Hospital‐Level Variation in Outcomes after In‐Hospital Cardiac Arrest in Denmark

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.

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Abstract 13686: Variation in Time in Therapeutic Range for Cooling for Out-of-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.144.suppl_2.13686 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Kevin M Wheelock ◽

Lian Chen ◽

Saket Girotra ◽

Paul S Chan ◽

Rohan Khera

Keyword(s):

Cardiac Arrest ◽

Clinical Practice ◽

Therapeutic Range ◽

Interpolation Method ◽

Controlled Trial ◽

Linear Interpolation ◽

Temperature Management ◽

Level Variation ◽

Time In Therapeutic Range ◽

Hospital Cardiac Arrest

Introduction: For comatose survivors of out-of-hospital cardiac arrest (OHCA), targeted temperature management (TTM) is strongly recommended with a goal temperature of 32-36C for a period of at least 24 hours. However, adherence to this target in clinical practice remains unknown. We developed time-in-therapeutic range (TTR) as a treatment metric for patients receiving TTM and evaluated patient- and site-level variation in TTR. Methods: We used data from the Resuscitation Outcomes Consortium-CCC trial which included patients with OHCA across 10 North American sites during 2011-2015. We identified patients who underwent TTM for >12 hours. Serial temperature measures were evaluated between hypothermia start and end times with temperatures between consecutive measures imputed using a linear interpolation method. TTR was defined as percent of time between 32C and 36C during TTM (Fig A). Site was defined based on trial clusters, which represented hospitals served by the same EMS agency. Site-level variation in TTR<90% was evaluated in hierarchical logistic regression using median odds ratio (OR), after adjustment for patient-level factors. Results: A total of 2,695 patients across 49 clusters were included with a median of 45 (IQR: 34 - 52) patients per cluster. The median duration of hypothermia was 23 (IQR: 21 - 24) hours with a median time outside therapeutic range of 0.9 (IQR: 0.0 - 4.2) hours. The median TTR was 96.1% but 1,654 (61%) patients had at least one temperature outside the therapeutic range and 991 (37%) patients had a TTR <90%. There was large variation across sites in the proportion of patients with TTR<90%, ranging from 10% to 68%, with a median OR of 1.74 (Fig B). Conclusions: Within a large randomized controlled trial, more than 1 in 3 OHCA patients treated with TTM had a TTR <90%, with large variation in TTR across sites. These findings highlight an urgent need to focus on improving quality of TTM in clinical practice.

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

JAMA Network Open ◽

10.1001/jamanetworkopen.2020.10403 ◽

2020 ◽

Vol 3 (7) ◽

pp. e2010403 ◽

Cited By ~ 1

Author(s):

Saket Girotra ◽

Brahmajee K. Nallamothu ◽

Yuanyuan Tang ◽

Paul S. Chan ◽

Keyword(s):

Cardiac Arrest ◽

Hospital Level ◽

Hospital Cardiac Arrest ◽

Overall Risk

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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

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Temporal trends and hospital-level variation of inhospital cardiac arrest incidence and outcomes in the Veterans Health Administration

American Heart Journal ◽

10.1016/j.ahj.2017.05.018 ◽

2017 ◽

Vol 193 ◽

pp. 117-123 ◽

Cited By ~ 8

Author(s):

Steven M. Bradley ◽

Peter Kaboli ◽

Lee A. Kamphuis ◽

Paul S. Chan ◽

Theodore J. Iwashyna ◽

...

Keyword(s):

Cardiac Arrest ◽

Temporal Trends ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Level Variation ◽

Hospital Level

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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.

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