Treatment Variation in In-Hospital Management of Out-of-Hospital Cardiac Arrest Patients: A Nationwide Retrospective Cohort Study

Background Clinicians follow clinical practice guidelines to choose in-hospital treatment for out-of-hospital cardiac arrest (OHCA) patients. Yet, treatment practice variations may still exist for recommended interventions. In this study, we aimed to examine variations in guideline-recommended in-hospital treatments for OHCA. Methods and findings This nationwide cohort study utilized the Japan Association for Acute Medicine OHCA (JAAM-OHCA) registry data from 2014 to 2019. We focused on four in-hospital OHCA treatments: epinephrine administration, amiodarone administration, targeted temperature management (TTM), and coronary angiography (CAG). We included adult patients (≥18 years old) with cardiogenic etiology undergoing in-hospital resuscitation, for whom each treatment was indicated. We calculated the coefficient of variation (CV) to gauge treatment variation and used funnel plots of standardized treatment ratios to detect outlier hospitals with significantly different practices. Results Of the 57,754 patients in the registry, we included 26,420 in the epinephrine cohort, 1,826 in the amiodarone cohort, 6,780 in the TTM cohort, and 6,823 in the CAG cohort. Epinephrine exhibited the slightest variation (unadjusted CV 16.9%, 95% confidence interval (CI) 14.7 to 19.9; adjusted CV 15.0%, 95% CI 13.0 to 17.0). The other three in-hospital treatments had CVs ranging between 40% and 50%. Funnel plots identified outlier hospitals, accounting for six (6.6%) in the epinephrine cohort, nine (11%) in the amiodarone cohort, nine (10%) in the TTM cohort, and nine (9.9%) in the CAG cohort. Conclusions Epinephrine use displayed smaller practice variation than the other treatments. However, some outlier hospitals were identified even for epinephrine. This underscores the inadequacy of developing stringent guidelines and highlights the vital need for active implementation monitoring.