Assumptions Discredit ALS vs. BLS Study


Sanghavi P, Jena AB, Newhouse JP, et al. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015;175(2):196—204.


The authors undertook a comparison of BLS vs. ALS care on the outcome of cardiac arrest by examining a representative sample of Medicare beneficiaries from non-rural counties in the United States who had “cardiac arrest” as their hospital admission diagnosis between 2009 and 2011.

They made the assumption an EMS agency that billed Medicare at the BLS rate delivered BLS care and billed ALS rates for ALS care. They linked the EMS cases to their respective hospital admission and examined their outcomes.

Cardiac arrest victims cared for with BLS had a greater likelihood of surviving to hospital discharge as compared to ALS (13.1% vs 9.2%, respectively). Survival to 90 days post-discharge was also higher than ALS (8.0% vs 5.4%). And not surprising, BLS patients had better neurological function than ALS (79.2% vs 55.7%).

Authors also examined the medical expenditures on the Medicare patients throughout the year following their cardiac arrest.

They concluded, “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.”

In their discussion portion of the paper the authors further state: “Our estimates suggest that each year, 1,479 additional Medicare beneficiaries who experience out-of-hospital cardiac arrest would survive to 90 days if provided BLS instead of ALS. Furthermore, incremental medical spending per additional survivor to one year for BLS relative to ALS was $154 333, substantially less than the mean medical spending per survivor to 1 year for ALS ($206 775).”


ALS or BLS? That question is the Holy Grail of EMS. From the Ontario Prehospital ALS (OPALS) study in Canada to today, countless numbers of system directors, governing bodies and medical directors have sought to determine if the level of care correlates to outcomes.

Unfortunately, this study fails to answer the question they pose. I congratulate the authors on their ingenious attempt to link level of care by examining Medicare billing. However, there’s no data to substantiate the linkage. The authors could have addressed the landslide of criticism that followed the publication by simply examining in detail a subset of cases to determine the following:

First, did the patients transported by BLS really suffer cardiac arrest and achieve return of spontaneous circulation (ROSC), and were being transported by BLS? Were these transports in communities without ALS intercept? What communities are included in “non-rural”? Why were nursing home patients with cardiac arrest more likely to be transported by BLS?

The authors present many analyses of their data to address these criticisms, but the bottom line comes down to the fallacy of their basic assumption that BLS cardiac arrest transports were the same as ALS transports.

Final thought? The search for the Holy Grail continues.


Lost in translation? I dream of the day a scientific study is completed by someone who has an understanding of our capabilities. This study is based on Medicare and hospital coding. The authors even admit that coding is often inaccurate.

Somewhere along the line, a huge component of patient survival and outcome was left out of the study. That being said, where’s the information on the ED resuscitation attempts, or lack thereof ? What about inpatient care? Doesn’t that play a huge part in outcomes?

Although I have to agree that intubation in the prehospital setting still needs some answers to resolve which ACLS medications make a difference, my experience tells me there must be distinct differences in BLS- and ALS-resuscitated patients. Yet, the authors provided no data on those differences other than more BLS patients came from nursing homes and were older. There was no description of the difference in treatment the patient received. Instead, they rest all their assumptions on BLS vs. ALS billing.

Although the study attempts to prove that BLS alone has better outcomes than ALS, It falls short in not having the understanding of the prehospital environment and considering that in their data analysis.

As with all street science, I have to ask if anything will be changed or re-examined based on the nature and outcome of this study. In this case, I would hope not. But knowing the ALS vs. BLS argument is a political one, I’m sure someone is going to use this study to change their EMS system all in the name of saving patient lives.

Learn more from Keith Wesley at the EMS Today Conference & Expo, Feb. 25—27, in Baltimore, Md.

More Research & Cardiac Care from

No posts to display