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The burden on healthcare systems from the utilisation of emergency transportation (ET) is increasing worldwide. Particularly care-dependent individuals and long-term care recipients are affected.
Objective
We aim to investigate the factors contributing to ET utilisation, particularly in these care-related groups and settings.
Methods
Using claims data on ET utilisation in conjunction with long-term care (LTC) insurance data, we identified 561,322 ET events from 2018–2022 in insured individuals of AOK Saxony-Anhalt, Germany. Age-standardised incidence rates (ASIR) were calculated with the duration of insurance as time at risk. Negative binomial regression assessed factors influencing ET utilisation.
Results
ET utilisation remained stable over 5 years, with an ASIR of 112.59 per 1000 insured person–years. High care dependency level correlates with higher ET rates, both in terms of IR and in the regression model. This correlation strengthens when combined with LTC settings involving formal caregivers, such as nursing homes and formal home care. Multimorbidity is suggested as a potential contributing factor, particularly for individuals with care levels 4 and 5, but did not fully explain the observed patterns.
Conclusion
Care dependency and professional care are strongly associated with increased ET utilisation. The findings suggest a need for structural improvements in LTC, clearer legal frameworks, and better competencies across all care providers, including enhanced training and education, to address unmet needs and reduce potentially avoidable ET events. Further research should explore these relationships in more depth to inform interventions aimed at relieving pressure on emergency services.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Background
Rising emergency services (EMS) utilisation, sometimes alongside a decrease in capacity, puts a significant burden on healthcare systems around the world [1‐4]. While cross-border variations exist, regional differences within countries must also be considered, as demonstrated by the example of Germany [5].
Nursing home residents show higher emergency utilisation rates than those in home care, as also seen internationally [3, 4]. In Germany, care-dependent individuals also have higher incidence rate (IR) and risk of emergency transportation (ET) utilisation than the general population [5, 6].
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There are many reasons for increased EMS use, but uncertainties remain. Commonly cited reasons include trivial cases, avoidable emergencies, population aging, and rising multimorbidity [7]. Additionally, frequent users have widely been studied, but findings are often inconclusive and overlap with the previously mentioned factors [8]. In 2019, 4% of the German federal state of Saxony-Anhalt cohort averaged more than one deployment per quarter, but accounted for 14.6% of ET [6].
Trivial cases are frequently cited in the literature but are rarely distinguished from potentially avoidable yet medically necessary emergencies [9, 10]. The latter may initially require an emergency response but might have been prevented through adequate outpatient care. However, a standardised definition and reliable assessment tools for such cases are still lacking [10‐12]. The growing older population is often associated with, though not limited to, both types of cases.
The increasing proportion of older and multimorbid individuals adds pressure to EMS [9]. Given that age and multimorbidity are linked to higher care dependency, understanding the relationship between care needs and ET utilisation is crucial. In Germany, the care dependency level, as assessed by expert assessors of the statutory insurance, classifies individuals’ care needs from minor (level 1) to severe impairment (level 5) and also considers functioning and participation issues.
The high utilisation rate among care-dependent people raises the question of whether these ET events are truly necessary or avoidable. ET poses a high burden on this vulnerable group, notably due to risks of delirium and nosocomial infections [13]. Despite this, care-dependent individuals are typically embedded in a professional care and support system. In long-term care (LTC) settings, formal home care and nursing home care often involve close collaboration with the outpatient medical sector. Informal home care is provided mostly by relatives, supplemented by regular advisory visits from nursing services. These support structures suggest some emergencies may be avoidable.
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To understand avoidability, it is important to distinguish between care dependency and LTC. While closely related, they are separate concepts. In Germany, access to LTC services requires a care dependency level of at least 2. Level 1 includes only limited support, but not regular nursing care.
These factors may influence ET utilisation differently, but their individual impact remains unclear. Given the high ET utilisation among care-dependent individuals, this study takes a longitudinal perspective to examine whether and how LTC settings, care dependency level, morbidity, and sociodemographic variables are associated with ET use, and whether these associations change over a 5-year period.
Methods
Our retrospective cohort study combines three datasets. The main set includes 2018–2022 ET claims from AOK Saxony-Anhalt, which insures persons living in Saxony-Anhalt. ET refers to ambulance services staffed with paramedics and, in some cases, emergency physicians, in contrast to nonemergency transports. After data cleaning (Figure A.1), 561,322 ET events remained. The second set includes demographics for all AOK Saxony-Anhalt-insured individuals residing in the state, with repeated annual entries. After excluding incomplete records, 3,981,727 individuals remained, covering 3,797,906 insured years (Table A.2). The third set consists of LTC insurance data. The datasets were linked by AOK Saxony-Anhalt using an anonymised person-level identifier.
ET frequency per person and year was calculated. Frequent users were defined as those utilising the service more than once per insured quarter on average, following established definitions [8].
Two care-related variables were used: care dependency level (levels 1–5) and LTC setting: (1) nursing home care, (2) formal home care, (3) informal home care and (4) no LTC.
The morbidity was assessed using the Charlson Comorbidity Index (CCI). Its score (CCS) was derived from outpatient and inpatient diagnoses [14] and could only be calculated for individuals with ET events, as no diagnosis data were available otherwise.
ET events and insured individuals served as units of analysis. Descriptive statistics focused on events, while regression analysis examined insured individuals.
Age-standardised incidence rates (ASIR) were calculated using insurance duration as time at risk and the “Germany 2011” standard population [15].
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A multivariable additive negative binomial regression model was fitted with IR of ET per year as dependent variable, with insured time in days as logarithmic offset and calendar year, age, gender, LTC setting, and care level as independent variables. A best fit model was selected using Akaike Information Criterion (AIC). Results are shown as incidence rate ratios (IRR) with 95% confidence intervals.
Results
Description of the sample
The total number of ET events over the entire 5‑year period is 561,322 (Table A.1). Annual values were stable with minor fluctuations. From 111,669 in 2018, the numbers remain steady until 2021, showing a slight dip to 109,746 (Table A.3). A slight increase occurred in 2022, reaching 116,390 events. ET patients had a mean age of 66.58 years (standard deviation [SD] 23.29); 52.59% of events involved females. In 35.63% of cases, ET patients had a care dependency level of 2 or higher.
The observations over the 5‑year period did not reveal any findings of substantial relevance to the research question; therefore, we refer to the online supplement (Table A.3).
Events per person
Across the 5‑year period, insured individuals averaged 1.54 events (SD 1.33). Frequent users made up 4.3% of individuals but accounted for 15.3% of ET events. Compared to regular users, the gender distribution was reversed: 57.64% of frequent-user events involved males (Table A.1). Trends in age, LTC, and care dependency were generally similar, though proportions were slightly higher among frequent users. For example, 33.52% were aged 60–79 (vs. 30.18%); 17.45% received formal home care (vs. 12.13%); and 15.72% had a care dependency level of 3 (vs. 11.79%).
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IR of ET utilisation
During the 5‑year analysis period, the crude IR of ET was 147.88 events per 1000 insured person–years, dropping to 112.59 ASIR. Rates slightly decreased in the two COVID-19 years, 2020 and 2021 (Table A.4). Otherwise, the rates remained stable, even across the sociodemographic subgroups or the other variables (Table A.5).
LTC and care dependency
Over the entire 5‑year period, 11.10% of ET events involved nursing home residents. A total of 12.59% were cared for at home, supported by professional caregivers (formal home care), while 11.59% were exclusively cared for by informal carers (informal home care; Table A.1).
The ASIR is highest among nursing home residents (983.54), followed by formal home care (704.03), informal home care (282.37), and those without LTC (94.03) (Table 1). Two main increases are notable: a sharp rise from 91.92 (no care dependency) to 321.75 at level 1, and a gradual rise from 324.54 (level 2) to 456.15 (level 4). A pronounced jump occurs at level 5, reaching 749.98. Stratification by LTC settings revealed similar trends, with highest rates at care level 5: 1262.60 (formal home care) and 1251.95 (nursing home care).
Table 1
Cross-table of age-standardised incidence rates of emergency transportation events stratified by level of care dependency and grouped by long-term care setting, overall years
No LTC
Informal home care
Formal home care
Nursing home care
Total
Level of care dependency
None
91.92
n/a
n/a
n/a
91.92
1
321.75
n/a
n/a
n/a
321.75
2
n/a
266.29
665.31
603.20
324.54
3
n/a
296.78
595.96
676.23
389.34
4
n/a
351.46
697.88
712.22
456.15
5
n/a
488.86
1262.60
1251.95
749.98
Total
94.03
282.37
704.03
983.54
112.59
Age-standardised with standard population “German 2011”
LTC Long-term care, n/a not applicable
Morbidity
The CCS of patients involved in ET events had a mean of 2.65 (SD 2.47) across all years, with frequent users scoring higher at 3.39 (2.58), compared to 2.52 (2.43) for regular users (Table A.6). The numbers ranged from 2.05 (2.35) for individuals without LTC to 3.88 (2.12) for those residing in nursing homes.
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Cross-tabulating CCS by LTC setting and care dependency levels reveals the largest mean differences at level 5, where formal home care was 0.53 points higher than informal home care and 0.20 points higher than nursing home care (Table A.7).
Along the level of care dependency, the ASIR and the CCS follow a similar trajectory, indicating that as levels increase, there is a corresponding rise in both the ASIR and the CCS (Fig. 1).
Fig. 1
Age-standardised incidence rates and Charlson Comorbidity Score of emergency transportation events compared along care dependency levels
The full and the best-fit model were identical (Table 2). The Theta value of 0.21 indicates moderate overdispersion in the data, as expected, supporting the choice of a negative binomial regression. Narrow confidence intervals reflect precise and statistically significant associations for all covariates.
Table 2
Negative binomial regression for the outcome emergency transportation frequency (person–year observations: n = 3,981,727)
Univariate
Full and best fit
IRR (95% CI)
IRR (95% CI)
Age in years
1.03 (1.031–1.032)
1.02 (1.025–1.025)
Gender (Ref.: Male)
1.01 (0.998–1.014)
0.78 (0.778–0.789)
Year in calendar
0.99 (0.990–0.995)
0.99 (0.990–0.995)
Long-term care setting (Ref.: none)
Formal home care
6.23 (6.123–6.344)
1.45 (1.405–1.497)
Informal home care
3.37 (3.321–3.421)
1.00 (0.974–1.031)
Nursing home care
7.66 (7.521–7.803)
1.39 (1.340–1.445)
Level of care dependency (Ref.: none)
1.77 (1.765–1.778)
1.37 (1.352–1.379)
IRR Incidence rate ratio, CI Confidence interval, Ref. reference
Offset: Number of insured days per calendar year, modelled on a logarithmic scale. Best fit assessed by Akaike Information Criterion (AIC) via R function MuMIn.dredge(). Frequent users: More than 1.0 emergency transportation events per insured quarter on average
An IRR of 0.99 for the calendar year indicates a 1% decrease of the IR of ET use per additional year. Age was modestly associated with an increased use of ET, with a 2% increased IR per additional year of age in the full model (IRR 1.02). Females had a 22% lower IR of ET use compared to males (IRR 0.78). With increasing care dependency, the rate of ET increases significantly by 37% (IRR 1.37).
The IR of ET was significantly higher among individuals receiving formal home care and nursing home care compared to the reference group without LTC. Formal home care was linked to a 45% increase (IRR 1.45), while nursing home care showed a 39% increase (IRR 1.39). No significant difference was found for informal home care (IRR 1.00). The univariate analysis indicated a 77% increase in IR per care dependency level, whereas after adjusting for other factors, the increase was reduced to 37%.
Discussion
Our analysis indicates that ET utilisation has remained stable over the investigated 5‑year period, with minor variations during the COVID-19 years. The overall ASIR was 112.59 events per 1000 insured person–years. Very high rates are found in groups with high care dependency, in those receiving LTC provided by professional caregivers (formal home care and nursing home care), and even higher when both dimensions are combined. Regression results support this pattern. However, the association with LTC and ET use must be considered in relation to care dependency.
High ET utilisation among care-dependent individuals and care recipients is expected [3‐5]. One explanation may be multimorbidity, as CCS correlates with care level and LTC. A higher disease burden is evident particularly in care levels 4 and 5. Within these levels, individuals receiving LTC with professional caregivers involved, such as formal home care or nursing home care, exhibit a notably higher CCS compared to those with an identical level of care dependency but receiving informal home care or no LTC at all. The maximum mean difference (0.53) is notably smaller than both the standard deviation and the step sizes in the CCI (1–6).
The high ASIR in level 1, nearly equal to level 2, despite relatively high self-sufficiency, does not necessarily indicate an unmet care gap. Rather, the findings indicate an observation gap: individuals in level 1 show a markedly higher morbidity burden (CCS 2.94 vs. 2.0 without care level, about half the full gradient, peaking at 4.02 in level 4). Because access to regular LTC starts only from level 2, this group remains less systematically monitored. Given their high morbidity, enhanced observation and, consequently, earlier interventions may be more appropriate than assuming unaddressed care needs.
In addition to multimorbidity, other factors are likely to play a role that are not captured in the data. These include person-related factors (e.g. socioeconomic status, polypharmacy) and context factors (e.g. organisation of health care and support systems, infrastructure, and other regional characteristics).
High ET utilisation among care-dependent people and users of professional LTC requires thorough consideration. Especially the LTC settings with very high rates, formal home care and nursing home care, which are part of an institutionalised and professional care system, triage and decision-making about emergencies could be more realistic and appropriately, potentially enabling better ET resource use.
It remains unclear whether factors related to LTC use, particularly nursing home and formal home care, contribute to or mitigate the high ET utilisation rate. Interview studies show that nursing home staff do not call EMS prematurely but often feel compelled to do so due to limited alternatives [16]. Reasons include self-protection, unclear responsibilities and lack of medical staff. Other studies indicate a higher risk of potentially avoidable admissions for nursing home residents [12]. Programmes like INTERACT or use of advanced practice nurses have shown success in reducing such admissions [17, 18]. In order to reduce ET utilisation, providing staff with legal clarity, more action options, and access to relevant professional groups seems essential.
However, as immanent to the nature of claims data and the method used for analysis, it is not possible to define the direction of the association between the LTC setting and the high rate of ET utilisation.
Some emergencies may be avoidable. For example, urological issues such as catheter care were identified as preventable causes in a German study on community paramedics [19]. Improved training for caregivers and paramedics could enable independent assessment and management of such cases, including bladder catheter replacement. In addition, it is essential to establish the legal foundations regarding the expansion of competencies and the necessary legal protections for this practice.
Beside care and health reasons, other factors influence ET utilisation. Regression results show that being male is a predictor, suggesting gender-based differences [7, 8]. However, the absence of any difference between the full and best-fit models suggests missing variables not captured in the data.
Unlike earlier studies, we observed no increase in ET utilisation between 2018 and 2022. Previous estimates based on extrapolated data indicated a national rise until 2016/17 [1]. In Bavaria, absolute cases increased since 2009 [2, 20]. However, based on our own calculation of IR using population data [21], this trend appears to levelled off around 2016. Our data from 2018 onwards reflect this stabilisation.
Our findings on frequent users align with previous research [8]. Furthermore, our analysis shows that the phenomenon is not confined to people with care dependency or those receiving LTC.
The large population sample observed over an extended period provides substantial statistical power for regression analyses. One notable strength compared to other studies is that the insured time is available and used as a more exact and realistic time at risk to calculate IR and ASIR. Additionally, analyses linking ET utilisation to a population of insured individuals over a multiyear period are currently unknown.
The substantially higher ASIR in our study compared to others may reflect underlying differences, as Saxony-Anhalt’s population and AOK-insured individuals generally show higher morbidity and lower socioeconomic status than other regions or insurance groups [22, 23]. AOK-insured persons are also older on average than the general populations of Saxony-Anhalt and Germany [24], though age should not be overemphasised due to standardisation. Moreover, ET utilisation rates vary substantially across German regions [5].
The generalisability of the results is therefore limited due to known differences in socioeconomic factors and morbidity across different insurance companies and regions. Additionally, insurance data in Saxony-Anhalt is based on still handwritten emergency protocols, which could introduce minor information bias.
Conclusion
Our analysis confirms previous findings: the utilisation of ET and the strain on EMS are not driven by age alone but also by the organisation of health care and support systems. This is particularly relevant considering anticipated demographic changes. Care dependency alone does not explain the observed patterns; rather, the structure and quality of professional LTC play a decisive role.
Notably, individuals with care dependency level 1 appear to form a distinct group with high morbidity but limited access to formal care, reflecting an observation gap rather than an unmet care gap, and warrant further attention.
Given that ET rates remain stable over time but are especially high among those in professional LTC settings, it is worth examining to what extent some emergencies may be avoidable. This highlights potential gaps in preventive and routine care. However, assessing avoidability must not delay necessary interventions.
Expanding the competencies of caregivers and paramedics, supported by improved training and legal clarity, could help reduce avoidable ET, especially in situations such as catheter-related issues. Structural improvements in LTC and better access to preventive services may also help relieve the burden on emergency systems.
It is noteworthy that the rate of ET is particularly high among those with severe care dependence in combination with formal home care or nursing home care. This observation lacks a clear explanation and deserves further investigation.
In conclusion, a multifaceted approach is needed, combining structural improvements in LTC, enhanced competencies of all professionals involved in care provision, to better meet the needs of vulnerable groups and reduce ET, thereby supporting a more efficient and sustainable healthcare system.
Funding
This work was supported by the AOK Saxon-Anhalt, Germany. The funders provided the raw data, supported data interpretation, and reviewed the results as well as the manuscript.
Declarations
Conflict of interest
C. Buhtz, S. Heinrich, C. Walther, S. Fleischer and G. Meyer declare that they have no competing interests.
Since this study has analysed anonymised secondary data, no ethical approval or consent was required. For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.
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