Risk prediction models for out-of-hospital cardiac arrest outcomes in England

Abstract

Aims: The out-of-hospital cardiac arrest (OHCA) outcomes project is a national research registry. One of its aims is to explore sources of variation in OHCA survival outcomes. This study reports the development and validation of risk prediction models for return of spontaneous circulation (ROSC) at hospital handover and survival to hospital discharge.

Methods and results: The study included OHCA patients who were treated during 2014 and 2015 by emergency medical services (EMS) from seven English National Health Service ambulance services. The 2014 data were used to identify important variables and to develop the risk prediction models, which were validated using the 2015 data. Model prediction was measured by area under the curve (AUC), Hosmer-Lemeshow test, Cox calibration regression, and Brier score. All analyses were conducted using mixed-effects logistic regression models. Important factors included age, gender, witness/bystander cardiopulmonary resuscitation (CPR) combined, aetiology, and initial rhythm. Interaction effects between witness/bystander CPR with gender, aetiology and initial rhythm and between aetiology and initial rhythm were significant in both models. The survival model achieved better discrimination and overall accuracy compared with the ROSC model (AUC = 0.86 vs. 0.67, Brier score = 0.072 vs. 0.194, respectively). Calibration tests showed over- and under-estimation for the ROSC and survival models, respectively. A sensitivity analysis individually assessing Index of Multiple Deprivation scores and location in the final models substantially improved overall accuracy with inconsistent impact on discrimination.

Conclusion: Our risk prediction models identified and quantified important pre-EMS intervention factors determining survival outcomes in England. The survival model had excellent discrimination.

Keywords: Cardiac arrest; Emergency medical services; Out-of-hospital cardiac arrest; Predictive model; Resuscitation.

Figure 1

Model development flowchart. *Non-significant main effect or interaction is removed unless the removal led to poorer model performance.

Figure 2

Hosmer–Lemeshow calibration plot of the development (top) and validation data (bottom) for return of spontaneous circulation at handover and survival to discharge. (Circles and bars are the observed proportions and 95% confidence intervals of achieved return of spontaneous circulation and survived to discharge in the deciles of predictions.)