Advance Life Support Measures Show No Benefit Over Basic Life Support Measures

Aaron E. Carroll discusses the negative health and economic impacts of using advanced life support measures in the following article, "Doing More for Patients Often Does No Good," featured in the New York Times.  Please share your thoughts as professionals on the impacts of these studies on medical billing and care provided. 

"Given the remarkable advances that have been made in the last 50 or so years in pharmaceuticals, medical devices and surgical procedures, it’s not a surprise that people want more, and more invasive, care than they have had in the past. Just as it’s hard to do nothing when you’re ill, it’s sometimes hard to do less than the maximum when there are different treatments to choose from.

Unfortunately, doing more often does no good. Sometimes, it even leads to harm.

In the United States, when it appears that someone might be in trouble, emergency medical services are dispatched. Many patients die from an out-of-hospital cardiac arrest, but steps taken out in the field can make a difference. Basic life support, the kind you might be taught in a CPR class — involving the use of bag valve masks, cardiopulmonary resuscitation and automated external defibrillators— can absolutely save a life.

Advanced life support, usually requiring a trained paramedic, involves much more. Trained providers may put in endotracheal breathing tubes; start intravenous lines; deliver sophisticated cardiac drugs; and defibrillate patients manually.

We’ve assumed, for the most part, that advanced life support is better than basic life support — so much so that in most areas where both options are available, advanced life support is almost always used. But a recent study in JAMA Internal Medicine brings this assumption into question. Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital from 2009 through most of 2011. They looked at how often patients survived to hospital discharge, and then months later.

What they found was that about 13 percent of patients who received basic life support survived and were discharged versus 9 percent of patients who received advanced life support. More patients who received basic life support lived for 90 days after discharge, too (8 percent versus 5 percent). Basic life support patients also had better neurological outcomes.

Now, of course, this is not a randomized controlled trial. It’s possible that sicker patients received advanced life support and that people who didn’t appear as sick received basic life support. But the authors called all of the state agencies, and they reported that this can’t really happen. After all, a 911 dispatcher can’t tell if it’s a “mild” or “severe” heart attack from a third party on the phone with no medical training. Dispatchers send out advanced life support if it’s available, and basic life support if it’s not.

It’s also possible that there could be differences in bystander CPR administration until help arrives. But the authors attempted to control for that, too. They conducted a number of sensitivity analyses, and in none of them did advanced life support outperform basic life support.

It would also be easier to dismiss this finding if it weren’t corroborated in many other studies. In 2004, results from the Ontario Prehospital Advanced Life Support Study were published in the New England Journal of Medicine. This was a multicenter controlled trial in 17 cities in Canada comparing advanced life support with basic life support. They found that if an instance of cardiac arrest were witnessed by a bystander, the chance of survival significantly improved. They also found that CPR administered by bystanders improved survival, and so did rapid defibrillation. These are all components of basic life support. The addition of advanced life support, however, made no difference in survival.

A 2007 study conducted in Taipei also found that advanced life support did not improve survival to discharge. Even the main components of advanced life support have failed to show results in studies. A 2008 systematic review showed no efficacy for emergency intubation. A 2010 cohort study found advanced airway methods — basically, putting in an airway tube rather than using a bag mask — to be associated with decreased survival compared with basic life support methods, as did a 2013 study in Japan.

A 2012 JAMA study found that the use of epinephrine was associated with worse outcomes, and a 2008 New England Journal of Medicine study found that adding vasopressin (another drug that, likeepinephrine, constricts blood vessels to raise blood pressure) didn’t improve things. A randomized controlled trial of these drugs, published in 2009 in JAMA, found that their use didn’t improve survival either.

The evidence is compelling. Advanced life support does not seem to provide any benefits in the randomized controlled trials, and it’s often associated with worse outcomes in the cohort studies. How can this be so? Some theorize that the things that work have already been incorporated into basic life support. All that the advanced life support may be doing is slowing things down in the field, distracting people from the useful basic life support measures, and delaying the time until a patient can get to the hospital.

It’s hard not to do more if we can, though. We see this in all sorts of areas of care. A few months ago, a study was published in JAMA that examined the outcomes of women with stage 0-III unilateral breast cancer who underwent breast conserving surgery with radiation compared with those who had a unilateral mastectomy and those who had a bilateral prophylactic mastectomy. The 10-year survival differences between the groups were negligible. Breast conservation therapy is more tolerable, is much less invasive and costs less.Continue reading the main story

In fact, breast conservation therapy has become a “standard of excellence” in breast cancer care. But a study published even more recently showed that from 1998 through 2011, the odds of a woman eligible for breast conservation therapy receiving a mastectomy increased. Rates of bilateral mastectomy went up over this time period as well, from 2 percent in 1998 to 11 percent in 2011.

And based on the data from many randomized controlled trials, we know that women who have radiation therapy for early breast cancer do well with less of it. The use of “hypofractionated” whole breast irradiation, which consists of fewer treatments with higher levels of radiation, has been shown to be equally effective for women without any excess side effects. It’s cheaper, easier and just as good. Hypofractionated whole breast radiation has been endorsed by the American Society for Radiation Oncology for women who satisfy certain criteria since 2011.

But a study published a month ago that looked at the use of radiationin women with early stage breast cancer found that in 2013, only about a third of women who qualified for hypofractionated radiation therapy were getting it. The rest got more, but not better, care.

The reasons for this are varied. With respect to the radiation therapy, it’s hard not to lay some of the blame on economics. After all, in a fee-for-service system, more visits and more treatments mean more money. Research shows that twice as many women want hypofractionated radiation therapy as want conventional therapy, but only half of radiation oncologists offer it.

But it’s not all money. It’s also probably fear. Many radiation oncologists are concerned that doing fewer treatments will lead to worse outcomes. That’s most likely the concern of women who choose much more invasive surgery than necessary as well.

It’s certainly the rationale for why advanced life support is so prevalent. The Ontario Prehospital Advanced Life Support Trial was supposed to be a randomized controlled trial, but the paramedicsevidently refused to do it because they felt that holding back advanced life support was unethical. This was in spite of the lack of evidence that it was effective.

More is expensive. More sometimes does no good. Sometimes, more is even harmful. When our policies and care ignore these facts, we all suffer."

Patient Identification and Matching Report Released by ONC

The Office of the National Coordinator for Health Information Technology (ONC) released the final version of the Patient Identification and Matching Report. The report evaluated best practices and current trends in using electronic health record systems to accurately identify patients and exchange information between providers, patients, and caregivers. Mistakes in properly identifying patient health records put patient safety at risk and has resulted in too many patient deaths. 

The drafting process for the report included an industry environmental scan with input from stakeholders at meetings, on calls, and requests for submitted comments and recommendations. NAHAM was an active participant throughout the drafting process and provided recommendations focused on improving patient safety that are featured in the report. NAHAM's recommendations can be found on page 76 of the report. 

The report resulted in 10 findings that ONC will use as they move forward with the process of improving electronic health record systems and patient matching to improve patient safety.The findings are below.

Findings

1. Standardized patient identifying attributes should be required in the relevant exchange transactions. 

2. Any changes to patient data attributes in exchange transactions should be coordinated with organizations working on parallel efforts to standardize healthcare transactions. 

3. Certification criteria should be introduced that require certified EHR technology (CEHRT) to capture the data attributes that would be required in the standardized patient identifying attributes.

4. The ability of additional, non-traditional data attributes to improve patient matching should be studied. 

5. Certification criteria should not be created for patient matching algorithms or require organizations to utilize a specific type of algorithm. 

6. Certification criteria that requires CEHRT that performs patient matching to demonstrate the ability to generate and provide to end users reports that detail potential duplicate patient records should be considered. 

7. Build on the initial best practices that emerged during the environmental scan by convening industry stakeholders to consider a more formal structure for establishing best practices for the matching process and data governance. 

8. Work with the industry to develop best practices and policies to encourage consumers to keep their information current and accurate. 

9. Work with healthcare professional associations and the Safety Assurance Factors for EHR Resilience (SAFER) Guide initiative to develop and disseminate education and training materials detail best practices for accurately capturing and consistently verifying patient data attributes. 

10. Continue collaborating with federal agencies and the industry on improving patient identification and matching processes. 

Congressional Gridlock Stalls Hopes for National Patient Identifier and Meaningful Use Stage 2 Delay

Many in the health IT field believe that implementing a national patient identifier and a deadline extension for stage 2 meaningful use requirements would ensure a more cohesive operation of patient access and identification systems and increase patient safety.  Both of these problems require congressional action to solve, but with a Congress that fails to pass even the most basic pieces of legislation and appropriations it is unlikely there will be any legislation addressing these issues in the year to come.

National Patient Identifier

A national patient identifier would go far to improve patient safety by improving the accuracy with which patients are matched with their medical records.  Ideally, a national patient identifier would be a unique number for each patient with a two-digit checksum at the end of the number. In practice this would allow a patient’s data to move completely through multiple data systems without comingling with other patients’ records that may contain similar names, addresses and other identifying factors.

However, the likelihood of legislation requiring a national patient identifier is very slim after Congress voted to overturn a HIPAA provision that would have required a patient identifier in 1998. Congressional opposition focused on privacy concerns and the capability providers have to identify patients with several different identifying factors. Former national health IT coordinator Farzad Mostashari, M.D., explained that he believed the odds were very low for a national patient identifier and that it would require the industry proving they are unable to keep patients straight by cross-checking a patient’s identity with other identifying factors available to the provider.

Meaningful Use Incentive Program

The electronic health records meaningful use incentive program was created to advance the adoption of health information technology nationwide. Beginning in 2014 eligible hospitals and professionals will have to comply with stage 2 of the regulatory standards in order to receive corresponding incentive payments. 

Senator Alexander and Senator Thune, along with 15 other Senators, wrote a letter to HHS Secretary Kathleen Sebelius requesting more time for implementation of stage 2 standards. Their letter stated, “If the goal is to improve care by achieving broad and meaningful utilization of EHRs, providing sufficient time to ensure a safe, orderly transition through Stage 2 is critical to having stakeholder buy-in, a necessary component of long-term success.

However, former national health IT coordinator Farzad Mostashari, M.D., does not think that this extension will be granted.  Without speaking to the merit of the request, Mostashari recently told a group gathered at the CHIME Fall Forum that the extension would take up to a year to approve, and the extension requested is a year. The overlap would through U.S. health IT into “total chaos” due to the uncertainty during the rulemaking process to amend the schedule.

 Resources

Don Fluckinger’s article, “Shut down thoughts of a national patient identifier,stage 2 extension,” 

A podcast discussing the benefits of a national patient identifier can be found here. 

Alexander-Thune Letter from 17 Senators to Secretary Kathleen Sebelius requesting a meaningful use stage 2 delay can be found here. 

Hidden Costs of Duplicate Patient Records

A recent article by Patricia Consolver, Minimizing Duplicate Patient Records to Maximize Cash Flow, highlighted the relationship between a reduction in duplicate patient records and increases in revenue cycle efficiency. A 2008 RAND Corporation study found that the average duplicate patient record is 8 percent. In addition to the inherent risks to patient safety, duplicate and incorrect patient identifications have the potential to impair downstream financial activities such as delayed payments, appeals, and denials. 

The costs associated with duplicate records also include instances of repetitious lab and diagnostic tests that were performed, but documented in a duplicate record. Insurance companies often deny claims for repetitive tests. This results in care that the hospital will not be reimbursed for and cannot collect. 

Texas Health Resources, a 13-hospital system that serves over 1 million patients per year, implemented a four-step process during the transition to EHRs that resulted in a duplicate patient record rate of 0.36 percent. 

The Four-Step Process

1. Scrubbing the existing MPI
2. Identifying and selecting the correct patient records
3. Educating key stakeholders on avoiding duplicate creation
4. Monitoring performance

Education was necessary to ensure the EHR did not devolve to the state of MPI's duplicate records. Texas Health Resources education efforts were focused on both registration and medical record department employees. These courses emphasized the importance of using a full, legal name and the ways that duplicate records affect downstream activities in several areas of the hospital's operations. Data integrity teams were created to monitor the records and focus new education efforts on common mistakes that needed to be corrected. 

The implementation of similar systems is being evaluated at hospitals across the country as Meaningful Use requirements become effective.