Bhardwaj, Abhishek

Background: Safety net hospitals treat a large burden of uninsured, or Medicaid insured patients, and have been linked to worse outcomes across several medical and surgical conditions. Currently, there is limited data on the effect of safety net burden on outcomes of inpatient cardiopulmonary resuscitation (CPR) for patients that suffered in-hospital cardiac arrest (IHCA) in the US. Hypothesis: Patients that experience IHCA in high burden safety net hospitals (HBH) will have worse outcomes compared to low burden safety net hospitals (LBH). Methods: Using the National Inpatient Sample database, from 2008 – 2018, we identified patients aged ≥ 18 years who experienced IHCA, using International Classification of Diseases (ICD) codes. Hospitals’ safety net burden was calculated from the proportions of Medicaid and uninsured patients using previously published methodology and categorized into LBH and HBH. Multivariate regression models were used to estimate the odds of key clinical outcomes Result: From 2008 to 2018, an estimated 555,016 unweighted adult hospitalizations underwent CPR for IHCA, out of which 19.2 % occurred at LBH and 55.2 % occurred at HBH. Compared with LBH, patients at HBH on average were younger 62 years ± 20 vs 67 years ± 17), less likely to be of White race, and more likely to be in the lowest median household income. On multivariate regression analysis, HBH was associated with lower chances of survival to hospital discharge (aOR 0.88; 95% CI 0.85 – 0.96) and lower odds of routine discharge (aOR 0.6; 95% CI 0.47 – 0.75)), compared to LBH. Patients who suffered IHCA in safety net hospitals with medium and large hospital bed size (aOR 0.96; 95% CI 0.94 – 0.98) and those publicly owned (aOR 0.95; 95% CI 0.92 – 0.98) were less likely to survive to hospital discharge. Median household income of patients in the 26 th – 100 th quartile and hospital location in the Midwest and Southern region were associated with better odds of hospital survival. Conclusion: Our study suggests that patients who experience IHCA at HBH had lower rates and odds of in-hospital survival and also less likely to be routinely discharged home. Patients’ income level and hospital-level characteristics appear to contribute to survival.

IMPORTANCE: High safety-net burden hospitals (HBHs) treating large numbers of uninsured or Medicaid-insured patients have generally been linked to worse clinical outcomes. However, limited data exist on the impact of the hospitals’ safety-net burden on in-hospital cardiac arrest (IHCA) outcomes in the United States. OBJECTIVES: To compare the differences in survival to discharge, routine discharge home, and healthcare resource utilization between patients at HBH with those treated at low safety-net burden hospital (LBH). DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study across hospitals in the United States: Hospitalized patients greater than or equal to 18 years that underwent cardiopulmonary resuscitation (CPR) between 2008 and 2018 identified from the Nationwide Inpatient Database. Data analysis was conducted in January 2022. EXPOSURE: IHCA. MAIN OUTCOMES AND MEASURES: The primary outcome is survival to hospital discharge. Other outcomes are routine discharge home among survivors, length of hospital stay, and total hospitalization cost RESULTS: From 2008 to 2018, an estimated 555,016 patients were hospitalized with IHCA, of which 19.2% occurred at LBH and 55.2% at HBH. Compared with LBH, patients at HBH were younger (62 ± 20 yr vs 67 ± 17 yr) and predominantly in the lowest median household income (< 25th percentile). In multivariate analysis, HBH was associated with lower chances of survival to hospital discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.85–0.96) and lower odds of routine discharge (aOR, 0.6; 95% CI, 0.47–0.75), compared with LBH. In addition, IHCA patients at publicly owned hospitals and those with medium and large hospital bed size were less likely to survive to hospital discharge, while patients with median household income greater than 25th percentile had better odds of hospital survival. CONCLUSIONS AND RELEVANCE: Our study suggests that patients who experience IHCA at HBH may have lower rates and odds of in-hospital survival and are less likely to be routinely discharged home after CPR. Median household income and hospital-level characteristics appear to contribute to survival.