Many of our colleagues have seen the October 10th Washington Post article which was electronically circulated this week Read the Article Here
The Post article was published to correspond with an academic study released early online in the Annals of Internal Medicine. As the title and the conclusions are both vexing and counterintuitive to many of us, we wanted to take a minute to put the article in a bit of perspective.
Below is a copy of the abstract of the article from the Annals of Internal Medicine. Following that are several comments on the generalizability of the study. A copy of the actual manuscript is attached as is an editorial written by an emergency physician.
Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital
Prachi Sanghavi, PhD; Anupam B. Jena, MD,
Ann Intern Med. doi:10.7326/M15-0557 www.annals.org This article was published online first at www.annals.org on 13 October
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 co-morbidities. 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 non-rural counties were studied.
Conclusion: Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS.
As Dr. Sasson points out in her editorial, this is study was done- not using clinical patient information- but rather on data obtained from a Medicare Beneficiary database, (mean patient age 80) which does not directly take into account many of the actions/treatments we know “matter” for these patients. Additionally while the study concludes that there may be harm with prehospital ALS, more likely the real answer is that this study has significant limitations and is not generalizable to the population for which we care. EMS care occurs in a complex system, that is often configured and delivered differently from location to location. It is difficult to sort out the direct benefit of the portion of care provided by EMS on the total care provided to a sick patient during the course of his/her illness. This is one of the reasons why at AMR we are working with RAPS as a surrogate for whether or not the patient experienced an improvement in condition during transport. While this is not a perfect metric, it does give us some sense of how our care affects our patients.
What we do know is that patients with time sensitive injuries have better outcomes when they are transported directly to a facility with the resources (and expertise in using them) that they need. There are multiple, well done studies that show this for trauma and for cardiac arrest. This is one area in which EMS often finds itself at odds with the incentives (if we are paid only to take patients to the nearest hospital, but not to the hospital to which they should ideally be transported, what do we do? The answer is “It Depends”).
In the meantime, I believe the strong message for us to remember is that we believe in what we do, and we know how well our crews care for our patients. We also take great pains to follow a scientifically sound process to develop support for our protocols and base our care and decisions as much as possible on a preponderance of GOOD EVIDENCE, (not on one study).
I hope this is helpful. Feel free to share.
National Director of Clinical Practice
American Medical Response
Greenwood Village, CO