Comparative Effectiveness of Basic and Advanced Life Support in Ambulances

描述（由申请人提供）：今天，大约65%的医疗保险受益人乘坐高级生命支持（ALS）救护车，其余大部分乘坐基本生命支持（BLS）卡车。关键的区别在于，ALS提供更多的现场护理，而BLS优先考虑到医院的时间。然而，目前还没有强有力的证据支持ALS疗法胜过BLS疗法，因为后者也更便宜。相反，大多数研究表明，ALS没有提供额外的好处，甚至可能增加一些患者的发病率和死亡率。然而，几乎所有这些工作都是在美国以外完成的，并且在数据质量、研究设计和方法方面存在严重缺陷。这种关于最佳院前护理的不确定性在美国跨地理区域ALS使用的巨大差异中也很明显。目前的建议旨在通过严格评估救护车中ALS的使用，推动院前护理系统的科学理解。第一个目的是描述全国范围内ALS使用的差异，其假设是，大部分差异是由于一个地区的健康和医疗保健外生因素的差异。第二个目的是比较BLS和ALS对不同亚组患者一系列健康结果的有效性。第三个目标是分析在前两个目标的数据准备过程中出现的医疗保险救护车索赔的不一致性。该项目将使用1992年至2010年间救护车和医院提供的医疗保险索赔数据的大量样本，其中包括居住在内城和农村地区的个人、妇女和老年人。在

DESCRIPTION (provided by applicant): Today, about 65% of emergency rides among Medicare beneficiaries are on Advanced Life Support (ALS) ambulances, and most of the remaining are on Basic Life Support (BLS) trucks. The key difference is that while ALS provides more onsite care, BLS prioritizes time to the hospital. However, there is no strong support for the use of ALS over BLS, which is also less expensive. On the contrary, most research has shown that ALS provides no additional benefits and may even increase rates of morbidity and mortality in some patients. Almost all of this work, though, has been done outside of the United States, and has serious weaknesses related with data quality, study design, and methodology. This uncertainty about optimal pre-hospital care is also apparent in the tremendous variation of ALS use across geographic areas in the United States. The current proposal aims to move the scientific understanding of pre-hospital care systems significantly forward by rigorously evaluating the use of ALS in ambulances. The first aim is to describe the differential uptake in ALS use across the country, and the hypothesis is that much of the variation is due to differences in factors exogenous to health and healthcare in an area. The second aim is to compare the effectiveness of BLS and ALS on a range of health outcomes for different subgroups of patients. The third aim is to analyze inconsistencies in Medicare ambulance claims that arise during data preparation for the first two aims. This project will use a large sample of Medicare claims data from ambulance and hospital providers between 1992 and 2010, which includes individuals living in inner cities and rural areas, women, and the elderly. In Aim 1, the county-level variation in ALS use across the country and over time will be modeled using individual and county-level predictors in a multilevel framework. This model will be used to predict the county-level propensities to provide ALS level of care. In the second aim, these probabilities will be used to compare BLS and ALS on outcomes, including mortality and neurological functioning. A few different study designs will be used here. For example, areas that experience sudden temporal shifts in ALS use will be analyzed, as well as areas that have different rates of ALS use but are otherwise comparable. Finally, the inconsistencies in the Medicare claims will be systematically analyzed by testing for valid explanations. This will be the first American study on the comparative effectiveness of BLS and ALS that is based on a large, population-level sample and rigorous quantitative analysis. The first aim will be useful for developing pre-hospital care policy solutions that are effective in diverse local settings. The second aim will help identify subgroups of patients that benefit from each ambulance type, and will help standardize pre-hospital care policy. The last aim has a direct connection with reducing health care costs of fraud and abuse, and the outcomes may be used to develop data-driven solutions. Thus, this project will have important policy implications for reducing morbidity and mortality in emergency health events, and improving spending efficiency for ambulance services.