Return to Work in Out-of-Hospital Cardiac Arrest Survivors: A Nationwide Register-Based Follow-Up Study.

BACKGROUND: Data on long-term function of out-of-hospital cardiac arrest survivors are sparse. We examined return to work as a proxy of preserved function without major neurologic deficits in survivors. METHODS AND RESULTS: In Denmark, out-of-hospital cardiac arrests have been systematically reported to the Danish Cardiac Arrest Register since 2001. During 2001-2011, we identified 4354 patients employed before arrest among 12 332 working-age patients (18-65 years), of whom 796 survived to day 30. Among 796 survivors (median age, 53 years [quartile 1-3, 46-59 years]; 81.5% men), 610 (76.6%) returned to work in a median time of 4 months [quartile 1-3, 1-19 months], with a median time of 3 years spent back at work. A total of 74.6% (N=455) remained employed without using sick leave during the first 6 months after returning to work. This latter proportion of survivors returning to work increased over time (66.1% in 2001-2005 versus 78.1% in 2006-2011; P=0.002). In multivariable Cox regression analysis, factors associated with return to work with ≥6 months of sustainable employment were as follows: (1) arrest during 2006-2011 versus 2001-2005, hazard ratio (HR), 1.38 (95% CI, 1.05-1.82); (2) male sex, HR, 1.48 (95% CI, 1.06-2.07); (3) age of 18 to 49 versus 50 to 65 years, HR, 1.32 (95% CI, 1.02-1.68); (4) bystander-witnessed arrest, HR, 1.79 (95% CI, 1.17-2.76); and (5) bystander cardiopulmonary resuscitation, HR, 1.38 (95% CI, 1.02-1.87). CONCLUSIONS: Of 30-day survivors employed before arrest, 76.6% returned to work. The percentage of survivors returning to work increased significantly, along with improved survival during 2001-2011, suggesting an increase in the proportion of survivors with preserved function over time.

Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest.

IMPORTANCE: Out-of-hospital cardiac arrest is a major health problem associated with poor outcomes. Early recognition and intervention are critical for patient survival. Bystander cardiopulmonary resuscitation (CPR) is one factor among many associated with improved survival. OBJECTIVE: To examine temporal changes in bystander resuscitation attempts and survival during a 10-year period in which several national initiatives were taken to increase rates of bystander resuscitation and improve advanced care. DESIGN, SETTING, AND PARTICIPANTS: Patients with out-of-hospital cardiac arrest for which resuscitation was attempted were identified between 2001 and 2010 in the nationwide Danish Cardiac Arrest Registry. Of 29,111 patients with cardiac arrest, we excluded those with presumed noncardiac cause of arrest (n = 7390) and those with cardiac arrests witnessed by emergency medical services personnel (n = 2253), leaving a study population of 19,468 patients. MAIN OUTCOMES AND MEASURES: Temporal trends in bystander CPR, bystander defibrillation, 30-day survival, and 1-year survival. RESULTS: The median age of patients was 72 years; 67.4% were men. Bystander CPR increased significantly during the study period, from 21.1% (95% CI, 18.8%-23.4%) in 2001 to 44.9% (95% CI, 42.6%-47.1%) in 2010 (P < .001), whereas use of defibrillation by bystanders remained low (1.1% [95% CI, 0.6%-1.9%] in 2001 to 2.2% [95% CI, 1.5%-2.9%] in 2010; P = .003). More patients achieved survival on hospital arrival (7.9% [95% CI, 6.4%-9.5%] in 2001 to 21.8% [95% CI, 19.8%-23.8%] in 2010; P < .001). Also, 30-day survival improved (3.5% [95% CI, 2.5%-4.5%] in 2001 to 10.8% [95% CI, 9.4%-12.2%] in 2010; P < .001), as did 1-year survival (2.9% [95% CI, 2.0%-3.9%] in 2001 to 10.2% [95% CI, 8.9%-11.6%] in 2010; P < .001). Despite a decrease in the incidence of out-of-hospital cardiac arrests during the study period (40.4 to 34.4 per 100,000 persons in 2001 and 2010, respectively; P = .002), the number of survivors per 100,000 persons increased significantly (P < .001). For the entire study period, bystander CPR was positively associated with 30-day survival, regardless of witnessed status (30-day survival for nonwitnessed cardiac arrest, 4.3% [95% CI, 3.4%-5.2%] with bystander CPR and 1.0% [95% CI, 0.8%-1.3%] without; odds ratio, 4.38 [95% CI, 3.17-6.06]). For witnessed arrest the corresponding values were 19.4% (95% CI, 18.1%-20.7%) vs 6.1% (95% CI, 5.4%-6.7%); odds ratio, 3.74 (95% CI, 3.26-4.28). CONCLUSIONS AND RELEVANCE: In Denmark between 2001 and 2010, an increase in survival following out-of-hospital cardiac arrest was significantly associated with a concomitant increase in bystander CPR. Because of the co-occurrence of other related initiatives, a causal relationship remains uncertain.

Repeated ambulance use is associated with chronic diseases - a population-based historic cohort study of patients' symptoms and diagnoses.

BACKGROUND: There is a growing demand for emergency medical services (EMS) and patients are repeatedly transported by ambulance services. For many patients, especially those with chronic disease, there may be better ways of delivering care. We examined the symptom at time of emergency call and the hospital diagnosis for those ambulance users who repeatedly received an ambulance. METHODS: Population-based historic cohort study of patients receiving an ambulance after an emergency call between 2011 and 2014: one-time users (i.e. one ambulance run in any 12 month period) were compared to two-time users (two runs in any 12 month period) and frequent users (>two runs). The presenting symptom according to the Danish Index for Emergency Care from the EMS calls and the hospital ICD-10 discharge diagnoses were obtained from patient records. RESULTS: We included 52 533 patients (65 932 emergency ambulance runs). Repeated users constituted 16% of the patients (two-time users 11% and frequent users 5%) and one third of all ambulance runs. The symptoms showing the largest increase in frequency with increasing ambulance use were breathing difficulty (N = 3 905-15% were frequent users); seizure (N = 2 437-10% were frequent users), chest pain (N = 7 616-17% were frequent users), and alcohol intoxication (N = 1 998-5% were frequent users). The hospital diagnoses with a corresponding increase were respiratory diseases (N = 4 381) - 13% were frequent users), mental disorders (predominately abuse of alcohol) (N = 3 087-10% were frequent users) and neurological diseases (predominately epilepsy) (N = 2 207-6% were frequent users). 5% of one-time users, 12% of two-time users and 16% of frequent users had a Charlson Comorbidity Index > = 3. CONCLUSION: Repeated use of ambulance services was common and associated with chronic health problems such as chronic respiratory diseases, epilepsy, mental disorders with alcohol abuse and comorbidity. Alternative methods of caring for many of these patients should be considered. TRIAL REGISTRATION: None.

The Danish prehospital emergency healthcare system and research possibilities.

The emergency medical healthcare system outside hospital varies greatly across the globe - even within the western world. Within the last ten years, the demand for emergency medical service systems has increased, and the Danish emergency medical service system has undergone major changes.Therefore, we aimed to provide an updated description of the current Danish prehospital medical healthcare system.Since 2007, Denmark has been divided into five regions each responsible for health services, including the prehospital services. Each region may contract their own ambulance service providers. The Danish emergency medical services in general include ambulances, rapid response vehicles, mobile emergency care units and helicopter emergency medical services. All calls to the national emergency number, 1-1-2, are answered by the police, or the Copenhagen fire brigade, and since 2011 forwarded to an Emergency Medical Coordination Centre when the call relates to medical issues. At the Emergency Medical Coordination Centre, healthcare personnel assess the situation guided by the Danish Index for Emergency Care and determine the level of urgency of the situation, while technical personnel dispatch the appropriate medical emergency vehicles. In Denmark, all healthcare services, including emergency medical services are publicly funded and free of charge. In addition to emergency calls, other medical services are available for less urgent health problems around the clock. Prehospital personnel have since 2015 utilized a nationwide electronic prehospital medical record. The use of this prehospital medical record combined with Denmark's extensive registries, linkable by the unique civil registration number, enables new and unique possibilities to do high quality prehospital research, with complete patient follow-up.

Trends in diagnostic patterns and mortality in emergency ambulance service patients in 2007-2014: a population-based cohort study from the North Denmark Region.

OBJECTIVE: Demand for ambulances is growing. Nevertheless, knowledge is limited regarding diagnoses and outcomes in patients receiving emergency ambulances. This study aims to examine time trends in diagnoses and mortality among patients transported with emergency ambulance to hospital. DESIGN: Population-based cohort study with linkage of Danish national registries. SETTING: The North Denmark Region in 2007-2014. PARTICIPANTS: Cohort of 148 757 patients transported to hospital by ambulance after calling emergency services. MAIN OUTCOME MEASURES: The number of emergency ambulance service patients, distribution of their age, sex, hospital diagnoses, comorbidity, and 1-day and 30-day mortality were assessed by calendar year. Poisson regression with robust variance estimation was used to estimate both age-and sex-adjusted relative risk of death and prevalence ratios for Charlson Comorbidity Index (CCI) to allow comparison by year, with 2007 as reference year. RESULTS: The annual number of emergency ambulance service patients increased from 24.3 in 2007 to 40.2 in 2014 per 1000 inhabitants. The proportions of women increased from 43.1% to 46.4% and of patients aged 60+ years from 39.9% to 48.6%, respectively. The proportion of injuries gradually declined, non-specific diagnoses increased, especially the last year. Proportion of patients with high comorbidity (CCI≥3) increased from 6.4% in 2007 to 9.4% in 2014, corresponding to an age- and sex-adjusted prevalence ratio of 1.27 (95% CI 1.16 to 1.39). The 1-day and 30 day mortality decreased from 2.40% to 1.21% and from 5.01% to 4.36%, respectively, from 2007 to 2014, corresponding to age-adjusted and sex-adjusted relative risk of 0.43 (95% CI 0.37 to 0.50) and 0.72 (95% CI 0.66 to 0.79), respectively. CONCLUSION: During the 8-year period, the incidence of emergency ambulance service patients, the proportion of women, elderly, and non-specific diagnoses increased. The level of comorbidity increased substantially, whereas the 1-day and 30-day mortality decreased.

Diagnosis and mortality in prehospital emergency patients transported to hospital: a population-based and registry-based cohort study.

OBJECTIVE: Knowledge about patients after calling for an ambulance is limited to subgroups, such as patients with cardiac arrest, myocardial infarction, trauma and stroke, while population-based studies including all diagnoses are few. We examined the diagnostic pattern and mortality among all patients brought to hospital by ambulance after emergency calls. DESIGN: Registry-based cohort study. SETTING AND PARTICIPANTS: We included patients brought to hospital in an ambulance dispatched after emergency calls during 2007-2014 in the North Denmark Region (580 000 inhabitants). We reported hospital diagnosis according to the chapters of the International Classification of Diseases, 10th Edition (ICD-10), and studied death on days 1 and 30 after the call. Cohort characteristics and diagnoses were described, and the Kaplan-Meier method was used to estimate mortality and 95% CIs. RESULTS: In total, 148 757 patients were included, mean age 52.9 (SD 24.3) years. The most frequent ICD-10 diagnosis chapters were: 'injury and poisoning' (30.0%), and the 2 non-specific diagnosis chapters: 'symptoms and abnormal findings, not elsewhere classified' (17.5%) and 'factors influencing health status and contact with health services' (14.1%), followed by 'diseases of the circulatory system' (10.6%) and 'diseases of the respiratory system' (6.7%). The overall 1-day mortality was 1.8% (CI 1.7% to 1.8%) and 30-day mortality 4.7% (CI 4.6% to 4.8%). 'Diseases of the circulatory system' had the highest 1-day mortality of 7.7% (CI 7.3% to 8.1%) accounting for 1209 deaths. After 30 days, the highest number of deaths were among circulatory diseases (2313), respiratory diseases (1148), 'symptoms and abnormal findings, not elsewhere classified' (1119) and 'injury and poisoning' (741), and 30 days mortality in percentage was 14.7%, 11.6%, 4.3% and 1.7%, respectively. CONCLUSIONS: Patients' diagnoses from hospital stay after calling 1-1-2 in this population-based study were distributed across all ICD-10 chapters. Mortality varied widely between diagnostic groups. Non-specific diagnoses accounted for one-third of the patients and contributed to mortality in terms of total number of deaths.

Impact of health care system delay in patients with ST-elevation myocardial infarction on return to labor market and work retirement.

System delay (delay from emergency medical service call to reperfusion with primary percutaneous coronary intervention [PPCI]) is acknowledged as a performance measure in ST-elevation myocardial infarction (STEMI), as shorter system delay is associated with lower mortality. It is unknown whether system delay also impacts ability to stay in the labor market. Therefore, the aim of the study was to evaluate whether system delay is associated with duration of absence from work or time to retirement from work among patients with STEMI treated with PPCI. We conducted a population-based cohort study including patients ≤67 years of age who were admitted with STEMI from January 1, 1999, to December 1, 2011 and treated with PPCI. Data were derived from Danish population-based registries. Only patients who were full- or part-time employed before their STEMI admission were included. Association between system delay and time to return to the labor market was analyzed using a competing-risk regression analysis. Association between system delay and time to retirement from work was analyzed using a Cox regression model. A total of 4,061 patients were included. Ninety-three percent returned to the labor market during 4 years of follow-up, and 41% retired during 8 years of follow-up. After adjustment, system delay >120 minutes was associated with reduced resumption of work (subhazard ratio 0.86, 95% confidence interval 0.81 to 0.92) and earlier retirement from work (hazard ratio 1.21, 95% confidence interval 1.08 to 1.36). In conclusion, system delay was associated with reduced work resumption and earlier retirement. This highlights the value of system delay as a performance measure in treating patients with STEMI.