Table 2.

Summary of findings in the articles presenting effectiveness of advanced vs. basic life support.

Reference no	research, author, country, publication year.	type on the study illness or injury. research population. n(ALS), n (BLS). severity of disease or injury	the implementer of the care. ALS, BLS. transport. ALS, BLS. treatments.	Outcome, mortality, other outcome variables, results	conclusion
12	Shuster et al. 1995 Canada	prospective chart review. acute cardiac disease. ALS n = 1821 BLS n = 1245.	ALS-PARAMEDIC, GA. BLS-EMT, GA. an urban setting with short transportation times (less than 10 minutes)	mortality ALS 16,5% BLS 19,5% risk of death ALS OR = 1 BLS OR 1,12 (0,78-1,61)	no difference between the groups
13	Boissel 1995 France	multicentre study in 16 countries, PHT compared with thrombolysis in a hospital. ALS (immediate PTH) n = 2750. BLS (hospital throbolysis) n = 2719.	ALS-MD, GA. BLS-MD, GA. both groups treated by a physician.	30-day mortality ALS 9,7%, BLS 11,1% adjusted p = 0,08	trend to favour PHT (ALS).
14	Alldredge et al., California, U.S.A., 1995	retrospective chart review. children with status epilepticus, ALS n = 19 (treatment on site) BLS n = 26 (treatment in a hospital)	ALS-PARAMEDIC, GA BLS-EMT, GA prehospital diazepam therapy (given rectally or intravenously)	duration of status epilepticus ALS 32 min, BLS 60 min (p = 0,007) repeated cramps ALS 56%, BLS 85% (p = 0,045), mortality 0%	favours ALS.
15	Adams et al.1996 Illinois, U.S.A.	retrospective study. declined level of (epilepsy, hypoglycaemia, stroke). ALS n = 113, BLS n = 90	ALS-paramedic, GA BLS-EMT, GA	mortality ALS 6%, n = 7 BLS 2%, n = 2	no difference between the groups
16	Demetriades et al. 1996 California, U.S.A.	retrospective, all traumas ALS or BLS n = 4856 private transport n = 926	ALS-PARAMEDIC ori BLS-EMT compared with patients transported by a private vehicle	mortality: ALS or BLS 9,3% private transport 4,0% adjusted RR 1.60 (P = .002).	better survival and less permanently disabled in privately transported patients
17	Silfvast and Ekstrand 1996 Finland	before-after-design, prehospital cardiac arrest before (Period I, retrospective) and after (Period II, prospective) reorganisation of the EMS system. Phase I: ALS-PHYSICIAN experienced physicians, n = 444 Phase II: ALS-PHYSICIAN junior physicians, n = 395	two ALS-systems. physicians experienced (Phase I) and less experienced (Phase II), both operated with a GA	total mortality: Phase I 90.8% Phase II 91,6% (NS) survival of patients with ventricular fibrillation phase I: 41 (34%) phase II: 33 (25%) p = 0,05	no difference between groups in total mortality. among patients with ventricular fibrillation better results in phase I
18	Nguyen-Van-Tam et al. 1997 England	retrospective cohort cardiac arrest ALS n = 285 BLS n = 144 dual response n = 79	ALS-PARAMEDIC, BLS-EMT dual response: both ALs and BLS in the scene. GA in all groups.	mortality: ALS 91,9%, dual 98,7%, BLS 93,8%, p = 0,63) ALS adjusted survival RR 1,21 (0,50-2,91)	no difference between ALS, BLS and dual response groups
19	Rainer et al. 1997a England	prospective trauma patients ALS n = 247 BLS n = 843	ALS-PARAMEDIC, ALS-EMT ALS GA BLS GA	mortality: ALS 4%, BLS 3% (NS) TRISS: unexpected deaths: ALS n = 5, BLS n = 18 unexpected survivals: ALS n = 6, BLS n = 9, (NS)	no difference between ALS and BLS groups
20	Rainer et al. 1997b England	prospective cardiac arrest ALS n = 111 BLS n = 110	ALS-PARAMEDIC, BLS-EMT ALS GA BLS GA	mortality ALS 93%, BLS 94% p = 0,59. resuscitation by a bystander and early defibrillation associated with better survival	no difference between ALS and BLS groups
21	Suominen et al. 1998 Finland	retrospective pediatric trauma, ALS n = 49 BLS n = 72, total material n = 288	ALS-PHYSICIAN, BLS-EMT ALS helicopter and GA, BLS GA	ALS 22,4% BLS 31,9% (NS)	no difference between groups, a subgroup ISS 25-49 ALS better (p = 0,04)
22	Nicholl et al. 1998 Sheffield, England	retrospective trauma ALS n = 882 BLS n = 331	ALS-PARAMEDIC, BLS-EMT GA in both groups	6 months follow-up: mortality ALS 6,0%, BLS 4,6% OR 2,02 (1,05-3,89) ALS: higher mortality in penetrating trauma and large fractures	higher mortality in ALS
23	Eisen and Dubinsky 1998, Canada	retrospective all patient groups in prehospital care BLS n = 1000 ALS n = 397	ALS-PARAMEDIC (level 2 and level 3, level 1 = BLS), BLS-EMT GA in both	mortality: ALS 5,8%, BLS 4,6% (NS), LOS. no difference between groups	no difference between groups
24	Abbott et al. 1998 California U.S.A.	prospective case-control closed head injury ALS-PHYSICIAN n = 196 ALS-PARAMEDIC n = 1090 HEMS manned by nurse or nurse/paramedic/physician	ALS-HEMS ALS-PARAMEDIC ALS-PHYSICIAN helicopter ALS-PARAMEDIC GA	ALS-PHYSICIAN 20% ALS-PARAMEDIC 31% OR 1,75 1,21 - 2,53 subgroups: age, GCS had effect on mortality	ALS-HEMS better than ALS-PARAMEDIC
25	Owen et al. 1999 Texas, U.S.A.	retrospective TRISS trauma patients, comparison between helicopter and GA, ALS-PARAMEDIC (GA) n = 687 ALS-PARAMEDIC (helicopter) n = 105	ALS-PARAMEDIC (GA) ALS-PARAMEDIC, ALS-N (helicopter) ALS-PARAMEDIC (GA) ALS-PARAMEDIC, ALS-N (helicopter)	mortality: 14,3%, 6,0% TRISS: GA predicted 39 deaths, actually 41, helicopter: predicted 16 deaths, actually 15	no difference between groups
26	Mitchell et al. 2000 Scotlandi	before-after design cardiac arrest, period 1 n = 259 period 2 n = 294	ALS-PARAMEDIC, GA	period 1 94,2% period 2 93,5%	no difference between groups
27	Eckstein et al. 2000 California, U.S.A.	retrospective serious trauma ALS n = 93 BLS n = 403	ALS-PARAMEDIC, BLS-EMT, ALS GA, BLS GA	mortality ALS 93%, BLS 67% adjusted 5,3 (2,3 -14,2)	higher mortality in ALS
28	Pitetti et al. 2001 Pennsylvania, U.S.A.	retrospective pediatric cardiac arrest ALS-PARAMEDIC n = 150 BLS-EMT n = 39	ALS-PARAMEDIC BLS-EMT ALS GA, BLS GA	ALS 96,7% BLS 0% (NS)	no difference between ALS and BLS groups
29	Garner et al. 2001 Australia	retrospective comparison between two ALS-systems blunt trauma in head ALS-PARAMEDIC n = 250 ALS-PHYSICIAN n = 46	comparison of two levels of ALS ALS-PARAMEDIC GA ALS-PHYSICIAN helicopter (91%)	mortality: ALS-PHYSICIAN 20% ALS-PARAMEDIC 31% survival ALS-PARAMEDIC OR = 1, ALS-PHYSICIAN OR = 2,70 (1,48-4,95)	ALS-PHYSICIAN better than ALS-PARAMEDIC
30	Di Bartolomeo et al. 2001 Italy	ALS patients compared with cases when ALS was requested but not obtained Serious brain injury ALS-PHYSICIAN n = 92 BLS-H n = 92	ALS-PHYSICIAN helicopter BLS-H GA	mortality: ALS 30%, BLS 24% adjusted no difference	no difference between groups
31	Kurola et al. 2002 Finland	expert panel all prehospital patients, specialist appraisal, ALS-PHYSICIAN n = 206	ALS-PHYSICIAN helicopter and GA	mortality 10,6%, no compatison, specialist appraisal	1,5% of patients benefit of ALS-treatment, 20.4% partial benefit
32	Bjerre et al. 2002 Danmark	chronic pulmonary disease ALS n = 67, BLS n = 72	ALS-PHYSICIAN, BLS-EMT ALS GA, BLS GA	mortality: ALS 15%, BLS 24%	ALS-PHYSICIAN better survival than BLS-EMT
33	Thomas et al. 2002 Massachusetts, U.S.A.	retrospective blunt trauma, ALS-PARAMEDIC helicopter n = 2292 ALS-PARAMEDIC GA, n = 3245, BLS-EMT GA n = 7723	3 groups: ALS-PARAMEDIC GA, ALS-PHYSICIAN helicopter, BLS-EMT GA	mortality: 9,4% (ALS helicopter or GA), BLS 3,0%; helicopter vs GA: OR 0,756 (0,59-0,98), BLS vs ALS 0,42 (0,32-0,56)	higher mortality in ALS than BLS higher mortality in GA than helicopter
34	Lossius et al. Norway 2002	expert panel all prehospital patients, ALS n = 1062 appraisal by specialist group, BLS no comparison material	ALS-PHYSICIAN 40% helicopter transport, 60% GA	mortality 20,7%, specialist appraisal 7% (n = 74) benefit fromALS-care	ALS useful, no controls
35	Lee et al. 2002 Australia	retrospective blunt trauma, head injury ALS-PARAMEDIC n = 1167 ALS-PHYSICIAN n = 224 BLS level 3 n = 452 BLS level 4 n = 45 BLS other n = 96	ALS-PHYSICIAN ALS-PARAMEDIC BLS-EMT (2 different levels) ALS GA, BLS GA	mortality: ALS-PARAMEDIC 24,8%, ALS-PHYSICIAN 19,6% BLS level 3 12,2%, BLS level 4 13,3%, BLS other 21% Adjusted: BLS OR = 1 ALS-PHYSICIAN OR = 4,27 ALS-PARAMEDIC OR = 2,18	higher mortality in ALS higer mortality in ALS-PHYSICIAN than in ALS-PARAMEDIC
36	Cristenzen et al. 2003 Danmark	retrospective before-after -design all prehospital patients ALS-PHYSICIAN n = 795+35 BLS-EMT n = 4989. before-after -study: in the second phase 28% of cases treated by ALS	ALS-PHYSICIAN BLS-EMT ALS GA BLS GA	phase I mortality 10,0% mortality in phase II = 10,5% phase II mortality in ALS-group 14,7%, phase II mortality in BLS-group 8,9% (p < 0,001) OR 1,06 (NS)	total mortality same in both periods
37	Osterwalder 2003 Switzerland	prospective TRISS multiple trauma ALS n = 196 BLS n = 71	ALS-PHYSICIAN, BLS-P, BLS-EMT EMT lower level education ALS GA or helicopter, BLS GA	mortality in ALS 11,2% BLS 14,1% (NS) predicted mortality in ALS 23,3%, actual mortality 22% predicted mortality in BLS 6,6% actual mortality 10%	ALS trend to lower mortality than BLS
38	Bochiccio et al. 2003 Maryland, U.S.A.	prospective retrospective brain injury: blunt (92%), penetrating (8%), comparison between patients intubated on site and those intubated in hospital intubated on site n = 78 intubated in hospital n = 113	all ALS-PARAMEDIC 67% had helicopter transport, others with GA	mortality: intubated on site 23% intubated in hospital 12,4% (p = 0,005)	higher mortality in patients intubated on site
39	Liberman et al. Canada, 2003	prospective epidemiological study all traumas Montreal ALS n = 801 Montreal BLS n = 4295 Toronto ALS n = 1000 Toronto BLS n = 1530 Quebec BLS n = 1779	Montreal ALS-PHYSICIAN Montreal BLS-EMT Toronto ALS-PARAMEDIC Toronto EMT-BLS Quebec BLS-EMT ALS GA, BLS GA	ALS 29% ISS 25-49 30% ISS 50-76 79% BLS 18% ISS 25-49 26% ISS 50-76 76% ALS-PHYSICIAN vs BLS 1,36* ALS-PARAMEDIC vs BLS 1,06**, ALS-PHYSICIAN vs ALS-PARAMEDIC 1,20** ALS vs BLS 1,21*, *p = 0,01 **p = NS	higher mortality in ALS
40	Danchin et al. 2004 France	retrospective chart review PHT n = 180 hospital trombolysis n = 365 CABG, PCI n = 434 no reperfusion n = 943	96% of PHT-patients got treatment from"mobile intensive care unit" all transported by GA	PHT 6% (1 year mortality) hospital thrombolysis 11% PCI 11%, no reperfusion treatment 21%, PHT mortality RR 0,49 (0,24 - 1,00)	lowest mortality in PHT Comparison between PHT and other reperfusion treatment RR = 0,52 (p = 0,08)
41	Biewener et al. 2004 Germany	prospective TRISS multiple trauma n = 403, 4 groups 1) HEMS-UNI n = 140 2) AMB-REG n = 102 3) AMB-UNI n = 70 4) INTER n = 91	all four goups ALS-PHYSICIAN 1) university hospital 2)regional hospital 3) university hospital 4) local hospital 1)transport by helicopter 2-4) transport by a GA	mortality rates: 1) 22,1% 2) 41,2% 3) 15,7% 4) 17,6% adusted risk 1) OR = 1 2) OR = 1,06 NS 3) OR = 4,06, p < 0,05 4) OR = 1,28, NS	ALS-PHYSICIAN + helicopter transport to university hospital is better than transport by a GA to regional hospital no difference in mortality between HEMS-UNI and AMB-UNI
42	Stiell et al. 2004 Canada	before-after -design cardiac arrest ALS n = 4247 BLS n = 1391	ALS-PARAMEDIC BLS-EMT ALS GA, BLS GA	mortality ALS 95,0% BLS 94,9% (p = 0,83) no adjustment No difference in QoL or cerebral performance	No difference in mortality.
43	Frankema et al. 2004 Netherlands	retrospective all serious injuries ALS n = 107 BLS n = 239	ALS-PHYSICIAN BLS-EMT, ALS helicopter, BLS GA	mortality: ALS 34,5%, BLS 24,3% adjustment: patients treated by ALS 2,4 fold probability to survive (p = 0,076). Blunt trauma OR 2,8, p = 0,036, penetrating trauma 0,2 (NS)	ALS better survival
44	Wang et al. 2004 Pennsylvania, U.S.A.	retrospective epidemiological study brain injury, comparison between patients intubated prehospitally with patients intubated in the hospital intubation on-site n = 1797 intubated in a hospital n = 2301	on-site intubation by ALS-PARAMEDIC or by ALS-PHYSICIAN, transportation by helicopter or by a GA	mortality on-site intubaltion 48,5%, hospitla intubation 28,2%, adjusted OR 3,99 (3,21-4,93)	patients intubated on-site had 4-fold risk of dying; patients intubated by using medication showed better survival.
45	Cameron et al. 2005 Australia	before-after-design all prehospital patients ALS-PHYSICIAN n = 211 ALS-PARAMEDIC BLS n = 163	ALS-PHYSICIAN, ALS-PARAMEDIC no BLS-group. ALS-PHYSICIAN helicopter ALS-PARAMEDIC helicopter	30 days mortality ALS-PHYSICIAN 2,8% ALS-PARAMEDIC 2,5%, NS	no difference bewtween ALS-PHYSICIAN and ALS-PARAMEDIC -groups
46	Mellado Vergel et al. 2005 Spain	retrospective cardiac infarct, PHT PHT n = 152 (ALS), hospital trombolysis (BLS) n = 829	ALS-PARAMEDIC BLS-EMT ALS GA, BLS GA	30 days mortality ALS 5,9%, BLS 26,6% (p = 0,066)	ALS (PHT) showed a trend to lower mortality
47	Di Bartolomeo et al. 2005 Italy	prospective traumatic cardiac arrest (blunt trauma) ALS n = 56, BLS n = 73	ALS-PHYSICIAN BLS-EMT+BLS-nurse ALS helicopter, BLS GA	ALS 96,5% only two patients survived BLS 100%, NS	no difference between ALS and BLS groups. prognosis still very poor
48	Davis et al. 2005 California, U.S.A.	retrospective epidemiological study brain injury ALS-helicopter n = 3017 ALS- GA n = 7295	Helicopter manned by paramedic, physician or nurse, ambulances manned by paramedics ALS helicopter, ALS GA	mortality: ALS helicopter 25,2% ALS ground ambulance 25,3% Adjusted OR 1,90 (1,60-2,25) mortality of patients intubated on site: ALS-helicopter 42,5% ALS-GA 43,1%, OR 1,42 (1,13-1,78)	ALS + helicopter + intubation on site better than ALS +GA + intubation in hospital
49	Björklund et al. Sweden, 2006	prospective prehospital trombolysis ALS n = 1690 BLS n = 3685 comparison between PHT entered in ambulance and thrombolysis in hospital	ALS-PARAMEDIC BLS-EMT, GA in both groups	mortality: ALS 5,4%, BLS 8,3 p < 0,001. ALS 0,71 (0,55-0,92) (1 year mortality); ALS 0,79 (0,61-1,03) 30 day mortality	ALS showed lower mortality
50	Sukumaran et al. 2006 Scotland	prospective TRISS all trauma patients ALS n = 12339 BLS n = 9078	ALS-PARAMEDIC BLS-EMT ALS GA, BLS GA	mortality: ALS 5,3%, BLS 4,5% p = 0,07; after adjustment no difference between groups	no difference between ALS and BLS groups
51	Iirola et al. 2006 Finland	retrospective before-after multiple trauma ALS n = 81, BLS n = 77	ALS-PHYSICIAN, BLS-EMT ALS helicopter (60%) or GA (39%) BLS GA	mortality: ALS 31%, BLS 18% p = 0,065; TRISS: material does not fit with MTOS-material QoL: no difference between groups	no difference between ALS and BLS groups, trend to bigger mortality in ALS-group (p = 0,065)
52	Klemen and Grmec 2006 Slovenia	prospective, historical controls multiple trauma, isolated head injury ALS n = 64, BLS n = 60	ALS-PHYSICIAN, ALS-EMT ALS GA, BLS GA	mortality ALS 40%, BLS 42% (NS). GOS level 4-5 achieved: ALS 53%, BLS 33%, p < 0,01	no difference in mortality in ALS better QoL
53	Stiell et al. 2007 Canada	prospective before-after dyspnoea, ALS n = 4218, BLS n = 3920	BLS-EMT, ALS-PARAMEDIC ALS GA, BLS GA	ALS 11,3% BLS 13,1% (p = 0,01)	lower mortality in ALS
54	Woodall et al. 2007 Australia	retrospective cardiac arrest ALS n = 1687 BLS n = 1288	ALS-PARAMEDIC BLS-EMT ALS GA, BLS GA	mortality: ALS 93,3%, BLS 95,3%; probablility for survival in all patients BLS = 1, ALS = 1,43 (1,02-1,99)	lower mortality ALS
55	Ma et al. 2007 Taiwan	prospective cardiac arrest ALS n = 386 BLS n = 1037	ALS-PARAMEDIC, BLS-EMT ALS GA, BLS GA	mortality ALS 93%, BLS 95% (NS); survival in ALS adjusted OR 1,41 (0,85-2,32)	no difference between groups
56	Seamon et al. 2007 Pennsylvania, U.S.A.	retrospective patients going to immediate thoracotomy comparison between ALS or BLS (n = 88) and private transport by laymen n = 92	ALS-PARAMEDIC ori BLS-EMT, compared to transportation by laymen.	mortality ALS,BLS 92% private transport 82,6% in multivariate analysis prehospital procedures were an independent predictor of mortality	better survival in persons transported by laymen
57	Stiell et al. 2008 Canada	Before-after -design. 92% blunt trauma, (ISS > 12), age ≥ 16 years ALS n = 1494 BLS n = 1373 Only 72% of the patients were transferred directly to the trauma centers from the scene.	ALS-PARAMEDIC, GA. BLS-PARAMEDIC, GA. Endotracheal intubation (7%), iv fluid (12%) and drug administration during the latter period.	Mortality ALS 18,9%, BLS 18,2% (p = 0,65) In patients with GCS < 9 mortality ALS 49,1%, BLS 40,0% (p = 0,02)	Implemantation of ALS did not decrease mortality or morbidity. In more severely injured patients (GCS < 9), mortality was lower in the BLS group.

Abbreviations: ALS = advanced life support, BLS = basic life support, EMT = emergency medical technician, LOS = length of stay (in hospital), ISS = Injury severity scale/score, TRISS = Trauma Score - Injury Severity Score, HEMS = Helicopter emergency medical service, GA = ground ambulance. PHT = prehospital throbolysis, OR = odds ratio, RR = risk ratio, ALS-N = advanced life support - nurse, ISS = injury severity score. QoL = quality of life.