Risk-Standardizing Survival for In-Hospital Cardiac Arrest to Facilitate Hospital Comparisons

doi:10.1016/j.jacc.2013.05.051

Journal of the American College of Cardiology

Volume 62, Issue 7, 13 August 2013, Pages 601-609

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Objectives

The purpose of this study is to develop a method for risk-standardizing hospital survival after cardiac arrest.

Background

A foundation with which hospitals can improve quality is to be able to benchmark their risk-adjusted performance against other hospitals, something that cannot currently be done for survival after in-hospital cardiac arrest.

Methods

Within the Get With The Guidelines (GWTG)-Resuscitation registry, we identified 48,841 patients admitted between 2007 and 2010 with an in-hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for survival to hospital discharge and calculated risk-standardized survival rates (RSSRs) for 272 hospitals with at least 10 cardiac arrest cases.

Results

The survival rate was 21.0% and 21.2% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.74) and excellent calibration. Eighteen variables were associated with survival to discharge, and a parsimonious model contained 9 variables with minimal change in model discrimination. Before risk adjustment, the median hospital survival rate was 20% (interquartile range: 14% to 26%), with a wide range (0% to 85%). After adjustment, the distribution of RSSRs was substantially narrower: median of 21% (interquartile range: 19% to 23%; range 11% to 35%). More than half (143 [52.6%]) of hospitals had at least a 10% positive or negative absolute change in percentile rank after risk standardization, and 50 (23.2%) had a ≥20% absolute change in percentile rank.

Conclusions

We have derived and validated a model to risk-standardize hospital rates of survival for in-hospital cardiac arrest. Use of this model can support efforts to compare hospitals in resuscitation outcomes as a foundation for quality assessment and improvement.

Key Words

cardiac arrest

risk adjustment

variation in care

Abbreviations and Acronyms

AHA

American Heart Association

DNR

do not resuscitate

GWTG

Get With The Guidelines

Cited by (0)

: The American Heart Association (AHA) Get With the Guidelines-Resuscitation Investigators (formerly, the National Registry of Cardiopulmonary Resuscitation) are listed in the Online Appendix. The underlying research reported in the article was funded by the U.S. National Institutes of Health. Drs. Chan (K23HL102224) and Merchant (K23109083) are supported by Career Development Grant Awards from the National Heart Lung and Blood Institute (NHBLI). Dr. Chan is also supported by funding from the AHA. GWTG-Resuscitation is sponsored by the AHA. Dr. Schwamm is the Chair of the AHA's GWTG National Steering Committee. Dr. Bhatt is on the advisory board of Medscape Cardiology; the Board of Directors of Boston VA Research Institute and the Society of Chest Pain Centers; is Chair of the AHA GWTG Science Subcommittee; has received honoraria from the American College of Cardiology (Editor, Clinical Trials, Cardiosource), Duke Clinical Research Institute (clinical trial steering committees), Slack Publications (Chief Medical Editor, Cardiology Today Intervention), WebMD (CME steering committees); is the Senior Associate Editor, Journal of Invasive Cardiology; has received research grants from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, and The Medicines Company; and has received unfunded research from FlowCo, PLx Pharma, and Takeda. Dr. Fonarow has received grant funding from the NHLBI and AHRQ; and consulting for Novartis and Medtronic. Dr. Spertus has received grant funding from the NIH, AHA, Lilly, Amorcyte, and Genentech; serves on Scientific Advisory Boards for United Healthcare, St. Jude Medical, and Genentech; and serves as a paid editor for Circulation: Cardiovascular Quality and Outcomes; has intellectual property rights for the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, Peripheral Artery Questionnaire; and has equity interest in Health Outcomes Sciences. Dr. Merchant has received grant funding from NIH, K23 Grant 10714038, Physio-Control, Zoll Medical, Cardiac Science, and Philips Medical. All other authors have reported they have no relationships relevant to the contents of this paper to disclose.