Friday, May 22, 2015

Outcomes of In-Hospital CPR in Patients Receiving Dialysis

We’ve talked a lot about the prognosis after receiving in-hospital CPR in this blog (here, here, and here to name a few). In a recent issue of JAMA Internal Medicine, Susan Wong and colleagues looked at what happens to individuals on maintenance dialysis when they receive in-hospital cardiopulmonary resuscitation (CPR).  The results are summarized in the infographic above, and discussed in a little more detail below.

The Study

The authors used data from the US Renal Data System (USRDS) registry that enrolls patients after the onset of end stage renal disease, identifying all patients 18 years or older without a prior kidney transplant who initiated maintenance dialysis from January 1, 2000, through December 31, 2010. Importantly, to be included in this study, these patients needed to be on dialysis for at least 90 days (thereby exluding the sickest of the sick). By linking Medicare claims, they determined who in this registry was hospitalized and who got in-hospital CPR (although they excluded ER CPR).

Outcomes of interest included incidence of in-hospital CPR, proportion of patients surviving to hospital discharge after their first inhospital CPR event, and post-discharge survival. Among those who died in the hospital, they also measured the proportion who received CPR during their terminal hospitalization.

What did they find?

Most of the key findings are in the infographic, but I'll just highlight a few here:
  • The vast majority of individuals on maintenance dialysis were hospitalized at least once during the follow-up period (81% of the cohort)
  • Of these individuals who were hospitalized, 6% underwent at least one episode of CPR while hospitalized with a trend toward higher rates of CPR in more recent years. 
  • The proportion of CPR recipients who survived to discharge has increased in from 2000 to 2011 (15.2% to 28%) but there was no substantial change in duration of post-discharge survival.
  • The median survival fromthe time of discharge was 5.0 months among those who survived to discharge.

The Take Home

The results of this study are in line with other studies that suggest less people die in the hospital, but that doesn't mean that their long-term prognosis is any better.  In particular, Joan Teno's work shows that despite a decline in hospital deaths and an increase in hospice use, end of life for Medicare decedents increasingly includes ICU stays, short hospice stays, and multiple health care transitions.   This is particularly true to the dialysis population who undergo CPR.   We are better able to get them out of the hospital alive, but their survival after hospital discharge really has not improved, making them otherwise prognostically eligible for hospice.

by: Eric Widera (@ewidera)

Note: for more on the geriatric and palliative care needs of those with end-stage renal disease see these posts:


Andrew Kamell said...

The problem with all of these studies is that this is not a representative population of ALL inpatients getting dialysis. Instead, this is representative only of those who were FULL CODE. But the sickest patients with the poorest prognosis are generally strongly encouraged to become DNR. Therefore, the study looked at a sub-population that is significantly healthier and more likely to survive CPR than the total population of inpatients on dialysis who undergo cardiac arrest.
I'm not sure how to get around this without a RCT (which of course would be unethical.) At the least studies like this should report the total number of this population who died in the hospital. This could show the % of this population who underwent cardiac arrest while DNR, and give an idea of how representative this sample is or isn't of the population overall.

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Bruce Scott said...

That's an interesting point Andrew. Of course you are right that we've selected out some of the sicker patients (who would presumably be considerably less likely to survive a resuscitation attempt).

I'd like to have seen an analysis of the neurologic/functional status of the survivors.

In that same JAMA issue, there is an invited commentary suggesting that we should be careful not to consider the combination of dialysis plus do not attempt resuscitation as a contradiction.

Joshua Uy said...

There's external validity issues raised by Andrew. I usually cut any survival number in half by virtue that I'm bringing up the issue in the first place. It'd be interesting to see the survival of those who have had a code status discussion vs those who have not.