PURPOSE: Functional outcomes vary between centers after out-of-hospital cardiac arrest (OHCA) and are partially explained by pre-existing health status and arrest characteristics, while the effects of in-hospital treatments on functional outcome are less understood. We examined variation in functional outcomes by center after adjusting for patient- and arrest-specific characteristics and evaluated how in-hospital management differs between high- and low-performing centers. METHODS: Analysis of observational registry data within the International Cardiac Arrest Registry was used to perform a hierarchical model of center-specific risk standardized rates for good outcome, adjusted for demographics, pre-existing functional status, and arrest-related factors with treatment center as a random effect variable. We described the variability in treatments and diagnostic tests that may influence outcome at centers with adjusted rates significantly above and below registry average. RESULTS: A total of 3855 patients were admitted to an ICU following cardiac arrest with return of spontaneous circulation. The overall prevalence of good outcome was 11-63% among centers. After adjustment, center-specific risk standardized rates for good functional outcome ranged from 0.47 (0.37-0.58) to 0.20 (0.12-0.26). High-performing centers had faster time to goal temperature, were more likely to have goal temperature of 33 °C, more likely to perform unconscious cardiac catheterization and percutaneous coronary intervention, and had differing prognostication practices than low-performing centers. CONCLUSIONS: Center-specific differences in outcomes after OHCA after adjusting for patient-specific factors exist. This variation could partially be explained by in-hospital management differences. Future research should address the contribution of these factors to the differences in outcomes after resuscitation.

Center for Outcomes Research Maine Medical Center Portland ME USA

Clinical and Translational Science Institute Tufts University Boston ME 02111 USA

Critical Care and Anesthesiology Research Group Stavanger University Hospital Stavanger Norway

Department Clinical Medicine University of Bergen Bergen Norway

Department of Anaesthesiology Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway

Department of Anesthesia and Intensive Care Landspitali University Hospital Reykyavik Iceland

Department of Anesthesia and Intensive Care Skåne University Hospital Lund University Lund Sweden

Department of Cardiology Northeast Georgia Medical Center Gainesville Georgia USA

Department of Clinical Sciences Anesthesia and Intensive Care Lund University Helsingborg Hospital Helsingborg Sweden

Department of Clinical Sciences Lund University Getingevägen 22185 Lund Sweden

Department of Critical Care Eastern Maine Medical Center Bangor ME USA

Department of Critical Care Services Maine Medical Center 22 Bramhall St Portland ME 04102 USA

Department of Intensive and Perioperative Care Skåne University Hospital Lund Sweden

Department of Intensive and Perioperative Care Skåne University Hospital Malmö Sweden

Department of Internal Medicine 2 Cardiovascular Medicine General Teaching Hospital and 1st Medical School Charles University Prague Prague Czech Republic

Department of Internal Medicine Division of Cardiology Kalmar County Hospital Kalmar Sweden

Department of Neurology Columbia Presbyterian Medical Center New York NY USA

Department of Surgical Sciences Anesthesiology and Intensive Care Uppsala University Uppsala Sweden

Division of Cardiology Sarver Heart Center University of Arizona Tucson USA

Division of Cardiovascular Medicine Lehigh Valley Hospital and Health Network Allentown PA USA

Division of Cardiovascular Medicine Vanderbilt University Medical Center Nashville TN USA

Institute of Clinical Medicine University of Oslo Oslo Norway

Medical Department National Rescue Services Luxembourg 14 rue Stümper 2557 Luxembourg Luxembourg

Mercy Hospital St Louis St Louis University St Louis MO USA

Stanford Neurocritical Care Program Department of Neurology and Neurological Sciences Stanford University School of Medicine Stanford CA USA

Intensive Care Med. 2019 Aug;45(8):1176. doi: 10.1007/s00134-019-05687-x. PubMed

See more in PubMed

Chamorro C, Borrallo JM, Romera MA, Silva JA, Balandin B, (2010) Anesthesia and analgesia protocol during therapeutic hypothermia after cardiac arrest: a systematic review. Anesthesia and analgesia 110: 1328–1335 PubMed

Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K, (2002) Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. The New England journal of medicine 346: 557–563 PubMed

Group HaCAS, (2002) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. The New England journal of medicine 346: 549–556 PubMed

Hollenbeck RD, McPherson JA, Mooney MR, Unger BT, Patel NC, McMullan PW Jr., Hsu CH, Seder DB, Kern KB, (2014) Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation 85: 88–95 PubMed

Pitcher JH, Dziodzio J, Keller J, May T, Riker RR, Seder DB, (2018) Hemodynamic, Biochemical, and Ventilatory Parameters are Independently Associated with Outcome after Cardiac Arrest. Neurocritical care PubMed

Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL, (2010) Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122: S768–786 PubMed

Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS, (2014) Hospital variation in survival after in-hospital cardiac arrest. Journal of the American Heart Association 3: e000400. PubMed PMC

Carr BG, Kahn JM, Merchant RM, Kramer AA, Neumar RW, (2009) Inter-hospital variability in post-cardiac arrest mortality. Resuscitation 80: 30–34 PubMed

Callaway CW, Schmicker RH, Brown SP, Albrich JM, Andrusiek DL, Aufderheide TP, Christenson J, Daya MR, Falconer D, Husa RD, Idris AH, Ornato JP, Rac VE, Rea TD, Rittenberger JC, Sears G, Stiell IG, (2014) Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest. Resuscitation 85: 657–663 PubMed PMC

Schober A, Sterz F, Laggner AN, Poppe M, Sulzgruber P, Lobmeyr E, Datler P, Keferbock M, Zeiner S, Nuernberger A, Eder B, Hinterholzer G, Mydza D, Enzelsberger B, Herbich K, Schuster R, Koeller E, Publig T, Smetana P, Scheibenpflug C, Christ G, Meyer B, Uray T, (2016) Admission of out-of-hospital cardiac arrest victims to a high volume cardiac arrest center is linked to improved outcome. Resuscitation 106: 42–48 PubMed

Elmer J, Callaway CW, Chang CH, Madaras J, Martin-Gill C, Nawrocki P, Seaman KAC, Sequeira D, Traynor OT, Venkat A, Walker H, Wallace DJ, Guyette FX, (2019) Long-Term Outcomes of Out-of-Hospital Cardiac Arrest Care at Regionalized Centers. Annals of emergency medicine 73: 29–39 PubMed PMC

Adrie C, Cariou A, Mourvillier B, Laurent I, Dabbane H, Hantala F, Rhaoui A, Thuong M, Monchi M, (2006) Predicting survival with good neurological recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: the OHCA score. European heart journal 27: 2840–2845 PubMed

Sladjana A, (2011) A prediction survival model for out-of-hospital cardiopulmonary resuscitations. Journal of critical care 26: 223.e211–228 PubMed

Hayakawa K, Tasaki O, Hamasaki T, Sakai T, Shiozaki T, Nakagawa Y, Ogura H, Kuwagata Y, Kajino K, Iwami T, Nishiuchi T, Hayashi Y, Hiraide A, Sugimoto H, Shimazu T, (2011) Prognostic indicators and outcome prediction model for patients with return of spontaneous circulation from cardiopulmonary arrest: the Utstein Osaka Project. Resuscitation 82: 874–880 PubMed

Okada K, Ohde S, Otani N, Sera T, Mochizuki T, Aoki M, Ishimatsu S, (2012) Prediction protocol for neurological outcome for survivors of out-of-hospital cardiac arrest treated with targeted temperature management. Resuscitation 83: 734–739 PubMed

Einav S, Kaufman N, Algur N, Strauss-Liviatan N, Kark JD, (2013) Brain biomarkers and management of uncertainty in predicting outcome of cardiopulmonary resuscitation: a nomogram paints a thousand words. Resuscitation 84: 1083–1088 PubMed

Ishikawa S, Niwano S, Imaki R, Takeuchi I, Irie W, Toyooka T, Soma K, Kurihara K, Izumi T, (2013) Usefulness of a simple prognostication score in prediction of the prognoses of patients with out-of-hospital cardiac arrests. International heart journal 54: 362–370 PubMed

May TL, S P, Frasers G, Riker RR, Seder DS, (2017) Outcomes in cardiac arrest vary by center after correction for case mix and severity of illness. Chest 152: Supp A72

Perkins GD, Jacobs IG, Nadkarni VM, Berg RA, Bhanji F, Biarent D, Bossaert LL, Brett SJ, Chamberlain D, de Caen AR, Deakin CD, Finn JC, Grasner JT, Hazinski MF, Iwami T, Koster RW, Lim SH, Huei-Ming Ma M, McNally BF, Morley PT, Morrison LJ, Monsieurs KG, Montgomery W, Nichol G, Okada K, Eng Hock Ong M, Travers AH, Nolan JP, (2015) Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Circulation 132: 1286–1300 PubMed

Zeiner A, Holzer M, Sterz F, Behringer W, Schorkhuber W, Mullner M, Frass M, Siostrzonek P, Ratheiser K, Kaff A, Laggner AN, (2000) Mild resuscitative hypothermia to improve neurological outcome after cardiac arrest. A clinical feasibility trial. Hypothermia After Cardiac Arrest (HACA) Study Group. Stroke; a journal of cerebral circulation 31: 86–94 PubMed

Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Aneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Kober L, Langorgen J, Lilja G, Moller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H, (2013) Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. The New England journal of medicine 369: 2197–2206 PubMed

Moulaert VR, van Heugten CM, Winkens B, Bakx WG, de Krom MC, Gorgels TP, Wade DT, Verbunt JA, (2015) Early neurologically-focused follow-up after cardiac arrest improves quality of life at one year: A randomised controlled trial. International journal of cardiology 193: 8–16 PubMed

Weimar C, Weber C, Wagner M, Busse O, Haberl RL, Lauterbach KW, Diener HC, (2003) Management patterns and health care use after intracerebral hemorrhage. a cost-of-illness study from a societal perspective in Germany. Cerebrovascular diseases (Basel, Switzerland) 15: 29–36 PubMed

Agarwal S, Presciutti A, Roth W, Matthews E, Rodriguez A, Roh DJ, Park S, Claassen J, Lazar RM, (2018) Determinants of Long-Term Neurological Recovery Patterns Relative to Hospital Discharge Among Cardiac Arrest Survivors. Critical care medicine 46: e141–e150 PubMed PMC

Kupari P, Skrifvars M, Kuisma M, (2017) External validation of the ROSC after cardiac arrest (RACA) score in a physician staffed emergency medical service system. Scandinavian journal of trauma, resuscitation and emergency medicine 25: 34 PubMed PMC

Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, Gautam S, Callaway C, (2014) Time to administration of epinephrine and outcome after inhospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry. BMJ (Clinical research ed) 348: g3028 PubMed PMC

Thomas JL, Bosson N, Kaji AH, Ji Y, Sung G, Shavelle DM, French WJ, Koenig W, Niemann JT, (2014) Treatment and outcomes of ST segment elevation myocardial infarction and out-of-hospital cardiac arrest in a regionalized system of care based on presence or absence of initial shockable cardiac arrest rhythm. The American journal of cardiology 114: 968–971 PubMed

Thomas AJ, Newgard CD, Fu R, Zive DM, Daya MR, (2013) Survival in out-of-hospital cardiac arrests with initial asystole or pulseless electrical activity and subsequent shockable rhythms. Resuscitation 84: 1261–1266 PubMed PMC

Li Y, Cai X, Glance LG, Spector WD, Mukamel DB, (2009) National release of the nursing home quality report cards: implications of statistical methodology for risk adjustment. Health services research 44: 79–102 PubMed PMC

Elmer J, Rittenberger JC, Coppler PJ, Guyette FX, Doshi AA, Callaway CW, (2016) Long-term survival benefit from treatment at a specialty center after cardiac arrest. Resuscitation 108: 48–53 PubMed PMC

Kern KB, Lotun K, Patel N, Mooney MR, Hollenbeck RD, McPherson JA, McMullan PW, Unger B, Hsu CH, Seder DB, (2015) Outcomes of Comatose Cardiac Arrest Survivors With and Without ST-Segment Elevation Myocardial Infarction: Importance of Coronary Angiography. JACC Cardiovascular interventions 8: 1031–1040 PubMed

Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C, Draegni T, Steen PA, (2007) Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 73: 29–39 PubMed

Gold B, Puertas L, Davis SP, Metzger A, Yannopoulos D, Oakes DA, Lick CJ, Gillquist DL, Holm SY, Olsen JD, Jain S, Lurie KG, (2014) Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early? Resuscitation 85: 211–214 PubMed

Paul M, Bougouin W, Geri G, Dumas F, Champigneulle B, Legriel S, Charpentier J, Mira JP, Sandroni C, Cariou A, (2016) Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry. Intensive care medicine 42: 1128–1136 PubMed

Dragancea I, Rundgren M, Englund E, Friberg H, Cronberg T, (2013) The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 84: 337–342 PubMed

Seder DB, Patel N, McPherson J, McMullan P, Kern KB, Unger B, Nanda S, Hacobian M, Kelley MB, Nielsen N, Dziodzio J, Mooney M, (2014) Geriatric experience following cardiac arrest at six interventional cardiology centers in the United States 2006–2011: interplay of age, do-not-resuscitate order, and outcomes. Critical care medicine 42: 289–295 PubMed

Bucholz EM, Butala NM, Ma S, Normand ST, Krumholz HM, (2016) Life Expectancy after Myocardial Infarction, According to Hospital Performance. The New England journal of medicine 375: 1332–1342 PubMed PMC

Kamps MJ, Horn J, Oddo M, Fugate JE, Storm C, Cronberg T, Wijman CA, Wu O, Binnekade JM, Hoedemaekers CW, (2013) Prognostication of neurologic outcome in cardiac arrest patients after mild therapeutic hypothermia: a meta-analysis of the current literature. Intensive care medicine 39: 1671–1682 PubMed

O’Connor GT, Plume SK, Olmstead EM, Morton JR, Maloney CT, Nugent WC, Hernandez F Jr., Clough R, Leavitt BJ, Coffin LH, Marrin CA, Wennberg D, Birkmeyer JD, Charlesworth DC, Malenka DJ, Quinton HB, Kasper JF, (1996) A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. Jama 275: 841–846 PubMed

Little NE, Feldman EL, (2014) Therapeutic hypothermia after cardiac arrest without return of consciousness: skating on thin ice. JAMA neurology 71: 823–824 PubMed