Accuracy of infection reporting in US nursing home ratings.

OBJECTIVE: To assess the accuracy of nursing home-reported data on urinary tract infections (UTIs), which are publicly reported on Nursing Home Care Compare, and pneumonia, which are not publicly reported. DATA SOURCES AND STUDY SETTING: We used secondary data for 100% of Medicare fee-for-service beneficiaries in the United States between 2011 and 2017. STUDY DESIGN: We identified Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017 and admitted to a hospital with a primary diagnosis of UTI or pneumonia. After linking these hospital claims to resident-level nursing home-reported assessment data in the Minimum Data Set, we calculated the percentages of infections that were appropriately reported and assessed variation by resident- and nursing home-level characteristics. We developed a claims-based nursing home-level measure of hospitalized infections and estimated correlations between this and publicly reported ratings. DATA EXTRACTION METHODS: Medicare fee-for-service beneficiaries who were nursing home residents and hospitalized for UTI or pneumonia during the study period were included. PRINCIPAL FINDINGS: Reporting rates were low for both infections (UTI: short-stay residents 29.1% and long-stay residents 19.2%; pneumonia: short-stay residents 66.0% and long-stay residents 70.6%). UTI reporting rates increased when counting additional assessments, but it is unclear whether these reports are for the same versus a newly developed UTI. Black residents had slightly lower reporting rates, as did nursing homes with more Black residents. Correlations between our claims-based measure and publicly reported ratings were poor. CONCLUSIONS: UTI and pneumonia were substantially underreported in data used for national public reporting. Alternative approaches are needed to improve surveillance of nursing home quality.

Underreporting of Quality Measures and Associated Facility Characteristics and Racial Disparities in US Nursing Home Ratings.

Importance: The US government rates nursing homes and reports the underlying quality measures on the Nursing Home Care Compare (NHCC) website. These measures are derived from facility-reported data, which research indicates to be substantially underreported. Objective: To assess the association between nursing home characteristics and reporting of major injury falls and pressure ulcers, which are 2 of 3 specific clinical outcomes reported by the NHCC website. Design, Setting, and Participants: This quality improvement study used hospitalization data for all Medicare fee-for-service beneficiaries between January 1, 2011, and December 31, 2017. Hospital admission claims for major injury falls and pressure ulcers were linked with facility-reported Minimum Data Set (MDS) assessments at the nursing home resident level. For each linked hospital claim, whether the nursing home had reported the event was determined and reporting rates were computed. The distribution of reporting across nursing homes and the associations between reporting and facility characteristics were examined. To assess whether nursing homes reported similarly on both measures, the association between reporting of major injury falls and pressure ulcers within a nursing home was estimated, and racial and ethnic disparities that might explain the observed associations were investigated. Small facilities and those that were not included in the sample continuously in each year of the study period were excluded. All analyses were performed throughout 2022. Main Outcomes and Measures: Two nursing home-level MDS reporting rates, stratified by long-stay vs short-stay population or by race and ethnicity, were used: fall reporting rate and pressure ulcer reporting rate. Results: The sample included 13 179 nursing homes where 131 000 residents (mean [SD] age, 81.9 [11.8] years; 93 010 females [71.0%]; 81.1% with White race and ethnicity) experienced major injury fall or pressure ulcer hospitalizations. There were 98 669 major injury fall hospitalizations, of which 60.0% were reported, and 39 894 stage 3 or 4 pressure ulcer hospitalizations, of which 67.7% were reported. Underreporting for both conditions was widespread, with 69.9% and 71.7% of nursing homes having reporting rates less than 80% for major injury fall and pressure ulcer hospitalizations, respectively. Lower reporting rates were associated with few facility characteristics other than racial and ethnic composition. Facilities with high vs low fall reporting rates had significantly more White residents (86.9% vs 73.3%), and facilities with high vs low pressure ulcer reporting rates had significantly fewer White residents (69.7% vs 74.9%). This pattern was retained within nursing homes, where the slope coefficient for the association between the 2 reporting rates was -0.42 (95% CI, -0.68 to -0.16). That is, nursing homes with more White residents had higher reporting rates for major injury falls and lower reporting rates for pressure ulcers. Conclusions and Relevance: Results of this study suggest widespread underreporting of major injury falls and pressure ulcers across US nursing homes, and underreporting was associated with the racial and ethnic composition of a facility. Alternative approaches to measuring quality need to be considered.

Hospitalisations for cardiovascular and respiratory disease among older adults living near unconventional natural gas development: a difference-in-differences analysis.

BACKGROUND: During 2008-15, the Marcellus shale region of the US state of Pennsylvania experienced a boom in unconventional natural gas development (UNGD) or "fracking". However, despite much public debate, little is known about the effects of UNGD on population health in local communities. Among other mechanisms, air pollution from UNGD might affect individuals living nearby through cardiovascular or respiratory disease, and older adults could be particularly susceptible. METHODS: To study the health impacts of Pennsylvania's fracking boom, we exploited the ban on UNGD in neighbouring New York state. Using 2002-15 Medicare claims, we conducted difference-in-differences analyses over multiple timepoints to estimate the risk of living near UNGD for hospitalisation with acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD) and bronchiectasis, heart failure, ischaemic heart disease, and stroke among older adults (aged ≥65 years). FINDINGS: Pennsylvania ZIP codes that started UNGD in 2008-10 were associated with more hospitalisations for cardiovascular diseases in 2012-15 than would be expected in the absence of UNGD. Specifically, in 2015, we estimated an additional 11·8, 21·6, and 20·4 hospitalisations for AMI, heart failure, and ischaemic heart disease, respectively, per 1000 Medicare beneficiaries. Hospitalisations increased even as UNGD growth slowed. Results were robust in sensitivity analyses. INTERPRETATION: Older adults living near UNGD could be at high risk of poor cardiovascular outcomes. Mitigation policies for existing UNGD might be needed to address current and future health risks. Future consideration of UNGD should prioritise local population health. FUNDING: University of Chicago and Argonne National Laboratories.

Comparison of survival outcomes among older adults with major trauma after trauma center versus non-trauma center care in the United States.

OBJECTIVE: To compare level 1 and 2 trauma centers with similarly sized non-trauma centers on survival after major trauma among older adults. DATA SOURCES AND STUDY SETTING: We used claims of 100% of 2012-2017 Medicare fee-for-service beneficiaries who received hospital care after major trauma. STUDY DESIGN: Survival differences were estimated after applying propensity-score-based overlap weights. Subgroup analyses were performed for ambulance-transported patients and by external cause. We assessed the roles of prehospital care, hospital quality, and volume. DATA COLLECTION: Data were obtained from the Centers for Medicare and Medicaid Services. PRINCIPAL FINDINGS: Thirty-day mortality was higher overall at level 1 versus non-trauma centers by 2.2 (95% confidence interval [CI]: 1.8, 2.6) percentage points (pp). Thirty-day mortality was higher at level 1 versus non-trauma centers by 2.3 (95% CI: 1.9, 2.8) pp for falls and 2.3 (95% CI: 0.2, 4.4) pp for motor vehicle crashes. Differences persisted at 1 year. Level 1 and 2 trauma centers had similar outcomes. Hospital quality and volume did not explain these differences. In the ambulance-transported subgroup, after adjusting for prehospital variables, no statistically significant differences remained. CONCLUSIONS: Trauma centers may not provide longer survival than similarly sized non-trauma hospitals for severely injured older adults.

Accuracy of Pressure Ulcer Events in US Nursing Home Ratings.

BACKGROUND: The US government relies on nursing home-reported data to create quality of care measures and star ratings for Nursing Home Compare (NHC). These data are not systematically validated, and some evidence indicates NHC's patient safety measures may not be reliable. OBJECTIVE: The objective of this study was to assess the accuracy of NHC's pressure ulcer measures, which are chief indicators of nursing home patient safety. RESEARCH DESIGN: For Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017, we identified hospital admissions for pressure ulcers and linked these to the nursing home-reported data at the patient level. We then calculated the percentages of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay status, and race. After developing an alternative claims-based measure of pressure ulcer events, we estimated the correlation between this indicator and NHC-reported ratings. SUBJECTS: Medicare nursing home residents with hospitalizations for pressure ulcers. MEASURES: Pressure ulcer reporting rates; nursing home-level claims-based measure of pressure ulcer events. RESULTS: Reporting rates were low for both short-stay (70.2% of 173,043 stage 2-4 pressure ulcer hospitalizations) and long-stay (59.7% of 137,315 stage 2-4 pressure ulcer hospitalizations) residents. Black residents experienced more severe pressure ulcers than White residents, however, this translated into having slightly higher reporting rates because higher staged pressure ulcers were more likely to be reported. Correlations between our claims-based measure and NHC ratings were poor. CONCLUSIONS: Pressure ulcers were substantially underreported in data used by NHC to measure patient safety. Alternative approaches are needed to improve surveillance of health care quality in nursing homes.

Trans- and Multigenerational Maternal Social Isolation Stress Programs the Blood Plasma Metabolome in the F3 Generation.

Metabolic risk factors are among the most common causes of noncommunicable diseases, and stress critically contributes to metabolic risk. In particular, social isolation during pregnancy may represent a salient stressor that affects offspring metabolic health, with potentially adverse consequences for future generations. Here, we used proton nuclear magnetic resonance (1H NMR) spectroscopy to analyze the blood plasma metabolomes of the third filial (F3) generation of rats born to lineages that experienced either transgenerational or multigenerational maternal social isolation stress. We show that maternal social isolation induces distinct and robust metabolic profiles in the blood plasma of adult F3 offspring, which are characterized by critical switches in energy metabolism, such as upregulated formate and creatine phosphate metabolisms and downregulated glucose metabolism. Both trans- and multigenerational stress altered plasma metabolomic profiles in adult offspring when compared to controls. Social isolation stress increasingly affected pathways involved in energy metabolism and protein biosynthesis, particularly in branched-chain amino acid synthesis, the tricarboxylic acid cycle (lactate, citrate), muscle performance (alanine, creatine phosphate), and immunoregulation (serine, threonine). Levels of creatine phosphate, leucine, and isoleucine were associated with changes in anxiety-like behaviours in open field exploration. The findings reveal the metabolic underpinnings of epigenetically heritable diseases and suggest that even remote maternal social stress may become a risk factor for metabolic diseases, such as diabetes, and adverse mental health outcomes. Metabolomic signatures of transgenerational stress may aid in the risk prediction and early diagnosis of non-communicable diseases in precision medicine approaches.

A national assessment of legacy versus new generation Medicaid data.

OBJECTIVE: To compare the performance of Medicaid legacy, Medicaid new generation, and Medicare claims on data analytic tasks. DATA SOURCES: Medicaid Analytic eXtract (MAX) claims (legacy) of 100% beneficiaries in 2011 (all states except Idaho), 2012 (all states), 2013 (28 states), and 2014 (17 states); 2016 Transformed Medicaid Statistical Information System Analytic Files (TAF) claims (new generation) of 100% beneficiaries from all states; Medicare claims of 20% beneficiaries in 2011-2014, 2016. STUDY DESIGN: We focused on the chain of events that starts with an out-of-hospital medical emergency and ends with hospital death or survival to discharge. We developed six data quality indicators to assess ambulance variables; linkage between claims; external cause of injury code reporting; and death reporting on hospital discharge status codes. For the latter, we estimated injury severity and modeled its association with death in the Medicare population. We used the model to compare reported versus expected deaths by injury severity in the Medicaid population. Datasets were compared by state and fee-for-service versus managed care. DATA EXTRACTION METHODS: Medicare and Medicaid beneficiaries with emergency ambulance transports. PRINCIPAL FINDINGS: Medicare claims had high performance across indicators and states; MAX claims substantially underperformed on multiple indicators in most states. For example, most states reported external cause codes for over 90% of Medicare but less than 15% of Medicaid injury cases. Medicaid fee-for-service did not consistently perform better than Medicaid managed care. Compared with MAX, TAF claims performed significantly better on some indicators but continued to have poor external cause code reporting. Finally, MAX and TAF managed care records reported deaths at discharge in the range of expected deaths; however, fee-for-service claims might have underreported high-severity injury deaths. CONCLUSIONS: New generation Medicaid claims performed better than legacy claims on some indicators, but much more improvement is needed to allow high-quality policy analysis.

Alterations in Urine Metabolomics Following Sport-Related Concussion: A 1H NMR-Based Analysis.

Objective: Millions of sport-related concussions (SRC) occur annually in North America, and current diagnosis of concussion is based largely on clinical evaluations. The objective of this study was to determine whether urinary metabolites are significantly altered post-SRC compared to pre-injury. Setting: Outpatient sports medicine clinic. Participants: Twenty-six male youth sport participants. Methods: Urine was analyzed pre-injury and after SRC by 1H NMR spectroscopy. Data were analyzed using multivariate statistics, pairwise t-test, and metabolic pathway analysis. Variable importance analysis based on random variable combination (VIAVC) was applied to the entire data set and resulted in a panel of 18 features. Partial least square discriminant analysis was performed exploring the separation between pre-injury and post-SRC groups. Pathway topography analysis was completed to identify biological pathway involvement. Spearman correlations provide support for the relationships between symptom burden and length of return to play and quantifiable metabolic changes in the human urinary metabolome. Results: Phenylalanine and 3-indoxysulfate were upregulated, while citrate, propylene glycol, 1-methylhistidine, 3-methylhistidine, anserine, and carnosine were downregulated following SRC. A receiver operator curve (ROC) tool constructed using the 18-feature classifier had an area under the curve (AUC) of 0.887. A pairwise t-test found an additional 19 altered features, 7 of which overlapped with the VIAVC analysis. Pathway topology analysis indicated that aminoacyl-tRNA biosynthesis and beta-alanine metabolism were the two pathways most significantly changed. There was a significant positive correlation between post-SRC 2-hydroxybutyrate and the length of return to play (ρ = 0.482, p = 0.02) as well as the number of symptoms and post-SRC lactose (ρ = 0.422, p = 0.036). Conclusion: We found that 1H NMR metabolomic urinary analysis can identify a set of metabolites that can correctly classify SRC with an accuracy of 81.6%, suggesting potential for a more objective method of characterizing SRC. Correlations to both the number of symptoms and length of return to play indicated that 2-hydroxybutyrate and lactose may have potential applications as biomarkers for sport-related concussion.

Association of Low-Value Care Exposure With Health Care Experience Ratings Among Patient Panels.

Importance: Patient reviews of health care experiences are increasingly used for public reporting and alternative payment models. Critics have argued that this incentivizes physicians to provide more care, including low-value care, undermining efforts to reduce wasteful practices. Objective: To assess associations between rates of low-value service provision to a primary care professional (PCP) patient panel and patients' ratings of their health care experiences. Design, Setting, and Participants: This quality improvement study used Medicare fee-for-service claims from January 1, 2007, to December 31, 2014, for a random 20% sample of beneficiaries to identify beneficiaries for whom each of 8 low-value services could be ordered but would be considered unnecessary. The study also used health care experience reports from independently sampled beneficiaries who responded to the 2010-2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare fee-for-service survey. Statistical analysis was performed from January 1, 2019, to December 9, 2020. Main Outcomes and Measures: The main outcomes were health care experience ratings from Medicare beneficiaries who responded to the CAHPS survey from 2 domains, namely "Your Health Care in the Last 6 Months" (overall health care, office wait time, timely access to nonurgent care, and timely access to urgent care) and "Your Personal Doctor" (overall personal physician and a composite score for interactions with personal physician). Beneficiaries in both samples were attributed to the PCP with whom they had the most spending. For each PCP, a composite score of low-value service exposure was constructed using the 20% sample; this score represented the adjusted relative propensity of the PCP patient panel to receive low-value care. The association between low-value service exposure and health care experience ratings reported by the CAHPS respondents in the PCP patient panel was estimated using regression analysis. Results: The final sample had 100 743 PCPs, with a mean of approximately 258 patients per PCP. Only 1 notable association was found; more low-value care exposure was associated with more frequent reports of having to wait more than 15 minutes after the scheduled time of an appointment (a mean of 0.448 points lower CAHPS score on a 10-point scale for PCP patient panels who received the most low-value care vs the least low-value care). Although some other associations were statistically significant, their magnitudes were substantially smaller than those typically considered meaningful in other CAHPS literature and were inconsistent in direction across levels of low-value service exposure. Conclusions and Relevance: This quality improvement study found that more low-value care exposure for a PCP patient panel was not associated with more favorable patient ratings of their health care experiences.

Identifying outlier patterns of inconsistent ambulance billing in Medicare.

OBJECTIVE: To illustrate a method that accounts for sampling variation in identifying suppliers and counties with outlying rates of a particular pattern of inconsistent billing for ambulance services to Medicare. DATA SOURCES: US Medicare claims for a 20% simple random sample of 2010-2014 fee-for-service beneficiaries. STUDY DESIGN: We identified instances in which ambulance suppliers billed Medicare for transporting a patient to a hospital, but no corresponding hospital visit appeared in billing claims. We estimated the distributions of outlier supplier and county rates of such "ghost rides" by fitting a nonparametric empirical Bayes model with flexible distributional assumptions to account for sampling variation. DATA COLLECTION: We included Basic and advanced life support ground emergency ambulance claims with a hospital destination. PRINCIPAL FINDINGS: "Ghost ride" rates varied considerably across both ambulance suppliers and counties. We estimated 6.1% of suppliers and 5.0% of counties had rates that exceeded 3.6%, which was twice the national average of "ghost rides" (1.8% of all ambulance transports). CONCLUSIONS: Health care fraud and abuse are frequently asserted but can be difficult to detect. Our data-driven approach may be a useful starting point for further investigation.

Outcomes of Medicaid home- and community-based long-term services relative to nursing home care among dual eligibles.

OBJECTIVE: To provide the first plausibly causal national estimates of health outcomes for older dual-eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect. DATA SOURCES: We use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable. STUDY DESIGN: We model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long-term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated. POPULATION STUDIED: 1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long-term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia. PRINCIPAL FINDINGS: HCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending. CONCLUSIONS: Shifting Medicaid long-term care funding for older adults from nursing homes to HCBS, while well-motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes-not just expansion-need more attention.

Public reporting of hydraulic fracturing chemicals in the USA, 2011-18: a before and after comparison of reporting formats.

BACKGROUND: Hydraulic fracturing often involves the injection of millions of gallons of fracturing fluids into underground shales to extract oil and natural gas, raising health concerns over potential water contamination. Many state and federal governmental agencies rely on the third-party FracFocus online registry for disclosure of chemical ingredients in fracturing fluids, but withholding chemicals as trade secrets is common. In 2016, a new format, known as the systems approach was widely encouraged as a method of reducing withholding by decoupling disclosed chemicals from their functions, protecting against reverse-engineering of fracture fluid formulas by competitors. In this study, we assess the extent to which elevated use of the systems approach in FracFocus version 3.0 translated into greater chemical disclosure. METHODS: We analysed 108 137 disclosure forms submitted to FracFocus between Jan 1, 2011, and Dec 31, 2018, to estimate the effect of expanded use of the systems approach on chemical withholding. We compared the proportion of forms withholding at least one chemical ingredient across time, between approaches, and by state and drilling operator. FINDINGS: Since the 2016 expansion of the systems approach, 15 677 (82%) of systems approach forms have withheld an ingredient. 13 462 (89%) of 15 062 traditional FracFocus version 3.0 forms withheld an ingredient. In the quarter following the transition (July, to September, 2016), 1211 (93%) of 1304 traditional forms withheld an ingredient, compared with only 958 (76%) of 1262 systems approach forms. However, withholding rates increased throughout 2017 and, by 2018, 6949 (87%) of 8016 systems approach forms were withholding ingredients. At the end of our analysis period in the fourth quarter of 2018, systems approach forms had even greater withholding (903 [88%] of 1025 forms) than did traditional forms (855 [85%] of 1004 forms). We did not find that states or operators that submitted more systems approach forms had lower withholding. INTERPRETATION: The systems approach has not reduced FracFocus chemical withholding, which continues to occur in around 87% of well fracture disclosures. FracFocus might not be an appropriate substitute for regulatory action, and measures are urgently needed for environmental and public safety. FUNDING: University of Chicago Argonne National Laboratory Seed Grant.

Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare.

OBJECTIVE: To assess the accuracy of nursing home self-report of major injury falls on the Minimum Data Set (MDS). DATA SOURCES: MDS assessments and Medicare claims, 2011-2015. STUDY DESIGN/METHODS: We linked inpatient claims for major injury falls with MDS assessments. The proportion of claims-identified falls reported for each fall-related MDS item was calculated. Using multilevel modeling, we assessed patient and nursing home characteristics that may be predictive of poor reporting. We created a claims-based major injury fall rate for each nursing home and estimated its correlation with Nursing Home Compare (NHC) measures. PRINCIPAL FINDINGS: We identified 150,828 major injury falls in claims that occurred during nursing home residency. For the MDS item used by NHC, only 57.5 percent were reported. Reporting was higher for long-stay (62.9 percent) than short-stay (47.2 percent), and for white (59.0 percent) than nonwhite residents (46.4 percent). Adjusting for facility-level race differences, reporting was lower for nonwhite people than white people; holding constant patient race, having larger proportions of nonwhite people in a nursing home was associated with lower reporting. The correlation between fall rates based on claims vs the MDS was 0.22. CONCLUSIONS: The nursing home-reported data used for the NHC falls measure may be highly inaccurate.

A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles.

The benefits of expanding funding for Medicaid long-term care home and community-based services (HCBS) relative to institutional care are often taken as self-evident. However, little is known about the outcomes of these services, especially for racial and ethnic minority groups, whose members tend to use the services more than whites do, and for people with dementia who may need high-intensity care. Using national Medicaid claims data on older adults enrolled in both Medicare and Medicaid, we found that overall hospitalization rates were similar for HCBS and nursing facility users, although nursing facility users were generally sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than non-Hispanic whites were, and the gap widened among blacks and whites with dementia. Also, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than for nonwhites, and higher Medicare and Medicaid hospital spending for blacks and Hispanics did not offset this difference. Our findings suggest that home and community-based services need to be carefully targeted to avoid adverse outcomes and that the racial/ethnic disparities in access to high-quality institutional long-term care are also present in HCBS. Policy makers should consider the full costs and benefits of shifting care from nursing facilities to home and community settings and the potential implications for equity.

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies.

BACKGROUND: Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. OBJECTIVE: To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. DESIGN: Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. SETTING: Traditional Medicare. PATIENTS: 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. MEASUREMENTS: Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. RESULTS: Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI. LIMITATION: Only Medicare beneficiaries from nonrural counties were studied. CONCLUSION: Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS. PRIMARY FUNDING SOURCE: National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.

Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support.

IMPORTANCE: Most out-of-hospital cardiac arrests receiving emergency medical services in the United States are treated by ambulance service providers trained in advanced life support (ALS), but supporting evidence for the use of ALS over basic life support (BLS) is limited. OBJECTIVE: To compare the effects of BLS and ALS on outcomes after out-of-hospital cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of a nationally representative sample of traditional Medicare beneficiaries from nonrural counties who experienced out-of-hospital cardiac arrest between January 1, 2009, and October 2, 2011, and for whom ALS or BLS ambulance services were billed to Medicare (31,292 ALS cases and 1643 BLS cases). Propensity score methods were used to compare the effects of ALS and BLS on patient survival, neurological performance, and medical spending after cardiac arrest. MAIN OUTCOMES AND MEASURES: Survival to hospital discharge, to 30 days, and to 90 days; neurological performance; and incremental medical spending per additional survivor to 1 year. RESULTS: Survival to hospital discharge was greater among patients receiving BLS (13.1% vs 9.2% for ALS; 4.0 [95% CI, 2.3-5.7] percentage point difference), as was survival to 90 days (8.0% vs 5.4% for ALS; 2.6 [95% CI, 1.2-4.0] percentage point difference). Basic life support was associated with better neurological functioning among hospitalized patients (21.8% vs 44.8% with poor neurological functioning for ALS; 23.0 [95% CI, 18.6-27.4] percentage point difference). Incremental medical spending per additional survivor to 1 year for BLS relative to ALS was $154,333. CONCLUSIONS AND RELEVANCE: 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.