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Advanced life support associated with higher mortality

Basic life support was associated with better survival and improved outcomes in patients who were transported to a hospital for a medical emergency, according to data published in the Annals of Internal Medicine.

"The predominant response to out-of-hospital medical emergencies by ambulance providers in the United States is advanced life support (ALS) rather than basic life support (BLS)," Prachi Sanghavi, PhD, an assistant professor in the department of public health sciences at the University of Chicago, and colleagues wrote. "Advanced life support accounts for 65% of emergency medical care among Medicare beneficiaries and even more among patients with high-acuity conditions, such as stroke. Ambulance crews using ALS are trained and equipped to provide sophisticated care on site ('stay and play'), whereas BLS emphasizes rapid transport to the hospital, so BLS ambulance crews provide only minimal treatment at the scene ('scoop and run')."

The researchers reviewed claims from January 2006 to October 2011 from a 20% sample of Medicare fee-for-service beneficiaries. Participants lived in nonrural counties and were transported to a hospital for one of the following medical emergencies: trauma, stroke, acute myocardial infarction (AMI) or respiratory failure.

Sanghavi and colleagues linked ambulance rides, patient claims, demographic data and death dates as part of their evaluation. Patient populations consisted of 79,687 patients (BLS = 30,919; ALS = 48,768) who experienced trauma; 119,989 patients (BLS = 19,985; ALS = 100,004) for stroke; 114,469 patients (BLS = 14,434; ALS = 100,035) for AMI; and 82,530 patients (BLS = 9,502; ALS = 73,028) for respiratory failure.

Propensity score analyses showed that survival to 90 days was higher with BLS than ALS for stroke (7 percentage points; 95% CI, 6.2-7.7), trauma (6.1 percentage points; 95% CI, 5.4-6.8) and respiratory failure (3.7 percentage points; 95% CI, 2.5-4.8). Survival to 90 days was higher with ALS than BLS for AMI (1 percentage point; 95% CI, 0.1-1.9).

Additionally, Sanghavi and colleagues found that neurologic performance was improved with BLS when compared to ALS for all patients.

They reported that an instrumental variable analysis demonstrated better survival with BLS than ALS for patients with AMI, stroke and trauma and no differences for patients with respiratory failure.

"For three of the four conditions we studied, unadjusted survival rates were higher among patients receiving BLS despite these patients being older and having more comorbid conditions on average than those receiving ALS," Sanghavi and colleagues wrote. "After adjustment, these outcome differences persisted; we found similar or better health outcomes associated with prehospital BLS than ALS in all of our analyses for major trauma, stroke, and respiratory failure. Because these high-acuity conditions necessitate early optimization of care, one would have expected any advantage of ALS over BLS to manifest itself in these diagnoses. Although ALS may be expected to improve outcomes because of early treatment, the opposite may occur in practice if ALS is associated with delays in hospital management or iatrogenic injury." – by Chelsea Frajerman Pardes

Disclosures: One author receives personal fees as a principal consultant to Precision Health Economics and another is a director of, and holds equity in, Aetna. Please see the study for a list of all other authors' relevant financial disclosures.