Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies

Abstract

Background Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. Objective To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. Design Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. Setting Traditional Medicare. Patients 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. Measurements Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. Results Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI. Limitation Only Medicare beneficiaries from nonrural counties were studied. Conclusion Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS. Primary Funding Source National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.

Delays in Emergency Care and Mortality during Major U.S. Marathons

“…18–20 Findings from observational studies that showed lower mortality among patients transported by basic life support ambulances versus advanced life support ambulances are also consistent with our findings to the extent that receipt of hospital care may be faster with transport by basic life support ambulances. 21,22 More likely, however, is that large relative increases in ambulance transport time may be a proxy for large absolute increases in transport time among patients who are not brought to the hospital by ambulance and therefore would be more affected by road closures. Approximately 23% of patients in our study were not brought to the hospital by ambulance.…”

Geographic Variation in Use of Ambulance Transport to the Emergency Department

“…39,46 Evidence indicates that ambulance use is associated with improved patient outcomes, particularly for time-sensitive acute medical events, such as, stroke, 8 myocardial infarction, cardiac arrest 11 and respiratory failure. 10 …”

Effect of Pre-Hospital Advanced Airway Management for Out-Of-Hospital Cardiac Arrest Caused by Respiratory Disease: A Propensity Score–Matched Study

“…The chain of survival, including advanced life support, is considered essential in cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) 1 . However, there are arguments for and against pre-hospital advanced life support, including epinephrine (adrenaline) administration and advanced airway management [2][3][4][5] . In particular, past studies that focused on pre-hospital advanced airway management indicated that such management might be associated with poor outcomes [6][7] .…”