Impact of Hospital Safety-Net Burden on Outcomes of In-Hospital Cardiac Arrest in the United States

Abstract

High safety-net burden hospitals (HBHs) treating large numbers of uninsured or Medicaid-insured patients have generally been linked to worse clinical outcomes. However, limited data exist on the impact of the hospitals' safety-net burden on in-hospital cardiac arrest (IHCA) outcomes in the United States.

Objectives: To compare the differences in survival to discharge, routine discharge home, and healthcare resource utilization between patients at HBH with those treated at low safety-net burden hospital (LBH).

Design setting and participants: Retrospective cohort study across hospitals in the United States: Hospitalized patients greater than or equal to 18 years that underwent cardiopulmonary resuscitation (CPR) between 2008 and 2018 identified from the Nationwide Inpatient Database. Data analysis was conducted in January 2022.

Exposure: IHCA.

Main outcomes and measures: The primary outcome is survival to hospital discharge. Other outcomes are routine discharge home among survivors, length of hospital stay, and total hospitalization cost.

Results: From 2008 to 2018, an estimated 555,016 patients were hospitalized with IHCA, of which 19.2% occurred at LBH and 55.2% at HBH. Compared with LBH, patients at HBH were younger (62 ± 20 yr vs 67 ± 17 yr) and predominantly in the lowest median household income (< 25th percentile). In multivariate analysis, HBH was associated with lower chances of survival to hospital discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.85-0.96) and lower odds of routine discharge (aOR, 0.6; 95% CI, 0.47-0.75), compared with LBH. In addition, IHCA patients at publicly owned hospitals and those with medium and large hospital bed size were less likely to survive to hospital discharge, while patients with median household income greater than 25th percentile had better odds of hospital survival.

Conclusions and relevance: Our study suggests that patients who experience IHCA at HBH may have lower rates and odds of in-hospital survival and are less likely to be routinely discharged home after CPR. Median household income and hospital-level characteristics appear to contribute to survival.

Keywords: cardiopulmonary resuscitation; in-hospital cardiac arrest; outcomes; safety net; survival.

Figure 1.

Temporal trends in the survival rates of in-hospital cardiac arrest patients at low safety-net burden hospital (LBH) and high safety-net burden hospital (HBH). nptrend = nonparametric rank-based test.

Figure 2.

Socioeconomic and hospital-level factors associated with survival to hospital discharge among in-hospital cardiac arrest patients at U.S. hospitals. More detailed information on the specific dollar amounts in each category of median household income and the number of hospital beds in each category can be found in Supplementary Table 2 (http://links.lww.com/CCX/B123) and nationwide inpatient sample description of data elements Healthcare Cost and Utilization Project US Home Page (ahrq.gov). Adjusted odds ratios (aORs) adjusted for age, sex, Charlson Comorbidity Index, tobacco abuse, obesity, history of diabetes mellitus, chronic kidney disease, end-stage renal disease on hemodialysis, chronic liver disease, hypertension, congestive heart failure, myocardial infarction, and stroke. Ref = reference.