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Advanced Life Support not as Effective as We Thought

2015-01-13

Here’s a study of advanced life support (ALS) versus basic life support(BLS) that appears to show ALS is less effective, that is, has poorer survival.  It was published in JAMA Internal Medicine and reviewed in the New York Times yesterday.

The study was an observational cohort, with 31 292 ALS cases and 1643 BLS cases.  That seems like a lot of advanced life support vs only a few basic cases; the difference is due to the availability of ALS in most instances.  When ALS is available, it is applied, regardless of circumstances.  This study corroborates earlier studies that showed, first, when a cardiac arrest is witnessed, survival is greater; and second, that bystander CPR (by definition BLS) improves outcomes.  Rapid external defibrillation helped outcomes, which confirms its use as a first option in witnessed cardiac arrests.  Another study showed that the use of epinephrine or vasopressin led to worse outcomes.  The use of tracheal intubation rather than continuing basic bag and mask ventilation did not help either.

The result was that, after 90 days, 8% of BLS cases survived and were discharged from the hospital.  Only 5% of ALS cases did as well.  Early on, after 30 days, 13% of BLS cases and 9% of ALS cases survived.  44% of ALS survivors had poor neurological function, while only 21% of BLS cases had poor neurological function.  All patients were Medicare eligible and the study was “nationally representative.”

The only caveat to these findings would be if patients who were doing poorly at onset were more likely to receive ALS.  This is a potential that could be evaluated if the cases were reviewed to see if ALS was not attempted because the patient responded immediately to BLS.  I wasn’t able to review to full JAMA study to see if this type of review was done, since access to the full article requires a paid subscription to JAMA.

Nevertheless, the point seems clear: some of the interventions used in ALS are pernicious.  Whether these involve intubation, administration of epinephrine or other drugs, or other procedures is not clear.

The New York Times article tries to make the point that sometimes, less is more.  This is certainly true of treatments for cancer.  Lumpectomy and limited radiation are superior to mastectomy in localized breast cancer, partly because some very early types of breast cancer never develop into clinically apparent disease.  Ductal carcinoma in situ (DCIS) is a case in point; studies show that many of these lesions never progress.

When a breast cancer is detected by screening, even DCIS, treatment is counted as success because there is no alternative; no one would allow a DCIS lesion to remain in place to see whether or not it progressed.  Therafter, minimal treatment is more successful than aggressive treatment because all the side effects of aggressive treatment count against it, whereas the untreated lesion never progresses and has no side effects.

There is a significant amount of overtreatment built into modern medicine.  Patients with sore throat visit the doctor and demand antibiotics, even though there is no evidence that antibiotics make any difference to the course of the average sore throat in the adult.  Even children usually don’t benefit from antibiotics, and even proven cases of streptococcal pharyngitis only do marginally better under treatment.  This is not to imply that a patient with a sore throat and a fever doesn’t need to take penicillin; in many cases, the penicillin brings about relief in less than 24 hours.  Studies of symptom relief don’t always have the ability to distinguish improvement in 48 hours from that in 8 hours.

Many other examples of overly aggressive treatment can be adduced, but by the same token, there are many examples of undertreatment due to lax standards and inadequate attention (brought on by overemphasis on trivial, ineffective treatments to the point where adequate long term treatments are not brought up because of lack of time.)

The NYT article is at: http://www.nytimes.com/2015/01/13/upshot/doing-more-for-patients-often-does-no-good-.html and the JAMA abstract is at: http://archinte.jamanetwork.com/article.aspx?articleid=1939373&utm_campaign=social_112514&utm_medium=twitter&utm_source=@jamainternalmed

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