799: Palliative Care Utilization Following Out-of-Hospital Cardiac Arrest in Pediatrics

AbstractAimsPrevious studies on sex differences in out-of-hospital cardiac arrest (OHCA) had limited scope and yielded conflicting results. We aimed to provide a comprehensive overall view on sex differences in care utilization, and outcome of OHCA.Methods and resultsWe performed a population-based cohort-study, analysing all emergency medical service (EMS) treated resuscitation attempts in one province of the Netherlands (2006–2012). We calculated odds ratios (ORs) for the association of sex and chance of a resuscitation attempt by EMS, shockable initial rhythm (SIR), and in-hospital treatment using logistic regression analysis. Additionally, we provided an overview of sex differences in overall survival and survival at successive stages of care, in the entire study population and in patients with SIR. We identified 5717 EMS-treated OHCAs (28.0% female). Women with OHCA were less likely than men to receive a resuscitation attempt by a bystander (67.9% vs. 72.7%; P < 0.001), even when OHCA was witnessed (69.2% vs. 73.9%; P < 0.001). Women who were resuscitated had lower odds than men for overall survival to hospital discharge [OR 0.57; 95% confidence interval (CI) 0.48–0.67; 12.5% vs. 20.1%; P < 0.001], survival from OHCA to hospital admission (OR 0.88; 95% CI 0.78–0.99; 33.6% vs. 36.6%; P = 0.033), and survival from hospital admission to discharge (OR 0.49, 95% CI 0.40–0.60; 33.1% vs. 51.7%). This was explained by a lower rate of SIR in women (33.7% vs. 52.7%; P < 0.001). After adjustment for resuscitation parameters, female sex remained independently associated with lower SIR rate.ConclusionIn case of OHCA, women are less often resuscitated by bystanders than men. When resuscitation is attempted, women have lower survival rates at each successive stage of care. These sex gaps are likely explained by lower rate of SIR in women, which can only partly be explained by resuscitation characteristics.

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Identifying patients at risk of futile resuscitation: palliative care indicators in out-of-hospital cardiac arrest

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2019-001828 ◽

2019 ◽

pp. bmjspcare-2019-001828

Author(s):

Mia Cokljat ◽

Adam Lloyd ◽

Scott Clarke ◽

Anna Crawford ◽

Gareth Clegg

Keyword(s):

At Risk ◽

Palliative Care ◽

Cardiac Arrest ◽

High Risk ◽

Low Risk ◽

Intermediate Risk ◽

Patients At Risk ◽

Risk Patients ◽

Record Review ◽

Hospital Cardiac Arrest

ObjectivesPatients with indicators for palliative care, such as those with advanced life-limiting conditions, are at risk of futile cardiopulmonary resuscitation (CPR) if they suffer out-of-hospital cardiac arrest (OHCA). Patients at risk of futile CPR could benefit from anticipatory care planning (ACP); however, the proportion of OHCA patients with indicators for palliative care is unknown. This study quantifies the extent of palliative care indicators and risk of CPR futility in OHCA patients.MethodsA retrospective medical record review was performed on all OHCA patients presenting to an emergency department (ED) in Edinburgh, Scotland in 2015. The risk of CPR futility was stratified using the Supportive and Palliative Care Indicators Tool. Patients with 0–2 indicators had a ‘low risk’ of futile CPR; 3–4 indicators had an ‘intermediate risk’; 5+ indicators had a ‘high risk’.ResultsOf the 283 OHCA patients, 12.4% (35) had a high risk of futile CPR, while 16.3% (46) had an intermediate risk and 71.4% (202) had a low risk. 84.0% (68) of intermediate-to-high risk patients were pronounced dead in the ED or ED step-down ward; only 2.5% (2) of these patients survived to discharge.ConclusionsUp to 30% of OHCA patients are being subjected to advanced resuscitation despite having at least three indicators for palliative care. More than 80% of patients with an intermediate-to-high risk of CPR futility are dying soon after conveyance to hospital, suggesting that ACP can benefit some OHCA patients. This study recommends optimising emergency treatment planning to help reduce inappropriate CPR attempts.

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Abstract 14599: Long-term Outcomes in Elderly Survivors of Myocardial Infarction With and Without Out-of-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.132.suppl_3.14599 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Christopher B Fordyce ◽

Tracy Y Wang ◽

Anita Y Chen ◽

Laine Thomas ◽

Christopher B Granger ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiac Arrest ◽

Care Utilization ◽

Post Discharge ◽

Term Survival ◽

Cox Models ◽

Kaplan Meier ◽

Long Term Prognosis ◽

Hospital Cardiac Arrest

Introduction: While out-of-hospital cardiac arrest (OHCA) is associated with worse in-hospital outcomes following acute myocardial infarction (MI), post-discharge mortality and health care utilization of elderly patients who survive hospitalization have not been well described. Understanding their long-term prognosis has implications for resource allocation for managing this growing population. Methods: Using linked NCDR ACTION-Registry GWTG and Centers for Medicare and Medicaid Services data, we analyzed 54,860 patients (mean age = 76.6) at 545 US hospitals with MI who survived to hospital discharge between April 2011 to December 2012. After excluding hospice patients (n=1,444), rates of observed 1-year mortality post-discharge were computed using the Kaplan-Meier method. Multivariable Cox models were used to examine the associations between OHCA and mortality or all-cause readmission within 1 year post-discharge. Results: Compared with elderly MI survivors without OHCA (n=54,219), those with OHCA (n=641) were younger, more likely to be male and smokers, but less likely to have diabetes, heart failure, or prior revascularization. OHCA patients presented to the hospital more often with STEMI and cardiogenic shock, and were more likely to experience adverse in-hospital events compared to patients without OCHA. Despite this, OHCA was associated with similar unadjusted (Figure, p=0.17) and adjusted 1-year post-discharge mortality (adjusted HR 0.87, 95% CI, 0.67 - 1.13) and lower combined unadjusted (44.0% vs. 50.0%, p=0.033) or adjusted 1-year mortality or all-cause readmission (adjusted HR 0.83, 95% CI, 0.71 - 0.96). Conclusions: Elderly survivors of MI complicated by OHCA have similar long-term survival and lower rates of healthcare utilization at 1 year post-discharge compared to those without OHCA. These findings support efforts to optimize pre- and intra- hospital processes of care to improve outcomes of elderly OHCA patients.

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Abstract 271: Care Patterns for Out Of Hospital Cardiac Arrest Differ From Other Emergency Care Sensitive Conditions

Circulation ◽

10.1161/circ.142.suppl_4.271 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

David G Buckler ◽

Douglas Wiebe ◽

Sarah Sims ◽

Ronan Doorley ◽

Alexis Zebrowski ◽

...

Keyword(s):

Cardiac Arrest ◽

Emergency Care ◽

Systems Of Care ◽

Heart Association ◽

Care Utilization ◽

Fee For Service ◽

Care Patterns ◽

Utilization Patterns ◽

Hospital Cardiac Arrest ◽

Sensitive Conditions

Background: Understanding utilization patterns for out of hospital cardiac arrest (OHCA) is critical to organizing regional systems of care as recommended by the American Heart Association. We examined the agreement between regional utilization patterns for out-of-hospital cardiac arrest (OHCA) and other emergency care sensitive conditions (ECSCs). Methods: We used Medicare fee-for-service outpatient and inpatient claims from 2013-2014 to describe geographic utilization patterns for 5 emergency care conditions as has been done previously. We compared these regional clusters developed for OHCA to similarly created clusters for other emergency cardiovascular (ECV) conditions (by adding STEMI and stroke). Regional ZIP code attributions were compared using a modified Jaccard index, measuring the agreement between region membership. We also calculated patient-level risk-adjusted survival probabilities (controlling for patient age, sex, race and presenting condition) and summarized for each region as an observed-to-expected (O:E) ratio. O:E ratios higher than 1 indicate better than expected survival. Each region was ranked based on its O:E ratio and ranks between the two sets of conditions were compared. Results: The analysis included 3,279,013 ECSC claims containing 246,342 OHCA and 1,037,472 ECV claims grouped into 234 OHCA regions and 343 ECV regions. When comparing OHCA only to all ECV utilization (clusters), agreement was 64%. O:E survival to hospital discharge for OHCA regions showed greater variability compared to ECV regions (OHCA: 0.53-2.2 vs. ECV: 0.90 - 1.10). In comparing ranked O:E outcomes between OHCA and ECV regions, we found 72% discordance in quartile rankings (κ = 0.28). Conclusion: Care utilization pattern and risk-adjusted survival for OHCA in older adults vary greatly when compared to other emergency cardiovascular conditions and should be benchmarked separately. Further research is needed to understand the role strong regionalization of care policies could play in improving outcomes and streamlining care processes.

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