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Survival
rates for elderly receiving hospital CPR did
not improve from 1992 to 2005
Proportion of deaths after CPR rose, and
rate of successful resuscitation and later
discharge fell
A study of elderly patients receiving CPR in the hospital
shows that rates of survival did not improve
from 1992 to 2005. During that period, the
proportion of hospital deaths preceded by
CPR rose, and the proportion of patients who
were successfully resuscitated and later
discharged home fell.
The researchers found that 18.3 percent of the Medicare
beneficiaries age 65 and older who underwent
in-hospital CPR survived to discharge.
Elderly black patients were more likely to receive CPR, but
less likely to survive, partially because
they were more likely to be treated in
hospitals with lower rates of post-CPR
survival and perhaps more likely to request
that resuscitation be attempted, according
to the report, which was published today in
The New England Journal of Medicine.
The adjusted odds for survival for black elderly
patients were 23.6 percent lower than for
similar white patients.
Older age, being a man, having more co-existing chronic
illnesses, and residing in a skilled nursing
facility before hospitalization also
lessened the chances of survival, according
to this study's findings. Higher income did
not improve survival.
The researchers looked at records of 433,985 patients who
both received CPR in U.S. hospitals from
1992 to 2005 and had Medicare coverage
through the Old-Age and Survivors Insurance
Fund, but who were not recipients of Social
Security Disability Income or enrolled in an
HMO.
The first author of the study is Dr. William J. Ehlenbach,
senior fellow, Division of Pulmonary and
Critical Care Medicine at Harborview Medical
Center and the University of Washington (UW)
in Seattle, and the senior author is Dr.
Renee D. Stapleton, formerly of the UW and
now at the Division of Pulmonary Care,
University of Vermont College of Medicine.
"CPR has become the default response to cardiac arrest in
or out of the hospital," the researchers
noted.
The authors conducted the study because it was unclear
whether advances in CPR or in care after
cardiac arrest have improved outcomes.
"Of significant concern," they wrote, "is our finding that
the proportion of patients who died in the
hospital after previously having undergone
in-hospital CPR has increased during a time
of more education and awareness of the
limits of CPR in patients with advanced
chronic illness and life-threatening acute
illness."
They added that although Do Not Attempt Resuscitation
orders became more common during the 1980s,
their availability has not effectively
decreased the frequency of administering CPR
to patients who are unlikely to benefit.
One possibility for their findings, the researcher noted,
is that attempts to enhance the delivery of
CPR have been less successful than changes
in out-of-hospital resuscitation efforts,
such as bystander CPR and automatic
defibrillators, trained emergency response
units, and dispatchers providing CPR
instruction over the phone, that have
contributed to improved survival.
The findings might also reflect changes over the years in
the type and severity of illness, the
underlying causes of the cardiac arrest, or
the initial heart rhythm abnormality that
made the heart stop beating.
For example, people whose cardiac arrest occurs from
ventricular fibrillation or fluttering or
from an abnormally rapid heart rate are more
likely to survive than someone whose heart
shows pulseless electrical activity.
In addition, heart disease has declined in the United
States, but critical illnesses such as
severe sepsis leading to irreversible shock
have increased.
The researchers also found that patients who were
successfully resuscitated and later
discharged were more likely to be sent to a
health-care facility than to return home.
They added that this finding might reflect the trend toward
shorter hospital stays or it could be due to
neurological or functional damage from the
cardiac arrest.
A limitation of the study, according to the researchers, is
that the Medicare claims data do not contain
potential predictors of survival after CPR,
such as severity and type of underlying
illness, the type of heart rhythm problem
preceding cardiac arrest, patient location
in hospital, and time to defibrillations.
Knowing such factors, they explained, may also help
in understanding differences in survival
associated with race and hospital.
The researchers hope the study provides information useful
to older patients and their doctors when
deciding whether to choose to attempt
resuscitation.
They also hope their findings stimulate efforts to
understand the association between race and
survival to eliminate disparities, and to
learn more about the specific factors
associated with the incidence of CPR and the
rate of survival for patients of all races.
###
In addition to Ehlenbach and Stapleton, the study authors
are Dr. Amber E. Barnato, Department of
Medicine, University of Pittsburgh; Dr. J.
Randall Curtis, Division of Pulmonary and
Critical Care, Harborview and UW School of
Medicine; Dr. William Kreuter, UW
Comparative Effectiveness Costs and Outcomes
Research Center; Dr. Thomas D. Koepsell,
Department of Epidemiology, UW School Public
Health; and Dr. Richard A. Deyo, Department
of Family Medicine and Medicine, Oregon
Health Sciences University.
The research was funded by a Physicians Geriatric
Development Research Award from the American
College of Physicians CHEST Foundation,
Atlantic Philanthropies, the John A.
Hartford Foundation and the Association of
Specialty Professors; a National Center for
Research Roadmap Award and additional awards
from the National Institutes of Health; and
a Centers of Biomedical Research Excellence
Award.
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