Worse Outcomes With Advanced Life Support in Out-of-Hospital Cardiac Arrest

November 24, 2014

BOSTON, MA — Providing advanced life support (ALS) services to patients who suffer an out-of-hospital cardiac arrest offers no benefit when compared with a more basic life support (BLS) strategy that emphasizes rapid transport and basic interventions such as chest compressions, bag-valve mask ventilation, and automated external defibrillation[1].

In a new observational analysis, individuals who received BLS were significantly more likely to survive to hospital discharge, had higher survival rates at 90 days, and had better neurological outcomes compared with patients who received ALS.

Survival to hospital discharge among cardiac-arrest patients receiving BLS was 13.1% vs 9.2% for those who received treatment from ALS providers trained to use invasive interventions such as endotracheal intubation, intravenous fluid and drug delivery, and semiautomatic defibrillation. For survival at 90 days in this analysis of nearly 33 000 Medicare beneficiaries from nonrural US counties, the rates were 8.0% and 5.4% for BLS and ALS medical services, respectively.

"Prehospital care is complex, expensive, and critical to survival after out-of-hospital cardiac arrest, making it crucial to understand the combined effect on morbidity and mortality of the medical interventions, transport time, and training that characterize the two dominant models of prehospital care," state Prachi Sanghavi (Harvard University, Boston, MA) and colleagues in their report, published online November 25, 2014 in JAMA: Internal Medicine.

BLS was also associated with significantly better neurological functioning among the hospitalized patients, too. For the cardiac-arrest patients admitted to the hospital, 21.8% of those treated with BLS had "poor" neurological functioning compared with 44.8% of those treated with ALS.

While mean medical spending was higher with BLS—mainly because patients lived longer and received more medical treatment—incremental medical spending per additional survivor to 1 year for BLS relative to ALS was $154 333. In the US, ALS is decidedly more common than the use of BLS. Among the individuals treated in this trial, there were 31 292 cases receiving ALS and just 1643 receiving BLS.

Based on their analysis, which they believe is the first large-scale systematic comparison of BLS and ALS in the US, ALS does not improve survival to hospital discharge after cardiac arrest, conclude Sanghavi et al. Their data are consistent with other international studies, they add.

In an editorial[2], Dr Michael Callaham (University of California, San Francisco) also notes that previous studies have shown no benefit with ALS and that the most beneficial changes to treatment in out-of-hospital cardiac arrest has not involved new modalities but the removal of those that are unproven (antiarrhythmic drugs, pulse checks, precordial thumps, among others).

"Some communities have demonstrated noteworthy improvements by prioritizing and optimizing the basic interventions that do work: bystander cardiopulmonary resuscitation, quick response, high-quality early cardiopulmonary resuscitation, and early defibrillation," writes Callaham. "We should complete the process of removing unproven and ineffective interventions from guidelines and practice until better interventions are backed up by evidence that meets contemporary standards."

Sanghavi is supported by a National Science Foundation Graduate Research Fellowship and Health Services Research Dissertation Award from the Agency for Healthcare Research and Quality. Disclosures for the coauthors are listed in the article. Callaham reports he has no relevant financial relationships.

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