Coming from JAMA Internal Medicine’s “Less is More” series is this latest evaluation prehospital care for out-of-hospital cardiac arrest.
These authors compared basic life support – CPR and defibrillation – with advanced life support – as above, but with feeling (and intubation and pharmacologic flogging) – to determine, once and for all, the winner. And the winner, by a wide margin, is BLS – 13.1% vs. 9.2% survival, and 21.8% vs. 44.8% poor neurologic functioning. Ah, so.
Naturally, as with everything in life, the details are far muddier than this simple conclusion. The study population established BLS or ALS level of care by utilizing a Medicare procedural coding database for ambulance services, not specific patient-level interventions. Patients were then linked to a Medicare billing database using ICD-9 codes for cardiac arrest “present on admission”, with multiple exclusions owing to poor underlying data quality. And, finally, their primary outcome of neurologic performance was inferred from ICD-9 codes for brain injury and vegetative state, not direct observations. To say these authors have performed potentially specious and indirect measurements is quite the understatement.
All that considered, however, these observations very likely reflect underlying truths. Any advantage of pre-hospital ALS over BLS for OHCA remains steadfastly unproven. Such interventions as endotracheal intubation and sympathomimetic therapy are likely harmful, despite having been persistently assumed to be beneficial. And, as this article points out, ALS-trained professionals are far more expensive than BLS – further salting the wound.
More, almost certainly not better.
“Outcomes After Out-of-Hospital Cardiac Arrest Treated by Basic vs Advanced Life Support”
http://www.ncbi.nlm.nih.gov/pubmed/25419698
(I'll start with the statement that I'd have stopped reading the study after their methodology section had JAMA's media department not done a PR blitz complete with dangerously unqualified statements from PhD students)
ALS versus BLS is a false dichotomy for our patients…and designing a system of care around less than 1% of your call volume is laughable. Moreover, if you try and take the "findings" from this paper you'll scratch your head when you look around and see that the areas in the US with the highest survival to discharge still utilize ALS providers.
What did we actually learn? I now know that billing the patient for BLS improves survival to discharge.
Ok, perhaps that was a bit too snarky, but I really don't know what I learned from Sanghavi et al. My service can't take anything from it to change our delivery model to improve survival to discharge. Do they honestly believe that switching from paramedics to EMTs will magically improve survival? Steill's OPALS study *a decade ago* used pre-hospital data and provided actionable conclusions, and many EMS systems took note.
More to the point, there were five-fold differences in survival among systems providing the same ALS and/or BLS treatments in the ROC group during a similar time period (Nichol 2008). This points to something greater than the treatments themselves. Hell, I'd offer that we really have no idea what works because we have almost zero standardization of measurements in studies of OHCA (and when we do measure, the variability is huge re: Yannopoulos' recent abstract on ITD+CPR quality). Crazy difficult problem to address.
Should we follow the guidance to "load and go" from their conclusions and the accompanying editorial? Nope, and I'd ask that providers treating me or my loved ones not as well…slapping me on a stretcher and doing CPR on the way to the hospital is a known factor in poor survival to discharge. I'm super happy JAMA gave the authors their 15 minutes of fame to spread this garbage far and wide. (and apologies to the authors if they truly do not know any better; JAMA certainly does)
Yes, step one is owning "BLS" techniques such as continuous chest compressions and early/appropriate defibrillation; but before you get to that step you'll see a much larger survival influence with dispatcher assisted T-CPR, bystander CPR, and public access to AED's! Should we get rid of EMS and go with laypersons? Again, I'm thinking no…but I'm a biased paramedic (COI disclosure).
We've got real outcomes disparity in the US but it's not a problem with ALS versus BLS, it's a problem with our systems of care.
You're absolutely dead-on with your assessment of "billing a patient for BLS improves survival to discharge." This is very limiting methodology, and provides no insight over what advantageous difference in therapy results in improved outcomes – or, frankly, whether this is all just noise in the data.
But, as far as OHCA is concerned, defibrillation, CPR, and rapid transport to definitive care really might be ideal. Or perhaps it's all the epinephrine. Or the advance airways. A lot of things done well in some EMS environments are mimicked by those who do them less well, and efficacious therapies implemented ineffectively are harmful.
It's not so much from this study you make wholesale changes – but it contributes to changing equipoise to revisiting our pre-hospital care in future study.
I guess my point should have been that OPALS did this in a better way in 2004 with real pre-hospital data and would be the ideal model to inform future pre-hospital studies on incremental system changes. To rehash it in 2014 based on adjusted billing data from the 2005 AHA guidelines era only poses the question, "did process variability produce poor outcomes 5 years ago?" Or perhaps, "does process variability STILL produce poor outcomes?" (Yes and yes)
Taking Bobrow's body of evidence and now Yannopoulos' retrospective CPR quality analysis on the ROC-PRIMED trial found <50% met basic benchmarks…I'm beginning to wonder whether I should bother to read any pre-hospital OHCA study that doesn't begin with the measured compression fraction and depths!