Among patients 65 years of age or older who survived an in-hospital cardiac arrest, 59% survived for at least 1 year and 50% survived for at least 2 years. The most vulnerable period after discharge was the first 3 months, during which 56% of the total number of deaths during the first 2 years occurred. The rates of 1-year survival were significantly lower among older patients than among younger patients, among men than among women, among blacks than among whites, and among patients with moderate or more severe neurologic disability at discharge than among those with mild or no neurologic disability. In addition, more than one third of the patients were not readmitted to the hospital within 1 year after discharge, and many of the patient characteristics associated with lower rates of 1-year survival were also associated with higher rates of readmission.
Until recently, there has been limited information on long-term outcomes in survivors of in-hospital cardiac arrest.4-8
The lack of data on long-term outcomes has prevented patients and clinicians from understanding what they may expect after recovery and has potentially contributed to nihilistic attitudes toward resuscitation efforts, especially for older patients. Our findings that almost 60% of patients were alive at 1 year and more than one third had not been readmitted to the hospital provide new insights into this population and challenge earlier assumptions. We found that survivors of in-hospital cardiac arrest had only modestly lower 2-year survival rates than did patients hospitalized for heart failure, with their survival curves converging at 3 years. Our findings suggest that survivors of in-hospital cardiac arrest do not have markedly worse survival trajectories than do patients with other serious medical conditions, such as heart failure.
We observed several predictors of 1-year survival. The finding that older age was associated with lower survival was not surprising, yet half the patients 85 years of age or older who were discharged from the hospital were alive at 1 year. Although in-hospital resuscitation efforts in patients of advanced age may be perceived as futile, the relatively high survival rate among these patients suggests that discussions about advance directives should be individualized and informed by patients’ preferences and health status. We also found that men were less likely than women to survive to 1 year, mirroring the pattern of lower rates of in-hospital survival among men after cardiac arrest.20
The physiological basis for the differences in these outcomes between men and women remains a focus of ongoing investigation.
The association of black race with lower rates of long-term survival is not intuitive and raises the possibility of disparities in care after discharge. We found racial differences in the rate of survival even after adjusting for factors, such as renal disease, that are more prevalent among black patients and are associated with a worse prognosis. To better understand the reasons for racial differences in the rates of survival after discharge, further investigations are needed to determine whether there are racial differences in discharge destination (e.g., hospice), rates of cardiac catheterization and implantation of a cardioverter–defibrillator during the index hospitalization, access to follow-up outpatient care, or other practice patterns. Finally, we found that patients with moderate neurologic disability at discharge had a significantly lower rate of 1-year survival than did patients with mild or no neurologic disability. This finding suggests that renewed efforts are needed to minimize neurologic injury during resuscitation care.
Our study has some limitations. First, Get with the Guidelines–Resuscitation is a quality-improvement registry. Although data are collected from a diverse group of hospitals, long-term outcomes in nonparticipating hospitals may differ. Second, we restricted the analysis to Medicare beneficiaries; outcomes in patients younger than 65 years of age may differ. Third, we excluded patients for whom a Get with the Guidelines–Resuscitation record could not be linked to a Medicare hospitalization. This scenario occurred when a patient was admitted to a non-Medicare hospital (e.g., a Veterans Affairs hospital), had insurance other than fee-for-service Medicare, was admitted to a hospital with few patients included in the registry (thus precluding a unique match), or did not have a qualifying ICD-9-CM diagnosis or procedure code for cardiac arrest in the Medicare files. Nonetheless, the characteristics of patients who were excluded from the study were similar to those of patients in the study cohort; therefore, the exclusion of those patients was unlikely to significantly bias the results. Finally, we did not have access to serial assessments of neurologic status or quality of life after discharge to allow for a more refined understanding of the trajectory of health status among those with long-term survival,21
nor did we have information about cause of death.
In conclusion, we found that 59% of elderly survivors of an in-hospital cardiac arrest were alive at 1 year, and one third were not readmitted to the hospital during that time. Survival and readmission rates differed according to the patients’ age, sex, race, and neurologic status at discharge.