Quality-of-Life and Formal Functional Testing of Survivors of Out-of-Hospital Cardiac Arrest Correlates Poorly With Traditional Neurologic Outcome Scales,☆☆,

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Abstract

Study hypothesis: The traditional (and unvalidated) five-point Cerebral Performance Category (CPC) score at hospital discharge does not correlate with the results yielded by a validated functional status instrument and subjective quality-of-life assessment. Methods: We compared CPC scores with the results of prospective standardized testing after discharge in survivors of out-of-hospital cardiac arrest. Consenting survivors were tested with the validated Functional Status Questionnaire (FSQ), a subjective quality-of-life assessment, and traditional CPC scoring. Results: Of the 3,130 arrests during the 52 months of the study, 93 patients survived. Thirty-five patients were tested (71% of those eligible at the time of follow-up). Of these patients, 34% said their quality of life was worse, 38% said it was the same, and 28% said it was better than before the cardiac arrest. Fifty-four percent of patients scored normally on all FSQ subscales, but the remainder had an average 2.1 areas (of 6) with significant impairment. CPC score correlated very poorly with quality-of-life rating and with all scores and subscores on the FSQ. A CPC of 1 on discharge (supposedly normal function) had a sensitivity of 78%, a specificity of 43%, a positive predictive value of 64%, and a negative predictive value of 60% for quality of life the same as or better than that before arrest. With regard to ability to predict the presence of any major areas of impairment on the FSQ, the respective figures were 32%, 43%, 43%, and 32%. Conclusion: The CPC score, relied on as a measure of functional outcome in cardiac arrest, correlates poorly with subsequent subjective quality of life and with validated objective functional testing instruments, and conclusions based on it are suspect. Future researchers should employ standardized testing instruments. [Hsu JWY, Madsen CD, Callaham ML: Quality-of-life and formal functional testing of survivors of out-of-hospital cardiac arrest correlates poorly with traditional neurologic outcome scales. Ann Emerg Med December 1996;28:597-605.]

Section snippets

INTRODUCTION

The neurologic function and quality of life of long-term survivors of cardiac arrest are obviously of great importance, certainly as important as survival alone. Despite this importance, previous studies of neurologic function in long-term survivors of cardiac arrest have been few, and none has assessed subjective quality of life. By far the most common neurologic scoring method for cardiac arrest survivors is the simple five-point CPC (Cerebral Performance Category) score. This scale is poorly

MATERIALS AND METHODS

Our study population comprised all patients in San Francisco who sustained out-of-hospital cardiac arrest between February 1989 and June 1993 and were discharged alive from the hospital. During this period, the San Francisco emergency medical services system had first responders with defibrillators on fire trucks, with an average response interval of approximately 4 minutes; and advanced life support (ALS) ambulances with two paramedics, with an average response interval of approximately 10

RESULTS

Between February 1989 and June 1993, 3,130 out-of-hospital cardiac arrests occurred in San Francisco. Paramedics refrained from instituting ALS measures, as indicated by local EMS protocols, in 626 (20%). We identified 126 patients in the various databases as having survived to hospital discharge, but careful review of records revealed that only 93 (74%) had sustained true arrests and survived to hospital discharge. Eight patients had actually died in the hospital, despite initial reports to

DISCUSSION

Quality of life and neurologic function are key outcomes in the successful resuscitation of a cardiac arrest victim, but they have been studied little. The authors of most existing studies have focused on short-term recovery, such as the prediction of awakening or discharge from hospital based on findings in the first few days after arrest.19, 20, 21, 22 The GCS, a validated instrument, is commonly used in these studies to assess short-term recovery, but never beyond a week or two of

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    From the School of Medicine, University of California at Los Angeles*, the Division of Emergency Medicine, University of California, San Francisco and the San Francisco Department of Public Health§, San Francisco, California.

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