Regional variability in survival outcomes of out-of-hospital cardiac arrest: The All-Japan Utstein Registry

      Abstract

      Objective

      There is a paucity of studies on the degree of regional variability in out-of-hospital cardiac arrest (OHCA) outcomes, particularly in neurological outcome. This study aimed to determine whether there is a significant regional variation in survival outcomes of OHCA across Japan.

      Methods

      We analyzed a prospective, nation-wide, population-based database (All-Japan Utstein Registry) involving all Japanese individuals who had non-traumatic OHCA resuscitated by emergency responders from January 2005 through December 2010. The primary study endpoint was favourable neurological survival at 1 month, defined as Cerebral Performance Category 1 or 2. We compared unadjusted and multivariable-adjusted rates of the outcome among seven geographic regions.

      Results

      In the total catchment population of 128 million, there were 539,641 non-traumatic OHCA patients. Unadjusted neurologically favourable survival varied across regions from 1.9% to 3.1% (rate difference, 1.2%; 95%CI, 1.0–1.3%); the Northeast region had a significantly lower rate compared to the Midwest region (unadjusted rate ratio, 0.62; 95%CI, 0.60–0.64). This disparity became larger after adjusting for patient- and prehospital-level confounders (adjusted rate ratio, 0.52; 95%CI, 0.51–0.54). Among 35,153 OHCA patients with return of spontaneous circulation, unadjusted neurologically favourable survival varied from 26.4% to 34.7% (rate difference, 8.3%; 95%CI, 6.6–10.1%); the East region had a significantly lower rate compared to the Midwest region (adjusted rate ratio, 0.72; 95%CI, 0.68–0.76).

      Conclusion

      In this prospective, nation-wide, population-based study in Japan, we found a two-fold regional difference in neurologically favourable survival after OHCA, suggesting regional disparities in prehospital care and in-hospital post-resuscitation care.

      Abbreviations:

      VF (ventricular fibrillation), VT (ventricular tachycardia)

      Abbreviations:

      EMS (emergency medical service), VF (ventricular fibrillation), VT (pulseless ventricular tachycardia), CPR (cardiopulmonary resuscitation), AED (automated external defibrillator), IQR (interquartile range)

      Abbreviation:

      CI (confidence interval)

      Abbreviations:

      CI (confidence interval), VF (ventricular fibrillation), VT (ventricular tachycardia)

      Abbreviation:

      CI (confidence interval)

      Keywords

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      References

        • Atwood C.
        • Eisenberg M.S.
        • Herlitz J.
        • Rea T.D.
        Incidence of EMS-treated out-of-hospital cardiac arrest in Europe.
        Resuscitation. 2005; 67: 75-80
        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Heart disease and stroke statistics – 2012 update: a report from the American Heart Association.
        Circulation. 2012; 125: e2-e220
        • Rea T.D.
        • Eisenberg M.S.
        • Becker L.J.
        • Murray J.A.
        • Hearne T.
        Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective.
        Circulation. 2003; 107: 2780-2785
        • Herlitz J.
        • Bang A.
        • Gunnarsson J.
        • et al.
        Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Goteborg, Sweden.
        Heart. 2003; 89: 25-30
        • MacKenzie E.J.
        • Rivara F.P.
        • Jurkovich G.J.
        • et al.
        A national evaluation of the effect of trauma-center care on mortality.
        N Engl J Med. 2006; 354: 366-378
        • Jacobs A.K.
        Regional systems of care for patients with ST-elevation myocardial infarction: being at the right place at the right time.
        Circulation. 2007; 116: 689-692
        • Iwami T.
        • Nichol G.
        • Hiraide A.
        • et al.
        Continuous improvements in “chain of survival” increased survival after out-of-hospital cardiac arrests: a large-scale population-based study.
        Circulation. 2009; 119: 728-734
        • Wang H.E.
        • Devlin S.M.
        • Sears G.K.
        • et al.
        Regional variations in early and late survival after out-of-hospital cardiac arrest.
        Resuscitation. 2012; 83: 1343-1348
        • Nichol G.
        • Thomas E.
        • Callaway C.W.
        • et al.
        Regional variation in out-of-hospital cardiac arrest incidence and outcome.
        JAMA. 2008; 300: 1423-1431
        • Carr B.G.
        • Kahn J.M.
        • Merchant R.M.
        • Kramer A.A.
        • Neumar R.W.
        Inter-hospital variability in post-cardiac arrest mortality.
        Resuscitation. 2009; 80: 30-34
        • Liu J.M.
        • Yang Q.
        • Pirrallo R.G.
        • Klein J.P.
        • Aufderheide T.P.
        Hospital variability of out-of-hospital cardiac arrest survival.
        Prehosp Emerg Care. 2008; 12: 339-346
        • McNally B.
        • Robb R.
        • Mehta M.
        • et al.
        Out-of-hospital cardiac arrest surveillance – Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010.
        MMWR Surveill Summ. 2011; 60: 1-19
        • Herlitz J.
        • Engdahl J.
        • Svensson L.
        • Angquist K.A.
        • Silfverstolpe J.
        • Holmberg S.
        Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest.
        Resuscitation. 2006; 70: 404-409
        • Stromsoe A.
        • Svensson L.
        • Claesson A.
        • Lindkvist J.
        • Lundstrom A.
        • Herlitz J.
        Association between population density and reported incidence, characteristics and outcome after out-of-hospital cardiac arrest in Sweden.
        Resuscitation. 2011; 82: 1307-1313
        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).
        Circulation. 2004; 110: 3385-3397
        • Cummins R.O.
        • Chamberlain D.A.
        • Abramson N.S.
        • et al.
        Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council.
        Circulation. 1991; 84: 960-975
      1. 2010 population census of Japan.
        Japan Statistical Association, Tokyo2011
        • Hasegawa K.
        • Hiraide A.
        • Chang Y.
        • Brown D.F.
        Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest.
        JAMA. 2013; 309: 257-266
      2. Japanese guidelines for emergency care and cardiopulmonary resuscitation 2010.
        Health Shuppansha, Tokyo2010
      3. Ministry of Health Labour and Welfare of Japan. Regional bureau of health and welfare. http://www.mhlw.go.jp/ [accessed 18.02.13].

        • Westreich D.
        • Cole S.R.
        • Young J.G.
        • et al.
        The parametric g-formula to estimate the effect of highly active antiretroviral therapy on incident AIDS or death.
        Stat Med. 2012; 31: 2000-2009
        • Berdowski J.
        • Berg R.A.
        • Tijssen J.G.
        • Koster R.W.
        Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies.
        Resuscitation. 2010; 81: 1479-1487
        • Kitamura T.
        • Iwami T.
        • Kawamura T.
        • Nagao K.
        • Tanaka H.
        • Hiraide A.
        Nationwide public-access defibrillation in Japan.
        N Engl J Med. 2010; 362: 994-1004
        • Kita T.
        Coronary heart disease risk in Japan – an east/west divide?.
        Eur Heart J. 2004; 6: A8-A11
        • National Institute of Population and Social Security Research
        Population projections for Japan: 2001–2050.
        Japanese Ministry of Health Labour and Welfare, 2002 (p. 12–4)
        • Carr B.G.
        • Goyal M.
        • Band R.A.
        • et al.
        A national analysis of the relationship between hospital factors and post-cardiac arrest mortality.
        Intensive Care Med. 2009; 35: 505-511
        • Rea T.D.
        • Cook A.J.
        • Stiell I.G.
        • et al.
        Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements.
        Ann Emerg Med. 2010; 55: 249-257
        • Becker L.B.
        • Han B.H.
        • Meyer P.M.
        • et al.
        Racial differences in the incidence of cardiac arrest and subsequent survival. The CPR Chicago Project.
        N Engl J Med. 1993; 329: 600-606
        • Menon V.
        • Rumsfeld J.S.
        • Roe M.T.
        • et al.
        Regional outcomes after admission for high-risk non-ST-segment elevation acute coronary syndromes.
        Am J Med. 2006; 119: 584-590
        • Bobrow B.J.
        • Spaite D.W.
        • Berg R.A.
        • et al.
        Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest.
        JAMA. 2010; 304: 1447-1454
        • Hollenberg J.
        • Herlitz J.
        • Lindqvist J.
        • et al.
        Improved survival after out-of-hospital cardiac arrest is associated with an increase in proportion of emergency crew – witnessed cases and bystander cardiopulmonary resuscitation.
        Circulation. 2008; 118: 389-396
        • Bernard S.A.
        • Gray T.W.
        • Buist M.D.
        • et al.
        Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.
        N Engl J Med. 2002; 346: 557-563
        • Garot P.
        • Lefevre T.
        • Eltchaninoff H.
        • et al.
        Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after cardiac arrest complicating ST-elevation myocardial infarction.
        Circulation. 2007; 115: 1354-1362
        • Rittenberger J.C.
        • Guyette F.X.
        • Tisherman S.A.
        • DeVita M.A.
        • Alvarez R.J.
        • Callaway C.W.
        Outcomes of a hospital-wide plan to improve care of comatose survivors of cardiac arrest.
        Resuscitation. 2008; 79: 198-204
        • Eisenberg M.
        • White R.D.
        The unacceptable disparity in cardiac arrest survival among American communities.
        Ann Emerg Med. 2009; 54: 258-260
        • Nichol G.
        • Aufderheide T.P.
        • Eigel B.
        • et al.
        Regional systems of care for out-of-hospital cardiac arrest: a policy statement from the American Heart Association.
        Circulation. 2010; 121: 709-729
        • Nolan J.P.
        • Hazinski M.F.
        • Billi J.E.
        • et al.
        Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
        Resuscitation. 2010; 81: e1-e25