Association of Hospital-Level Acute Resuscitation and Postresuscitation Survival With Overall Risk-Standardized Survival to Discharge for In-Hospital Cardiac Arrest

Background: Improving the quality of in-hospital cardiac arrest (IHCA) care within the Veterans Health Administration (VHA) has received significant attention. Yet there are no national VHA data on the incidence and mortality outcomes of IHCA to guide or evaluate these efforts. We sought to determine overall trends and hospital-level variation in the incidence and 30-day mortality of IHCA within the VHA. Methods: Among 2,731,295 patients hospitalized at 115 VHA hospitals between 2008 and 2012, we defined IHCA using specific ICD-9 procedure codes for cardiac arrest and cardiopulmonary resuscitation. Among patients suffering IHCA, we used the VA Vital Status file to identify 30-day mortality from hospital admission. A severity of illness score was used to account for case-mix and determined from a logistic multivariate adaptive regression spline (MARS) model fit to our mortality outcome with covariates for age, race, gender, admission diagnosis category, 29 comorbid conditions, and 11 lab values drawn within 24 hours of admission. Hospital-level IHCA incidence and 30-day mortality rates were compared using empirical Bayes random effects estimates from multi-level regression models after risk- and reliability-adjustment. Results: 8,565 (0.3%) patients suffered IHCA between 2008 and 2012 and there was no significant trend in the rate of IHCA over this time period. The hospital-level incidence of IHCA varied and was statistically significantly higher than the median rate at 38 (34%) hospitals and significantly lower at 24 (21%) hospitals (Figure A, p<0.05 without adjustment for multiple comparisons). Among patients suffering IHCA, the overall 30-day mortality rate was 68.6% and the risk-adjusted 30-day mortality rate decreased from 71.2% in 2008 to 66.1% in 2012 (p for trend <0.01). Hospital-level 30-day mortality was significantly higher than the median rate at 5 (4%) hospitals and significantly lower at 7 (6%) hospitals (Figure B). Conclusions: Within the VHA, the incidence of IHCA has remained stable while 30-day mortality has improved. However, hospital-level variation in IHCA incidence and mortality rates suggest variation in care processes related to IHCA and a target for future investigation to improve patient outcomes.

Download Full-text

Association of acute resuscitation and post-resuscitation survival with overall risk-standardized survival to discharge for in-hospital cardiac arrest

European Heart Journal ◽

10.1093/ehjci/ehaa946.0754 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Girotra ◽

B Nallamothu ◽

Y Tang ◽

P Chan

Keyword(s):

Cardiac Arrest ◽

Spontaneous Circulation ◽

Public Institution ◽

Hierarchical Regression ◽

Funding Source ◽

High Survival ◽

Return Of Spontaneous Circulation ◽

Adjusted Rate ◽

Hospital Cardiac Arrest ◽

Overall Risk

Abstract Background Although survival for in-hospital cardiac arrest (IHCA) varies markedly across sites, it remains unknown whether high survival at top-performing hospitals is due to high rates of acute resuscitation survival (i.e., achievement of return of spontaneous circulation [ROSC]), post-resuscitation survival (i.e., survival to discharge among patients who achieved ROSC), or both. Methods Using 2015–2018 Get With The Guidelines (GWTG)-Resuscitation data, we identified 290 hospitals (86,426 patients) with IHCA. For each hospital, we calculated overall risk-standardized survival (RSSR) to discharge for IHCA using a previously validated hierarchical regression model and categorized hospitals into quartiles based on that metric. Risk-adjusted rates of acute resuscitation survival (defined as return of spontaneous circulation for >20 minutes [ROSC]) and post-resuscitation survival (defined as the proportion of patients achieving ROSC who survived to hospital discharge) were also computed for each hospital. We examined the correlation between a hospital's overall RSSR with its risk-adjusted rate of acute resuscitation and post-resuscitation survival. Results Among study hospitals, the median RSSR was 25.1% (inter-quartile range [IQR]: 21.9%–27.7%). The median risk-adjusted rate of acute resuscitation survival was 72.4% (IQR: 67.9%–76.9%) and post-resuscitation survival was 34.0% (IQR: 31.5%–37.7%). Hospital rates of RSSR were less strongly correlated with risk-adjusted rates of acute resuscitation survival (rho=0.50, P<0.001) than post-resuscitation survival (rho=0.90, P<0.001). Compared with hospitals in the lowest quartile of RSSR, hospitals in the highest quartile had substantially higher rates of acute resuscitation survival (Q4: 75.4% vs. Q1: 66.8%; P<0.001) and post-resuscitation survival (Q4: 40.3% vs. Q1: 28.7%; P<0.001). Notably, there was no correlation between hospital risk-adjusted rates of acute resuscitation survival and post-resuscitation survival (rho=0.09, P=0.11). Conclusion Hospital that excel in overall IHCA survival in general excel in either acute resuscitation or post-resuscitation care. As most hospital-based quality improvement initiatives largely focus on acute resuscitation survival, our findings suggest that efforts to strengthen post-resuscitation care may offer additional opportunities to improve IHCA survival. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): NHLBI

Download Full-text

Variability in survival after in-hospital cardiac arrest depending on the hospital level of care

Resuscitation ◽

10.1016/j.resuscitation.2006.08.022 ◽

2007 ◽

Vol 73 (1) ◽

pp. 73-81 ◽

Cited By ~ 28

Author(s):

M.B. Skrifvars ◽

M. Castrén ◽

S. Aune ◽

A.B. Thoren ◽

J. Nurmi ◽

...

Keyword(s):

Cardiac Arrest ◽

Level Of Care ◽

Hospital Level ◽

Hospital Cardiac Arrest

Download Full-text

Abstract 183: Association of Hospital-Level Factors With Variation in Survival After Out-Of-Hospital Cardiac Arrest Between Receiving Hospitals in Japan

Circulation ◽

10.1161/circ.140.suppl_2.183 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Satoshi Koyama ◽

Koichiro Gibo ◽

Yutaka Yamaguchi ◽

Masashi Okubo

Keyword(s):

Cardiac Arrest ◽

Patient Outcomes ◽

Cerebral Performance Category ◽

Temperature Management ◽

Secondary Outcome ◽

Hospital Level ◽

Extracorporeal Cardiopulmonary Resuscitation ◽

Patient Level ◽

Hospital Variation ◽

Hospital Cardiac Arrest

Background: Patient outcomes after out-of-hospital cardiac arrest (OHCA) varies at multiple levels (geographic regions, emergency medical service agencies, and receiving hospitals). However, the contribution of hospital-level factors to the outcome variation is unclear. We aimed to investigate the association between hospital-level factors and variation in outcomes after OHCA between hospitals. Methods: We performed secondary analysis of the Japanese Association for Acute Medicine OHCA Registry, a prospective multi-center registry. We included adults (≥18 years) with OHCA of medical origin between June 2014 and December 2015. The primary outcome was 1-month survival and secondary outcome was 1-month survival with favorable functional status, defined as Cerebral Performance Category scale 1 or 2. We constructed two multivariable hierarchical logistic regression models for each outcome: (1) patient-level factors and (2) patient- and hospital-level factors. Hospital-level factors included the number of medical staff involved in resuscitation, proportion of patients who received targeted temperature management among those with return of spontaneous circulation, and proportion of patients who received extracorporeal cardiopulmonary resuscitation among those with shockable rhythm. We calculated adjusted outcomes for each hospital and median odds ratios (MORs) to evaluate the effects of hospital-level factors on between-hospital variation in outcomes. Results: We analyzed the data of 9,303 adults with OHCA of medical origin treated at 67 hospitals. After adjustment for patient-level factors, 1-month survival was 0.02-0.14 (adjusted MOR, 1.36; 95% credible interval (CI), 1.17-1.77). After adjustment for patient- and hospital-level factors, the adjusted MOR was 1.14 (95% CI, 1.05-1.33). Similarly, the adjusted MORs for favorable functional outcomes were 1.48 (95% CI 1.18-2.12) with adjustment for patient-level factors and 1.30 (95% CI 1.07-1.80) with adjustment for patient- and hospital-level factors. Conclusions: With adjustment for hospital-level factors, we noted attenuation of variation in patient outcomes after OHCA across hospitals, suggesting that hospital-level factors may partly explain outcome variations.

Download Full-text