Association between Cerebral Performance Category, Modified Rankin Scale, and discharge disposition after cardiac arrest

doi:10.1016/j.resuscitation.2011.03.034

Resuscitation

Volume 82, Issue 8, August 2011, Pages 1036-1040

https://doi.org/10.1016/j.resuscitation.2011.03.034 Get rights and content

Abstract

Background

Cerebral Performance Category (CPC), Modified Rankin Scale (mRS) and discharge disposition are commonly used to determine outcomes following cardiac arrest. This study tested the association between these outcome measures.

Methods

Retrospective chart review of subjects who survived to hospital discharge between 1/1/2006 and 12/31/2009 was conducted. Charts were reviewed for outcomes (CPC, mRS, and discharge disposition). Discharge disposition was classified in 6 categories: home with no services, home with home healthcare, acute rehabilitation facility, skilled nursing facility, long term acute care facility, and hospice. Intra-and inter-rater reliabilities were calculated for outcome measures. Rates of “good outcome” (defined as a CPC of 1–2, mRS of 0–3, or discharge disposition to home or acute rehabilitation facility) were also determined. Kendall's tau correlation coefficients explored relationships among measures.

Results

A total of 211 charts were reviewed. Mean age was 60 years (SD 16), the majority (75%) were white males, in- and out-of hospital cardiac arrests were equally prevalent, and ventricular dysrhythmia was most common (N = 109, 52%). Half of the subjects were comatose following resuscitation and 75 (35%) received therapeutic hypothermia. Inter-rater percentage agreement for CPC and mRS abstraction was 95.24% (kappa 0.89, p < 0.001) and 95.24% (kappa 0.90, p < 0.001) respectively. “Good outcomes” were found in 44 subjects (20%) using the CPC definition, 47 subjects (22%) using the mRS definition, and 129 subjects (61%) subjects using discharge disposition definition. There was fair relationship between the CPC and mRS (tau 0.43) and poor relationships between CPC and discharge disposition (tau 0.23) and between mRS and discharge disposition (tau 0.25).

Conclusions

Determination of the CPC, mRS and discharge disposition at hospital discharge is reliable from chart review. These instruments provide widely differing estimates of “good outcome”. Agreement between these measures ranges from poor to fair. A more nuanced outcome measure designed for the post-cardiac arrest population is needed.

Introduction

Determining the neurological and physical disability status of cardiac arrest survivors is important for evaluating the outcome of resuscitation interventions. The Cerebral Performance Category (CPC) has been the traditional standard outcome measure for cardiac arrest survivors and can be determined through chart review.1, 2, 3 However, previous work demonstrated that the CPC has limited ability to discriminate between mild and moderate brain injury.⁴ The Modified Rankin Scale (mRS) has been used as a measurement of global disability in stroke, brain injury, and neurosurgical patients.5, 6, 7 The mRS has some similarity to the CPC, though more focused on functional domains, and can also be determined using chart review.⁸ Finally, discharge disposition has been used as a surrogate for the CPC or mRS on the assumption that disposition is largely determined by patient condition.9, 10, 11

Presently, several definitions of a “good outcome” are used in the literature, each based on summative outcome measures. In previous work, good outcome after cardiac arrest has been defined as a CPC of 1–2,¹² mRS of 0–3,¹³ or discharge disposition to home or acute rehabilitation facility.10, 11 While these measures are used interchangeably to define “good outcome”, it is unknown which of these measures are most useful or reliable for describing the patient outcome at discharge, because each of these measures is differentially affected by four factors: cognitive and physical impairments, recovery of function, and ability to participate in everyday life. Furthermore, the CPC, mRS and discharge disposition are global scores that each place different emphases on these factors. The utility of discharge disposition lies only in its ability to capture current status and predict future outcomes. However, the CPC and mRS can be repeated over time, thus capturing short and long-term patient outcomes. Like discharge disposition, scores at discharge may be used to predict future patient outcomes.

It is critical for clinical studies to employ a valid and reliable outcome measure, and it is desirable to be able to compare studies that use different outcome measures. However, there is a paucity of comparative performance data about the CPC, mRS and discharge disposition. Therefore, this study examined the association among the CPC, mRS, and discharge disposition as outcome descriptors in a well-characterized cardiac arrest population. For the CPC and mRS we also determined the intra- and inter-rater reliability of assessment from chart review. This study tested the hypothesis that these different outcomes would be strongly associated with each other.

Section snippets

Participants and procedures

We completed a retrospective review of all subjects >18 years of age and resuscitated following either in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) who survived to hospital discharge in a single tertiary care facility between 1/1/2006 and 12/31/2009. Since 2007, this facility has incorporated a comprehensive post-cardiac arrest care program that includes use of therapeutic hypothermia for all comatose post-cardiac arrest patients regardless of initial cardiac

Results

Of the 512 subjects treated during the study period, 216 (42%) survived and had outcome measures determined. Five subjects were transferred to other hospitals, two due to insurance coverage and three due to psychiatric illness. These 5 subjects were excluded from analysis leaving 211 subjects for analysis.

Mean age was 60 years (SD 16) and the majority (75%) was white males (Table 2). IHCA and OHCA were equally prevalent, and ventricular dysrhythmia was most common (N = 109, 52%). Half of the

Discussion

The purpose of the study was to examine associations among CPC, mRS, and discharge disposition. These results do not support our hypothesis that these different outcome measures are strongly associated with each other. In contrast, significant variability exists among CPC, mRS, and discharge disposition as outcome measures. Relationships among these measures range from poor to fair. Thus, the percentage of subjects demonstrating a “good outcome” following cardiac arrest varies greatly depending

Conclusion

Determination of the CPC, mRS and disposition at hospital discharge after cardiac arrest is reliable from chart review using standardized instruments. However, different instruments provide widely differing estimates of “good outcome”. Agreement between these measures ranges from poor to fair. A more nuanced outcome measure specifically designed for the post-cardiac arrest population is needed.

Conflict of interest

The authors have no conflicts of interest to report.

Acknowledgements

Dr. Rittenberger is supported by Grant Number 1KL2RR024154-02 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Dr. Rittenberger is also supported by an unrestricted grant from the National Association of EMS Physicians/Zoll EMS Resuscitation Research Fellowship.

Drs. Raina, Holm, and Callaway received support from the National Heart Lung and Blood Institute Resuscitation Outcomes Consortium (5U01

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.03.034.

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Clinical paperAssociation between Cerebral Performance Category, Modified Rankin Scale, and discharge disposition after cardiac arrest☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Participants and procedures

Results

Discussion

Conclusion

Conflict of interest

Acknowledgements

Lancet

Resuscitation

Mayo Clin Proc

Resuscitation

Resuscitation

Lancet

Ann Emerg Med

Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest

N Engl J Med

Circulation

Interobserver agreement for the assessment of handicap in stroke patients

Stroke

Diffusion-weighted MR imaging in closed head injury: High correlation with initial Glasgow Coma Scale score and score on Modified Rankin Scale at discharge

Radiology

Clinical paper
Association between Cerebral Performance Category, Modified Rankin Scale, and discharge disposition after cardiac arrest☆