Cardiac arrests among elderly, especially people aged above the age of 65 is associated with significant morbidity and mortality (Merchant et al.,2011). However, most of the prior studies that have been done only seem to focus on prehospital and in-hospital survival therefore little is known about long-term outcomes among those who survive. This study aims to fill this gap and investigates how elderlies who manage to survive out-of-hospital cardiac arrests fare on in the long run. It examines long-term mortality, readmission incidence, and cumulative inpatient costs at 1 year among the elderlies that survived the out-of-hospital cardiac arrests and were discharged from the hospital. Furthermore, it analyzes data found in the Cardiac Arrest Registry to Enhance Survival (CARES) to obtain the necessary cohorts required to come up accurate statistical information from which inferences can be made. The research concludes that among the elderly patients that survive cardiac arrests, one thirds succumb within the first year and readmissions were common. Moreover, long term mortality is affected by whether CPR was initiated at the onset, patient neurological status at discharge, and hospital disposition.
Critical Appraisal
The study addresses a clearly focused issue and the cohorts were formed in an acceptable way. The population studied goes through a rigorous process that adheres to the purpose of the study. To put this into perspective, the population is trimmed from a total of 31, 881 patients who are 18 years or older to 1127 patients. A number of factors are considered that significantly reduce the data acquired. First, those under the age of 65 are removed from the CARES population followed by those who died prior to hospital admission. Those who are not linked to medicare files and those who died during index hospitalization are later on removed to come up with 1127 patients who are then used for the study.
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The cohorts used were not only representative but also minimized bias as the measurements used were objective and accurate. The measures are reflective of what was being analyzed. Survival curves were constructed using Kaplan-Meier estimates to figure out the unadjusted rates of mortality. Moreover, the cumulative readmission incidence rates at 1 year of follow up are summed cummulatively and from these, the average rate of readmissions is determined. Finally, multivariable cox proportional hazard models were also constructed that were instrumental in identifying predictors of 1-year mortality.
The results of this study show that 46.3% of the survivors had a cardiac arrest. 61% of the patients were at home when they went into cardiac arrest, 12% were at a nursing home facility, and 14.3% in a public area. In only 34.3% of the instances, there was a nonmedical bystander who administered CPR to the patient. The mortality rates were initially at 12.7% at 30 days and gradually rose to 31.8% at 1 year and 47.2% at 3 years. However, the 1-year mortality rates for those who had no or mild neurological disability was 21.4 % while for those severe neurological disability, the rate doubled. CPR initiated by bystanders at the very instance of the arrest showed a reduction of the long-term mortality rates for those who had received them. During the first year, 638 patients were readmitted representing 56.6% of the patients and 279 patients were readmitted more than 3 times. The mean and median of the 1-year cost of readmissions for the whole cohort were $23,765 and $7054 respectively. From these results, it is evident that important factors required by the study are measured and from here one can make an inference about the population.
Quality and Strength of the Evidence
The quality of the evidence especially for this study is high. The evidence is quite convincing as it reflects on actual data obtained by emergency medical services (EMS), 911 dispatch centers and receiving hospitals. The stringent process that was undertook to ensure that the information from CARES reflected the target population plays a big role in the quality of the evidence. The analyses done on the data also gives prominence in proving that bystander CPR and neurological disability have an effect on the long-term outcomes of the patients.
Practice Implications
The results illustrate that immediate CPR by a non-professional when an elderly is experiencing a cardiac arrest may actually allow the individual to live longer in case they survive the ordeal. Moreover, the neurological disability has a negative effect on the long-term outcomes of elderlies that suffer and survive cardiac arrests. This therefore means that clinics should include neurological assessments especially when a person who has had cardiac arrest is brought to the clinic.
References
Merchant, R. M., Yang, L., Becker, L. B., Berg, R. A., Nadkarni, V., Nichol, G., ... & Groeneveld, P. W. (2011). Incidence of treated cardiac arrest in hospitalized patients in the United States. Critical care medicine , 39 (11), 2401.
Chan, P. S., McNally, B., Nallamothu, B. K., Tang, F., Hammill, B. G., Spertus, J. A., & Curtis, L. H. (2016). Long ‐ Term Outcomes Among Elderly Survivors of Out ‐ of ‐ Hospital Cardiac Arrest. Journal of the American Heart Association , 5 (3), e002924.
Chan, P. S., Nallamothu, B. K., Krumholz, H. M., Spertus, J. A., Li, Y., Hammill, B. G., & Curtis, L. H. (2013). Long-term outcomes in elderly survivors of in-hospital cardiac arrest. New England Journal of Medicine , 368 (11), 1019-1026.
