-judiciaires de la prise en charge d’un décès en mer par le SMUR maritime de Lanvéoc Poulmic

Tout décès doit être certifié par un médecin. La certification ne s’arrête pas au simple constat, elle demande au médecin de s’assurer d’écarter toute intervention d’un tiers dans le processus ayant conduit au décès. En cas de doute, il cocherait alors la case "obstacle médico-légal à l’inhumation" permettant ainsi à la justice de prendre les moyens nécessaires pour lever ou confirmer ce doute. La médecine pré hospitalière, de par son essence, rend difficile l’acte médical de certification, et ced’autant pour les interventions de secours qui se déroulent en mer. L’auteur a repris l’ensemble des données des interventions concernant les personnes décédées prises en charge par le SMUR maritime de Lanvéoc Poulmic (29) depuis 2009. Il relève des différences de pratique significatives, s’expliquant de par l’absence de consensus et de la méconnaissance du droit maritime par les équipes. Son travail a donc été d’identifier et d’étudier les particularités de cet aspect de la prise en charge dès lors que les opérations se déroulent en mer, tant sur le plan médical que juridique. Il a ensuite réunit les différents protagonistes afin de pouvoir proposer un protocole consensuel de prise en charge de l’obstacle médico-légal en milieu maritime. Il serait intéressant maintenant de pouvoir tester ce protocole, dans l’objectif, s’il s’avère opérationnel, de le diffuser et de le rendre accessible à tous les SMUR maritime de France

Trends of pre-hospital emergency medical services activity over 10 years : a population-based registry analysis

BACKGROUND: The number of requests to pre-hospital emergency medical services (PEMS) has increased in Europe over the last 20 years, but epidemiology of PEMS interventions has little be investigated. The aim of this analysis was to describe time trends of PEMS activity in a region of western Switzerland. METHODS: Use of data routinely and prospectively collected for PEMS intervention in the Canton of Vaud, Switzerland, from 2001 to 2010. This Swiss Canton comprises approximately 10% of the whole Swiss population. RESULTS: We observed a 40% increase in the number of requests to PEMS between 2001 and 2010. The overall rate of requests was 35/1000 inhabitants for ambulance services and 10/1000 for medical interventions (SMUR), with the highest rate among people aged ≥ 80. Most frequent reasons for the intervention were related to medical problems, predominantly unconsciousness, chest pain respiratory distress, or cardiac arrest, whereas severe trauma interventions decreased over time. Overall, 89% were alive after 48 h. The survival rate after 48 h increased regularly for cardiac arrest or myocardial infarction. CONCLUSION: Routine prospective data collection of prehospital emergency interventions and monitoring of activity was feasible over time. The results we found add to the understanding of determinants of PEMS use and need to be considered to plan use of emergency health services in the near future. More comprehensive analysis of the quality of services and patient safety supported by indicators are also required, which might help to develop prehospital emergency services and new processes of care

Endotracheal Intubation Success Rate in an Urban, Supervised, Resident-Staffed Emergency Mobile System: An 11-Year Retrospective Cohort Study.

In the prehospital setting, endotracheal intubation (ETI) is sometimes required to secure a patient's airways. Emergency ETI in the field can be particularly challenging, and success rates differ widely depending on the provider's training, background, and experience. Our aim was to evaluate the ETI success rate in a resident-staffed and specialist-physician-supervised emergency prehospital system. This retrospective study was conducted on data extracted from the Geneva University Hospitals' institutional database. In this city, the prehospital emergency response system has three levels of expertise: the first is an advanced life-support ambulance staffed by two paramedics, the second is a mobile unit staffed by an advanced paramedic and a resident physician, and the third is a senior emergency physician acting as a supervisor, who can be dispatched either as backup for the resident physician or when a regular Mobile Emergency and Resuscitation unit (Service Mobile d'Urgence et de Réanimation, SMUR) is not available. For this study, records of all adult patients taken care of by a second- and/or third-level prehospital medical team between 2008 and 2018 were screened for intubation attempts. The primary outcome was the success rate of the ETI attempts. The secondary outcomes were the number of ETI attempts, the rate of ETI success at the first attempt, and the rate of ETIs performed by a supervisor. A total of 3275 patients were included in the study, 55.1% of whom were in cardiac arrest. The overall ETI success rate was 96.8%, with 74.4% success at the first attempt. Supervisors oversaw 1167 ETI procedures onsite (35.6%) and performed the ETI themselves in only 488 cases (14.9%). A resident-staffed and specialist-physician-supervised urban emergency prehospital system can reach ETI success rates similar to those reported for a specialist-staffed system

Epidemiology of physician interventions in maritime environment by the Marseille Fire Brigade (BMPM) from 2005 to 2017

Background: Marseille is the second largest city in France. The Marseille Fire Brigade (BMPM) is the largest unity of the French Navy. This organization is in charge of rescue operations and medical intervention in the Marseille area. The aim of the study was to describe the epidemiology of interventions that required a physician to be present that were performed by the BMPM between the years of 2005 to 2017.  Materials and methods: The statistical office database of the BMPM and the medical interventions forms (FIM) acquired from the BMPM medical ambulances (SMUR) archives were analysed from the years 2005 to 2017.  Results: The BMPM performed a total of 2,375 interventions in the maritime environment between 2005 and 2017. A physician was necessary for intervention a total of 186 times. The extraction and analysis reports of 107 medical intervention forms found the BMPM archives revealed a significant number of interventions (67%) in the southern bay of Marseille and Frioul, specifically from the If and Planier islands. The majority of interventions (77%) took place within the 300m band. The most common cause of medical intervention was due to an accidental fall into the water, followed by boating (sailing and motor), and swimming. Drowning was the most common cause of mortality, consisting of 34% of all interventions. Diving accidents represented 14% of interventions. Trauma affected 22% of the study population and 83% of trauma patients were transported to the hospital under the supervision of a physician.  Conclusions: Potential areas for improvement in the management of drowning victims are the use of Szpilman’s classification, sonography, and non-invasive ventilation. A recertification course for medical education training of BMPM doctors on the management of diving accidents could help to optimize the information recorded on FIM. Accident prevention training should be continued and reinforced when it comes to maritime activities.