Statewide variation in post-cardiac arrest hospital care in Michigan
Swor R, Berger D, Reynolds J, Otero R, Miller J, Chen NW, Pribble JM, Welch RD, and West JR. Statewide variation in post-cardiac arrest hospital care in Michigan. Acad Emerg Med 2019; 26:S147-S148.
Acad Emerg Med
Background: Optimal care after return of spontaneous circulation (ROSC) is crucial to improving out of hospital cardiac arrest (OHCA) outcomes. Integrated medical systems of care save lives, in part by decreasing variation. Our objective was to characterize the variation in two key interventions following ROSC -targeted temperature management (TTM) and left heart catheterization (LHC). Methods: Using the Michigan Cardiac Arrest to Enhance Survival (CARES) registry, which covers approximately 2/3 of the state, we analyzed all adult OHCA patients with ROSC from 2014 through 2017 that survived to hospital admission. We excluded patients that required transfer to another hospital. Assessed were frequencies of TTM and LHC by hospital, strongly encouraged CARES data elements in the state. Hospitals (N=42) were included if they managed > 30 cases/ 4-years for all rhythms and > 20 cases/4-years for shockable patients. We report procedure rates by hospital with median,(interquartile range, IQR), and overall range. Results: Of 5,406 eligible adult patients, 317 were excluded due to transfers or management at low volume hospitals (N=193) leaving 4896 patients for analysis. Missing data was minimal for TTM (N=7) but substantial for LHC (N=563). Number of patients per included hospital varied from 32 to 373. Of included hospitals, the median [IQR] rate of TTM provision was 44.4% [34.7%, 57.7%] and LHC 23.2% [13.0%, 30.8%]. For shockable patients, the median [IQR] rate of TTM provision and LHC were 54.3%, [39.7, 62.2%] and 53.4%, [41.7%, 61.2%] respectively. For all arrest rhythms, we observed a 13-fold variation in rate of hospital provision of TTM (range 5.8% - 74.6%) and eight-fold variation in LHC (range 5.3% - 43.0%). For shockable patients, less variation was observed in the provision of TTM (13.3% - 83.3%) and LHC (20.5% - 79.6%). Conclusion: We observed substantial variation in hospital provision of important post-arrest interventions, although less variation for OHCA patients with shockable rhythm. Further work is needed to assess whether patient, hospital, or system factors explain this variation.