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Original Investigation |

Association Between a Hospital’s Rate of Cardiac Arrest Incidence and Cardiac Arrest Survival

Lena M. Chen, MD, MS1,3; Brahmajee K. Nallamothu, MD, MPH2,3; John A. Spertus, MD, MPH4,5; Yan Li, PhD4; Paul S. Chan, MD, MSc4,5,6; American Heart Association’s Get With the Guidelines–Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators
[+] Author Affiliations
1Division of General Medicine, University of Michigan, Ann Arbor
2Divison of Cardiovascular Medicine, University of Michigan, Ann Arbor
3Department of Internal Medicine, University of Michigan, and Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor
4St Luke’s Mid-America Heart and Vascular Institute, Kansas City, Missouri
5University of Missouri, Kansas City
6currently with the Division of General Medicine, Department of Internal Medicine, University of Michigan, and Veterans Affairs Ann Arbor Healthcare System
JAMA Intern Med. 2013;173(13):1186-1195. doi:10.1001/jamainternmed.2013.1026.
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Importance  National efforts to measure hospital performance in treating cardiac arrest have focused on case survival, with the hope of improving survival after cardiac arrest. However, it is plausible that hospitals with high case-survival rates do a poor job of preventing cardiac arrests in the first place.

Objective  To describe the association between inpatient cardiac arrest incidence and survival rates.

Design  Within a large, national registry, we identified hospitals with at least 50 adult in-hospital cardiac arrest cases between January 1, 2000, and November 30, 2009. We used multivariable hierarchical regression to evaluate the correlation between a hospital’s cardiac arrest incidence rate and its case-survival rate after adjusting for patient and hospital characteristics.

Main Outcomes and Measures  The correlation between a hospital’s incidence rate and case-survival rate for cardiac arrest.

Results  Of 102 153 cases at 358 hospitals, the median hospital cardiac arrest incidence rate was 4.02 per 1000 admissions (interquartile range, 2.95-5.65 per 1000 admissions), and the median hospital case-survival rate was 18.8% (interquartile range, 14.5%-22.6%). In crude analyses, hospitals with higher case-survival rates also had lower cardiac arrest incidence (r, −0.16; P = .003). This relationship persisted after adjusting for patient characteristics (r, −0.15; P = .004). After adjusting for potential mediators of this relationship (ie, hospital characteristics), the relationship between incidence and case survival was attenuated (r, −0.07; P = .18). The one modifiable hospital factor that most attenuated this relationship was a hospital’s nurse-to-bed ratio (r, −0.12; P = .03).

Conclusions and Relevance  Hospitals with exceptional rates of survival for in-hospital cardiac arrest are also better at preventing cardiac arrests, even after adjusting for patient case mix. This relationship is partially mediated by measured hospital attributes. Performance measures focused on case-survival rates seem an appropriate first step in quality measurement for in-hospital cardiac arrest.

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Figures

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Figure 1.
Study Cohort
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Figure 2.
Distribution of Unadjusted Hospital Rates

A, Cardiac arrest incidence. B, In-hospital case survival.

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Figure 3.
Correlation Between Hospital Rates of Cardiac Arrest Incidence and Case Survival

A, Unadjusted rates (correlation, −0.16; P = .003). B, Rates adjusted for patient factors only (r, −0.15; P = .004). Incidence is adjusted for the Centers for Medicare and Medicaid Services case-mix index for hospital admissions, and case survival is adjusted for patient factors (ie, age, sex, race/ethnicity, and preexisting conditions), including event characteristics (ie, initial arrest rhythm, year of admission, night vs day, and weekend vs weekday).

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Figure 4.
Mediation Analysis of Hospital Factors That May Account for the Correlation Between Hospital Rates of Cardiac Arrest Incidence and Case Survival

Regression models were adjusted for both patient and hospital factors to determine whether certain hospital factors may, in part, mediate this relationship. Incidence is adjusted for the Centers for Medicare and Medicaid Services case-mix index for hospital admissions and hospital factors (ie, teaching status, ownership, geographical region, urban vs rural, full-time–equivalent nurse ratio, number of beds, and certification as a trauma center). Case survival is adjusted for case-mix index, patient factors, and hospital factors (r, −0.07; P = .18).

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