Prachi Sanghavi, PhD; Anupam B. Jena, MD, PhD; Joseph P. Newhouse, PhD; Alan M. Zaslavsky, PhD
Note: Dr. Sanghavi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The data in this article were obtained from the Centers for Medicare & Medicaid Services (CMS) within the U.S. Department of Health and Human Services. The authors' data use agreement with CMS does not allow sharing of individual records. These data can be obtained by others through CMS. However, if there are quantities of interest relevant to the paper that are not in the article, the authors can share results at a higher level of aggregation as long as the CMS data-sharing policies are met.
Grant Support: By a National Science Foundation Graduate Research Fellowship (Dr. Sanghavi), an Agency for Healthcare Research and Quality grant (1R36HS022798-01; Dr. Sanghavi), and the National Institutes of Health Early Independence Award (1DP5OD017897-01; Dr. Jena).
Disclosures: Dr. Jena receives personal fees as a principal consultant to Precision Health Economics. Dr. Newhouse is a director of, and holds equity in, Aetna. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/Conflict OfInterestForms.do?msNum=M15-0557.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement:Study protocol: Not applicable. Statistical code: Available from Dr. Sanghavi (e-mail, firstname.lastname@example.org). Data set: Available from www.resdac.org.
Requests for Single Reprints: Prachi Sanghavi, PhD, Department of Public Health Sciences, The University of Chicago, 5841 South Maryland Avenue, MC2000, Chicago, IL 60637; e-mail, email@example.com.
Current Author Addresses: Dr. Sanghavi: Department of Public Health Sciences, The University of Chicago, 5841 South Maryland Avenue, MC2000, Chicago, IL 60637.
Drs. Jena, Newhouse, and Zaslavsky: Department of Health Care Policy, Harvard Medical School, 180A Longwood Avenue, Boston, MA 02115.
Author Contributions: Conception and design: P. Sanghavi, A.B. Jena, A.M. Zaslavsky.
Analysis and interpretation of the data: P. Sanghavi, A.B. Jena, J.P. Newhouse, A.M. Zaslavsky.
Drafting of the article: P. Sanghavi, A.B. Jena, A.M. Zaslavsky.
Critical revision of the article for important intellectual content: P. Sanghavi, A.B. Jena, J.P. Newhouse, A.M. Zaslavsky.
Final approval of the article: P. Sanghavi, A.B. Jena, J.P. Newhouse, A.M. Zaslavsky.
Statistical expertise: P. Sanghavi, A.M. Zaslavsky.
Obtaining of funding: P. Sanghavi.
Collection and assembly of data: P. Sanghavi.
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.
To compare outcomes after ALS and BLS in out-of-hospital medical emergencies.
Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use.
20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure.
Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years.
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.
Only Medicare beneficiaries from nonrural counties were studied.
Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS.
National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.
Prachi Sanghavi, Anupam B. Jena, Joseph P. Newhouse, Alan M. Zaslavsky. Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies. Ann Intern Med. 2015;163:681–690. doi: 10.7326/M15-0557
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Published: Ann Intern Med. 2015;163(9):681-690.
Published at www.annals.org on 13 October 2015
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