Racial Gap for In-hospital Cardiac Arrest Mortality Narrows

By Josh Garcia
Monday, January 1, 2018
Specialty: 

Recent research based on data from Get With the Guidelines–Resuscitation (GWTG-R) shows a substantial decrease in the difference in survival rates between black and white patients who suffer in-hospital cardiac arrest.

Several studies published during the past decade have examined this disparity. One such study, led by Paul Chan, MD, Professor of Medicine at St. Luke’s Hospital and the University of Missouri–Kansas City, was published in JAMA in 2009.

It found the rate of survival for black in-hospital cardiac arrest patients was markedly lower than that of white in-hospital cardiac arrest patients, based on data from the National Registry of Cardiopulmonary Resuscitation — now known as GWTG-R — provided by the American Heart Association (AHA).

“When the study was published, white patients had a 37 percent survival rate, while black patients had a 25 percent survival rate,” Dr. Chan says. “There was no survival gap that large in other conditions. We wanted to perform a follow-up study to examine if the gap had changed over time.”

“Disparities [in patient survival] — when they do exist — are dynamic, and we need to continue conducting research to see how we can reduce the disparities instead of just describing them. This doesn’t just apply to cardiac arrest but to any condition.”
— Paul Chan, MD, Professor of Medicine at St. Luke’s Hospital and the University of Missouri–Kansas City

Rapid Improvement

The follow-up study, published in JAMA Cardiology in August 2017, examined data from GWTG-R over a 14-year period. It found that not only had survival rates improved for both populations, but the difference between the two had decreased considerably. Risk-adjusted survival rates between black and white patients differed by less than 2 percent in 2014.

“We found that there was a striking reduction in survival differences 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 findings 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 registry between 2000 and 2009 and found that hospitals that participated in GWTG-R saw improvements in survival for patients who had experienced in-hospital cardiac arrest.

“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

A Question of Variables

While the data from neither study clearly conclude this, it is possible that hospitals participating in a national registry that is focused on quality improvement with regard to in-hospital cardiac arrest may increase their survival rates when compared with hospitals that do not.

“Unfortunately, only 5 percent of all U.S. hospitals are part of the GWTG-R registry,” says Myron L. Weisfeldt, MD, Professor of Medicine at Johns Hopkins University School of Medicine. “It’s possible that the GWTG-R program encourages better performances in these hospitals, but there are other possible explanations for the improvement [in survival rates in the studies], such as the rise of rapid-response teams and declaring some patients not appropriate [for resuscitation].”

For example, patients who underwent palliative care and opted for a do-not-resuscitate order would not be counted in the study results if they experienced an in-hospital cardiac arrest, as no resuscitation efforts would be made.

The Data Imperative

No comprehensive national database tracks the survival of cardiac arrest patients in all 5,000 hospitals in the U.S., which makes it impossible for researchers to determine with certainty the survival rates for in-hospital cardiac arrest patients nationwide or why rates improved in studies that utilized the GWTG-R registry.

“[P]ractitioners need to understand how important it would be to have a national database to give comparable data from all hospitals,” says Lance Becker, MD, Chair of Emergency Medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

In a new effort called the National Cardiac Arrest Collaborative, organizations such as the AHA and the American Red Cross are working toward creating a national registry that would enable every hospital to improve its performance, notes Dr. Becker, who co-wrote an editorial with Dr. Weisfeldt regarding the findings in the 2017 JAMA Cardiology article.