Cardiac arrest patients in Finnish intensive care units : insights into incidence, long-term outcomes and costs

Background: Sudden cardiac arrest (CA) represents a significant cause of death worldwide. Inhospital patients carry a particularly high risk of CA, both on the general ward and in the intensive care unit (ICU). With over 10,000 CAs occurring daily globally, undoubtedly CA has a significant socioeconomic impact. However, data on in-hospital CA (IHCA) and CA-related healthcare costs in Finland and globally, remain limited. Critically ill patients are often admitted to ICUs to undergo complex treatments that may or may not influence patient outcomes. Yet, changes in treatment intensity can potentially reflect a specific patient’s clinical condition and carry additional prognostic value. Aims: This study aimed to systematically review published literature on in-ICU CA (ICUCA), to investigate outcomes and healthcare-associated costs for CA patients treated within Finnish ICUs and to explore the individual effects of early treatment intensity and cardiopulmonary resuscitation on hospital mortality amongst Finnish ICU patients. Methods: The study consisted of a systematic review of the published literature (study I) summarising scientific evidence on CA in critically ill patients, and three original substudies on patients treated in Finnish ICUs between 2003 and 2013. The data for the substudies were acquired from the databases of the Finnish Intensive Care Consortium (FICC), the Social Insurance Institution of Finland (SII) and the Finnish Population Register Centre. Cost data comprised index hospitalisation expenses, rehabilitation costs and social security costs up to one year after CA. Effective cost per one-year survivor reflected the economic impact of CA, calculated as the sum of the total of healthcare costs divided by the number of survivors. Results: Across substudies, patient population size varied from n = 1024 to n = 164,255. A systematic review of the literature analysed 18 studies published between 1990 and 2013. Most of the reviewed publications were single-centre and retrospective with highly variable incidence and the outcome of ICU-CA. In Finland, there were 29 ICU-CAs for every 1000 ICU admissions. ICU-CA hospital mortality reached 56%. Amongst CA patients treated in a tertiary teaching hospital ICUs, 58% of out-of-hospital CA (OHCA) patients, 41% of IHCA patients and 39% of ICU-CA patients remained alive at one year following the initial arrest, of these 88% to 94% had a favourable neurological outcome. The effective cost, expressed in 2013 euro, was €94,688 for a one-year ICU-treated CA survivor and €102,722 for a one-year survivor with a favourable neurological outcome. A CA event and poor preadmission functional status were associated with a similar increase in the risk of hospital mortality. An increase in the intensity of early treatment associated with a higher risk of in-hospital death, particularly amongst patients with an initially low mortality risk. Conclusions: The incidence of ICU-CA amongst Finnish critically ill patients was higher and mortality was lower than previously published findings. The effective costs for one-year survivors were comparable to or lower than costs for ICU-treated patients with acute renal failure and critically ill cancer patients, healthcare expenditures considered generally acceptable. The increase in the risk of in-hospital death due to CA was comparable in magnitude to a poor preadmission functional status. Early increase in treatment intensity can serve as an additional warning sign of deterioration in Finnish critically ill patients.Äkillinen sydämenpysähdys on merkittävä kuolinsyy maailmanlaajuisesti. Erityisen korkea sydämenpysähdyksen riski on sairaalahoidossa olevilla potilailla sekä tavallisella vuodeosastolla että myös teho-osastolla. Maailmassa tapahtuu noin 10000 sydämenpysähdystä päivittäin, näin ollen sydämenpysähdyksen taloudellinen vaikutus on kiistaton. Tämän tutkimuksen tavoitteina oli arvioida systemaattisesti julkaistua kirjallisuutta tehohoidossa olevien potilaiden sydämenpysähdyksestä, selvittää ennuste ja hoitoon liittyvät kustannukset suomalaisilla teho-osastoilla hoidetuilla sydämenpysähdyspotilailla ja arvioida tehohoitopotilaiden hoitointensiteetin nousun ja tehohoidon aikaisen sydämenpysähdyksen itsenäiset vaikutukset potilaiden kuolemanriskiin pohjautuen Suomen Tehohoitokonsortion, Väestörekisterikeskuksen ja Kansaneläkelaitoksen potilastietokantoihin. Systemaattisen kirjallisuuskatsauksen perusteella todettiin, että suurin osa teho-osastoilla tapahtuvaa sydämenpysähdystä käsittelevistä tutkimuksista oli retrospektiivisia ja peräisin yhdestä keskuksesta. Teho osastolla tapahtuvan sydämenpysähdyksen esiintyvyys ja siihen liittyvä kuolleisuus vaihtelivat laajalti tutkimusympäristöstä ja potilasaineistosta riippuen. Suomalaisilla teho-osastoilla jokaista 1000 tehohoitojaksoa kohti oli 29 sydämenpysähdystä ja sydämenpysähdyksen jälkeinen sairaalakuolleisuus oli 56%. Sydämenpysähdystapahtumaan ja heikkoon tehohoitojaksoa edeltävään toimintakykyyn liittyvät sairaalakuolleisuusriskit olivat keskenään verrannollisia. Lisäksi korkeampi kuolleisuusriski liittyi myös varhaiseen hoitointensiteetin nousuun erityisesti potilailla, joiden kuolleisuusriski oli arvioitu matalaksi sairauden vaikeusasteen perusteella tehohoitojakson alussa. Ison suomalaisen yliopistollisen sairaalan teho-osastoilla hoidetuista sydämenpysähdyspotilaista 58% sairaalan ulkopuolella elvytetyistä, 41% sairaalan sisällä elvytetyistä ja 39% teho-osastolla elvytetyistä oli elossa vuoden kohdalla primääristä sydämenpysähdystapahtumasta. Näistä 88-94% selvisi myös neurologisesti hyvin. Hoitokustannukset yhtä vuoden kohdalla elossa olevaa sydämenpysähdyspotilasta kohti olivat 94688 euroa ja yhtä neurologisesti hyvin selvinnyttä potilasta kohti 102722 euroa. Hoitokustannukset olivat verrattavissa muiden tehohoidon potilasryhmien hoitokustannuksiin, joita pidetään yleisesti hyväksyttävinä

Intensive care-treated cardiac arrest : a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs

BackgroundCardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital.MethodsThis single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital's ICU between 2005 and 2013. We stratified the study population into two age groups: 75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1-2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome.ResultsThis study included a total of 1,285 patients, of which 212 (16%) were >= 75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (pPeer reviewe

Afferent limb failure revisited - A retrospective, international, multicentre, cohort study of delayed rapid response team calls

Aim: The efficiency of rapid response teams (RRTs) is decreased by delays in activation of RRT (afferent limb failure, ALF). We categorized ALF by organ systems and investigated correlations with the vital signs subsequently observed by the RRT and associations with mortality. Methods: International, multicentre, retrospective cohort study including adult RRT patients without treatment limitations in 2017-2018 in one Australian and two Finnish tertiary hospitals. Results: A total of 5,568 RRT patients' first RRT activations were included. In 927 patients (17%) ALF was present within 4 h before the RRT call, most commonly for respiratory criteria (419 patients, 7.5%). In 3516 patients (63%) overall, and in 756 (82%) of ALF patients, the RRT observed abnormal vital signs upon arrival. The organ-specific ALF corresponded to the RRT observations in 52% of cases for respiratory criteria, in 60% for haemodynamic criteria, in 55% for neurological criteria and in 52% of cases for multiple organ criteria. Only ALF for respiratory criteria was associated with increased hospital mortality (OR 1.71, 95% CI 1.29-2.27), whereas all, except haemodynamic, criteria at the time of RRT review were associated with increased hospital mortality. Conclusions: Vital signs were rarely normal upon RRT arrival in patients with ALF, while organ-specific ALF corresponded to subsequent RRT observations in just over half of cases. Our results suggest that systems mandating timely responses to abnormal respiratory criteria in particular may have potential to improve deteriorating patient outcomes.Peer reviewe

Early hyperoxemia is not associated with cardiac arrest outcome

Aim: Studies suggest that hyperoxemia increases short-term mortality after cardiopulmonary resuscitation (CPR), but the effect of hyperoxemia on long-term outcomes is unclear. We determined the prevalence of early hyperoxemia after CPR and its association with long-term neurological outcome and mortality. Methods: We analysed data from adult cardiac arrest patients treated after CPR in tertiary ICUs during 2005-2013. We retrieved data from the resuscitation and the first arterial blood sample collected after return of spontaneous circulation (ROSC) (severe hyperoxemia defined as PaO2 > 40 kPa and moderate as PaO2 16-40 kPa). We inspected two outcomes, neurological performance at one year after resuscitation according to the Cerebral Performance Category and one-year mortality. We used logistic regression to test associations between hyperoxemia and the outcome and interaction analyses to test the effect of hyperoxemia exposure on the outcomes in smaller subgroups. Results: Of 1110 patients 11% had severe hyperoxemia, prevalence was 10% for out-of-hospital arrests, 13% for in-hospital arrests and 9% for in-ICU arrests. In total 585(53%) patients had an unfavourable neurological outcome. Compared to normoxemia, severe (Odds ratio [OR] 0.81, 95% confidence interval [CI] 0.50-1.30) and moderate hyperoxemia (OR 0.94 95%CI 0.69-1.27) did not associate with neurological outcome. Additionally, hyperoxemia had no association with mortality. In subgroup analyses there were no significant associations between severe hyperoxemia and outcomes regardless of cardiac arrest location, initial rhythm or time-to-ROSC. Conclusion: We found no association between early post-arrest hyperoxemia and unfavourable outcome, Subgroup analysis found no differential effect depending on arrest location, initial rhythm or time-to-ROSC.Peer reviewe

Outcomes and healthcare-associated costs one year after intensive care-treated cardiac arrest

Correction Volume: 133 Pages: 193-193 DOI: 10.1016/j.resuscitation.2018.09.022 Published: DEC 2018Background: Despite the significant socioeconomic burden associated with cardiac arrest (CA), data on CA patients' long-term outcome and healthcare-associated costs are limited. The aim of this study was to determine one-year survival, neurological outcome and healthcare-associated costs for ICU-treated CA patients. Methods: This is a single-centre retrospective study on adult CA patients treated in Finnish tertiary hospital's ICUs between 2005 and 2013. Patients' personal identification number was used to crosslink data between several nationwide databases in order to obtain data on one-year survival, neurological outcome, and healthcare-associated costs. Healthcare-associated costs were calculated for every patient stratified by cardiac arrest location (OHCA = out-of-hospital cardiac arrest, IHCA = all in-hospital cardiac arrest, ICU-CA = in-ICU cardiac arrest) and initial cardiac rhythm. Cost-effectiveness was estimated by dividing total healthcare-associated costs for all patients from the respective group by the number of survivors and survivors with favourable neurological outcome. Results: The study population included 1,024 ICU-treated CA patients. The sum of costs for all patients was (sic)50,847,540. At one-year after CA, 58% of OHCAs, 44% of IHCAs, and 39% of ICU-CAs were alive. Of one-year survivors 97% of OHCAs, 88% of IHCAs, and 93% of ICU-CAs had favourable neurological outcome. Effective cost per one-year survivor was (sic)76,212 for OHCAs, (sic)144,168 for IHCAs, and (sic)239,468 for ICU-CAs. Effective cost per one-year survivor with favourable neurological outcome was (sic)81,196 for OHCAs, (sic)164,442 for IHCAs, and _(sic)257,207 for ICU-CAs. Conclusions: In-ICU CA patients had the lowest one-year survival with the effective cost per survivor three times higher than for OHCAs.Peer reviewe

Association of extracerebral organ failure with 1-year survival and healthcare-associated costs after cardiac arrest : an observational database study

BackgroundOrgan dysfunction is common after cardiac arrest and associated with worse short-term outcome, but its impact on long-term outcome and treatment costs is unknown.MethodsWe used nationwide registry data from the intensive care units (ICU) of the five Finnish university hospitals to evaluate the association of 24-h extracerebral Sequential Organ Failure Assessment (24h-EC-SOFA) score with 1-year survival and healthcare-associated costs after cardiac arrest. We included adult cardiac arrest patients treated in the participating ICUs between January 1, 2003, and December 31, 2013. We acquired the confirmed date of death from the Finnish Population Register Centre database and gross 1-year healthcare-associated costs from the hospital billing records and the database of the Finnish Social Insurance Institution.ResultsA total of 5814 patients were included in the study, and 2401 were alive 1year after cardiac arrest. Median (interquartile range (IQR)) 24h-EC-SOFA score was 6 (5-8) in 1-year survivors and 7 (5-10) in non-survivors. In multivariate regression analysis, adjusting for age and prior independency in self-care, the 24h-EC-SOFA score had an odds ratio (OR) of 1.16 (95% confidence interval (CI) 1.14-1.18) per point for 1-year mortality.Median (IQR) healthcare-associated costs in the year after cardiac arrest were Euro47,000 (Euro28,000-75,000) in 1-year survivors and Euro12,000 (Euro6600-25,000) in non-survivors. In a multivariate linear regression model adjusting for age and prior independency in self-care, an increase of one point in the 24h-EC-SOFA score was associated with an increase of Euro170 (95% CI Euro150-190) in the cost per day alive in the year after cardiac arrest. In the same model, an increase of one point in the 24h-EC-SOFA score was associated with an increase of Euro4400 (95% CI Euro3300-5500) in the total healthcare-associated costs in 1-year survivors.ConclusionsExtracerebral organ dysfunction is associated with long-term outcome and gross healthcare-associated costs of ICU-treated cardiac arrest patients. It should be considered when assessing interventions to improve outcomes and optimize the use of resources in these patients.Peer reviewe

Association of extracerebral organ failure with 1-year survival and healthcare-associated costs after cardiac arrest: an observational database study

Abstract Background Organ dysfunction is common after cardiac arrest and associated with worse short-term outcome, but its impact on long-term outcome and treatment costs is unknown. Methods We used nationwide registry data from the intensive care units (ICU) of the five Finnish university hospitals to evaluate the association of 24-h extracerebral Sequential Organ Failure Assessment (24h-EC-SOFA) score with 1-year survival and healthcare-associated costs after cardiac arrest. We included adult cardiac arrest patients treated in the participating ICUs between January 1, 2003, and December 31, 2013. We acquired the confirmed date of death from the Finnish Population Register Centre database and gross 1-year healthcare-associated costs from the hospital billing records and the database of the Finnish Social Insurance Institution. Results A total of 5814 patients were included in the study, and 2401 were alive 1 year after cardiac arrest. Median (interquartile range (IQR)) 24h-EC-SOFA score was 6 (5–8) in 1-year survivors and 7 (5–10) in non-survivors. In multivariate regression analysis, adjusting for age and prior independency in self-care, the 24h-EC-SOFA score had an odds ratio (OR) of 1.16 (95% confidence interval (CI) 1.14–1.18) per point for 1-year mortality. Median (IQR) healthcare-associated costs in the year after cardiac arrest were €47,000 (€28,000–75,000) in 1-year survivors and €12,000 (€6600–25,000) in non-survivors. In a multivariate linear regression model adjusting for age and prior independency in self-care, an increase of one point in the 24h-EC-SOFA score was associated with an increase of €170 (95% CI €150–190) in the cost per day alive in the year after cardiac arrest. In the same model, an increase of one point in the 24h-EC-SOFA score was associated with an increase of €4400 (95% CI €3300–5500) in the total healthcare-associated costs in 1-year survivors. Conclusions Extracerebral organ dysfunction is associated with long-term outcome and gross healthcare-associated costs of ICU-treated cardiac arrest patients. It should be considered when assessing interventions to improve outcomes and optimize the use of resources in these patients

Association of extracerebral organ failure with 1-year survival and healthcare-associated costs after cardiac arrest:an observational database study

Abstract Background: Organ dysfunction is common after cardiac arrest and associated with worse short-term outcome, but its impact on long-term outcome and treatment costs is unknown. Methods: We used nationwide registry data from the intensive care units (ICU) of the five Finnish university hospitals to evaluate the association of 24-h extracerebral Sequential Organ Failure Assessment (24h-EC-SOFA) score with 1-year survival and healthcare-associated costs after cardiac arrest. We included adult cardiac arrest patients treated in the participating ICUs between January 1, 2003, and December 31, 2013. We acquired the confirmed date of death from the Finnish Population Register Centre database and gross 1-year healthcare-associated costs from the hospital billing records and the database of the Finnish Social Insurance Institution. Results: A total of 5814 patients were included in the study, and 2401 were alive 1 year after cardiac arrest. Median (interquartile range (IQR)) 24h-EC-SOFA score was 6 (5–8) in 1-year survivors and 7 (5–10) in non-survivors. In multivariate regression analysis, adjusting for age and prior independency in self-care, the 24h-EC-SOFA score had an odds ratio (OR) of 1.16 (95% confidence interval (CI) 1.14–1.18) per point for 1-year mortality. Median (IQR) healthcare-associated costs in the year after cardiac arrest were €47,000 (€28,000–75,000) in 1-year survivors and €12,000 (€6600–25,000) in non-survivors. In a multivariate linear regression model adjusting for age and prior independency in self-care, an increase of one point in the 24h-EC-SOFA score was associated with an increase of €170 (95% CI €150–190) in the cost per day alive in the year after cardiac arrest. In the same model, an increase of one point in the 24h-EC-SOFA score was associated with an increase of €4400 (95% CI €3300–5500) in the total healthcare-associated costs in 1-year survivors. Conclusions: Extracerebral organ dysfunction is associated with long-term outcome and gross healthcare-associated costs of ICU-treated cardiac arrest patients. It should be considered when assessing interventions to improve outcomes and optimize the use of resources in these patients