Association between health insurance status and transfer of patients with return of spontaneous circulation after out-of-hospital cardiac arrest

Veno-venous Extracorporeal Membrane Oxygenation for COVID-19: A Call For System-Wide Checks to Ensure Equitable Delivery For All

Extracorporeal membrane oxygenation (ECMO) has emerged in the COVID-19 pandemic as a potentially beneficial yet scare resource for treating critically ill patients, with variable allocation across the United States. The existing literature has not addressed barriers patients may face in access to ECMO as a result of healthcare inequity. We present a novel patient-centered framework of ECMO access, providing evidence for potential bias and opportunities to mitigate this bias at every stage between a marginalized patient's initial presentation to treatment with ECMO. While equitable access to ECMO support is a global challenge, this piece focuses primarily on patients in the United States with severe COVID-19-associated ARDS to draw from current literature on VV-ECMO for ARDS and does not address issues that affect ECMO access on a more international scale.

Cardiac arrest centres: what, who, when, and where?

PURPOSE OF REVIEW

Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions.

RECENT FINDINGS

CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer.

SUMMARY

Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

Differences in the diagnosis and treatment of hematologic malignancies attributable to health insurance coverage

Medical care should be equally provided to the public regardless of their financial capability. In the real world, expenditures directly out from the patient sector decide the medical journey, even in a country with national health insurance. The aim of this study was to investigate whether there are differences in the diagnostic and treatment processes in hematologic malignancies based on patient characteristics, such as health insurance status.Through the review of 5614 "CBCs with differential count" results with abnormal cells from 358 patients from January 2010 to June 2017, 238 patients without past medical histories of hematologic malignancies were enrolled. Excluding reactive cases, 206 patients with hematologic malignancy were classified into 8 disease categories: acute leukemia, myelodysplastic syndrome, myeloproliferative neoplasm (MPN), myelodysplastic syndrome/MPN, lymphoid neoplasm, plasma cell neoplasm, r/o hematologic malignancy, and cancer.The patients' age, sex, disease categories and follow-up durations showed associations with the clinical course. The "refusal of treatment" group was the oldest and had a relatively higher percentage of females, whereas those who decided to transfer to a tertiary hospital were younger. The age, clinical course, and follow-up durations were different across health insurance statuses. The medical aid group was the oldest, and the group whose status changed from a medical insurance subscriber to a medical aid beneficiary during treatment was the youngest. The majority of patients who refused treatment or wished to be transferred to a tertiary hospital were medical insurance subscribers. The percentage of patients who were treated in this secondary municipal hospital was higher in the medical-aid beneficiaries group than in the medical insurance group. Follow-up durations were longest in the status change group and shortest in the medical insurance group.Almost all medical aid beneficiaries with hematologic malignancies opted to continue treatment at this secondary/municipal hospitals, indicating that this category of medical institutions provides adequate levels and qualified healthcare services to those patients. The secondary municipal hospital provides qualified healthcare services for medical aid beneficiaries with hematologic malignancies.

Effects of pre-hospital re-arrest on outcomes based on transfer to a heart attack centre in patients with out-of-hospital cardiac arrest

AIM

We aimed to investigate the interaction effects between transfer to a heart attack centre [HAC] and prehospital re-arrest on the clinical outcomes of patients with out-of-hospital cardiac arrest [OHCA].

METHODS

We included adult patients with OHCA of presumed cardiac aetiology from January 2012 to December 2018. The main exposure variable was prehospital re-arrest, defined as recurrence of cardiac arrest with a loss of palpable pulse upon hospital arrival. The other exposure variable was the resuscitation capacity of the receiving hospital [HAC or Non-HAC]. The outcome variable was neurological recovery. A multivariable logistic regression was performed to determine the interaction effects.

RESULTS

The final analysis included 6935 patients. Of these, 21.9% (n = 1521) experienced prehospital re-arrest, whereas 41.3% (n = 2866) were transferred to a non-HAC. The prehospital re-arrest group associated with poor neurological recovery (adjusted odds ratio [AOR], 0.25; 95% confidence interval [CI], 0.21-0.29;). Transfer to an HAC had beneficial effects on neurological recovery (AOR, 3.40 [95% CI, 3.04-3.85]. In the interaction model, wherein prehospital re-arrest patients who were transferred to a non-HAC were used as reference, the AOR of prehospital re-arrest patients who were transferred to an HAC, non-re-arrest patients who were transferred to a non-HAC, and non-re-arrest patients who were transferred to a non-HAC was 2.41 (95% CI, 1.73-3.35), 3.09 (95% CI, 2.33-4.10), and 11.07 (95% CI, 8.40-14.59) respectively (interaction p = 0.001).

CONCLUSION

Transport to a heart attack centre was beneficial to the clinical outcomes of patients who achieved prehospital ROSC after OHCA. The magnitude of that benefit was significantly modified by whether prehospital re-arrest had occurred.

Impact of insurance type on outcomes in cardiac arrest patients from 2004 to 2015: A nation-wide population-based study

OBJECTIVES

There do not appear to be many studies which have examined the socio-economic burden and medical factors influencing the mortality and hospital costs incurred by patients with cardiac arrest in South Korea. We analyzed the differences in characteristics, medical factors, mortality, and costs between patients with national health insurance and those on a medical aid program.

METHODS

We selected patients (≥20 years old) who experienced their first episode of cardiac arrest from 2004 to 2015 using data from the National Health Insurance Service database. We analyzed demographic characteristics, insurance type, urbanization of residential area, comorbidities, treatments, hospital costs, and mortality within 30 days and one year for each group. A multiple regression analysis was used to identify an association between insurance type and outcomes.

RESULTS

Among the 487,442 patients with cardiac arrest, the medical aid group (13.3% of the total) had a higher proportion of females, rural residents, and patients treated in low-level hospitals. The patients in the medical aid group also reported a higher rate of non-shockable conditions; a high Charlson Comorbidity Index; and pre-existing comorbidities, such as hypertension, diabetes mellitus, and renal failure with a lower rate of providing a coronary angiography. The national health insurance group reported a lower one-year mortality rate (91.2%), compared to the medical aid group (94%), and a negative association with one-year mortality (Adjusted OR 0.74, 95% CI 0.71-0.76). While there was no significant difference in short-term costs between the two groups, the medical aid group reported lower long-term costs, despite a higher rate of readmission.

CONCLUSIONS

Medical aid coverage was an associated factor for one-year mortality, and may be the result of an insufficient delivery of long-term services as reflected by the lower long-term costs and higher readmission rates. There were differences of characteristics, comorbidities, medical and hospital factors and treatments in two groups. These differences in medical and hospital factors may display discrepancies by type of insurance in the delivery of services, especially in chronic healthcare services.

Developing a time-adaptive prediction model for out-of-hospital cardiac arrest: Results from a nationwide cohort study in Korea (Preprint)

Background

Out-of-hospital cardiac arrest (OHCA) is a serious public health issue, and predicting the prognosis of OHCA patients can assist clinicians in making decisions about the treatment of patients, use of hospital resources, or termination of resuscitation.

Objective

This study aimed to develop a time-adaptive conditional prediction model (TACOM) to predict clinical outcomes every minute.

Methods

We performed a retrospective observational study using data from the Korea OHCA Registry in South Korea. In this study, we excluded patients with trauma, those who experienced return of spontaneous circulation before arriving in the emergency department (ED), and those who did not receive cardiopulmonary resuscitation (CPR) in the ED. We selected patients who received CPR in the ED. To develop the time-adaptive prediction model, we organized the training data set as ongoing CPR patients by the minute. A total of 49,669 patients were divided into 39,602 subjects for training and 10,067 subjects for validation. We compared random forest, LightGBM, and artificial neural networks as the prediction model methods. Model performance was quantified using the prediction probability of the model, area under the receiver operating characteristic curve (AUROC), and area under the precision recall curve.

Results

Among the three algorithms, LightGBM showed the best performance. From 0 to 30 min, the AUROC of the TACOM for predicting good neurological outcomes ranged from 0.910 (95% CI 0.910-0.911) to 0.869 (95% CI 0.865-0.871), whereas that for survival to hospital discharge ranged from 0.800 (95% CI 0.797-0.800) to 0.734 (95% CI 0.736-0.740). The prediction probability of the TACOM showed similar flow with cohort data based on a comparison with the conventional model’s prediction probability.

Conclusions

The TACOM predicted the clinical outcome of OHCA patients per minute. This model for predicting patient outcomes by the minute can assist clinicians in making rational decisions for OHCA patients.

Socioeconomic disparities in Rapid ambulance response for out-of-hospital cardiac arrest in a public emergency medical service system: A nationwide observational study

OBJECTIVES

This study aimed to examine whether county socioeconomic status (SES) is associated with emergency medical service (EMS) response time and dual dispatch response of out-of-hospital cardiac arrest (OHCA) patients using county property tax per capita in Korea.

METHODS

All EMS-treated adults who suffered OHCAs were enrolled between 2015 and 2017, excluding cases witnessed by EMS providers. The main exposure was property tax per capita in the county where the OHCA occurred. The primary outcome was response time interval, with a secondary outcome of dual dispatch response. Negative binomial regression analysis to calculate incidence rate ratio (IRR) with a 95% confidence interval (CI) was conducted for EMS response time. A multivariable logistic regression analysis for response time interval (<8 min) and dual dispatch response was also conducted.

RESULTS

A total of 71,326 patients in 228 counties were enrolled. Compared to the lowest SES quartile, OHCA patients in the highest SES quartile had shorter median (interquartile range [IQR]) response time intervals (9.5 [5.9] minutes vs. 7.6 [4.2] minutes, IRR [95% CI] 0.95 [0.94-0.96], respectively). The AOR (95% CI) for response time within 8 min was 1.07 (1.01-1.13) for the highest SES quartile compared to the lowest SES quartile. Those in the highest SES quartile also had higher rates of dual dispatch response compared to those in the lowest quantile (50.9% vs 26.6%; AOR [95% CI]: 2.16 [2.03-2.30]).

CONCLUSION

In OHCA patients, those in a lower SES are associated with longer response times and lower dual dispatch response.

Association between chronic liver disease and clinical outcomes in out-of-hospital cardiac arrest

OBJECTIVES

Out-of-hospital cardiac arrest (OHCA) and chronic liver disease (CLD) are global health issues. The purpose of this study is to evaluate the association between chronic liver disease and clinical outcomes in OHCA.

METHODS

A retrospective observation study, using a nationwide population-based OHCA registry, was conducted. Adult patients with cardiac OHCAs who were treated by emergency medical service (EMS) providers between January 2013 and December 2015 were screened. The main exposure was the status of chronic liver disease that had been diagnosed before OHCA, categorized into three groups: no CLD, CLD without cirrhosis, and CLD with cirrhosis. Multivariable logistic regression analysis for survival and neurologic recovery were conducted to calculate the adjusted odds ratio (AOR) and confidence intervals (CIs). Interaction analysis for age, gender were performed and sensitivity analysis by imputation for main exposure missing was also.

RESULT

A total of 8844 eligible OHCA patients were enrolled. There were 361 (4.1%) patients in the CLD without cirrhosis group and 1323 (15%) patients in the CLD with cirrhosis group. Compared to no CLD group, CLD with cirrhosis group was less likely to have favorable outcomes for good neurological recovery and survival to discharge. Patients with CLD but without cirrhosis showed similar associations in neurologic recovery and survival with those without CLD. In multivariable logistic regression analysis, the AOR and 95% CIs for good neurological outcome and survival to discharge were as below; good neurological outcome - 1.07 (0.70-1.64) for CLD without cirrhosis, 0.08 (0.04-0.16) for CLD with cirrhosis, survival to discharge - 1.01 (0.70-1.45) for CLD without cirrhosis, 0.13 (0.08-0.20) for CLD with cirrhosis. Same trends of association were demonstrated in interaction and imputation analysis.

CONCLUSION

OHCA patients with liver cirrhosis showed poor clinical outcomes and CLD had no negative association unless they progressed to cirrhotic status.