title: Unexpected versus all-cause mortality as the endpoint for investigating the effects of a Rapid Response System in hospitalized patients.
abstract: BACKGROUND
  The purpose of this study was to assess the effect of replacing all-cause mortality by death without limitation of medical treatments (LOMT) as the endpoint in a study of rapid response teams (RRTs) in hospitalized patients. We also described the time course of LOMT orders in patients dying on a general ward and the influence of RRTs on such orders.
  
  
  METHODS
  This study is a secondary analysis of the COMET trial, a pragmatic prospective Dutch multicenter before-after study. We repeated the original analysis of the influence of RRTs on death before hospital discharge by replacing all-cause mortality by death without an LOMT order. In a subgroup of all patients dying before hospital discharge, we documented patient demographics, admission characteristics and LOMT orders of each patient. Patients age 18 ears or above were included.
  
  
  RESULTS
  In total, 166,569 patients were included in the study. The unadjusted ORs were 0.865 (95 % CI 0.77-0.98) in the original analysis using all-cause mortality and 0.557 (95 % CI 0.40-0.78) when choosing death without LOMT as the endpoint. In total, 3408 patients died before discharge. At time of death, 2910 (85 %) had an LOMT order. Median time from last change in LOMT status and death was 2 days (IQR 1-5) in the before-phase and median time after introduction of the RRT was 1 day (IQR 1-4) (p value not significant).
  
  
  CONCLUSIONS
  The improvement in survival of hospitalized patients after introduction of a rapid response team in the COMET study was more pronounced when choosing death without limitation of medical treatment, rather than all deaths as the endpoint. Most patients who died during hospitalization had limitation of medical treatments ordered, often shortly before death. Rapid response teams did not influence the institution of limitation of medical treatments.
authors.affiliation: Department of Intensive Care, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, Netherlands. A.H.Brunsveld-Reinders@lumc.nl.
authors.forename: Anja H
authors.initials: AH
authors.lastname: Brunsveld-Reinders
authors.affiliation: Department of Anesthesiology, Academic Medical Center, Amsterdam, Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Ludikhuize
authors.affiliation: Department of Clinical Research Unit, Academic Medical Center, Amsterdam, Netherlands.
authors.forename: Marcel G W
authors.initials: MG
authors.lastname: Dijkgraaf
authors.affiliation: Department of Intensive Care, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, Netherlands.|Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: M Sesmu
authors.initials: MS
authors.lastname: Arbous
authors.affiliation: Department of Intensive Care, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, Netherlands.
authors.forename: Evert
authors.initials: E
authors.lastname: de Jonge
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003142:Communication; D003362:Cost-Benefit Analysis / Q000379:methods*; D005260:Female; D017052:Hospital Mortality; D057209:Hospital Rapid Response Team; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D018447:Medical Futility; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D013997:Time Factors
keywords: Limitations of medical treatment; Medical record; Patient safety; Rapid response team; Unexpected death