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IIR 13-079 – HSR&D Study

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IIR 13-079
REcovery after in hoSpital Cardiac arrest: late outcomes and Utilization_ResCU
Brahmajee K. Nallamothu MD
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: August 2014 - July 2017

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.


Journal Articles

  1. Lederer DJ, Bell SC, Branson RD, Chalmers JD, Marshall R, Maslove DM, Ost DE, Punjabi NM, Schatz M, Smyth AR, Stewart PW, Suissa S, Adjei AA, Akdis CA, Azoulay É, Bakker J, Ballas ZK, Bardin PG, Barreiro E, Bellomo R, Bernstein JA, Brusasco V, Buchman TG, Chokroverty S, Collop NA, Crapo JD, Fitzgerald DA, Hale L, Hart N, Herth FJ, Iwashyna TJ, Jenkins G, Kolb M, Marks GB, Mazzone P, Moorman JR, Murphy TM, Noah TL, Reynolds P, Riemann D, Russell RE, Sheikh A, Sotgiu G, Swenson ER, Szczesniak R, Szymusiak R, Teboul JL, Vincent JL. Control of Confounding and Reporting of Results in Causal Inference Studies. Guidance for Authors from Editors of Respiratory, Sleep, and Critical Care Journals. Annals of the American Thoracic Society. 2019 Jan 1; 16(1):22-28.
  2. 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.
  3. Quasim T, Shaw M, McPeake J, Hughes M, Iwashyna TJ. Safety of Extubating Mechanically Ventilated Patients Receiving Vasoactive Infusions: A Retrospective Cohort Study. American journal of respiratory and critical care medicine. 2018 Oct 15; 198(8):1093-1096.
  4. Iwashyna TJ, McPeake J. Choosing outcomes for clinical trials: a pragmatic perspective. Current opinion in critical care. 2018 Oct 1; 24(5):428-433.
  5. Govindan S, Prenovost K, Chopra V, Iwashyna TJ. A comprehension scale for central-line associated bloodstream infection: Results of a preliminary survey and factor analysis. PLoS ONE. 2018 Sep 13; 13(9):e0203431.
  6. Haines KJ, Beesley SJ, Hopkins RO, McPeake J, Quasim T, Ritchie K, Iwashyna TJ. Peer Support in Critical Care: A Systematic Review. Critical care medicine. 2018 Sep 1; 46(9):1522-1531.
  7. Hodgson CL, Haines KJ, Bailey M, Barrett J, Bellomo R, Bucknall T, Gabbe BJ, Higgins AM, Iwashyna TJ, Hunt-Smith J, Murray LJ, Myles PS, Ponsford J, Pilcher D, Udy AA, Walker C, Young M, Jamie Cooper DJ, ICU-Recovery Investigators. Predictors of return to work in survivors of critical illness. Journal of Critical Care. 2018 Dec 1; 48:21-25.
  8. Zampieri FG, Iwashyna TJ, Viglianti EM, Taniguchi LU, Viana WN, Costa R, Corrêa TD, Moreira CEN, Maia MO, Moralez GM, Lisboa T, Ferez MA, Freitas CEF, de Carvalho CB, Mazza BF, Lima MFA, Ramos GV, Silva AR, Bozza FA, Salluh JIF, Soares M, ORCHESTRA Study Investigators. Association of frailty with short-term outcomes, organ support and resource use in critically ill patients. Intensive Care Medicine. 2018 Sep 1; 44(9):1512-1520.
  9. Iwashyna TJ, Viglianti EM. Patient and Population-Level Approaches to Persistent Critical Illness and Prolonged Intensive Care Unit Stays. Critical care clinics. 2018 Oct 1; 34(4):493-500.
  10. Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL, Kronick SL, Krein SL, Iwashyna TJ, Saint S, Chan PS. How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study. Circulation. 2018 Jul 10; 138(2):154-163.
  11. Schuler A, Wulf DA, Lu Y, Iwashyna TJ, Escobar GJ, Shah NH, Liu VX. The Impact of Acute Organ Dysfunction on Long-Term Survival in Sepsis. Critical care medicine. 2018 Jun 1; 46(6):843-849.
  12. Viglianti EM, Kramer R, Admon AJ, Sjoding MW, Hodgson CL, Bellomo R, Iwashyna TJ. Late organ failures in patients with prolonged intensive care unit stays. Journal of Critical Care. 2018 Aug 1; 46:55-57.
  13. Govindan S, Prescott HC, Chopra V, Iwashyna TJ. Sample size implications of mortality definitions in sepsis: a retrospective cohort study. Trials. 2018 Mar 27; 19(1):198.
  14. Kerlin MP, Epstein A, Kahn JM, Iwashyna TJ, Asch DA, Harhay MO, Ratcliffe SJ, Halpern SD. Physician-Level Variation in Outcomes of Mechanically Ventilated Patients. Annals of the American Thoracic Society. 2018 Mar 1; 15(3):371-379.
  15. Reamaroon N, Sjoding MW, Lin K, Iwashyna TJ, Najarian K. Accounting for Label Uncertainty in Machine Learning for Detection of Acute Respiratory Distress Syndrome. IEEE journal of biomedical and health informatics. 2019 Jan 1; 23(1):407-415.
  16. Chang VW, Langa KM, Weir D, Iwashyna TJ. The obesity paradox and incident cardiovascular disease: A population-based study. PLoS ONE. 2017 Dec 7; 12(12):e0188636.
  17. Govindan S, Wallace B, Iwashyna TJ, Chopra V. Do Experts Understand Performance Measures? A Mixed-Methods Study of Infection Preventionists. Infection control and hospital epidemiology. 2018 Jan 1; 39(1):71-76.
  18. McPeake J, Shaw M, Iwashyna TJ, Daniel M, Devine H, Jarvie L, Kinsella J, MacTavish P, Quasim T. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE). Early evaluation of a complex intervention. PLoS ONE. 2017 Nov 29; 12(11):e0188028.
  19. Liu VX, Fielding-Singh V, Greene JD, Baker JM, Iwashyna TJ, Bhattacharya J, Escobar GJ. The Timing of Early Antibiotics and Hospital Mortality in Sepsis. American journal of respiratory and critical care medicine. 2017 Oct 1; 196(7):856-863.
  20. Bucy RA, Hanisko KA, Kamphuis LA, Nallamothu BK, Iwashyna TJ, Pfeiffer PN. Suicide Risk Management Protocol in Post-Cardiac Arrest Survivors: Development, Feasibility, and Outcomes. Annals of the American Thoracic Society. 2017 Mar 1; 14(3):363-367.
  21. Sukul D, Kamphuis LA, Iwashyna TJ, Bradley SM, Chan PS, Sinha SS, Nallamothu BK. Clinical documentation of in-hospital cardiac arrest in a large national health system. Resuscitation. 2017 Mar 1; 112:e9-e10.
  22. Sinha SS, Sukul D, Lazarus JJ, Polavarapu V, Chan PS, Neumar RW, Nallamothu BK. Identifying Important Gaps in Randomized Controlled Trials of Adult Cardiac Arrest Treatments: A Systematic Review of the Published Literature. Circulation. Cardiovascular quality and outcomes. 2016 Nov 1; 9(6):749-756.
  23. Govindan S, Iwashyna T. Annals for Hospitalists Inpatient Notes - Sepsis-3 for Hospitalists-Sepsis Without SIRS. Annals of internal medicine. 2016 Aug 16; 165(4):HO2-HO3.
Journal Other

  1. Sjoding MW, Iwashyna TJ. Response. [Letter to the Editor]. Chest. 2018 Jul 1; 154(1):227-228.
  2. X Liu V, Fielding-Singh V, Iwashyna TJ, Bhattacharya J, Escobar GJ. Reply: The Timing of Early Antibiotics and Hospital Mortality in Sepsis: Playing Devil's Advocate. [Editorial]. American journal of respiratory and critical care medicine. 2017 Oct 1; 196(7):935-936.
Conference Presentations

  1. 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.
  2. 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.
  3. Iwashyna T. Big Data: What is It? How to Get It? How can It Go Wrong? Paper presented at: Society of Critical Care Medicine Annual Congress; 2016 Feb 24; Orlando, FL.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.

DRA: Aging, Older Veterans' Health and Care, Cardiovascular Disease
DRE: Prognosis
Keywords: Outcomes - Patient, Outcomes - System, Practice Patterns/Trends, Quality Improvement, Utilization, Best Practices, Cardiovascular Disease, Decision-Making, Risk Factors
MeSH Terms: none