The Covert Rationing Blog

Sudden Death Is Still the Healthcare System’s Friend

January 3rd, 2008 by DrRich

In an article published in the January 3 issue of the New England Journal of Medicine, researchers report that hospitalized patients who have cardiac arrest (sudden loss of cardiac function due to the onset of a heart arrhythmia known as ventricular fibrillation) are often not receiving defibrillation (an electrical shock delivered to the chest) within the recommended 2-minute window of opportunity. Further, patients whose defibrillation is delayed beyond the 2-minute window have a substantially reduced chance of surviving the cardiac arrest. The researchers recommend that hospitals take steps to administer defibrillation more quickly to patients with cardiac arrest, in order to improve patient outcomes.

An accompanying editorial (written by Dr. Leslie Saxon, an old friend of DrRich) points out that in public areas where Automatic External Defibrillators (AEDs) are available, such as casinos, the odds of surviving a cardiac arrest is over 50%. In contrast, the odds of surviving cardiac arrest in a hospital, according to this new study, is only 34%.

Dr. Saxon goes on to suggest that hospitals ought to employ readily available technology (technology ubiquitously found in AEDs and implantable defibrillators) to improve their survival statistics - presumably, to nearly the levels achieved in casinos and shopping malls.

DrRich finds this study enlightening, and the recommendations made by Dr. Saxon admirable.

But, unfortunately, there is a big and fundamental difference between the business interests of hospitals, and those of other institutions in which cardiac arrest is relatively likely to occur (i.e., institutions that tend to attract persons of a certain age and body habitus, who are likely to enjoy sedentary forms of excitement, and who do not particularly mind tobacco smoke).

Which is to say that in a casino, saving the life of a customer is good for business. Aside from the favorable publicity you might get on a slow news day, the saved person and his/her family and friends are likely to think favorably of your establishment for years (and scores of Social Security checks) to come.

The healthcare system, on the other hand, thinks differently about people who are prone to cardiac arrest. These are typically individuals with chronic and expensive medical problems - most often they have coronary artery disease, diabetes, or heart failure - and (as DrRich has pointed out before) their sudden death today will save the system countless dollars tomorrow. While nobody ever talks about this, one simply needs to look at behaviors to see the truth of it.

Hospitals ought to be embarrassed by these latest statistics. But, DrRich suspects, their principle reaction more likely will be one of concern, a concern that will take this form: Will this new study generate the kind of publicity that might force us to actually do some of what Dr. Saxon suggests?

We can expect hospital administrators to lie low and watch the media. If this study creates a ripple, expect a few press releases here and there about how they’re studying various process improvements, coupled with mild disclaimers about how sick these patients really are, being hospitalized and all, so one musn’t expect miracles.

In the meantime, if you’re one of the millions of Americans who are at increased risk for cardiac arrest, then unless you’re also one of the fortunate few whose doctors see fit to offer you an implantable defibrillator, you’re probably better off spending as much time as you can in front of the slot machines than in your local healthcare institution.

References:
Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008; 358:9-17.
Saxon, LA. Survival after Tachyarrhythmic Arrest — What Are We Waiting For? N Engl J Med 2008; 358:77-79.

Posted in General Rationing Issues

7 Responses to “Sudden Death Is Still the Healthcare System’s Friend”

1. Tamer Mahrous wrote on 01/3/08 at 3:01 pm :

   Now, I haven’t seen the study, but there are a few variables that would need to be accounted for before I get all excited. First of all, I would hope that we are talking apples to apples here. Are we only talking about VT/VF arrests both in and out of hospital. I hope so to get any sense of comparability.

   I might also say that the fact the person is at a casino says to me they lead at least a resemblence of a functional life and have some evidence of health to them.

   Folks who code in the hospital generally only code when they are sick, very sick, have overwhelming sepsis or multiorgan failure, or have incredibly acutely sick hearts for which is the reason they are in the hospital.

   I do remember a few years ago hearing a lecture at an SHM meeting that for every minute a person in VT/VF is not shocked their survival decreases (or mortality increases, in can’t remember which) 7%. So yes. early defibrillation is very important. But so is the health status of the patient.

   If the goal of the article was to insure early defibrillation in VT/VF, I would agree, this should be a priority. And why I always insist on placing the paddles on the patient directly if they are not on telemetry when a code is initiated to get a sense on what the rhythm is immediately.

2. Bob Danielson wrote on 01/4/08 at 8:44 am :

   I would add that in a casino, any bystander, whether an employee or a patron, probably considers himself competent to do what has to be done in applying an AED to a cardiac arrest victim. Defibrillators in public areas have big clear labels telling YOU how to use the machine RIGHT NOW.

   Hospital employees, as we know, are credentialed and scope-of-practiced to an almost Byzantine degree. You can rest assured that there is no equipment mounted on hospital walls (other than perhaps a fire extinguisher) which is clearly labeled for use by anyone in an emergency.

   So we’ve set ourself up for a situation in which a cardiac arrest victim in a hospital corridor can assume that defib will not commence until someone with the right letters behind their name arrives to start the defibrillator.

3. DrRich wrote on 01/4/08 at 10:13 am :

   Tamer,

   The study did indeed look only at cardiac arrests due to ventricular arrhythmias (to the extent this distinction is possible). And while it is true that patients in hospital are (at least temporarily) sicker than people in a casino, their survival from VT/VF arrest is still related to the delay in therapy. There are many reasons the delay in therapy in hospitals is “built in.” See Bob’s comment for one of these.

4. DrRich wrote on 01/4/08 at 10:24 am :

   Bob,

   Thanks for elaborating on this point, which is one of the chief ways in which hospitals have built-in delays in responding to cardiac arrest. The hospital environment remains one of the few where first responders are actively prevented from delivering the kind of “definitive” therapy that AEDs can readily provide.

   AED’s as you point out, have been painstakingly designed to be readily usable by the great unwashed - and uncredentialed. Which is why you will seek in vain for AEDs in hospitals.

5. Michael Rack, MD wrote on 01/5/08 at 11:07 am :

   When a very sick person suddenly dies, it may benefit the “system” but individual hospitals and doctors have a financial incentive to keep sick patients alive as long as possible so they can be tortured with profitable procedures. Medicare/taxpayers are the ones who benefit when a person dies suddenly, which may explain why (in addition to the high cost of an implantable defibrillator) Medicare limits who is elgible for an implantable defibrillator.

6. Health Care BS wrote on 01/6/08 at 11:47 am :

   THE DEFIBRILLATION PLOT…

   The reason most conspiracy theories fail the giggle test is that they require implausible levels of venality and cooperation on the part of the conspirators. An illustrative example of this can be found in Dr. Rich’s theory on why cardiac…

7. Mike C. wrote on 01/6/08 at 1:37 pm :

   I agree with Dr. Rack. The profit motive is to keep them alive. Hospitals don’t care about how much money “the system” saves, they care about their own bottom line.

   I think the main problem is that hospitals are overwhelmed by the sheer complexity of the many and varied processes they have to improve. You have to beat them over the head with something for them to attack it, which is why studies like these are so useful.

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