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Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support.

ABSTRACT: IMPORTANCE:Most out-of-hospital cardiac arrests receiving emergency medical services in the United States are treated by ambulance service providers trained in advanced life support (ALS), but supporting evidence for the use of ALS over basic life support (BLS) is limited. OBJECTIVE:To compare the effects of BLS and ALS on outcomes after out-of-hospital cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS:Observational cohort study of a nationally representative sample of traditional Medicare beneficiaries from nonrural counties who experienced out-of-hospital cardiac arrest between January 1, 2009, and October 2, 2011, and for whom ALS or BLS ambulance services were billed to Medicare (31,292 ALS cases and 1643 BLS cases). Propensity score methods were used to compare the effects of ALS and BLS on patient survival, neurological performance, and medical spending after cardiac arrest. MAIN OUTCOMES AND MEASURES:Survival to hospital discharge, to 30 days, and to 90 days; neurological performance; and incremental medical spending per additional survivor to 1 year. RESULTS:Survival to hospital discharge was greater among patients receiving BLS (13.1% vs 9.2% for ALS; 4.0 [95% CI, 2.3-5.7] percentage point difference), as was survival to 90 days (8.0% vs 5.4% for ALS; 2.6 [95% CI, 1.2-4.0] percentage point difference). Basic life support was associated with better neurological functioning among hospitalized patients (21.8% vs 44.8% with poor neurological functioning for ALS; 23.0 [95% CI, 18.6-27.4] percentage point difference). Incremental medical spending per additional survivor to 1 year for BLS relative to ALS was $154,333. CONCLUSIONS AND RELEVANCE:Patients with out-of-hospital cardiac arrest who received BLS had higher survival at hospital discharge and at 90 days compared with those who received ALS and were less likely to experience poor neurological functioning.

SUBMITTER: Sanghavi P

PROVIDER: S-EPMC4314335 | biostudies-literature | 2015 Feb

REPOSITORIES: biostudies-literature

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Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support.

Sanghavi Prachi P Jena Anupam B AB Newhouse Joseph P JP Zaslavsky Alan M AM

JAMA internal medicine 20150201 2

<h4>Importance</h4>Most out-of-hospital cardiac arrests receiving emergency medical services in the United States are treated by ambulance service providers trained in advanced life support (ALS), but supporting evidence for the use of ALS over basic life support (BLS) is limited.<h4>Objective</h4>To compare the effects of BLS and ALS on outcomes after out-of-hospital cardiac arrest.<h4>Design, setting, and participants</h4>Observational cohort study of a nationally representative sample of trad ...[more]

PMID: 25419698

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Project description: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.Traditional Medicare.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.

Project description:ObjectivesThis research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective?SettingA single National Health Service ambulance service and a charity-funded prehospital critical care service in England.ParticipantsThe patient population is adult, non-traumatic OHCA.MethodsWe combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses.ResultsCosts of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%-5%.ConclusionThis is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field.Trial registration numberISRCTN18375201.

Project description:The PulsePoint Respond app is a novel system that can be implemented in emergency dispatch centers to crowdsource basic life support (BLS) for patients with cardiac arrest and facilitate bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator use while first responders are en route.The aim of this study was to conduct a North American survey to evaluate the public perception of the above-mentioned strategy, including acceptability and willingness to respond to alerts.We designed a Web-based survey administered by IPSOS Reid, an established external polling vendor. Sampling was designed to ensure broad representation using recent census statistics.A total of 2415 survey responses were analyzed (1106 from Canada and 1309 from the United States). It was found that 98.37% (1088/1106) of Canadians and 96% (1259/1309) of Americans had no objections to PulsePoint being implemented in their community; 84.27% (932/1106) of Canadians and 55.61% (728/1309) of Americans said they would download the app to become a potential responder to cardiac arrest, respectively. Among Canadians, those who said they were likely to download PulsePoint were also more likely to have ever had CPR training (OR 1.7, 95% CI 1.2-2.4; P=.002); however, this was not true of American respondents (OR 1.0, 95% CI 0.79-1.3; P=.88). When asked to imagine themselves as a cardiac arrest victim, 95.39% (1055/1106) of Canadians and 92.44% (1210/1309) of Americans had no objections to receiving crowdsourced help in a public setting; 88.79% (982/1106) of Canadians and 84.87% (1111/1309) of Americans also had no objections to receiving help in a private setting, respectively. The most common concern identified with respect to PulsePoint implementation was a responder's lack of ability, training, or access to proper equipment in a public setting.The North American public finds the concept of crowdsourcing BLS for out-of-hospital cardiac arrest to be acceptable. It demonstrates willingness to respond to PulsePoint CPR notifications and to accept help from others alerted by the app if they themselves suffered a cardiac arrest.

Project description:ImportanceBystander-delivered defibrillation (hereinafter referred to as bystander defibrillation) of patients with out-of-hospital cardiac arrests (OHCAs) remains limited despite the widespread dissemination of automated external defibrillators (AEDs).ObjectiveTo examine calendar changes in bystander defibrillation and subsequent survival according to a public or a residential location of the cardiac arrest after nationwide initiatives in Denmark to facilitate bystander-mediated resuscitative efforts, including bystander defibrillation.Design, setting, and participantsThis nationwide study identified 18 688 patients in Denmark with first-time OHCA from June 1, 2001, to December 31, 2012, using the Danish Cardiac Arrest Registry. Patients had a presumed cardiac cause of arrest that was not witnessed by emergency medical services personnel. Data were analyzed from April 1, 2015, to December 10, 2016.ExposuresNationwide initiatives to facilitate bystander resuscitative efforts, including bystander defibrillation, consisted of resuscitation training of Danish citizens, dissemination of on-site AEDs, foundation of an AED registry linked to emergency medical dispatch centers, and dispatcher-assisted guidance of bystander resuscitation efforts.Main outcomes and measuresThe proportion of patients who received bystander defibrillation according to the location of the cardiac arrest and their subsequent 30-day survival.ResultsOf the 18 688 patients with OHCAs (67.8% men and 32.2% women; median [interquartile range] age, 72 [62-80] years), 4783 (25.6%) had a cardiac arrest in a public location and 13 905 (74.4%) in a residential location. The number of registered AEDs increased from 141 in 2007 to 7800 in 2012. The distribution of AED location was consistently skewed in favor of public locations. Bystander defibrillation increased in public locations from 3 of 245 (1.2%; 95% CI, 0.4%-3.5%) in 2001 to 78 of 510 (15.3%; 95% CI, 12.4%-18.7%) in 2012 (P < .001) but remained unchanged in residential locations from 7 of 542 (1.3%; 95% CI, 0.6%-2.6%) in 2001 to 21 of 1669 (1.3%; 95% CI, 0.8%-1.9%) in 2012 (P = .17). Thirty-day survival after bystander defibrillation increased in public locations from 8.3% (95% CI, 1.5%-35.4%) in 2001/2002 to 57.5% (95% CI, 48.6%-66.0%) in 2011/2012 (P < .001) in residential locations, from 0.0% (95% CI, 0.0%-19.4%) in 2001/2002 to 25.6% (95% CI, 14.6%-41.1%) in 2011/2012 (P < .001).Conclusions and relevanceInitiatives to facilitate bystander defibrillation were associated with a marked increase in bystander defibrillation in public locations, whereas bystander defibrillation remained limited in residential locations. Concomitantly, survival increased after bystander defibrillation in residential and public locations.

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Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support.

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Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support.

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