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Racial and Ethnic Disparities in Postcardiac Arrest Targeted Temperature Management Outcomes

Jacobs, Claire S. MD, PhD1; Beers, Louis BA2; Park, Suna BA, MS2; Scirica, Benjamin MD3; Henderson, Galen V. MD2; Hsu, Liangge MD4; Bevers, Matthew MD, PhD2; Dworetzky, Barbara A. MD2; Lee, Jong Woo MD, PhD2

doi: 10.1097/CCM.0000000000004001
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Objectives: To evaluate racial and ethnic disparities in postcardiac arrest outcomes in patients undergoing targeted temperature management.

Design: Retrospective study.

Setting: ICUs in a single tertiary care hospital.

Patients: Three-hundred sixty-seven patients undergoing postcardiac arrest targeted temperature management, including continuous electroencephalogram monitoring.

Interventions: None.

Measurements and Main Results: Clinical variables examined in our clinical cohort included race/ethnicity, age, time to return of spontaneous circulation, cardiac rhythm at time of arrest, insurance status, Charlson Comorbidity Index, and time to withdrawal of life-sustaining therapy. CT at admission and continuous electroencephalogram monitoring during the first 24 hours were used as markers of early injury. Outcome was assessed as good (Cerebral Performance Category 1–2) versus poor (Cerebral Performance Category 3–5) at hospital discharge. White non-Hispanic (“White”) patients were more likely to have good outcomes than white Hispanic/nonwhite (“Non-white”) patients (34.4 vs 21.7%; p = 0.015). In a multivariate model that included age, time to return of spontaneous circulation, initial rhythm, combined electroencephalogram/CT findings, Charlson Comorbidity Index, and insurance status, race/ethnicity was still independently associated with poor outcome (odds ratio, 3.32; p = 0.003). Comorbidities were lower in white patients but did not fully explain outcomes differences. Nonwhite patients were more likely to exhibit signs of early severe anoxic changes on CT or electroencephalogram, higher creatinine levels and receive dialysis, but had longer duration to withdrawal of lifesustaining therapy. There was no significant difference in catheterizations or MRI scans. Subgroup analysis performed with patients without early electroencephalogram or CT changes still revealed better outcome in white patients.

Conclusions: Racial/ethnic disparity in outcome persists despite a strictly protocoled targeted temperature management. Nonwhite patients are more likely to arrive with more severe anoxic brain injury, but this does not account for all the disparity.

1Department of Neurology, Massachusetts General Hospital, Boston, MA.

2Department of Neurology, Brigham and Women’s Hospital, Boston, MA.

3Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital, Boston, MA.

4Department of Radiology, Brigham and Women’s Hospital, Boston, MA.

This work was performed at Brigham and Women’s Hospital.

Dr. Jacobs contributed to acquisition of data, analysis of the data, and drafting the article. Mr. Beers and Ms. Park contributed to acquisition of data. Drs. Scirica and Hsu contributed to acquisition of data and revising the article for intellectual content. Dr. Henderson contributed to revising the article for intellectual content. Dr. Bevers contributed to analysis of the data and revising the article for intellectual content. Dr. Dworetzky contributed to analysis of the data and writing of the article. Dr. Lee contributed to design of the study, acquisition of data, analysis of the data, and drafting the article.

Dr. Jacobs is partially supported (80%) by the National Institutes of Health (NIH) National Institute of Neurological Disorders and Stroke (NINDS) R25NS065743, principal investigator (PI), 2017–2019 (ongoing), she performs contract work (electroencephalogram [EEG] reading) for Carle Foundation Hospital, and she disclosed that she is an inventor on two (unlicensed) patents relating to work she performed during graduate school (United States Patent US 7,935,530 B2. November 28, 2007; United States Patent US 9,630,950. April 25, 2017); she has not received any compensation related to these patents. Drs. Jacobs and Lee received support for article research from the NIH. Ms. Park disclosed work for hire. Dr. Scirica received research grants via Brigham and Women’s Hospital from AstraZeneca, Eisai, Novartis, and Merck, and he has received consulting fees from AbbVie, Allergan, AstraZeneca, Boehringer Ingelheim, Covance, Eisai, Elsevier Practice Update Cardiology, GlaxoSmithKline, Lexicon, Medtronic, Merck, NovoNordisk, Sanofi, and equity in Health [at] Scale, outside the submitted work. Dr. Bevers receives research support from the American Academy of Neurology and David Heitman Neurovascular Research Fund (unrelated to the current work), outside the scope of the submitted work; he reports grants and personal fees from Biogen and EBSCO Health, outside the scope of the submitted work; and he reports personal fees for editorial work from Dynamed, LCC, outside the scope of the submitted work. Dr. Dworetzky reads EEGs in her clinical practice (25% effort) and bills for this, performs contract work with SleepMed/DigiTrace, is a consultant for SleepMed (EEG interpretation) and for Best Doctors (clinical consults) & Oxford University Press (royalties). Dr. Lee reads EEGs in his clinical practice (25% effort) and bills for this, performs contract work with SleepMed/DigiTrace and Advance Medical; he was supported by the NIH (NINDS R03NS091864 02, PI, 2015–2018). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: jlee38@bwh.harvard.edu

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