The Success of In-Hospital CPR in the Elderly
Abstract & Commentary
By John P. DiMarco, MD, PhD, Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville. Dr. DiMarco is a consultant for Novartis, and does research for Medtronic and Guidant. This article originally appeared in the August 2009 issue of Clinical Cardiology Alert. It was edited by Michael H. Crawford, MD, and peer reviewed by Ethan J. Weiss, MD. Dr. Crawford is Professor of Medicine, Chief of Cardiology, University of California, San Francisco, and Dr. Weiss is Assistant Professor of Medicine, Division of Cardiology and CVRI, University of California, San Francisco. Dr. Crawford is on the speaker's bureau for Pfizer, and Dr. Weiss reports no financial relationships relevant to this field of study.
Source: Ehlenbach WJ, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361:22-31.
This paper describes the results of an epidemiologic survey of the results of in-hospital cardiopulmonary resuscitation (CPR) in U.S. hospitals. Ehlenbach et al analyzed the Medicare Provider Analysis and Review (MedPAR) hospital claims database for the years from 1992-2005 and identified Medicare beneficiaries for whom a claim for in-hospital CPR had been made. The primary outcome for these patients was survival to hospital discharge. Potential predictors of outcome that were analyzed included: age, sex, race, presence and severity of coexisting chronic illness, median income for the zip code of the patient's residence, admission from a skilled nursing facility, hospital size, hospital location, teaching status of hospital, and individual hospital performance. Chronic illness burden was assessed using the Deyo-Charlson score. This score does not measure the type or severity of acute illness. Discharge destination codes were classified as home, another hospital, skilled nursing facility, or hospice, and were used to estimate functional status at discharge.
The analysis identified more than 433,000 beneficiaries who underwent in-hospital CPR on one or more occasions during the study period. The survival rate to hospital discharge was 18.3%. Factors associated with decreased survival were: male gender, older age, black or nonwhite race, admission from a skilled nursing facility, higher chronic illness score, and care in a metropolitan or teaching hospital. Survival remained constant during the 13 years of analysis. The incidence of in-hospital CPR was 2.73 events per 1,000 admissions, and this rate also did not change substantially during the period from 1992 through 2005. The incidence of CPR, however, differed according to race. There were 4.35 CPR deliveries per 1,000 admissions among black patients vs. 2.5 among white patients and 3.85 among patients of other races. There also was an unequal proportion of hospital deaths that were preceded by in-hospital CPR according to race. For black patients, 6.6% of possible deaths were preceded by in-hospital CPR, compared to 5.8% for patients of other races and 3.9% for white patients. The proportion of hospital deaths preceded by CPR increased over time during the study from 3.8% in 1992 to 5.2% in 2005. At the beginning of the survey, almost 60% of hospital survivors of CRP were discharged home, but this fell to less than 40% by the end of the survey, as more CPR survivors were sent to another hospital, a skilled nursing facility, or for hospice care. Shorter, initial hospital stays may have accounted for some or all of this trend. In multivariate analysis, the association of teaching hospital status with decreased survival disappeared, probably reflecting the increased acute illness severity in patients in teaching hospitals.
Ehlenbach et al conclude that the information generated may prove useful to older patients and to clinicians considering decisions about resuscitation status. They also note that the race-based differences in survival and CPR delivery are unexplained and require further study.
Commentary
The most significant observation made in this paper is that survival after in-hospital CPR did not improve over a 13-year period. The explanation for this lack of improvement cannot be made from the MedPAR data analyzed. In particular, the severity of the acute illness that led to the hospitalization was not included in the MedPAR database. If hospitalized patients, in whom CPR was attempted, were more severely ill over time, this might well account for the failure to improve survival rates after CPR. In-hospital resuscitation techniques also have changed little during the time period surveyed. Among patients monitored in intensive care units, or on telemetry wards, personnel and equipment for prompt resuscitation have always been readily available. Survival in those cases is more likely to be influenced by the severity of the acute illness rather than any change in resuscitation techniques. Among unmonitored patients, the arrest may not be immediately identified, resulting in delays in delivery of potentially life-saving resuscitation. If the availability of monitoring, or the criteria used to select patients for monitoring for CPR have changed, real changes in CPR success may have occurred but would not be detected in a study of this type.
The racial differences observed in both delivery of CPR and survival rate are interesting and should be the subject of more detailed investigation. It is likely that numerous medical and social factors account for these observations, and a better understanding of these factors could improve resuscitation outcomes among all patients.
This paper describes the results of an epidemiologic survey of the results of in-hospital cardiopulmonary resuscitation (CPR) in U.S. hospitals.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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