In-hospital cardiac arrest (IHCA) is common and associated with considerable mortality, morbidity and resource costs. Inpatient survival after IHCA has improved nationally over the last decade, although similar statistics within the VHA are not available. More importantly, however, few contemporary data exist - either nationally or in the VHA - on the long-term survival, care requirements and health status of patients with IHCA.
The fundamental goal of ResCU was to understand patterns of long-term outcomes and healthcare utilization across hospitals after IHCA and then to use these insights to develop new strategies for quality improvement both within the VHA and elsewhere. Aim 1: Measure long-term outcomes and care requirements after IHCA and determine key patient-level factors that are linked to adverse outcomes. Aim 2: Identify hospital-level factors related to long-term outcomes and utilization. Aim 3: Determine the extent of variation in long-term, risk-adjusted outcomes across hospitals and VISNs.
For Aim 1, we identified Veterans who were discharged alive from a VA Medical Center with ICD-9-CM codes of 427.5 (cardiac arrest), 99.60 (cardiopulmonary resuscitation), and 99.63 (closed chest cardiac massage) from October 1, 2014 to January 5, 2016. After manual confirmation of eligibility through medical record review by trained research assistants (RAs), eligible Veterans were recruited by phone. Veterans who consented were surveyed by phone or mail at 3, 6, 9, and 12 months post-discharge
For Aims 2 and 3, we identified all IHCA associated hospitalizations at VHA hospitals nationally from January 2013 to June 2015 using administrative claims codes supplemented with chart review. Hierarchical logistic regression modeling (HLRM) was used.
Aim 1: There were 2,554 IHCA in VA hospitals during the period 2014 to 2016. Of these, 1,188 (47%) appeared to survive at least 8 weeks, and were eligible for enrollment. 564 (48% of 1,188) were confirmed by manual chart review to have had an IHCA; 253 (21% of 1,188) were not eligible upon screening and 371 (31% of 1,188) were deceased upon screening. 90 (16% of 564) were found to have died prior to potential enrollment, and 16 (3% of 564) were excluded upon potential enrollment, leaving a final eligible cohort of 458. Of these, 325 (71% of 458) were located, gave informed consent, and completed the first survey at 3 months post discharge.
Of these 325 patients, 280 (86%) survived until 12-months after their discharge. 263 patients allowed linkage of their subsequent healthcare utilization to survey data. Rates of any recurrent VA hospitalization were 35.7%, 25.5%, 24.2%, and 17.4% for each quarter after hospital discharge (p=<0.001 rejecting the hypothesis that there is no difference over time).
At 3 months after IHCA, 107 (33%) patients reported having no impairments in their ADLs or IADLs due to health-related problems; 121 (37%) reported mild-to-moderate disability, 1 to 3 impairments; and 97 (30%) reported severe disability, 4 or more impairments. By 12-months, those figures were 109 (42% of survivors), 80 (31%), and 73 (27%) for no, mild-to-moderate and severe disability, respectively, among survivors. Ongoing loss or recovery from disability was persistent throughout the 3 to 12 month period, not concentrated in the earlier period. Excluding transitions to death, there were 119 transitions among the 3-categories of disability between months 3 and 6, 96 between months 6 and 9, and 101 between months 9 and 12.
In multinomial logistic regression, patients whose IHCA occurred during a medical (as opposed to surgical) admission or with longer hospitalizations were more likely to have declining function during months 3 to 12 relative to stable function. Age and pre-IHCA comorbidity were not associated with increased risk of decline versus stability; the effects of race, prior nursing home use, and gender were not statistically significant but were too imprecisely estimated to rule-out clinically meaningful effects.
We also sought to evaluate IHCA clinical documentation, including the reporting of key IHCA characteristics. Of 101 patients who experienced IHCA between April 8, 2015, and May 5, 2015, presenting rhythm could not be ascertained from the medical record in 15 (15%) cases; duration of CPR could not be ascertained in 34 (34%); and time from IHCA to start of CPR could not be ascertained in 68 (67%). A freestanding IHCA clinical document was absent in 50 (50%) patients.
Aims 2/3: Our final cohort consisted of 5,252 patients across 94 hospitals. A median of 33.6% of patients survived to discharge, and of the survivors, 63.6% were alive at 1 year. While there was substantial variation across hospitals in in-hospital survival across hospitals (range 23.2%-56.1%), there was little minimal variation in 1 year post-discharge survival (range 61.6%-66.0%). In-hospital survival also was not correlated with 1 year post-discharge survival at the hospital level (R-squared=0.005). In multivariable models, age (OR 0.97 per year, p<0.001) and black vs. white race (OR 0.78, p=0.032) were associated with poorer 1 year post-discharge survival.
In this prospective national sample of patients who survived hospitalization after a serious illness with IHCA, we demonstrated that there is substantial ongoing recovery from disability-as well as loss of function-across the year after hospital discharge. Indeed nearly 1 in 3 survivors of IHCA experience marked decline or prominent recovery in the period from 3 months to 12 months after discharge from an IHCA hospitalization. We conclude that the entire year after hospitalization for serious illness, exemplified here by hospitalizations in which an IHCA occurred, is a highly dynamic period for patients. This suggests that there may be substantial plasticity and opportunities for recovery for patients even with quite poor initial function. We have submitted a follow-on grant to identify ways to maximize recovery from disability among Veterans.
Further, there currently exist wide variation in IHCA practices across VAs, and important opportunities to improve and standardize those practices for these most vulnerable patients.
External Links for this Project
Grant Number: I01HX001276-01A1
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- Levy MM, Gesten FC, Phillips GS, Terry KM, Seymour CW, Prescott HC, Friedrich M, Iwashyna TJ, Osborn T, Lemeshow S. Mortality Changes Associated with Mandated Public Reporting for Sepsis. The Results of the New York State Initiative. American journal of respiratory and critical care medicine. 2018 Dec 1; 198(11):1406-1412. [view]
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- Iwashyna T. Big Data’s Dangers: Increasingly Confident Wrong Answers. Paper presented at: Intensive Care and Emergency Medicine International Symposium; 2016 Mar 15; Brussels, Belgium. [view]
- Viglianti EM, Hanisko K, Bucy R, Ewing L, Youles B, Kepreos K, Lehrich J, Guyer H, Chan P, Nallamothu BK, Iwashyna T. One Year Later: Patient-Reported Outcomes Among Survivors of In-Hospital Cardiac Arrest in Veterans Administration Hospitals. Poster session presented at: American Heart Association Annual Scientific Sessions; 2015 Nov 7; Orlando, FL. [view]
- Viglianti EM, Hanisko K, Bucy R, Ewing L, Youles B, Kepreos K, Lehrich J, Guyer H, Chan P, Nallamothu BK, Iwashyna T. One Year Later: Patient-Reported Outcomes Among survivors of In-Hospital Cardiac Arrest in Veterans Administration Hospitals. Poster session presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2015 May 27; Ann Arbor, MI. [view]
- Hanisko K, Bucy R, Ewing L, Davis J, Youles B, Kepreos K, Lehrich J, Guyer H, Chan P, Iwashyna T, Nallamothu BK. Recovery after in hospital Cardiac arrest : late outcomes and Utilization (ResCU)-Study Overview and Recruitment Process. Poster session presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2015 May 27; Ann Arbor, MI. [view]
- Bucy R, Hanisko K, Ewing L, Pfeiffer PN, Nallamothu BK, Iwashyna T. Responding to Suicidal Ideation in an Observational Cohort Study. Poster session presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2016 Apr 27; Ann Arbor, MI. [view]
- Bradley SM, Kepreos K, Ewing L, Chan P, Iwashyna T, Nallamothu BK. Temporal Trends and Hospital-level Variation in the Incidence and 30-day Mortality of In-Hospital Cardiac Arrest within the Veterans Health Administration. Poster session presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Scientific Annual Forum; 2015 Apr 29; Baltimore, MD. [view]
- Bucy R, Hanisko K, Ewing L, Davis J, Kepreos K, Youles B, Lehrich J, Nord KM, Chan P, Nallamothu BK, Iwashyna T. Validity of In-Hospital Cardiac Arrest ICD-9-CM Codes in Veterans. Poster session presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2015 May 27; Ann Arbor, MI. [view]
Aging, Older Veterans' Health and Care, Cardiovascular Disease