Variation Across Hospitals in In-Hospital Cardiac Arrest Incidence Among Medicare Beneficiaries

Abstract

Importance: Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last 2 decades, survival rates have plateaued in recent years. A better understanding of hospital differences in IHCA incidence may provide important insights regarding best practices for prevention of IHCA.

Objective: To determine the incidence of IHCA among Medicare beneficiaries, and evaluate hospital variation in incidence of IHCA.

Design, setting, and participants: This observational cohort study analyzes 2014 to 2017 data from 170 hospitals participating in the Get With The Guidelines-Resuscitation registry, linked to Medicare files. Participants were adults aged 65 years and older. Statistical analysis was performed from January to December 2021.

Exposures: Case-mix index, teaching status, and nurse-staffing.

Main outcomes and measures: Hospital incidence of IHCA among Medicare beneficiaries was estimated as the number of IHCA patients divided by the total number of hospital admissions. Multivariable hierarchical regression models were used to calculate hospital incidence rates adjusted for differences in patient case-mix and evaluate the association of hospital variables with IHCA incidence.

Results: Among a total of 4.5 million admissions at 170 hospitals, 38 630 patients experienced an IHCA during 2014 to 2017. Among the 38 630 patients with IHCAs, 7571 (19.6%) were non-Hispanic Black, 26 715 (69.2%) were non-Hispanic White, and 16 732 (43.3%) were female; the mean (SD) age at admission was 76.3 (7.8) years. The median risk-adjusted IHCA incidence was 8.5 per 1000 admissions (95% CI, 8.2-9.0 per 1000 admissions). After adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals ranging from 2.4 per 1000 admissions to 25.5 per 1000 admissions (IQR, 6.6-11.4; median odds ratio, 1.51 [95% CI, 1.44-1.58]). Among hospital variables, a higher case-mix index, higher nurse staffing, and teaching status were associated with a lower hospital incidence of IHCA.

Conclusions and relevance: This cohort study found that the incidence of IHCA varies markedly across hospitals, and hospitals with higher nurse staffing and teaching status had lower IHCA incidence rates. Future studies are needed to better understand processes of care at hospitals with exceptionally low IHCA incidence to identify best practices for cardiac arrest prevention.

Figure 1.. Study Cohort Flowchart

CMS indicates Centers for Medicare & Medicaid Services; GWTG-R, Get With the Guidelines-Resuscitation; and IHCA, in-hospital cardiac arrest.

Figure 2.. Hospital Variation in the Case-Mix Adjusted Incidence of IHCA Among Medicare Beneficiaries Per 1000 Admission

The x-axis represents each hospital arranged in the ascending order of IHCA incidence, and the y-axis represents the IHCA incidence expressed as per-1000 admissions. Error bars represent 95% CIs. The horizontal dotted line represents the median adjusted IHCA incidence (8.5) for our study. The graph is color coded for dark blue = quartile 1, cyan = quartile 2, brown = quartile 3, and orange = quartile 4.