Comparative Effectiveness of Basic and Advanced Life Support in Ambulances

描述（由申请人提供）：今天，大约65%的医疗保险受益人的紧急乘车是在高级生命支持（ALS）救护车上，其余的大部分是在基本生命支持（BLS）卡车上。关键的区别是，虽然ALS提供更多的现场护理，但BLS优先考虑到医院的时间。然而，没有强烈支持使用ALS而不是BLS，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，甚至可能增加某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境外完成的，并且在数据质量，研究设计和方法学方面存在严重缺陷。这种关于最佳院前护理的不确定性在美国不同地理区域ALS使用的巨大差异中也很明显。目前的提案旨在通过严格评估ALS在救护车上的使用，大大推进对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使用的差异吸收，假设大部分变化是由于一个地区健康和医疗保健的外源性因素的差异。第二个目的是比较BLS和ALS对不同亚组患者的一系列健康结果的有效性。第三个目标是分析医疗救护车索赔中出现的前两个目标的数据准备过程中的不一致。该项目将使用1992年至2010年期间来自救护车和医院提供者的大样本医疗保险索赔数据，其中包括居住在内城和农村地区的个人，妇女和老年人。在 目标1，在全国范围内，随着时间的推移，ALS使用的县级变化将在多层次框架中使用个人和县级预测因子进行建模。该模型将用于预测县一级倾向，以提供ALS水平的护理。在第二个目标中，这些概率将用于比较BLS和ALS的结局，包括死亡率和神经功能。这里将使用几种不同的研究设计。例如，将分析在ALS使用中经历突然时间变化的区域，以及具有不同ALS使用率但在其他方面具有可比性的区域。最后，医疗保险索赔中的不一致之处将通过测试有效的解释进行系统分析。这将是 美国第一项关于BLS和ALS的比较有效性的研究，该研究基于大规模的人口水平样本和严格的定量分析。第一个目标将有助于制定在不同地方环境中有效的院前护理政策解决方案。第二个目标将有助于确定受益于每种救护车类型的患者亚组，并将有助于标准化院前护理政策。最后一个目标与减少欺诈和滥用的医疗保健成本有直接关系，其结果可用于开发数据驱动的解决方案。因此，该项目将对降低紧急卫生事件中的发病率和死亡率以及提高救护车服务的支出效率产生重要的政策影响。

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.