Pre-Hospital Outcomes for Evidence-Based Evaluation (PHOEBE)

• Professor Niroshan Siriwardena, Associate Clinical Director / Professor of Primary and Pre-hospital Health Care, East Midlands Ambulance Service & Community and Health Research Unit, School of Health & Social Care, University of Lincoln
• Ms Janette Turner, Research Fellow, School of Health & Related Research (ScHARR)
• Professor Jonathan Nicholl, Director, Medical Care Research Unit (MCRU), School of Health & Related Research (ScHARR), University of Sheffield
• Professor Steve Goodacre, Professor of Emergency Medicine, School of Health & Related Research (ScHARR), University of Sheffield
• Professor Ronan Lyons, Professor of Health Services Research, School of Medicine, Swansea University
• Mr Andrew Booth, Reader in Evidence-Based Information Practice and Director of Information, School of Health & Related Research (ScHARR), University of Sheffield
• Professor Helen Snooks, Professor of Health Services Research, School of Medicine, Swansea University
• Professor John Brazier, Professor of Health Economics, School of Health & Related Research (ScHARR), University of Sheffield
• Dr James Gray, Medical Director, East Midlands Ambulance Service NHS Trust
• Dr Alison Walker, Medical Director, Yorkshire Ambulance Service NHS Trust
• Professor Mike Campbell, Professor in Medical Statistics, School of Health & Related Research (ScHARR)
• Mrs Joanne Coster, Research Associate, School of Health & Related Research (ScHARR), University of Sheffield
• Professor Alicia O’Cathain, Professor of Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield
• Professor David Meechan, Director, East Midlands Public Health Observatory & Trent Cancer Registry

1. To review and synthesise the research literature on pre-hospital care outcome measures and identify measures relevant to the NHS and patients for further development
2. To create a dataset linking routinely collected pre-hospital data, hospital data and mortality data to provide outcome information
3. To develop new ways of measuring process and outcome indicators including building the adjustment models that predict the outcomes using the linked data
4. To explore the practical use of the linked dataset and the risk adjustment models to measure the effectiveness and quality of ambulance service care and assess how they can be best used to support quality improvement strategies.

1. Synthesis of evidence on outcome measures and identification of measures for further development – review and assessment of the evidence base on outcome measurement for pre-hospital care and a consensus study to identify measures relevant to patients and NHS staff
2. Linking pre-hospital data with other patient data sources – creating a single dataset that links ambulance service electronic care records with routinely collected hospital episode statistics (HES) and national mortality data
3. Development of risk adjustment models for outcomes in patients attended by the ambulance service – using the linked data to develop risk adjustment tools that will allow patient differences to be taken into account and differences between expected and actual outcomes to be detected
4. Testing the risk adjustment models to assess if they can be used to measure effectiveness and quality – exploring the practical application of the measures by using them to assess if different ways of quality – exploring the practical application of the measures by using them to assess if different ways of providing ambulance service care result in different consequences for patients, and assessing the views of potential users about how they can best be implemented in the NHS.

• Turner J, Siriwardena AN, Coster J, Jacques R, Irving A, Crum A, Gorrod HB, Nichol J, Phung VH, Togher F, Wilson R, O’Cathain A, Booth A, Bradbury D, Goodacre S, Spaight A, Shewan J, Pilbery R, Fall D, Marsh M, Broadway-Parkinson A, Lyons R, Snooks H, Campbell M. Developing new ways of measuring the quality and impact of ambulance service care: the PhOEBE mixed-methods research programme. NIHR Programme Grants for Applied Research Journal 2019.
• Coster J, Irving AD, Turner JK, Phung VH, Siriwardena AN (2017). Prioritizing novel and existing ambulance performance measures through expert and lay consensus: a three-stage multimethod consensus study. Health Expectations 00-1-12 (online).
• Irving A, Turner J, Marsh M, Broadway-Parkinson A, Fall D, Coster J, Siriwardena AN (2017). A coproduced patient and public event: an approach to developing and prioritizing ambulance performance measures. Health Expectations 00:1-9 (online).
• Siriwardena AN, Togher FJ. Feeling reassured: the glue that holds together patients’ experiences of ambulance service care. Ambulance Today 2015: 33-35.
• Togher F, O’Cathain A, Phung VH, Turner J,  Siriwardena AN. Reassurance as a key outcome valued by emergency ambulance service users: a qualitative interview study. Health Expectations 2014 (online).

Conference presentations:

• Coster J,  Siriwardena AN, Turner J, Jacques R, Crum A, Nicholl J,  OP06 Multi-method development of new amdbulance service quality and performance measures. Emerg Med J 2017 34: e2.
• Coster J, Jacques R, Turner J, Crum A, Nicholl J. PP12 New indicators for measuring patient survival following ambulance service care. Emerg Med J 2017 34: e4.
• Crum A, Coster J, Turner J,  Siriwardena AN. PP16 Creating a linked dataset to explore patient outcomes after leaving ambulance care. Emerg Med J 2017 34: e6.
• Togher F, Turner J,  Siriwardena AN, O’Cathain A. What do users value about the emergency ambulance service? Emerg Med J 2015;32:e9.
• Phung V, Booth A, Coster J, Turner J, Wilson R,  Siriwardena AN. Prehospital outcomes for ambulance service care: systematic review. Emerg Med J 2015, 32 (5): e10.2-e10.
• Coster J,Wilson R, Siriwardena AN,Phung V-H. Developing new ways of measuring the impact of ambulance service care. 8th European Congress on Emergency Medicine, 28 September -1 October 2014, Westergasfabriek BV, Amsterdam.
• Coster J. How should we measure ambulance service quality and performance? Results from a Delphi study. 8th European Congress on Emergency Medicine, 28 September -1 October 2014, Westergasfabriek BV, Amsterdam 8th European Congress on Emergency Medicine, 28 September -1 October 2014, Westergasfabriek BV, Amsterdam. Top scoring abstract: How should we measure ambulance service quality and performance? This was a high scoring abstract (ranked in the top 3 out of 1000) and was presented at the EuSEM 2014 Awards Ceremony and at the Prehospital Emergency Medicine Lightning Session at the European Society of Emergency Medicine (EuSEM).
• Turner J,Irving A,Wilson R, Siriwardena AN,Phung VH. How should we measure ambulance service quality and performance? International Conference on Emergency Medicine, 11-14 June 2014, Hong Kong Convention and Exhibition Centre.
• Turner J,Irving A,Wilson R, Siriwardena AN,Phung V-H. Moving on from response rates: linking patient level ambulance data to ED, hospital and survival data to assess quality and performance. International Conference on Emergency Medicine, 11-14 June 2014, Hong Kong Convention and Exhibition Centre.
• Coster JE, Turner J,  Siriwardena AN, Wilson R, Phung VH. OP70 Prioritising outcome measures for ambulance service care: a three stage consensus study. J Epidemiol Community Health 2013;67:A33-A34.
• Coster J. Prioritising outcomes measures for ambulance service care: a three stage consensus study. Society for Social Medicine 57th Annual Scientific Meeting 2013.
• Coster J. Prioritising pre-hospital outcome measures with a multi-stakeholder group: a consensus methods study. International Forum on Quality & Safety in Health Care 2013.
• Togher F. What service users value in their experience of emergency ambulance use. Society for Academic Primary Care Annual Scientific Meeting, Nottingham, 3-5 July 2013.
• Togher F. What do users value about the emergency ambulance service? Trent Regional SAPC Meeting, Sheffield, 5 March 2013.

• This project has contributed to changes in the way that the quality of ambulance services is measured, enabling ambulance services to go beyond just measuring performance in terms of response times. This is already impacting on the operation of ambulance services from organisations that concentrate on meeting response time targets to those that are geared to improving  quality of care and patient outcomes.
• The Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) programme has led to the development of new quality measures for ambulance services. The findings have already informed the UK Ambulance Response Programme and shaped the new ambulance standards introduced in 2017.
• The programme also featured in a recent National Institute for Health Research Themed Review in 2017, ‘Care at the scene: NIHR research on urgent and emergency care outside hospital’.
• The findings have been shared through the National Ambulance Research Steering Group (NARSG), the National Ambulance Services Clinical Quality Group (NASCQG), the National Ambulance Services Medical Director’s group (NaSMed) and the Association of Ambulance Chief Executives (AACE).
• The findings were shared by Professor Siriwardena with US Emergency Medical Services physicians in an invited lecture at the North American EMS Physicians conference in San Diego, Ca, in January 2018 and are already influencing the development of ambulance indicators in the US and Canada.
• The findings for the programme have been summarised in an animation video produced by Vivid Creative 2017.