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Original Investigation |

Development and Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) Score to Predict Neurologically Intact Survival After In-Hospital Cardiopulmonary Resuscitation

Mark H. Ebell, MD, MS1,2; Woncheol Jang, PhD3; Ye Shen, PhD1; Romergryko G. Geocadin, MD4; for the Get With the Guidelines–Resuscitation Investigators
[+] Author Affiliations
1Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens
2Institute for Evidence-Based Practice in the Health Professions, University of Georgia, Athens
3Department of Statistics, Seoul National University, Seoul, Republic of Korea
4Departments of Neurology, Anesthesiology–Critical Care Medicine, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Intern Med. 2013;173(20):1872-1878. doi:10.1001/jamainternmed.2013.10037.
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Importance  Informing patients and providers of the likelihood of survival after in-hospital cardiac arrest (IHCA), neurologically intact or with minimal deficits, may be useful when discussing do-not-attempt-resuscitation orders.

Objective  To develop a simple prearrest point score that can identify patients unlikely to survive IHCA, neurologically intact or with minimal deficits.

Design, Setting, and Participants  The study included 51 240 inpatients experiencing an index episode of IHCA between January 1, 2007, and December 31, 2009, in 366 hospitals participating in the Get With the Guidelines–Resuscitation registry. Dividing data into training (44.4%), test (22.2%), and validation (33.4%) data sets, we used multivariate methods to select the best independent predictors of good neurologic outcome, created a series of candidate decision models, and used the test data set to select the model that best classified patients as having a very low (<1%), low (1%-3%), average (>3%-15%), or higher than average (>15%) likelihood of survival after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status. The final model was evaluated using the validation data set.

Main Outcomes and Measures  Survival to discharge after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status (neurologically intact or with minimal deficits) based on a Cerebral Performance Category score of 1.

Results  The best performing model was a simple point score based on 13 prearrest variables. The C statistic was 0.78 when applied to the validation set. It identified the likelihood of a good outcome as very low in 9.4% of patients (good outcome in 0.9%), low in 18.9% (good outcome in 1.7%), average in 54.0% (good outcome in 9.4%), and above average in 17.7% (good outcome in 27.5%). Overall, the score can identify more than one-quarter of patients as having a low or very low likelihood of survival to discharge, neurologically intact or with minimal deficits after IHCA (good outcome in 1.4%).

Conclusions and Relevance  The Good Outcome Following Attempted Resuscitation (GO-FAR) scoring system identifies patients who are unlikely to benefit from a resuscitation attempt should they experience IHCA. This information can be used as part of a shared decision regarding do-not-attempt-resuscitation orders.

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Figure.
Hosmer-Lemeshow Graph for the Full Model

The Hosmer-Lemeshow graph is shown for the full logistic regression model, which uses variable selection based on the Bayesian information criterion.

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