title: Prehospital transportation to therapeutic hypothermia centers and survival from out-of-hospital cardiac arrest.
abstract: BACKGROUND
  Clinical trials supporting the use of therapeutic hypothermia (TH) in the treatment of out-of-hospital cardiac arrest (OHCA) are based on small patient samples and do not reflect the wide variation in patient selection, cooling methods, and other elements of post-arrest care that are used in everyday practice. This study provides a real world evaluation of the effectiveness of post-arrest care in TH centers during a time of growing TH dissemination in the state of New Jersey (NJ).
  
  
  METHODS
  Using a linked database of prehospital, hospital, and mortality records for NJ in 2009-2010, we compared rates of neurologically intact survival at discharge and at 30 days for OHCA patients transported to TH centers (N = 2363) versus other hospitals (N = 2479). We used logistic regression to adjust for patient and hospital covariates. To account for potential endogeneity in prehospital transportation decisions, we used an instrumental variable (IV) based on differential distance to the nearest TH and non-TH hospitals.
  
  
  RESULTS
  Patients taken to TH centers were older, more likely to have a witnessed arrest, more likely to receive defibrillation, and waited a shorter amount of time for initial EMS response. Also, TH hospitals were larger, more likely to be teaching facilities, and operated in a service area with a relatively lower poverty rate compared to hospitals statewide. A Stock-Yogo test confirmed the strength of our IV (F = 2349.91, p < 0.0001). Nevertheless, the data showed no evidence of endogenous transportation to TH centers related to in-hospital survival (Z = -0.08, p = 0.934) or 30-day survival (Z = 0.94, p = 0.349). In logistic regression models, treatment at a TH center was associated with greater odds of 30-day neurologically intact survival (OR = 1.70; 95% CI: 1.19 - 2.42) but not associated with the odds of neurologically intact survival to hospital discharge (OR = 0.90; 95% CI: 0.61 - 1.31).
  
  
  CONCLUSIONS
  Post-arrest outcomes are more favorable at TH centers but these improved outcomes are not apparent until after hospital discharge. This finding may reflect superior care by TH centers in later stages of post-arrest treatment such as care provided in the intensive care unit, which has greater potential to affect longer term outcomes than initial treatment in the emergency department.
authors.affiliation: Center for State Health Policy, Rutgers University, 112 Paterson St., Room 540, New Brunswick, NJ, 08901, USA. ddelia@ifh.rutgers.edu.
authors.forename: Derek
authors.initials: D
authors.lastname: DeLia
authors.affiliation: Department of Emergency Medicine, University of Alabama at Birmingham, 266N Jefferson Tower, 625 19th Street south, Birmingham, AL, 35249-7013, USA. hwang@uabmc.edu.
authors.forename: Henry E
authors.initials: HE
authors.lastname: Wang
authors.affiliation: Simulation Center at Winthrop University Hospital, Englewood Hospital and Medical Center, Winthrop University Hospital, 259 First St, Mineola, NY, 11501, USA. jkutzin@gmail.com.
authors.forename: Jared
authors.initials: J
authors.lastname: Kutzin
authors.affiliation: Rutgers School of Public Health, Attending, Emergency Medicine, Newark Beth Israel Medical Center, Newark Beth Israel Medical Center, 201 Lyons Avenue, Newark, NJ, 07112, USA. MMerlin@barnabashealth.org.
authors.forename: Mark
authors.initials: M
authors.lastname: Merlin
authors.affiliation: Center for State Health Policy, Rutgers University, 112 Paterson St., Room 540, New Brunswick, NJ, 08901, USA. jnova@ifh.rutgers.edu.
authors.forename: Jose
authors.initials: J
authors.lastname: Nova
authors.affiliation: Center for State Health Policy, Rutgers University, 112 Paterson St., Room 540, New Brunswick, NJ, 08901, USA. klloyd@ifh.rutgers.edu.
authors.forename: Kristen
authors.initials: K
authors.lastname: Lloyd
authors.affiliation: Center for State Health Policy, Rutgers University, 112 Paterson St., Room 540, New Brunswick, NJ, 08901, USA. jcantor@ifh.rutgers.edu.
authors.forename: Joel C
authors.initials: JC
authors.lastname: Cantor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D016208:Databases, Factual; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D007036:Hypothermia, Induced; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009515:New Jersey; D058687:Out-of-Hospital Cardiac Arrest / Q000628:therapy; D016019:Survival Analysis; D014187:Transportation of Patients