Issue link: https://viewer.e-digitaledition.com/i/918942
" With the help of the Get With The Guidelines–Resuscitation registry, we have learned a lot about in-hospital cardiac arrest in regard to quality of care and deviations in quality of care among hospitals, but we have only just begun to scratch the surface. For example, we know that survival rates vary by more than fourfold across hospitals even when we account for differences among patient cases. We need to understand what distinguishes high-performing hospitals from others." SAKET GIROTRA, MD, SM, ASSISTANT PROFESSOR OF INTERNAL MEDICINE‡ CARDIOVASCULAR MEDICINE AT THE UNIVERSITY OF IOWA CARVER COLLEGE OF MEDICINE la rge in other conditions. We wa nted to perform a follow-up study to exa mine if the gap had cha nged over time." RAPID IMPROVEMENT The fol low-up st udy, published i n JA M A Cardiology i n August 2017, examined data from GWTG-R over a 14-year period. It found that not only had sur viva l rates improved for both populations, but the diƒ erence between the two had decreased considerably. Risk-adjusted survival rates between black and white patients diƒ ered by less than 2 percent in 2014. " We found that there was a striking reduction in survival diƒ erences between black and white patients over time both on an absolute scale and a relative scale," says Saket Girotra, MD, SM, Assistant Professor of Internal Medicine–Cardiovascular Medicine at the University of Iowa Carver College of Medicine. "Survival increased both in hospitals with proportionally fewer black patients and in hospitals that proportionally treated more black patients, but the magnitude of improvement was much larger in hospitals with a higher proportion of black patients." The rising rate of survival for both white and black patients echoes the fi ndings of another study published in The New England Journal of Medicine that also involved Drs. Chan and Girotra. That study followed 374±hospitals in the GWTG-R registr y between 2000 and 2009 and found that hospita ls that participated in GWTG-R saw improvements in survival for patients who had experienced in-hospital cardiac arrest. A QUESTION OF VARIABLES W hile the data from neither study clea rly conclude this, it is possible that hospita ls pa r ticipating in a nationa l reg istr y that is focused on qua lit y improvement w ith rega rd to in- hospita l ca rdiac a rrest may increa se their sur v iva l rates when compa red with hospita ls that do not. " Unfor tunately, on ly 5 percent of a ll U. S. hospita ls a re part of the GWTG-R registr y," says Myron L . Weisfeldt, MD, Professor of Medicine at Johns Hopkins Universit y School of Med ici ne. " It 's possible t hat t he GW TG -R prog ra m encoura ges bet ter per for ma nces in t hese hospita ls, but there a re other possible expla nations for the improvement [in sur viva l rates in the studies], such as the rise of rapid- response teams and declaring some patients not appropriate [for resuscitation]." For exa mple, patients who under went pa lliative ca re a nd opted for a do-not-resuscitate order would not be counted in the study results if they experienced a n in-hospita l ca rdiac a rrest, as no resuscitation effor ts would be made. THE DATA IMPERATIVE No comprehensive nationa l databa se tracks the sur v iva l of ca rdiac a rrest patients in a ll 5,000±hospita ls in the U.S., which ma kes it impossible for researchers to determine with cer ta int y the sur viva l rates for in-hospita l ca rdiac a rrest patients nationwide or why rates improved in studies that utilized the GW TG -R reg istr y. "[P]ractitioners need to understa nd how impor ta nt it wou ld be to have a nationa l databa se to g ive compa rable data from a ll hospita ls," says La nce Becker, MD, Cha ir of Emergency Medicine at the Dona ld a nd Ba rba ra Zucker School of Medicine at Hofstra/Nor thwell. I n a new ef for t c a l le d t he Nat ion a l Ca r d i a c A r r e s t Col laborat ive, orga n i zat ion s such a s t he A H A a nd t he A merican Red Cross are working toward creating a nationa l reg istr y that wou ld enable ever y hospita l to improve its performa nce, notes Dr. Becker, who co-wrote a n editoria l with Dr. Weisfeldt rega rding the f indings in the 2017 JA M A Cardiology a r ticle. ■ 2 1 M D N E W S .C O M /// M D N E W S C E N T R A L N Y ■ 2 018