Variation in survival after out-of-hospital cardiac arrest between emergency medical services agencies
Open accessAbstract
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 43 656 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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Deferred consent may be necessary because the therapeutic window is too narrow to obtain a valid preenrolment consent.
“Deferred consent (i.e. obtaining consent from a surrogate and/or patient as soon as possible after enrolment) may be necessary because the therapeutic window is too narrow to obtain a valid preenrolment consent. 63,317,322 324”
From European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions (2021) · cites this paper as [324]
The Study Design and Setting section (page unavailable) says investigators used a waiver of informed consent for a minimal-risk intervention. It does not discuss deferred consent or say that a narrow therapeutic window prevented valid pre-enrolment consent. Searches for those terms and for post-enrolment surrogate consent found no supporting passage. (LLM, conf=0.75)
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Self-citation
- Authors
- Okubo, M., Schmicker, R. H., Wallace, D. J., Idris, A. H., Nichol, G., Austin, M. A., Grunau, B., Wittwer, L. K., Richmond, N., Morrison, L. J., Kurz, M. C., Cheskes, S., Kudenchuk, P. J., Zive, D. M., Aufderheide, T. P., Wang, H. E., Herren, H., Vaillancourt, C., Davis, D. P., Vilke, G. M., Scheuermeyer, F. X., Weisfeldt, M. L., Elmer, J., Colella, R., Callaway, C. W., & for the Resuscitation Outcomes Consortium Investigators
- Affiliations
- University of Pittsburgh (US)
- University of Washington (US)
- The University of Texas Southwestern Medical Center (US)
- University of Ottawa (CA)
- University of British Columbia (CA)
- Clark County Emergency Medical Services, Vancouver, Washington
- MedStar, Inc, Fort Worth, Texas
- St. Michael's Hospital (CA)
- University of Alabama at Birmingham (US)
- Oregon Health & Science University (US)
- Medical College of Wisconsin (US)
- The University of Texas Health Science Center at Houston (US)
- University of California San Diego (US)
- Johns Hopkins University (US)
- Corresponding author
- Okubo, Masashi
- ORCID
- Okubo, Masashi
- Schmicker, Robert H.
- Wallace, David J.
- Idris, Ahamed H.
- Nichol, Graham
- Austin, Michael A.
- Grunau, Brian
- Morrison, Laurie J.
- Kurz, Michael C.
- Cheskes, Sheldon
- Kudenchuk, Peter J.
- Aufderheide, Tom P.
- Wang, Henry E.
- Vaillancourt, Christian
- Davis, Daniel P.
- Vilke, Gary M.
- Scheuermeyer, Frank X.
- Elmer, Jonathan
- Callaway, Clifton W.
- Venue
- JAMA Cardiology
- Publisher
- American Medical Association (AMA)
- Published
- 2018-10-01
- Volume
- 3
- Issue
- 10
- Pages
- 989
- ISSN
- 2380-6583 (ISSN-L)
- PMC
- PMC6233822
- OpenAlex
- W2893225097
- Cited by
- 75
- References
- 36
- Citations by year
- 2026: 4 · 2025: 8 · 2024: 3 · 2023: 11 · 2022: 9 · 2021: 13 · 2020: 18 · 2019: 8 · 2018: 1
- FWCI
- 12.22
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Cardiology (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- American Heart Association (5U01 HL077863)
- Heart and Stroke Foundation of Canada
- University of Washington
- University of Alabama
- ZOLL Medical Corporation
- National Institutes of Health (5u01hl077863-11)
- Canadian Institutes of Health Research (5U01 HL077863)
- National Heart, Lung, and Blood Institute (5 U01 HL077863, U01-HL077863, HL077866)
- National Institute of Neurological Disorders and Stroke (5U01 HL077863)
- Institute of Circulatory and Respiratory Health (5U01 HL077863)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
- Health Sciences › Medicine › Emergency Medicine › Trauma and Emergency Care Studies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Keywords
- out-of-hospital cardiac arrest, emergency medical services, survival to hospital discharge, return of spontaneous circulation, functional outcome, prehospital care, quality of care variation, median odds ratio
- MeSH terms
- Aged, Aged, 80 and over, Emergency Medical Services, Female, Humans, Male, Middle Aged, Patient Discharge, Prospective Studies, Registries, Cohort Studies, Logistic Models, Survival Analysis, Cardiopulmonary Resuscitation, Out-of-Hospital Cardiac Arrest
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