Variation in Survival after Out-of-Hospital Cardiac Arrest between Emergency Medical Services Agencies

Masashi Okubo, Robert H. Schmicker, David J. Wallace, Ahamed H. Idris, Graham Nichol, Michael A. Austin, Brian Grunau, Lynn K. Wittwer, Neal Richmond, Laurie J. Morrison, Michael C. Kurz, Sheldon Cheskes, Peter J. Kudenchuk, Dana M. Zive, Tom P. Aufderheide, Henry E. Wang, Heather Herren, Christian Vaillancourt, Daniel P. Davis, Gary M. Vilke & 5 others Frank X. Scheuermeyer, Myron L. Weisfeldt, Jonathan Elmer, Riccardo Colella, Clifton W. Callaway

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

Importance: Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood. Objective: To quantify variation in patient outcomes after OHCA across EMS agencies. Design, Setting, and Participants: This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018. Exposure: Treating EMS agency. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies. Results: We identified 43656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency-level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]). Conclusions and Relevance: We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency-level variables..

Original languageEnglish (US)
Pages (from-to)989-999
Number of pages11
JournalJAMA Cardiology
Volume3
Issue number10
DOIs
StatePublished - Oct 1 2018

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Out-of-Hospital Cardiac Arrest
Emergency Medical Services
Survival
Odds Ratio
Hospital Emergency Service
North America
Logistic Models
Resuscitation
Observational Studies
Cluster Analysis
Registries
Patient Care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Okubo, M., Schmicker, R. H., Wallace, D. J., Idris, A. H., Nichol, G., Austin, M. A., ... Callaway, C. W. (2018). Variation in Survival after Out-of-Hospital Cardiac Arrest between Emergency Medical Services Agencies. JAMA Cardiology, 3(10), 989-999. https://doi.org/10.1001/jamacardio.2018.3037

Variation in Survival after Out-of-Hospital Cardiac Arrest between Emergency Medical Services Agencies. / Okubo, Masashi; Schmicker, Robert H.; Wallace, David J.; Idris, Ahamed H.; Nichol, Graham; Austin, Michael A.; Grunau, Brian; Wittwer, Lynn K.; Richmond, Neal; Morrison, Laurie J.; Kurz, Michael C.; Cheskes, Sheldon; Kudenchuk, Peter J.; Zive, Dana M.; Aufderheide, Tom P.; Wang, Henry E.; Herren, Heather; Vaillancourt, Christian; Davis, Daniel P.; Vilke, Gary M.; Scheuermeyer, Frank X.; Weisfeldt, Myron L.; Elmer, Jonathan; Colella, Riccardo; Callaway, Clifton W.

In: JAMA Cardiology, Vol. 3, No. 10, 01.10.2018, p. 989-999.

Research output: Contribution to journalArticle

Okubo, M, Schmicker, RH, Wallace, DJ, Idris, AH, Nichol, G, Austin, MA, Grunau, B, Wittwer, LK, Richmond, N, Morrison, LJ, Kurz, MC, Cheskes, S, Kudenchuk, PJ, Zive, DM, Aufderheide, TP, Wang, HE, Herren, H, Vaillancourt, C, Davis, DP, Vilke, GM, Scheuermeyer, FX, Weisfeldt, ML, Elmer, J, Colella, R & Callaway, CW 2018, 'Variation in Survival after Out-of-Hospital Cardiac Arrest between Emergency Medical Services Agencies', JAMA Cardiology, vol. 3, no. 10, pp. 989-999. https://doi.org/10.1001/jamacardio.2018.3037
Okubo, Masashi ; Schmicker, Robert H. ; Wallace, David J. ; Idris, Ahamed H. ; Nichol, Graham ; Austin, Michael A. ; Grunau, Brian ; Wittwer, Lynn K. ; Richmond, Neal ; Morrison, Laurie J. ; Kurz, Michael C. ; Cheskes, Sheldon ; Kudenchuk, Peter J. ; Zive, Dana M. ; Aufderheide, Tom P. ; Wang, Henry E. ; Herren, Heather ; Vaillancourt, Christian ; Davis, Daniel P. ; Vilke, Gary M. ; Scheuermeyer, Frank X. ; Weisfeldt, Myron L. ; Elmer, Jonathan ; Colella, Riccardo ; Callaway, Clifton W. / Variation in Survival after Out-of-Hospital Cardiac Arrest between Emergency Medical Services Agencies. In: JAMA Cardiology. 2018 ; Vol. 3, No. 10. pp. 989-999.
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abstract = "Importance: Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood. Objective: To quantify variation in patient outcomes after OHCA across EMS agencies. Design, Setting, and Participants: This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018. Exposure: Treating EMS agency. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies. Results: We identified 43656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0{\%}-28.9{\%}; unadjusted MOR, 1.43 [95{\%} CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0{\%}-57.1{\%}; unadjusted MOR, 1.53 [95{\%} CI, 1.43-1.65]), and favorable functional outcome (range, 0{\%}-20.4{\%}; unadjusted MOR, 1.54 [95{\%} CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency-level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95{\%} CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95{\%} CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95{\%} CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95{\%} CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95{\%} CI, 1.20-1.59]). Conclusions and Relevance: We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency-level variables..",
author = "Masashi Okubo and Schmicker, {Robert H.} and Wallace, {David J.} and Idris, {Ahamed H.} and Graham Nichol and Austin, {Michael A.} and Brian Grunau and Wittwer, {Lynn K.} and Neal Richmond and Morrison, {Laurie J.} and Kurz, {Michael C.} and Sheldon Cheskes and Kudenchuk, {Peter J.} and Zive, {Dana M.} and Aufderheide, {Tom P.} and Wang, {Henry E.} and Heather Herren and Christian Vaillancourt and Davis, {Daniel P.} and Vilke, {Gary M.} and Scheuermeyer, {Frank X.} and Weisfeldt, {Myron L.} and Jonathan Elmer and Riccardo Colella and Callaway, {Clifton W.}",
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TY - JOUR

T1 - Variation in Survival after Out-of-Hospital Cardiac Arrest between Emergency Medical Services Agencies

AU - Okubo, Masashi

AU - Schmicker, Robert H.

AU - Wallace, David J.

AU - Idris, Ahamed H.

AU - Nichol, Graham

AU - Austin, Michael A.

AU - Grunau, Brian

AU - Wittwer, Lynn K.

AU - Richmond, Neal

AU - Morrison, Laurie J.

AU - Kurz, Michael C.

AU - Cheskes, Sheldon

AU - Kudenchuk, Peter J.

AU - Zive, Dana M.

AU - Aufderheide, Tom P.

AU - Wang, Henry E.

AU - Herren, Heather

AU - Vaillancourt, Christian

AU - Davis, Daniel P.

AU - Vilke, Gary M.

AU - Scheuermeyer, Frank X.

AU - Weisfeldt, Myron L.

AU - Elmer, Jonathan

AU - Colella, Riccardo

AU - Callaway, Clifton W.

PY - 2018/10/1

Y1 - 2018/10/1

N2 - Importance: Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood. Objective: To quantify variation in patient outcomes after OHCA across EMS agencies. Design, Setting, and Participants: This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018. Exposure: Treating EMS agency. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies. Results: We identified 43656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency-level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]). Conclusions and Relevance: We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency-level variables..

AB - Importance: Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood. Objective: To quantify variation in patient outcomes after OHCA across EMS agencies. Design, Setting, and Participants: This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018. Exposure: Treating EMS agency. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies. Results: We identified 43656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency-level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]). Conclusions and Relevance: We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency-level variables..

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