title: Prognostic Implications of Level-of-Care at Tertiary Heart Centers Compared With Other Hospitals After Resuscitation From Out-of-Hospital Cardiac Arrest.
abstract: BACKGROUND
  Studies have found higher survival rates after out-of-hospital cardiac arrest and admission to tertiary heart centers. The aim was to examine the level-of-care at tertiary centers compared with nontertiary hospitals and the association with outcome after out-of-hospital cardiac arrest.
  
  
  RESULTS
  Consecutive out-of-hospital cardiac arrest patients (n=1078) without ST-segment-elevation myocardial infarction admitted to tertiary centers (54%) and nontertiary hospitals (46%) were included (2002-2011). Patient charts were reviewed focusing on level-of-care and comorbidity. Survival to discharge differed significantly with 45% versus 24% of patients discharged alive (P<0.001), and after adjustment for prognostic factors admissions to tertiary centers were still associated with lower 30-day mortality (hazard ratio, 0.78 [0.64-0.96; P=0.02]), independent of comorbidity. The adjusted odds of predefined markers of level-of-care were higher in tertiary centers: admission to intensive care unit (odds ratio [OR], 1.8 [95% confidence interval, 1.2-2.5]), temporary pacemaker (OR, 6.4 [2.2-19]), vasoactive agents (OR, 1.5 [1.1-2.1]), acute (<24 hours) and late coronary angiography (OR, 10 [5.3-22] and 3.8 [2.5-5.7]), neurophysiological examination (OR, 1.8 [1.3-2.6]), and brain computed tomography (OR, 1.9 [1.4-2.6]), whereas no difference in therapeutic hypothermia was noted. Patients at tertiary centers were more often consulted by a cardiologist (OR, 8.6 [5.0-15]), had an echocardiography (OR, 2.8 [2.1-3.7]), and survivors more often had implantable cardioverter defibrillator's implanted (OR, 2.1 [1.2-3.6]).
  
  
  CONCLUSIONS
  Admissions to tertiary centers were associated with significantly higher survival after out-of-hospital cardiac arrest in patients without ST-segment-elevation myocardial infarction in the Copenhagen area even after adjustment for prognostic factors including comorbidity. Level-of-care seems higher in tertiary centers both in the early phase, during the intensive care unit admission, and in the workup before discharge. The varying level-of-care may contribute to the survival difference; however, differences in comorbidity do not seem to matter significantly.
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.). helle.soholm@gmail.com.
authors.forename: Helle
authors.initials: H
authors.lastname: Søholm
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Jesper
authors.initials: J
authors.lastname: Kjaergaard
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: John
authors.initials: J
authors.lastname: Bro-Jeppesen
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Jakob
authors.initials: J
authors.lastname: Hartvig-Thomsen
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Freddy
authors.initials: F
authors.lastname: Lippert
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Lars
authors.initials: L
authors.lastname: Køber
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Niklas
authors.initials: N
authors.lastname: Nielsen
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Magaly
authors.initials: M
authors.lastname: Engsig
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Morten
authors.initials: M
authors.lastname: Steensen
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Michael
authors.initials: M
authors.lastname: Wanscher
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Finn Michael
authors.initials: FM
authors.lastname: Karlsen
authors.affiliation: From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
authors.forename: Christian
authors.initials: C
authors.lastname: Hassager
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003718:Denmark / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D058687:Out-of-Hospital Cardiac Arrest / Q000401:mortality*; D011379:Prognosis; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012151:Resuscitation; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*
keywords: cardiac arrest; health care; outcome assessment