title: Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis.
abstract: BACKGROUND
  Evidence suggests that EMS-physician-guided cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OOHCA) may be associated with improved outcomes, yet randomized controlled trials are not available. The goal of this meta-analysis was to determine the association between EMS-physician- versus paramedic-guided CPR and survival after OOHCA.
  
  
  RESULTS
  Studies that compared EMS-physician- versus paramedic-guided CPR in OOHCA published until June 2014 were systematically searched in MEDLINE, EMBASE and Cochrane databases. All studies were required to contain survival data. Data on study characteristics, methods, and as well as survival outcomes were extracted. A random-effects model was used for the meta-analysis due to a high degree of heterogeneity among the studies (I(2) = 44%). Return of spontaneous circulation [ROSC], survival to hospital admission, and survival to hospital discharge were the outcome measures. Out of 3,385 potentially eligible studies, 14 met the inclusion criteria. In the pooled analysis (n = 126,829), EMS-physician-guided CPR was associated with significantly improved outcomes compared to paramedic-guided CPR: ROSC 36.2% (95% confidence interval [CI] 31.0 - 41.7%) vs. 23.4% (95% CI 18.5 - 29.2%) (pooled odds ratio [OR] 1.89, 95% CI 1.36 - 2.63, p < 0.001); survival to hospital admission 30.1 % (95% CI 24.2 - 36.7%) vs. 19.2% (95% CI 12.7 - 28.1%) (pooled OR 1.78, 95% CI 0.97 - 3.28, p = 0.06); and survival to discharge 15.1% (95% CI 14.6 - 15.7%) vs. 8.4% (95% CI 8.2 - 8.5%) (pooled OR 2.03, 95% CI 1.48 - 2.79, p < 0.001).
  
  
  CONCLUSIONS
  This systematic review suggests that EMS-physician-guided CPR in out-of-hospital cardiac arrest is associated with improved survival outcomes.
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany. bernd.boettiger@uk-koeln.de.
authors.forename: Bernd W
authors.initials: BW
authors.lastname: Böttiger
authors.affiliation: Emergency Department, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany. michael.bernhard@medizin.uni-leipzig.de.
authors.forename: Michael
authors.initials: M
authors.lastname: Bernhard
authors.affiliation: Department of Anesthesiology and Pain Therapy, Bern University Hospital, Freiburgstr. 4, 3010, Bern, Switzerland. juergen.knapp@med.uni-heidelberg.de.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Knapp
authors.affiliation: Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA. nagelep@wustl.edu.
authors.forename: Peter
authors.initials: P
authors.lastname: Nagele
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000401:mortality* / Q000592:standards*; D004632:Emergency Medical Services / Q000379:methods*; D006801:Humans; D058687:Out-of-Hospital Cardiac Arrest / Q000401:mortality*; D010351:Patient Discharge / Q000706:statistics & numerical data / Q000639:trends; D063868:Patient Outcome Assessment; D010820:Physicians / Q000706:statistics & numerical data*; D016019:Survival Analysis; D013997:Time Factors