Racial Gap in Survival After In-Hospital Cardiac Arrest Nearly Closed

MedicalResearch.com Interview with:
Dr. Lee Joseph, MD, MS

Postdoctoral fellow at University of Iowa
Division of Cardiovascular Diseases
Department of Internal Medicine
University of Iowa Carver College of Medicine
Iowa City

MedicalResearch.com: What is the background for this study?

Response: In-hospital cardiac arrest (IHCA) is common and affects more than 200,000 patients every year. Although survival for in-hospital cardiac arrest has improved in recent years, marked racial differences in survival are present. A previous study showed that black patients with in-hospital cardiac arrest have 27% lower chance of surviving an in-hospital cardiac arrest due to a shockable rhythm compared to white patients. Moreover, lower survival in black patients was largely attributable to the fact that black patients were predominantly treated in lower quality hospitals compared to white patients.  In other words, racial disparities in survival are closely intertwined with hospital quality, and this has been borne out in multiple other studies as well

In this study, we were interested in determining whether improvement in in-hospital cardiac arrest survival that has occurred in recent years benefited black and white patients equally or not? In other words, have racial differences in survival decreased as overall survival has improved. If so, what is the mechanism of that improvement? And finally, did hospitals that predominantly treat black patients make the greatest improvement in survival?

To address these questions, we used data from the Get With The Guidelines-Resuscitation, a large national quality improvement registry of in-hospital cardiac arrest that was established by the American Heart Association in the year 2000. Participating hospitals submit rich clinical data on patients who experience in-hospital cardiac arrest. Over the last 17 years, the registry has grown markedly and currently includes information on >200,000 patients from > 500 hospitals. The primary purpose is quality improvement. But it has also become an important resource to conduct research into the epidemiology and outcomes associated with in-hospital cardiac arrest.

Using data from the Get With the Guidelines-Resuscitation, we identified 112,139 patients at 289 hospitals between 2000-2014. Approximately 25% of the patients were of black race and the remainder were white patients. We constructed two-level hierarchical regression models to estimate yearly risk adjusted survival rates in black and white patients and examined how survival differences changed over time both on an absolute and a relative scale.

MedicalResearch.com: What are the main findings?

Response: We found survival after IHCA has improved over time in both groups. Survival in white patients improved from 15.8% in 2000 to 23.2% in 2014. Survival in black patients also improved from 11.3% in 2000 to 21.4% in 2014. What was striking was that as overall survival improved in both race, differences in survival between black and white patients decreased significantly over time, both on an absolute scale and a relative scale.

We also looked at survival from a hospital-level. To do this, we stratified our study hospitals into 2 groups based on the proportion of black IHCA patients in these hospitals, i.e., hospitals below the median and above the median. As expected, we found that hospitals with lower proportion of black patients had higher survival at baseline compared to hospitals with higher proportion of black patients. Survival improved at both hospital groups, but the magnitude of improvement was much larger at hospitals with a higher proportion of black patients. In other words, a reduction in racial differences were due to a greater improvement in survival at hospitals that disproportionately treat black patients.

MedicalResearch.com: What should clinicians and patients take away from your report?

Response: A number of previous studies have consistently shown the link between racial disparities and hospital quality. However, in this paper we demonstrate that efforts targeted towards improving hospital quality not only lead to an improvement in patient outcomes but also a reduction in racial disparities. Our findings should provide impetus to ongoing quality improvement efforts such as the GWTG-Resuscitation program and bolster quality improvement efforts in the hospitals across the United States.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Over the last 15 years, we have learned a lot about in-hospital cardiac arrest largely due to the work supported by the AHA GWTG-Resuscitation program with regards to quality of care and the associated variation. However, we have only begun to scratch at the surface and a lot more work needs to be done. Given that racial disparities are so intertwined with hospital quality, future work needs to be focused on understanding the determinants of high quality resuscitation care. We know from prior work, survival rates for IHCA vary by more than 4-fold across U.S. hospitals even after adjusting for differences in patient case-mix. What are the factors that distinguish high performing hospitals from poor performing hospitals? What can we learn from such high performing hospitals that consistently achieve exceptional survival rates while other hospitals struggle? And can we apply these lessons to all hospitals so that outcomes can improve across the board and racial disparities can be completely eliminated. We are really excited about some of this work which is ongoing, and will help us find answers to these important questions

MedicalResearch.com: Is there anything else you would like to add?

Response: Dr. Girotra (K08HL122527) and Dr. Chan (R01HL123980) are supported by funding from the National Heart, Lung and Blood Institute.
Dr. Chan has served as a consultant for the American Heart Association.  None of the other authors has any conflicts of interest or financial interests to disclose.
GWTG-Resuscitation is sponsored by the American Heart Association, which had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.  The manuscript is reviewed and approved by the GWTG-Resuscitation research and publications committee prior to journal submission.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.


Joseph L, Chan PS, Bradley SM, Zhou Y, Graham G, Jones PG, Vaughan-Sarrazin M, Girotra S, for the American Heart Association Get With the Guidelines–Resuscitation Investigators. Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest. JAMA Cardiol. Published online August 09, 2017. doi:10.1001/jamacardio.2017.2403

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Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on August 9, 2017 by Marie Benz MD FAAD