Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study.

BACKGROUND: During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. METHODS: Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines­Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. FINDINGS: 31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6-21) compared with 20 min (14-30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min [IQR 15-17]), those at hospitals in the quartile with the longest attempts (25 min [25-28]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06-1·18; p<0·0001) and survival to discharge (1·12, 1·02-1·23; 0·021). INTERPRETATION: Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. FUNDING: American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.

Physician specialty and carotid stenting among elderly medicare beneficiaries in the United States.

BACKGROUND: The use of carotid stenting is rising across the United States. How physician specialty relates to its utilization rates or outcomes is uncertain. METHODS: We performed an observational analysis of fee-for-service Medicare beneficiaries 65 years or older undergoing carotid stenting between 2005 and 2007 in 306 hospital referral regions (HRRs). We first determined how frequently carotid stenting was performed by different specialists within each HRR and then used multivariable regression models to compare population-based utilization rates and 30-day outcomes for this procedure across HRRs based on the proportion performed by cardiologists, surgeons, radiologists, or a mix of specialists. RESULTS: In 272 HRRs where at least 15 procedures were performed during the study period, we identified 28 700 carotid stenting procedures performed by 2588 operators. While cardiologists made up approximately one-third of these operators, they were responsible for 14 919 (52.0%) procedures. Significant differences were noted in the characteristics of patients treated by cardiologists compared with other specialties, including higher rates of invasive cardiac procedures and lower rates of acute stroke or transient ischemic attacks in the 180 days prior to carotid stenting. Population-based utilization rates were significantly higher in HRRs where cardiologists performed most procedures relative to HRRs where most were done by other specialists or a mix of specialists (P < .001). In contrast, risk-standardized outcomes did not differ across HRRs based on physician specialty. CONCLUSIONS: Carotid stenting is being performed by operators from diverse specialties. Hospital referral regions where cardiologists perform most procedures have higher population-based utilization rates with similar outcomes.