BLUF: Don't hit the panic button, there are most likely methodology flaws in this study although the question raised is valid, and they are right to a certain extent.
This is the same group that wrote a paper (last year? maybe early this year?) about outcomes after cardiac arrest when comparing ALS and BLS. Although I don't have full access to the current study, given that it is the same group, using the same raw data and looking at the same question, I'm confident in saying that they did the same thing and made the same mistake. Yes, I know the first response will be to blow this off without thinking.
The problem is that they are using medicare billing codes to group people into groups for comparison. Great idea, except it goes by the belief that a cardiac arrest is always a cardiac arrest and always the same, or in this case, a stroke/trauma/MI/respiratory failure is always a stroke/trauma/MI/respiratory failure and always the same. This is patently not true; the simple act of using a medicare code to indicate what was wrong with the patient (especially when done by EMS providers) and possibly how severe the problem is does not allow the true comparison of 2 similarly coded people without actually looking at the individual patient. To put it another way; one group might say that patient X had a stroke, while another says patient Y also had a stroke and use the same codes...except patient X had a mild CVA with almost full resolution, and patient Y had a severe cerebral hemorrhage. Or, very likely given that it's EMS, patient X didn't even have a stroke but was coded that way by the ambulance company. If all that is looked at is medicare codes and who transported the patient, not the actual patient severity, this leads to a false comparison.
Before anyone says it, in the first study they did look at some of the initial hospital medicare codes as well and I bet they did the same here; unfortunately this does not validate the whatever was chosen by the ambulance companies. Medicare allows billing and coding if the problem was "present at any time" (or words to that effect), and given the problems that were looked at (cardiac arrest, MI, CVA, major trauma, respiratory failure) it would be very unsurprising if many hospitals and doctors coded these encounters in a specific way due to the initial concern and reception.
At least in the first study (and again, I don't have access to the full version of the current one) the way they analyzed the numbers to "prove" their validity also showed the flaws in their reasoning, although this was not recognized by the authors. It was recognized by several other doctors who were nice enough to write in to the Annals of Internal Medicine about it. While not meant as a disparagement towards AIM in any way, shape or form, I think there may have been a reason that both studies were published there and not in any of the emergency medicine journals.
So, is the authors conclusion wrong? Well...I don't think so, though it isn't really fully right either. I do think they reached their conclusion in the wrong way and are using a broad brush (even a spray gun one might say) to paint a picture that needs a finer touch. In reality, paramedics are very much misused in America, and even though we do tend to treat a vast number of patients (in most places) the majority of those people don't NEED any treatement; they would have the same outcome if they got a quick ride to an ER and waited for a bit longer. And when I say majority, I mean about 95% or more. The times when a paramedic will have a real impact (and in this setting comfort and symptom relief don't come into play) on a patient's outcome are very few and far between.
The sooner this is recognized the better of EMS will be.
This is the same group that wrote a paper (last year? maybe early this year?) about outcomes after cardiac arrest when comparing ALS and BLS. Although I don't have full access to the current study, given that it is the same group, using the same raw data and looking at the same question, I'm confident in saying that they did the same thing and made the same mistake. Yes, I know the first response will be to blow this off without thinking.
The problem is that they are using medicare billing codes to group people into groups for comparison. Great idea, except it goes by the belief that a cardiac arrest is always a cardiac arrest and always the same, or in this case, a stroke/trauma/MI/respiratory failure is always a stroke/trauma/MI/respiratory failure and always the same. This is patently not true; the simple act of using a medicare code to indicate what was wrong with the patient (especially when done by EMS providers) and possibly how severe the problem is does not allow the true comparison of 2 similarly coded people without actually looking at the individual patient. To put it another way; one group might say that patient X had a stroke, while another says patient Y also had a stroke and use the same codes...except patient X had a mild CVA with almost full resolution, and patient Y had a severe cerebral hemorrhage. Or, very likely given that it's EMS, patient X didn't even have a stroke but was coded that way by the ambulance company. If all that is looked at is medicare codes and who transported the patient, not the actual patient severity, this leads to a false comparison.
Before anyone says it, in the first study they did look at some of the initial hospital medicare codes as well and I bet they did the same here; unfortunately this does not validate the whatever was chosen by the ambulance companies. Medicare allows billing and coding if the problem was "present at any time" (or words to that effect), and given the problems that were looked at (cardiac arrest, MI, CVA, major trauma, respiratory failure) it would be very unsurprising if many hospitals and doctors coded these encounters in a specific way due to the initial concern and reception.
At least in the first study (and again, I don't have access to the full version of the current one) the way they analyzed the numbers to "prove" their validity also showed the flaws in their reasoning, although this was not recognized by the authors. It was recognized by several other doctors who were nice enough to write in to the Annals of Internal Medicine about it. While not meant as a disparagement towards AIM in any way, shape or form, I think there may have been a reason that both studies were published there and not in any of the emergency medicine journals.
So, is the authors conclusion wrong? Well...I don't think so, though it isn't really fully right either. I do think they reached their conclusion in the wrong way and are using a broad brush (even a spray gun one might say) to paint a picture that needs a finer touch. In reality, paramedics are very much misused in America, and even though we do tend to treat a vast number of patients (in most places) the majority of those people don't NEED any treatement; they would have the same outcome if they got a quick ride to an ER and waited for a bit longer. And when I say majority, I mean about 95% or more. The times when a paramedic will have a real impact (and in this setting comfort and symptom relief don't come into play) on a patient's outcome are very few and far between.
The sooner this is recognized the better of EMS will be.
