Racial Gap in In-Hospital Arrest Survival Shrinks in Registry

Marlene Busko

August 21, 2017

IOWA CITY, IA — The racial gap for survival to discharge after an in-hospital cardiac arrest has markedly decreased over the past 15 years in the 6% of American hospitals that participate in the Get With The Guidelines–Resuscitation registry, researchers report[1].

Moreover, surviving the acute resuscitation phase—from no pulse to return of pulse—is now the same for black and white patients.

Hospitals that treat a larger proportion of black patients had the largest improvements in cardiac-arrest survival, Dr Lee Joseph (University of Iowa Carver College of Medicine, Iowa City) and colleagues report in the study, published online August 9, 2017 in JAMA Cardiology.

"These findings are really encouraging and really should provide impetus to quality-improvement programs," senior author Dr Saket Girotra (University of Iowa Carver College of Medicine) told theheart.org | Medscape Cardiology.

"Here we have a study that shows, at least for in-hospital cardiac arrest, in hospitals that pay attention to resuscitation and try to emphasize quality, we find no difference in race—that's the big important message," Dr Myron Westfeldt (Johns Hopkins University, Baltimore, MD), who coauthored an accompanying editorial with Dr Lance Becker (Hofstra Northwell School of Medicine, Manhasset, NY),[2] said in an interview.

Disappearing Disparities Between Blacks, Whites?

"There has been a sense of nihilism . . . because survival rates with cardiac arrest have been poor, but we noticed through prior work that survival for in-hospital cardiac arrest has improved tremendously over the past 15 years or so," Girotra said. However, it was not clear how survival rates may have changed in blacks and whites.  

To investigate this, the researchers identified 30,241 black patients (27%) and 81,898 white patients (73%) who had an in-hospital cardiac arrest during the January 2000–December 2014 period at 289 hospitals out of nearly 5000 US hospitals in the American Heart Association's Get With The Guidelines–Resuscitation registry.

These patients all had a cardiac arrest on a ward or in the ICU (not the ER), and the hospitals had at least 3 years of data and had treated at least 10 cardiac arrests a year.

Compared with white patients, black patients were younger (mean age 62 vs 68) and less likely to have an initial rhythm of ventricular fibrillation (8% vs 12%) or pulseless ventricular tachycardia (5% vs 8%) or to have a current or prior MI (10% vs 18% and 11% vs 18%, respectively).

Compared with white patients, black patients were also more likely to have renal insufficiency (46% vs 34%), diabetes (36% vs 31%), depressed central nervous system function (15% vs 11%), septicemia (23% vs 18%), or recent dialysis (5% vs 3%).

Survival—adjusted for patient differences as well as time and location of the cardiac arrest—steadily improved from 2000 to 2014 for both blacks and whites.

Notably, by 2014, about three in five patients survived the acute phase of in-hospital cardiac arrest and roughly one in five survived until discharge.

Rates of In-Hospital Cardiac Arrest Survival (%) in 2000 vs 2014a

Survival period Race 2000 2014 Pb
Acute resuscitation White 47.1 64.0 <0.001
Black 44.6 64.1 <0.001
Postresuscitation White 33.6 36.3 <0.001
Black 32.0 33.6 <0.001
To discharge White 15.8 23.2 <0.001
Black 11.3 21.4 <0.001
a. Adjusted for differences in baseline characteristics, nighttime or weekend, and location of cardiac arrest
b. P for race interaction

The researchers also looked at defect-free care, which included all eligible interventions and was defined as care that met these five registry resuscitation quality measures:

  • Device confirmation of correct endotracheal tube placement.

  • A monitored or witnessed cardiac arrest event

  • Time to first chest compression of 1 minute or less.

  • Time to first defibrillation of 2 minutes or less for ventricular tachycardia or ventricular fibrillation.

  • Administration of epinephrine or vasopressin for pulseless electrical activity or asystole within 5 minutes.

From 2000 to 2014, the percentage of patients who received defect-free care rose from 73% to 80% for white patients and, even more markedly, from 69% to 80%, in black patients.

Notably, survival to discharge increased from 12% to 21% in hospitals with a high proportion of black patients compared with increasing from 17% to 23% in hospitals with a low proportion of black patients.

What individual hospitals did to improve the quality of resuscitation is not known, Girotra said.

"It is possible that strategies to improve CPR quality, audiovisual feedback, routine mock codes, and team debriefing, which are currently unmeasured in GWTG-Resuscitation, explain the aforementioned trends in survival by race," the authors suggest. Improvement might also be due to the greater use of do-not-resuscitate codes.

The findings may not be generalizable to hospitals that are not part of this quality-improvement registry, they acknowledge.

Westfeldt and Becker note that over the past 15 years there has been a "dramatic rise of in-hospital palliative-care units and the use of 'do-not-resuscitate' or 'do-not-intubate' advance directives," as well as a greater number of rapid-response teams in US hospitals.

Nevertheless, they write "it is good news that rates of survival from in-hospital cardiac arrest have become identical for black and white individuals while overall survival has increased in both groups" in participating hospitals.

"We would all like to see more patients survive cardiac arrest and have good cardiologic care to prevent another arrest," said Westfeldt. "What we can do inside and outside the hospital is improve the quality of the resuscitation and the appropriateness of the patients" who are being resuscitated.

Get With the Guidelines–Resuscitation is sponsored by the American Heart Association. The study was funded by grants from the National Heart, Lung, and Blood Institute and National Institutes of Health. Joseph and Girotra have no relevant financial relationships. Disclosures for the coauthors are listed in the paper. The editorialists have no relevant financial relationships.

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