RECOVERY AFTER IN-HOSPITAL CARDIAC ARREST: LATE OUTCOMES &UTILIZATION (RESCU) ABSTRACT In-hospital cardiac arrest (IHCA) is common, life-threatening, and hospitals allocate substantial resources to care for it. Inpatient survival after IHCA has improved nationally over the last decade, although similar statistics within the VHA are unavailable. More importantly, however, few contemporary data exist - either nationally or in the VHA - on the long-term survival, care requirements or health status of patients with IHCA. This is a critical "gap" in knowledge: information on late outcomes after IHCA is essential for clinical decision-making, especially as emerging data suggest survivors may do reasonable well after discharge. Although hospitals do much to care for patients with IHCA, little research to date has been done on understanding how these efforts may be associated with the end results of care. No empirical analyses have linked hospital micro-systems or organizational culture to the wide outcome variations noted after IHCA in the "real-world". Within the VHA, growing concerns about quality have led to an active VHA Directive 2008-063 that specifically calls for data on IHCA to be "aggregated, analyzed, compared internally over time and externally with other sources of information when available (benchmarking)" and "used to identify and implement desired changes" at both hospital and VISN-levels. In this context, IHCA also is now a high priority for the Ischemic Heart Disease (IHD) Quality Enhancement Research Initiative (QUERI) and VHA National Program Director for Cardiology. Yet while the VHA has demonstrated clear interest in this area and established world-class tools for measuring inpatient quality in other settings, no operational systems have been constructed to provide feedback on IHCA. Accordingly, the fundamental goal of the ResCU proposal is to understand patterns of long-term outcomes and healthcare utilization across hospitals after IHCA and then to use these insights to develop new strategies for quality improvement both within the VHA and elsewhere. Its 3 Aims will: (1) measure long-term outcomes (including health status) and healthcare utilization in patients after IHCA within the VHA and then determine key patient-level factors that are linked to adverse outcomes;(2) identify hospital-level factors that are associated with long-term outcomes and healthcare utilization;and (3) determine the extent of variation in long-term, risk-adjusted outcomes across hospitals and VISNs. This project will be performed largely as a retrospective cohort study using existing data on all hospitalized Veterans who suffered IHCA in the United States between 2005 and 2012. For these objectives, patient-level data on over 4,500 survivors of IHCA from the Inpatient Evaluation Center (IPEC) will be linked to the Medical SAS files and other administrative data sources-both inside VHA and non-VHA. For a subset of ~540 survivors enrolled in a prospective cohort, long-term outcomes will also include measures of self-reported health status over time, collected via a telephone-based survey. Multilevel modeling will be performed to determine heterogeneity in patients'long-term outcomes, and the extent to which such heterogeneity is attributable to the site they received care. In the future, this proposal's findings will directly enhance Veterans' care by: improving clinical decision-making (Aim 1);identifying hospital-level factors associated with improved outcomes (Aim 2);and making possible risk-adjusted measures that may be used for feedback and benchmarking to guide quality efforts (Aim 3).
The ResCU proposal will increase the capacity at the VHA to improve long-term, patient-centered outcomes for Veterans who suffer IHCA by building on existing quality programs, such as those in Clinical Analytics & Reporting in the Office of Information and Analytics. This project will be among the first to link acute inpatient care to long-term outcomes, such 1-year mortality;subsequent medical resource use;nursing home use;and, for a subset of patients, self-reported health status over time. This study fits squarely within the HSR&D priority area of informatics. It also directly addresses challenges raised by an active (but as yet unfulfilled) national VHA Directive (2008-063) for better oversight and monitoring of IHCA while tackling a disease condition that is a high-priority area for the IHD QUERI and VHA National Program Director for Cardiology. In summary, the ResCU proposal will benefit the large number of Veterans suffering IHCA each year by improving clinical decision-making, identifying hospital factors associated with better outcomes, and making possible feedback and benchmarking to facilities and VISNs for optimizing long-term care in these high-risk patients.