Points to consider: EULAR-UEMS standards for the training of European rheumatologists

BACKGROUND

Postgraduate rheumatology training programmes are already established at a national level in most European countries. However, previous work has highlighted a substantial level of heterogeneity in the organisation and, in part, content of programmes.

OBJECTIVE

To define competences and standards of knowledge, skills and professional behaviours required for the training of rheumatologists.

METHODS

A European Alliance of Associations for Rheumatology (EULAR) task force (TF) of 23 experts, including two members of the European Union of Medical Specialists (UEMS) section of rheumatology, was convened. The mapping phase consisted of the retrieval of key documents on specialty training in rheumatology and other related specialties across a broad set of international sources. The content of these documents was extracted and represented the foundation for the document draft that underwent several rounds of online discussion within the TF, and afterwards was also distributed to a broad group of stakeholders for collecting feedback. The list of generated competences was voted on during the TF meetings, while the level of agreement (LoA) with each statement was established by anonymous online voting.

RESULTS

A total of 132 international training curricula were retrieved and extracted. In addition to the TF members, 253 stakeholders commented and voted on the competences through an online anonymous survey. The TF developed (1) an overarching framework indicating the areas that should be addressed during training, (2) 7 domains defining broad areas that rheumatology trainees should master by the end of the training programme, (3) 8 core themes defining the nuances of each domain and (4) 28 competences that trainees should acquire to cover each of the areas outlined in the overarching framework. A high LoA was achieved for all competences.

CONCLUSION

These points to consider for EULAR-UEMS standards for the training of European rheumatologists are now defined. Their dissemination and use can hopefully contribute to harmonising training across European countries.

Quality assessment of prenatal and puerperium care

OBJECTIVE

To evaluate prenatal and puerperium care levels received and identify their association with sociodemographic and obstetric characteristics.

METHODS

This cross-sectional study was conducted from May to December 2020 and included women who gave birth at the Municipal Hospital of Fazenda Rio Grande, Paraná, Brazil. Data were collected through interviews and review of portfolios and medical records. The variables extracted from the prenatal protocols of Paraná and the Ministry of Health were grouped into five compliance indices: CI1 - clinical examination; CI2 - health education; CI3 - queries; CI4 - examinations and vaccines; and CI5 - postpartum appointments. Prenatal care was considered adequate when 80% or more adequacy was obtained.

RESULTS

A total of 307 women participated in this study. Prenatal compliance was 16.6% considering the entire set of variables. The best performance was for CI4 (54.7%) and the worst for CI5 (13.3%). The lowest adequacy occurred among single women (10.9%) compared to those who lived with a partner (19.9%) (p=0.043) and among women with black/brown skin color (9.5%) compared to those with white/yellow skin color (20.3%) (p=0.016).

CONCLUSION

Most women did not receive adequate care, with those in situations of greater social vulnerability received worse quality care.

What is the best target in a treat-to-target strategy in rheumatoid arthritis? Results from a systematic review and meta-regression analysis

OBJECTIVES

A treat-to-target (T2T) strategy has been shown to be superior to usual care in rheumatoid arthritis (RA), but the optimal target remains unknown. Targets are based on a disease activity measure (eg, Disease Activity Score-28 (DAS28), Simplified Disease Activity Indices/Clinical Disease Activity Indices (SDAI/CDAI), and a cut-off such as remission or low disease activity (LDA). Our aim was to compare the effect of different targets on clinical and radiographic outcomes.

METHODS

Cochrane, Embase and (pre)MEDLINE databases were searched (1 June 2022) for randomised controlled trials and cohort studies after 2003 that applied T2T in RA patients for ≥12 months. Data were extracted from individual T2T study arms; risk of bias was assessed with the Cochrane Collaboration tool. Using meta-regression, we evaluated the effect of the target used on clinical and radiographic outcomes, correcting for heterogeneity between and within studies.

RESULTS

115 treatment arms were used in the meta-regression analyses. Aiming for SDAI/CDAI-LDA was statistically superior to targeting DAS-LDA regarding DAS-remission and SDAI/CDAI/Boolean-remission outcomes over 1-3 years. Aiming for SDAI/CDAI-LDA was also significantly superior to DAS-remission regarding both SDAI/CDAI/Boolean-remission (over 1-3 years) and mean SDAI/CDAI (over 1 year). Targeting DAS-remission rather than DAS-LDA only improved the percentage of patients in DAS-remission, and only statistically significantly after 2-3 years of T2T. No differences were observed in Health Assessment Questionnaire and radiographic progression.

CONCLUSIONS

Targeting SDAI/CDAI-LDA, and to a lesser extent DAS-remission, may be superior to targeting DAS-LDA regarding several clinical outcomes. However, due to the risk of residual confounding and the lack of data on (over)treatment and safety, future studies should aim to directly and comprehensively compare targets.

PROSPERO REGISTRATION NUMBER

CRD42021249015.

Modelling admission lengths within psychiatric intensive care units

OBJECTIVES

To examine whether discharge destination is a useful predictor variable for the length of admission within psychiatric intensive care units (PICUs).

METHODS

A clinician-led process separated PICU admissions by discharge destination into three types and suggested other possible variables associated with length of stay. Subsequently, a retrospective study gathered proposed predictor variable data from a total of 368 admissions from four PICUs. Bayesian models were developed and analysed.

RESULTS

Clinical patient-type grouping by discharge destination displayed better intraclass correlation (0.37) than any other predictor variable (next highest was the specific PICU to which a patient was admitted (0.0585)). Patients who were transferred to further secure care had the longest PICU admission length. The best model included both patient type (discharge destination) and unit as well as an interaction between those variables.

DISCUSSION

Patient typing based on clinical pathways shows better predictive ability of admission length than clinical diagnosis or a specific tool that was developed to identify patient needs. Modelling admission lengths in a Bayesian fashion could be expanded and be useful within service planning and monitoring for groups of patients.

CONCLUSION

Variables previously proposed to be associated with patient need did not predict PICU admission length. Of the proposed predictor variables, grouping patients by discharge destination contributed the most to length of stay in four different PICUs.

Building an antimicrobial stewardship program: A narrative of six years under the Donabedian perspective

Introduction: Antimicrobial resistance (AMR) is increasing and represents one of the world's major challenges. AMR increase morbimortality, length of hospital stay and costs. Antimicrobial Stewardship Programs (ASP) are one of the key strategies to promote the rational use of antimicrobials since AMR is mostly driven by antimicrobial consumption. Objective: To describe the ASP implementation in a teaching hospital from the perspective of Donabedian quality assessment and the Brazilian regulatory requirements. Method: This was a descriptive study with secondary data collection, including document review of the ASP. The study setting was a general public 392-bed hospital. The ASP activities were performed by the hospital infection control committee (HICC), hospital pharmacy (HP) and diagnostic support laboratory (DSL). The description of the three services mainly involved in the ASP was based on a quality assessment model involving the dimensions of "structure", "process" and "result" proposed by Donabedian. The distribution among dimensions was guided by the checklist of essential elements of the ASP that compose the Brazilian regulatory requirements. The checklist was applied in July, 2022, and the ASP results described from 2016 to 2021. Results: ASP actions have been gradually implemented since 2008 with the implementation of HICC and improved over the years. Regarding structure, the investments in technology were mapped, quantifying 26 computers and three software programs employed to computerize the ASP processes performed in specific physical areas by HICC, HP and DSL. Institutional guidelines used by HICC, HP and DSL guided clinical practices to operationalize ASP. The evaluation metrics improved for 10 indicators and worsened for four indicators. From the 60 items composing the checklist, the hospital met the requirements in 73.3% of the items (n = 44). Conclusion: This study described the implementation of ASP in a teaching hospital, applying the Donabedian perspective. Although the hospital still does not have a classic ASP model, there were investments to improve structure, processes and results, aiming to comply with international guidelines. A high proportion of key elements of ASP in the hospital were followed according to the Brazilian regulatory requirements. Aspects related to antimicrobial consumption and the emergence of microbial resistance deserve further investigations.

Twenty-first century house calls: a survey of ambulatory care providers to inform organisational telehealth strategy

OBJECTIVES

While patient interest in telehealth increases, clinicians' perspectives may influence longer-term adoption. We sought to identify facilitators and barriers to continued clinician incorporation of telehealth into practice.

METHODS

A cross-sectional 24-item web-based survey was emailed to 491 providers with ≥50 video visits (VVs) within an academic health system between 1 March 2020 and 31 December 2020. We quantitatively summarised the characteristics and perceptions of respondents by using descriptive and test statistics. We used systematic content analysis to qualitatively code open-ended responses, double coding at least 25%.

RESULTS

247 providers (50.3%) responded to the survey. Seventy-nine per cent were confident in their ability to deliver excellent clinical care through VV. In comparison, 48% were confident in their ability to troubleshoot technical issues. Most clinicians (87%) expressed various concerns about VV. Providers across specialties generally agreed that VV reduced infection risk (71%) and transportation barriers (71%). Three overarching themes in the qualitative data included infrastructure and training, usefulness and expectation setting for patients and providers.

DISCUSSION

As healthcare systems plan for future delivery directions, they must address the tension between patients' and providers' expectations of care within the digital space. Telehealth creates new friction, one where the healthcare system must fit into the patient's life rather than the usual dynamic of the patient fitting into the healthcare system.

CONCLUSION

Telehealth infrastructure and patient and clinician technological acumen continue to evolve. Clinicians in this survey offered valuable insights into the directions healthcare organisations can take to right-size this healthcare delivery modality.

Safety and efficacy of the SGLT2 inhibitor dapagliflozin in patients with systemic lupus erythematosus: a phase I/II trial

OBJECTIVE

Sodium-glucose cotransporter-2 inhibitors have been identified profound renal/cardiac protective effects in different diseases. Here, we assessed the safety and efficacy of dapagliflozin among adult patients with systemic lupus erythematosus (SLE).

METHODS

We conducted a single-arm, open-label, investigator-initiated phase I/II trial of dapagliflozin in Chinese patients with SLE with/without lupus nephritis (LN). Patients received oral dapagliflozin at a daily dose of 10 mg added to the standard of care for 6 months. The primary end point was the safety profile. The secondary efficacy end points were composite assessments of disease activity.

RESULTS

A total of 38 eligible patients were enrolled. Overall, 19 (50%) adverse events (AEs) were recorded, including 8 (21%) AEs leading to drug discontinuation, of which 4 (10.5%) were attributed to dapagliflozin. Two serious AEs (one of major lupus flare and one of fungal pneumonia) were recorded. Lower urinary tract infection was observed in one (2.63%) patient. The secondary end points revealed no improvement of SLE Disease Activity Index scores or proteinuria (among 17 patients with LN); the cumulative lupus flare rate was 18%, and a reduction of ~30% in the prednisone dose was captured. Net changes in body mass index (-0.50 kg/m2), systolic blood pressure (-3.94 mm Hg) and haemoglobin levels (+8.26 g/L) were detected. The overall estimated glomerular filtration rate (eGFR) was stable, and there was an improvement in the eGFR slope among patients with LN with a baseline eGFR <90 mL/min/1.73 m2.

CONCLUSION

Dapagliflozin had an acceptable safety profile in adult patients with SLE. Its possible renal/cardiac protective effects and long-term safety issues in patients with SLE, patients with LN in particular, call for further exploration.

TRIAL REGISTRATION NUMBER

ChiCTR1800015030.

Instrument selection for the ASAS core outcome set for axial spondyloarthritis

OBJECTIVES

To define the instruments for the Assessment of SpondyloArthritis international Society-Outcomes Measures in Rheumatology (ASAS-OMERACT) core domain set for axial spondyloarthritis (axSpA).

METHODS

An international working group representing key stakeholders selected the core outcome instruments following a predefined process: (1) identifying candidate instruments using a systematic literature review; (2) reducing the list of candidate instruments by the working group, (3) assessing the instruments' psychometric properties following OMERACT filter 2.2, (4) selection of the core instruments by the working group and (5) voting and endorsement by ASAS.

RESULTS

The updated core set for axSpA includes seven instruments for the domains that are mandatory for all trials: Ankylosing Spondylitis Disease Activity Score and Numerical Rate Scale (NRS) patient global assessment of disease activity, NRS total back pain, average NRS of duration and severity of morning stiffness, NRS fatigue, Bath Ankylosing Spondylitis Function Index and ASAS Health Index. There are 9 additional instruments considered mandatory for disease-modifying antirheumatic drugs (DMARDs) trials: MRI activity Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joints and SPARCC spine, uveitis, inflammatory bowel disease and psoriasis assessed as recommended by ASAS, 44 swollen joint count, Maastricht Ankylosing Spondylitis Enthesitis Score, dactylitis count and modified Stoke Ankylosing Spondylitis Spinal Score. The imaging outcomes are considered mandatory to be included in at least one trial for a drug tested for properties of DMARD. Furthermore, 11 additional instruments were also endorsed by ASAS, which can be used in axSpA trials on top of the core instruments.

CONCLUSIONS

The selection of the instruments for the ASAS-OMERACT core domain set completes the update of the core outcome set for axSpA, which should be used in all trials.

Clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and rheumatic disease: a comparative cohort study from a US 'hot spot'

OBJECTIVE

To investigate differences in manifestations and outcomes of coronavirus disease 2019 (COVID-19) infection between those with and without rheumatic disease.

METHODS

We conducted a comparative cohort study of patients with rheumatic disease and COVID-19 (confirmed by severe acute respiratory syndrome coronavirus 2 PCR), compared in a 1:2 ratio with matched comparators on age, sex and date of COVID-19 diagnosis, between 1 March and 8 April 2020, at Partners HealthCare System in the greater Boston, Massachusetts area. We examined differences in demographics, clinical features and outcomes of COVID-19 infection. The main outcomes were hospitalisation, intensive care admission, mechanical ventilation and mortality.

RESULTS

We identified 52 rheumatic disease patients with COVID-19 (mean age, 63 years; 69% female) and matched these to 104 non-rheumatic disease comparators. The majority (39, 75%) of patients with rheumatic disease were on immunosuppressive medications. Patients with and without rheumatic disease had similar symptoms and laboratory findings. A similar proportion of patients with and without rheumatic disease were hospitalised (23 (44%) vs 42 (40%)), p=0.50) but those with rheumatic disease required intensive care admission and mechanical ventilation more often (11 (48%) vs 7 (18%), multivariable OR 3.11 (95% CI 1.07 to 9.05)). Mortality was similar between the two groups (3 (6%) vs 4 (4%), p=0.69).

CONCLUSIONS

Patients with rheumatic disease and COVID-19 infection were more likely to require mechanical ventilation but had similar clinical features and hospitalisation rates as those without rheumatic disease. These findings have important implications for patients with rheumatic disease but require further validation.

2019 EULAR points to consider for the assessment of competences in rheumatology specialty training

BACKGROUND AND AIM

Striving for harmonisation of specialty training and excellence of care in rheumatology, the European League Against Rheumatism (EULAR) established a task force to develop points to consider (PtCs) for the assessment of competences during rheumatology specialty training.

METHODS

A systematic literature review on the performance of methods for the assessment of competences in rheumatology specialty training was conducted. This was followed by focus groups in five selected countries to gather information on assessment practices and priorities. Combining the collected evidence with expert opinion, the PtCs were formulated by the multidisciplinary task force, including rheumatologists, medical educationalists, and people with rheumatic and musculoskeletal diseases. The level of agreement (LoA) for each PtC was anonymously voted online.

RESULTS

Four overarching principles and 10 PtCs were formulated. The overarching principles highlighted the importance of assessments being closely linked to the rheumatology training programme and protecting sufficient time and resources to ensure effective implementation. In the PtCs, two were related to overall assessment strategy (PtCs 1 and 5); three focused on formative assessment and portfolio (PtCs 2-4); three focused on the assessment of knowledge, skills or professionalism (PtCs 6-8); one focused on trainees at risk of failure (PtC 9); and one focused on training the trainers (PtC 10). The LoA (0-10) ranged from 8.75 to 9.9.

CONCLUSION

These EULAR PtCs provide European guidance on assessment methods throughout rheumatology training programmes. These can be used to benchmark current practices and to develop future strategies, thereby fostering continuous improvement in rheumatology learning and, ultimately, in patient care.

Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multicentre cohort

BACKGROUND

Current data suggest that COVID-19 is less frequent in children, with a milder course. However, over the past weeks, an increase in the number of children presenting to hospitals in the greater Paris region with a phenotype resembling Kawasaki disease (KD) has led to an alert by the French national health authorities.

METHODS

Multicentre compilation of patients with KD in Paris region since April 2020, associated with the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ('Kawa-COVID-19'). A historical cohort of 'classical' KD served as a comparator.

RESULTS

Sixteen patients were included (sex ratio=1, median age 10 years IQR (4·7 to 12.5)). SARS-CoV-2 was detected in 12 cases (69%), while a further three cases had documented recent contact with a quantitative PCR-positive individual (19%). Cardiac involvement included myocarditis in 44% (n=7). Factors prognostic for the development of severe disease (ie, requiring intensive care, n=7) were age over 5 years and ferritinaemia >1400 µg/L. Only five patients (31%) were successfully treated with a single intravenous immunoglobulin (IVIg) infusion, while 10 patients (62%) required a second line of treatment. The Kawa-COVID-19 cohort differed from a comparator group of 'classical' KD by older age at onset 10 vs 2 years (p<0.0001), lower platelet count (188 vs 383 G/L (p<0.0001)), a higher rate of myocarditis 7/16 vs 3/220 (p=0.0001) and resistance to first IVIg treatment 10/16 vs 45/220 (p=0.004).

CONCLUSION

Kawa-COVID-19 likely represents a new systemic inflammatory syndrome temporally associated with SARS-CoV-2 infection in children. Further prospective international studies are necessary to confirm these findings and better understand the pathophysiology of Kawa-COVID-19. Trial registration number NCT02377245.

Computer-Based Stratified Primary Care for Musculoskeletal Consultations Compared With Usual Care: Study Protocol for the STarT MSK Cluster Randomized Controlled Trial

BACKGROUND

Musculoskeletal (MSK) pain is a major cause of pain and disability. We previously developed a prognostic tool (Start Back Tool) with demonstrated effectiveness in guiding primary care low back pain management by supporting decision making using matched treatments. A logical next step is to determine whether prognostic stratified care has benefits for a broader range of common MSK pain presentations.

OBJECTIVE

This study seeks to determine, in patients with 1 of the 5 most common MSK presentations (back, neck, knee, shoulder, and multisite pain), whether stratified care involving the use of the Keele Start MSK Tool to allocate individuals into low-, medium-, and high-risk subgroups, and matching these subgroups to recommended matched clinical management options, is clinical and cost-effective compared with usual nonstratified primary care.

METHODS

This is a pragmatic, two-arm parallel (stratified vs nonstratified care), cluster randomized controlled trial, with a health economic analysis and mixed methods process evaluation. The setting is UK primary care, involving 24 average-sized general practices randomized (stratified by practice size) in a 1:1 ratio (12 per arm) with blinding of trial statistician and outcome data collectors. Randomization units are general practices, and units of observation are adult MSK consulters without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records are tagged and individuals invited using a general practitioner (GP) point-of-consultation electronic medical record (EMR) template. The intervention is supported by an EMR template (computer-based) housing the Keele Start MSK Tool (to stratify into prognostic subgroups) and the recommended matched treatment options. The primary outcome using intention-to-treat analysis is pain intensity, measured monthly over 6 months. Secondary outcomes include physical function and quality of life, and an anonymized EMR audit to capture clinician decision making. The economic evaluation is focused on the estimation of incremental quality-adjusted life years and MSK pain-related health care costs. The process evaluation is exploring a range of potential factors influencing the intervention and understanding how it is perceived by patients and clinicians, with quantitative analyses focusing on a priori hypothesized intervention targets and qualitative approaches using focus groups and interviews. The target sample size is 1200 patients from 24 general practices, with >5000 MSK consultations available for anonymized medical record data comparisons.

RESULTS

Trial recruitment commenced on May 18, 2018, and ended on July 15, 2019, after a 14-month recruitment period in 24 GP practices. Follow-up and interview data collection was completed in February 2020.

CONCLUSIONS

This trial is the first attempt, as far as we know, at testing a prognostic stratified care approach for primary care patients with MSK pain. The results of this trial should be available by the summer of 2020.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN15366334; http://www.isrctn.com/ISRCTN15366334.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17939.

Digital crowdsourcing: unleashing its power in rheumatology

The COVID-19 pandemic forces the whole rheumatic and musculoskeletal diseases community to reassemble established treatment and research standards. Digital crowdsourcing is a key tool in this pandemic to create and distil desperately needed clinical evidence and exchange of knowledge for patients and physicians alike. This viewpoint explains the concept of digital crowdsourcing and discusses examples and opportunities in rheumatology. First experiences of digital crowdsourcing in rheumatology show transparent, accessible, accelerated research results empowering patients and rheumatologists.

How to Optimize Measurement Protocols: An Example of Assessing Measurement Reliability Using Generalizability Theory

Purpose: This article identifies how to assess multiple sources of measurement error and identify optimal measurement strategies for obtaining clinical outcomes. Method: Obtaining, interpreting, and using information gained from measurements is instrumental in physiotherapy. To be useful, measurements must have a sufficiently small measurement error. Traditional expressions of reliability include relative reliability in the form of an intra-class correlation coefficient and absolute reliability in the form of the standard error of measurement. Traditional metrics are limited to assessing one source of error; however, real-world measurements consist of many sources of error. The measurement framework generalizability theory (GT) allows researchers to partition measurement errors into multiple sources. GT further allows them to calculate the relative and absolute reliability of any measurement strategy, thereby allowing them to identify the optimal strategy. We provide a brief comparison of classical test theory and GT, followed by an overview of the terminology and methodology used in GT, and then an example showing how GT can be used to minimize error associated with measuring knee extension power. Conclusion: The methodology described provides tools for researchers and clinicians that enable detailed interpretation and understanding of the error associated with their measurements.

Time to Surgery Reduction in Hip Fracture Patients on an Integrated Orthogeriatric Unit: A Comparative Study of Three Healthcare Models

Objective

To investigate the clinical efficacy of three different healthcare models (Traditional Model, Geriatric Consultant Model, and Orthogeriatric Unit Model) consecutively applied to a single academic center (University Hospital of Salamanca, Spain) for older hip fracture patients.

Methods

We performed a retrospective study, including 2741 hip fracture patients older than 64 years, admitted between 1 January 2003 and 31 December 2014 to the University Hospital of Salamanca. Patients were divided into three groups according to the healthcare model applied. There were 983 patients on the Traditional Model, 945 patients on the Geriatric Consultant Model, and 813 patients on the Orthogeriatric Unit Model. We recorded age and gender of patients, functional status at admission (Barthel Index, Katz Index, and Physical Red Cross Scale), type of fracture, and intervention, and we analyzed the length of stay, time to surgery, post‐surgical stay, and in‐hospital mortality according to the healthcare model applied.

Results

Hip fractures are much more frequent in women, and an increase in the average age of patients was observed along with the study (P < 0.001). The most common type of fracture in the three models studied was an extracapsular fracture, for which the most common surgical procedure used was osteosynthesis. On the functional status of patients, there were no differences on the ambulatory ability previous to fracture, measured by the Physical Red Cross Scale, and the percentage of patients with a slight dependence determined by the Barthel Index (>60) was similar in both groups, but considering the Katz Index, the percentage of patients with a high degree of independence (A‐B) was significantly higher for the group of patients treated on the Orthogeriatric Unit Model period (56%, P = 0.009).

The Orthogeriatric Unit Model registered the greatest percentage of patients undergoing surgery (96.1%, P < 0.001) and the greatest number of early surgical procedures (<24 h) (24.8%, P < 0.001). The orthogeriatric unit model showed the shortest duration of stay (9 days median), decreasing by one day in respect of each of the other models studied (P < 0.001). Time to surgery was also significantly reduced with the Orthogeriatric Unit Model (median of 3 days, P < 0.001). With regard to in‐hospital follow‐up, there was a reduction in in‐hospital mortality during the study period. We observed differences among the three healthcare models, but without statistical significance.

Conclusions

The healthcare model based on an Orthogeriatric Unit seems to be the most efficient, because it reaches a reduction in time to surgery, with an increased number of patients surgically treated on in the first 24 h, and the greatest frequency of surgically‐treated patients.

Impact of Change in 2010 American Heart Association Cardiopulmonary Resuscitation Guidelines on Survival After Out-of-Hospital Cardiac Arrest in the United States: An Analysis From 2006 to 2015

BACKGROUND

In October 2010, the American Heart Association/Emergency Cardiovascular Care updated cardiopulmonary resuscitation guidelines. Its impact on the survival rate among out-of-hospital cardiac arrest patients (OHCA) is not well studied. We sought to assess the survival trends in OHCA patients before and after the introduction of the 2010 American Heart Association cardiopulmonary resuscitation guidelines in the United States.

METHODS

A retrospective observational study from the National Emergency Department (ED) Sample was designed to identify patients presenting to the ED primarily after an OHCA in the United States between January 1, 2006, and December 31, 2015. The main outcome studied was the change in trends of ED survival and survival-to-discharge rates before and after guideline modification.

RESULTS

Among 1 282 520 patients presenting to the ED after OHCA (mean [SD] age, 65.8 [17.2] years; 62% men), ED survival rate (23%) and survival-to-discharge rate (16%) trends showed significant improvement after implementation of the 2010 American Heart Association cardiopulmonary resuscitation guidelines, 1.25% ([95% CI, 0.72%-1.78%] P=0.001) and 0.89% ([95% CI, 0.35%-1.43%] P=0.006), respectively. Notably, among patients with nonshockable rhythm (change in ED survival rate trend, 1.3% [95% CI, 0.89%-1.74%]; P<0.001 and survival-to-discharge trend, 0.94% [95% CI, 0.42%-1.47%]; P=0.004). Among patients admitted to the presenting hospital (n=145 592), 46% were discharged alive, of which 49% were discharged home. Significant decrease in discharge to home was noted (-1.7% [95% CI, -3.18% to -0.22%]; P=0.03), while a significant increase in neurological complication (0.17% [95% CI, 0.06%-0.28%]; P=0.007) was noted with the guideline modification.

CONCLUSIONS

The change in 2010 American Heart Association cardiopulmonary resuscitation guidelines was associated with only slight improvement in ED survival and survival-to-discharge trends among US OHCA patients and only 1 in 6 OHCA patients survival to discharge.