Table 1

Characteristics of included studies

Lead author (year), country	Aim	Method	Study population					Quality appraisal MMAT score /***	Short overall critical considerations
Setting	Aim	Method	EMS staff (n)	Professional background	Patients (n)	Age range or mean (SD) of patients	Specific elderly population	Quality appraisal MMAT score /***	Short overall critical considerations
Aftyka51 (2014), Poland The regional Directorate of EMS in Lublin	To compare the actions and referral decisions of nurses and paramedics taken in the field.	QUAN—retrospective observational study. Analysis of ambulance records.	n=992	Pmedics, n=555; RN, n=437.	n=1082	0>90 years.	No	**	Methodological and statistical inconsistencies, making the results and conclusions difficult to interpret. Lacks a statistical power analysis.
Alicandro49 (1995), USA Four suburban volunteer EMS in Suffolk county, New York	To evaluate the effect of a documentation checklist and online medical control contact on EMS conveyance decisions in patients refusing medical assistance.	QUAN—non-randomised controlled trial. Prospective sequential intervention study.	ND	Volunteer, ALS providers, BLS providers.	n=361	Phase 1, 39 (22) years. Phase 2, 39 (22) years. Phase 3, 41 (20) years.	No	*	Small sample size and the absence of a power calculation; no data on patient enrolment, unclear if all eligible patients were enrolled; results obtained in volunteer EMS, with both BLS and ALS personnel. Generalisability in non-volunteer EMS unclear.
Burrell52 (2013), UK Ambulance clinicians from South London	To examine the decision-making process of ambulance clinicians in situations of epilepsy.	QUAL—phenomenological study. Face-to-face and topic-guided interviews.	n=15	Pmedic, n=5; EMT 2, n=1; EMT 3, n=4; EmCP, n=1; PTL, n=4.	NA	NA	No	***	Convenience sample may have led to selection bias. No information on saturation in order to determine the qualitative sample size. Awareness of the impact of doing interviews by a colleague.
Burstein60 (1998), USA Suburban volunteer EMS in Suffolk county, New York	To measure the effect of physician assertiveness on EMS conveyance decisions of patients attempted refusal of medical assistance.	QUAN—cohort study. Prospective analysis of different outcome variables.	ND	Volunteer, ALS providers, BLS providers.	n=130	ND	No	***	No table of patient characteristics included; instrument for measuring assertiveness not validated; the sample was aware of being studied which may cause bias. Generalisability in non-volunteer EMS unclear.
Cooper53 (2004), UK Westcountry Ambulance NHS Trust	To evaluate the role of emergency care practitioners on the conveyance decision and compare that with the paramedics.	MM—sequential explanatory design. Two stages of data collection: (1) retrospective data analysis, (2) individual and focus groups interviews with ECPs, Pmedics, managers and other staff members.	n=15	ECP, n=4; Pmedic, n=11; ECP and Pmedics mean work experience=8 years.	n=692; 51% males, 49% females.	0–99	No	***	No statistical comparison between ECPs and Pmedics in terms of years of experience. ECPs treated more patients under the age of 16 years compared with the Pmedics (p=0.001).
Ebrahimian62 (2014), Iran EMS staff working in different districts of Tehran	To explore factors affecting EMS staff’s decision about conveyance to medical facilities.	QUAL—phenomenological study. Content analysis with semistructured interviews.	n=18 (males)	Diploma medical emergency (2-year course) or nursing (4-year course). Age: 28–39 years (min–max). Mean work experience=6.61 years.	NA	NA	No	***	Brief description of demographic profile of the respondents. Lack of intercoder reliability which is a crucial component in content analysis. External validity may be impaired because of non-Western culture/country.
Halter69 (2011), UK London Ambulance Service	To clarify the EMS conveyance decisions, after the use of a clinical assessment tool, in older people who have a fall.	QUAL—phenomenological study. Semistructured interview.	n=12 (7 females, 5 males)	Pmedic, n=1; EMT, n=11. Mean work experience =3.5 years .	ND	ND	Yes, elderly fallers	****	Convenience sample with low experience level of EMS staff.
O’Hara63 (2015), UK Three ambulance trusts in England	To explore systemic influences on decision-making by paramedics relating to care transitions to identify potential risk factors.	QUAL—multimethod study including a ethnographic study. Two phases of data collection: (1) semistructured interviews, (2) observation, digital diaries, focus groups.	n=88	Pmedic, n=57; SP , n=13; EMT, n=18. Experience EMS staff, <1–20 years.	NA	NA	No	***	Selection on participants is unclear, no information on sampling.
Persse48(2002), USA City of Houston Emergency Medical Service	To determine if providing follow-up information about non-conveyed elderly patients would change the future decision-making by paramedics.	QUAN—prospective chart review (descriptive study)	NA	Pmedic’s	n=260	≥65 years of age	Yes, patients aged ≥65 requested 911 services.	**	Demographic information comparing groups in phase 1, 2 and 3 is missing. Differences between groups may account for any differences in outcomes. Less than 60% being contacted after non-conveyance. No power calculation.
Murphy-Jones66 (2016), UK English NHS ambulance trust	To explore how Pmedics make conveyance decisions in end-of-life care situations.	QUAL—phenomenological study. Semistructured interviews.	n=6 (3 females,3 males)	Pmedics age, 24–42 years. Work experience range 2–8 years.	NA	ND	Yes, nursing home residents.	***	Small sample size (n=6). Unknown if data saturation is reached. Working experience of Pmedics ≤8 years.
Schaefer68 (2002), USA King county EMS	To determine if EMS staff could decrease the rate of conveyance to the ED, in patients with no urgent concerns, by identifying and safely triaging them to alternate care destinations.	QUAN—cohort study. Matched historical control group.	ND	EMT and BLS training. Pmedic and ALS training.	n=3633; 45.9% versus 47.4% males.	Range, 0–104, Mdn=33.	No	****	Study took place within BLS response teams. One physician determined the eligibility for alternate destination of care based on predefined criteria. No level of agreement between physicians was measured. The significant difference in destination of care should be interpreted with caution because of the non-randomised study design.
Snooks75 (2004), UK Two ambulance services in West London	To evaluate the effectiveness of ‘treat and refer’ protocols.	QUAN—controlled trial without randomisation. Run sheet analysis and analysis of ED and GP records. Follow-up questionnaire of non-conveyed patients.	ND	Pmedics and EMTs	INT, n=788 CON, n=251 , 52% vs 51% males (p=0.69).	Mean age, 54 vs 47 years (p=0.08).	No	****	Power calculation was conducted but was reduced because of lower recruitment to study groups than anticipated. No table of patient characteristics, data reported in text.
Snooks61 (2005), UK Two ambulance stations in London	To report the views and attitudes of EMS staff in conveyance decision-making in and in a new triage intervention on for non-conveyance.	QUAL—Phenomenological study focus groups.	n=21 (20 males,1 female)	Duration of service, mean (range in years): Focus group 1, 7 (4–16); Focus group 2, 12 (0.5–25); Focus group 3, 8 (4–16).	NA	NA	No	***	Brief description on qualitative data analysis/coding procedure.
Snooks55 (2014), UK 9 Ambulance stations across a mixed rural and urban area in the UK	To investigate the effectiveness of a computerised clinical decision support tool for emergency paramedics in conveyance decisions of older people who have fallen.	QUAN—cluster randomised controlled trial.	n=42	Pmedic’s .	INT, n=436 CON, n=343	≥65 years. Mdn age INT 83 years CON 82 years.	Yes, older people who have fallen.	***	Study is slightly underpowered.
Stuhlmiller54 (2005), USA Cleveland EMS	To assess the ability of EMS to determine medical decision-making capacity and in obtaining an informed refusal of transport.	QUAN—retrospective observational study. Analysis of run sheets, non-transport worksheets and associated recorded refusal calls.	ND	Pmedics and online medical command physicians.	n=137	45.9 (22.6), range 0–91	No	***	Calls randomly generated.
Vilke50 (2002), USA San Diego Medical Services Enterprise	To obtain information and experiences of patients (≥65 years of age) who refused transport by EMS and determine the potential role of online physician–patient contact.	QUAN—prospective observational study, telephone survey and ambulance records analysis.	NA	EMT-Ps, EMT-Ds.	n=100	72.2 (6.4)	Yes, patients aged ≥65 and signed out against medical advice .	**	Telephone survey with possibility of reporting bias. Of the total sample population, 16% of the patients were reached by telephone and agreed (100/636). Data collection tool was not validated.
Waldron56 (2012), USA Hospital-based ambulance service in New York	To determine if there is an association between EMT gender and the patients decision to refuse conveyance to the hospital by ambulance.	QUAN—case–control study. Retrospective ambulance records analysis.	n=322 Male/male=271 Male/female and female/female=51	EMT-Bs, EMT-Ps.	Refusing medical aid, n= 161; 47.2% male Non refusing medical aid, n=161; 48.4% male	Non-refusal, 53.1 (2.6); Refusal, 53.6 (1.5).	No	***	Data on association and refusal of medical aid rate retrieved after propensity score matching to control for variables.
Waldrop57 (2015), USA EMS staff from an emergency medical service	To explore and describe how EMS staff assess and manage end-of-life emergency calls.	QUAL—phenomenology in-depth interviews.	n=43, 77% males	Pmedic, n=33; EMTs, n=10; age, 21–65 years, mean 39 (SD11).	NA	NA	No	***	Rigour or the trustworthiness of qualitative data analysis is described. Researcher–participant relationship unclear.
Waldrop58 (2014), USA EMS staff from an emergency medical service	To identify how EMS providers deal with end of life calls and determine their perceived confidence in managing these situations, and perspectives on improved preparation.	QUAL—cross-sectional survey. Questionnaire.	n=178, 79% males	76 EMT-B, 102 Pmedic. Mean years of working experience 12 (SD 9.5).	NA	NA	No	***	Power analyses was not conducted. Participants were invited to be interviewed.
Zorab59 (2015), UK South Western Ambulance Service NHS Foundation Trust	To identify how EMS staff assess health information; ascertain if a lack of information could lead to a suboptimal care pathway; explore whether increasing amount of information leads to a more appropriate pathway.	QUAL—cross-sectional survey. Online questionnaire.	n=302, 63% males	EmCP or CCP n=36 Pmedic, n=185 EmCA, student UP, n=58. Most respondents (85.6%) were aged between 26 and 55 years.	NA	NA	No	***	Response rate of 12%.
Déziel70 (2017), USA Virginia Department of Health Office of EMS	To identify any differences in the transport decision among agency ownership types.	QUAN— retrospective observational study.	NA	Fire-based EMS. Non-fire based EMS. Private organisation non-profit. Private organisation for-profit.	4.6 million	Mean age 52 years.	No	****	Very large dataset.
Langabeer65 (2016), USA Houston EMS	To compare the effectiveness of an alternative EMS telehealth delivery model relative to traditional EMS care.	QUAN—observational case–control study.	NA	NA	n=287	Mdn age, INT 44 years CON 45 years.	No	***	Case–control study, controls are matched afterwards. Control group not matched on inclusion criteria but on demographic data.
Larrson71 (2017), Sweden Ambulance organisation of Sweden	To examine early prehospital assessment of non-urgent patients and its impact on the choice of the appropriate level of care.	QUAN—exploratory study based on a consecutive and retrospective review of patient records.	ND	Ambulance nurses.	INT, n=184 CON, n=210	Aged ≥18 years. Mean age, INT 75.4 years CON 74.1 years. Range INT 23–96 years CON 18–98 years.	No	****	Comparison with retrospective control group.
Noble72 (2016), UK NHS Ambulance Trusts	To explore the experiences of EMS staff managing patients with seizures.	QUAL—semi structured interviews.	n=19	Pmedic, n=19.	NA	NA	No	****	Independent and experienced interviewer with already validated topic tool.
Porter64 (2007), UK NHS Ambulance Service Trust	To examine EMS staff’s view on how decision-making about non-conveyance works in practice.	QUAL—three focus-group interviews using a topic guide.	n=25	Pmedics, n=25.	NA	NA	No	***	Short and compromised method section. Degree of independence between researcher and group unclear.
Simpson73 (2017), Australia State-based Australian ambulance service	To explore the decision-making process used by paramedics when caring for older fallers.	QUAL—grounded theory methodology. Semistructured interviews and focus groups.	n=33 (21 males, 12 females)	QP=16, ICP=11, ECP=6 Years of working experience 12 (SD 6)	NA	NA	Yes, older people who have fallen.	****	Data analysis and coding were done by one single researcher (also paramedic), but subjectivity was regularly checked during the analysis and challenged by members of the research team.
Snooks74 (2017), UK Three UK ambulance services	To determine clinical and cost-effectiveness of a paramedic protocol for the care of older people who fall.	QUAN—cluster randomised trial.	n=215	Pmedics, n=215.	INT, n=2391 CON, 2264	INT 82.54 (7.97) CON 82.14 (8.11)	Yes, aged≥65 years.	****	Self-reported outcome results should be interpreted with caution. Response rate was very low, with high risk of selection bias.
Villarreal76 (2017), UK West Midlands Ambulance Service	To evaluate the impact of a service development involving a partnership between EMS crew and GPs on reducing conveyance rates to the ED.	QUAN—one group post-test only design.	ND	Pmedics	n=1903	63.1% of study population aged ≥61 years.	No	****	No control group, no data on outcome.
Williams67 (2018), USA Wake County Emergency Medical Services	To determine whether unnecessary transport can be avoided.	QUAN—Prospective cohort study.	ND	Pmedics	n=840	85.5 (8.3) years.	Yes	****	‘Time-sensitive’ outcome measures seem to be somewhat random chosen.

ALS, advanced life support; BLS, basic life support; ED, emergency department; EmCP, emergency medical care practitioner; EMS, emergency medical service; EMT 2, emergency medical technician (supervised patient assessment); EMT 3, emergency medical technician (unsupervised patient assessment); GP, general practitioner; MMAT, mixed-methods appraisal tool; NA, not applicable; ND, not described; NHS, National Health Service; Pmedics, paramedics; PTL, paramedic team leader; QUAL, qualitative research; QUAN, quantitative research; RN, registered nurse.