Survival After In‐Hospital Cardiac Arrest and Return of Spontaneous Circulation: An Exploration of Outcome Variation and Relationship to Hospital Area Social Deprivation

Abstract Background In-hospital cardiac arrest (IHCA) survival has improved over the past two decades, resulting from better acute resuscitation survival. Post-resuscitation care is a key link in the IHCA chain-of-survival, yet post-resuscitation survival has remained stagnant over time. Hypothesis We hypothesized substantial hospital-to-hospital variation exists in risk-standardized post-resuscitation survival rate (RSSR) and hospital-area social deprivation is associated with worse RSSR. Methods We performed a cohort study of the American Heart Association Get With The Guidelines ® -Resuscitation registry, linked to the American Hospital Association survey. We included adult IHCA patients with sustained return of spontaneous circulation (ROSC) from 2001–2024. Post-resuscitation RSSR was the ratio of the predicted (hospital-specific average of patient-level predictions from mixed-effects model) to expected (adjusted population-averaged predictions) survival, multiplied by the unadjusted full-cohort survival. Social deprivation index (SDI) was assigned by ZIP-to-ZCTA linkage and analyzed by quartile. Hospitals lacking ZCTA linkage were excluded from SDI analyses. Results Of 686,273 IHCA, 206,467 from 755 hospitals were included for primary analysis. Overall, 71,691 (34.7%) patients who achieved ROSC survived to discharge. Median RSSR was 33.9% (IQR 32.6-35.1%). Variation in RSSR across hospitals was substantial—ranging from 25.0 to 44.8%. A total of 595 (78.8%) hospitals were linked by zip-code to SDI. Patients at hospitals in the lowest quartile of SDI (least deprivation) had higher post-resuscitation RSSR compared to patients in the highest quartile (aOR 1.13, 95% CI 1.03-1.23, p<0.01), although no monotonic relationship existed between hospital SDI quartile and RSSR quartile. Hospitals in higher SDI quartiles (more deprivation) had higher proportions of early post-resuscitation fever and death. Conclusions Substantial hospital-to-hospital variation exists in post-resuscitation survival, and greater community social deprivation predicts worse post-resuscitation outcomes at the patient level. These results identify the post-resuscitation phase of care as a promising area for future quality improvement and research efforts to improve outcomes after IHCA. Summary With the Get With The Guidelines ® -Resuscitation registry (2001-2024) we evaluated adults with sustained return of circulation after in-hospital cardiac arrest to quantify hospital-level variation in risk-standardized post-resuscitation survival and explore whether hospital-area social deprivation is associated with worse post-resuscitation outcomes. Author Statement This is original work from the authors, has not been published previously, and is not under consideration elsewhere. Approval This work was approved by the Albert Einstein College of Medicine Institutional Review Board (2025-16756) with exempt status. Conflicts of Interest There are no conflicts of interest for any authors. Funding Information – Luke Andrea: Grant from the Clinical and Translational Science Award (CTSA) program, funded by the National Center for Advancing Translational Sciences (NCATS) at the National Institutes of Health (NIH) grant number K12TR004411 to perform research unrelated to this project. – Ari Moskowitz: Grant from the National Institutes of Health/National Heart, Lung, and Blood Institute (4R33HL162980) to perform research unrelated to this project; Volunteer member of the ILCOR Advances Life Support Task Force; Volunteer Member of the American Heart Association Post-Cardiac Arrest Care Guideline Writing Group. – Authors Luke Andrea and Ari Moskowitz are supported by an award from the American Heart Association (24GWTGDRA1308863).