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A Population-Based Analysis of Intraoperative Cardiac Arrest in the United States

Appendix – Supplementary Statistical Methods and Results

Vikram Fielding-Singh, MD, JD,1 Mark D. Willingham, MD, MS,2 Matthew A. Fischer, MD, MS,1 Tristan Grogan, MS,3 Peyman Benharash, MD,4 Jacques P. Neelankavil, MD1

1 Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; 2 Division of Cardiothoracic Anesthesiology and Perioperative Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri; 3 Department of Medicine, Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; 4 Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California

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Table of ContentsSupplementary Methods..................................................................................................................3

Supplementary Table 1. Identification of Surgical Subtypes for Multivariable Models.............3Supplementary Table 2. Identification of Elixhauser Comorbidities for Multivariable Models.4Supplementary Table 3. Identification of Variables for Exploratory Analyses..........................5

Supplementary Results....................................................................................................................6Supplementary Figure. Selection of Subpopulations for Analysis of Intraoperative Cardiac Arrest...........................................................................................................................................6Supplementary Table 4. Incidence and 95% Confidence Interval of Intraoperative Cardiac Arrest per 10,000 Hospital Admissions Involving Operating Room Procedures by All Patient and Admission Characteristics....................................................................................................7Supplementary Table 5. Adjusted Odds Ratios for In-Hospital Mortality, Full Model..............9Supplementary Table 6. Linear Regression Coefficients for Length of Stay, Full Model........11Supplementary Table 7. Linear Regression Coefficients for Total Admission Costs, Full Model.........................................................................................................................................13Supplementary Table 8. Baseline Patient and Admission Characteristics Before and After Propensity Score Matching........................................................................................................15Supplementary Table 9. Effect Estimates for Secondary Outcomes from Linear and Logistic Regression Models in the Propensity Score Matched Cohort...................................................18Supplementary Table 10. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Full Model...................................................................................................................................................19Supplementary Table 11. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Subgroup Analyses.....................................................................................................................................21Supplementary Table 12. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Elective Admissions with Procedures on Day 0......................................................................................24Supplementary Table 13. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Exploratory Analysis, Selected Covarariates.................................................................................................26Supplementary Table 14. Adjusted Odds Ratios for Mortality During Admissions with Intraoperative Cardiac Arrest, Full Model.................................................................................27

References......................................................................................................................................29

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Supplementary MethodsSupplementary Table 1. Identification of Surgical Subtypes for Multivariable ModelsSurgical subtype Multi-level CCS Procedure

CategoryICD-10-CM

Cardiac 7.1-7.9Endocrine 2Intraabdominal general 8.3, 9Genitourinary 10 (excluding 10.4), 11Gynecologic 12Heart and lung transplant 02YA0Z0, 02YA0Z1, 02YA0Z2,

0BYC0Z0, 0BYC0Z1, 0BYC0Z2, 0BYD0Z0, 0BYD0Z1, 0BYD0Z2, 0BYF0Z0, 0BYF0Z1, 0BYF0Z2, 0BYG0Z0, 0BYG0Z1, 0BYG0Z2, 0BYH0Z0, 0BYH0Z1, 0BYH0Z2, 0BYJ0Z0, 0BYJ0Z1, 0BYJ0Z2, 0BYK0Z0, 0BYK0Z1, 0BYK0Z2, 0BYL0Z0, 0BYL0Z1, 0BYL0Z2, 0BYM0Z0, 0BYM0Z1, 0BYM0Z2

Neurosurgery 1Noncardiac transplant 10.4 07YM0Z0, 07YM0Z1, 07YM0Z2,

07YP0Z0, 07YP0Z1, 07YP0Z2, 0DY50Z0, 0DY50Z1, 0DY50Z2, 0DY60Z0, 0DY60Z1, 0DY60Z2, 0DY80Z0, 0DY80Z1, 0DY80Z2, 0DYE0Z0, 0DYE0Z1, 0DYE0Z2, 0FY00Z0, 0FY00Z1, 0FY00Z2, 0FYG0Z0, 0FYG0Z1, 0FYG0Z2, 0UY00Z0, 0UY00Z1, 0UY00Z2, 0UY10Z0, 0UY10Z1, 0UY10Z2, 0WY20Z0, 0WY20Z1, 0XYJ0Z0, 0XYJ0Z1, 0XYK0Z0, 0XYK0Z1, 3E030U0, 3E030U1, 3E033U0, 3E033U1, 3E0J3U0, 3E0J3U1, 3E0J7U0, 3E0J7U1, 3E0J8U0, 3E0J8U1

Obstetrics 13Ophthalmologic 3Orthopedic 14Otolaryngology 4, 5Skin and subcutaneous tissue 15Thoracic 6Vascular 7.10-7.19

* The Healthcare Cost and Utilization Project’s Clinical Classifications Software1 was used to categorize surgical subtype when appropriate. When the Clinical Classifications Software category contained procedures performed by different surgical specialties or procedures likely to have significantly different rate of intraoperative cardiac arrest, individual ICD-10-PCS codes were used to assign surgical subtypes. For example, heart and lung transplantation was separated from other transplantation procedures using individual ICD-10-PCS codes.

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Supplementary Table 2. Identification of Elixhauser Comorbidities for Multivariable ModelsComorbidity AHRQ Comorbidity Variable

Hypertension HTN_CDiabetes mellitus without complications DMDiabetes mellitus with complications DMCXEnd-stage renal disease RENLFAILValvular heart disease VALVECongestive heart failure CHFPulmonary circulation disorders PULMCIRCPeripheral vascular disease PERIVASCChronic lung disease CHRNLUNGLiver disease LIVERObesity OBESEAlcohol use disorder ALCOHOLDrug abuse DRUGParalysis PARAOther neurologic disorders NEUROHypothyroidism HYPOTHYChronic peptic ulcer disease ULCERHIV or AIDS AIDSLymphoma LYMPHMetastatic tumor METSSolid tumor without metastases TUMORRA / collagen vascular disease ARTHCoagulation deficiency COAGWeight loss WGHTLOSSFluid and electrolyte disorders LYTESBlood loss anemia BLDLOSSDeficiency anemias ANEMDEFPsychoses PSYCHDepression DEPRESS

AHRQ = Agency for Healthcare Research and Quality; AIDS = acquired immune deficiency syndrome; HIV = human immunodeficiency virus; RA = rheumatoid arthritis.

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Supplementary Table 3. Identification of Variables for Exploratory AnalysesComorbidity Single-level

CCS Diagnosis Category

Multi-level CCS Diagnosis Category

Single-level CCS Procedure Category

ICD-10 Code

Coronary artery disease 101Prior coronary revascularization

Z951, Z955, Z9861

Tracheal or laryngeal surgery

33, 34, 35

Venous thromboembolism

Z86711, I82501, I82502, I82503, I82509, I82511, I82512, I82513, I82519, I82521, I82522, I82523, I82529, I82531, I82532, I82533, I82539, I82541, I82542, I82543, I82549, I82591, I82592, I82593, I82599, I825Y1, I825Y2, I825Y3, I825Y9, I825Z1, I825Z2, I825Z3, I825Z9, I82701, I82702, I82703, I82709, I82711, I82712, I82713, I82719, I82721, I82722, I82723, I82729, I82891, I8291, I82A21, I82A22, I82A23, I82A29, I82B21, I82B22, I82B23, I82B29, I82C21, I82C22, I82C23, I82C29, I87001, I87002, I87003, I87009, I87011, I87012, I87013, I87019, I87021, I87022, I87023, I87029, I87031, I87032, I87033, I87039, I87091, I87092, I87093, I87099, Z86718, Z8672

Active smoker O99330, O99331, O99332, O99333, O99334, O99335, Z716, Z720, F17200, F17201, F17203, F17208, F17209, F17210, F17213, F17218, F17219

History of stroke 7.3CCS = Clinical Classifications Software; ICD = International Classification of Disease.

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Supplementary ResultsSupplementary Figure. Selection of Subpopulations for Analysis of Intraoperative Cardiac Arrest

Confidence intervals excluded for observation estimates.* Observation subtotals are not mutually exclusive.

35,675,421 Admissions in the National Inpatient Sample in 2016

9,642,825 Admissions for patients 18 years or older who underwent operative room procedures

26,032,596 Admissions excluded*25,688,126 No operating room procedure5,479,699 Age under 18 years

Subgroup Analyses7,316,498 Admissions without obstetric procedures8,158,472 Admissions without cardiac procedures3,287,951 Elective admissions with a procedure on day 020,270 Admissions matched using propensity scores5,230 Admissions involving intraoperative cardiac

arrest

Primary Analysis9,244,861 Admissions for patients 18 years or older who

underwent operative room procedures with complete data

397,964 Admissions with missing data

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Supplementary Table 4. Incidence and 95% Confidence Interval of Intraoperative Cardiac Arrest per 10,000 Hospital Admissions Involving Operating Room Procedures by All Patient and Admission CharacteristicsCharacteristic Number of

Admissions(n = 9,244,861)

Number of Intraoperative Cardiac Arrests(n = 5,230)

Incidence per 10,000 Admissions(95% CI)

Age, years18-39 2,700,118 350 1.3 (1-1.7)40-59 2,288,594 1,180 5.2 (4.5-5.9)60-79 3,357,174 2,715 8.1 (7.4-8.8)80+ 898,975 985 11 (9.4-12.7)

Sex Male 3,528,339 3,120 8.8 (8.1-9.6)Female 5,716,522 2,110 3.7 (3.3-4.1)

Race White 6,155,756 3,500 5.7 (5.2-6.2)Black 1,058,225 750 7.1 (6-8.4)Hispanic 972,610 330 3.4 (2.6-4.4)Asian or Pacific Islander 275,205 170 6.2 (4.4-8.6)Native American 46,955 40 8.5 (4.3-16.9)Other 281,010 115 4.1 (2.7-6.3)Missing 455,101 325 7.1 (5.6-9.1)

Payor status Medicare 3,578,789 3,255 9.1 (8.4-9.9)Medicaid 1,572,179 435 2.8 (2.2-3.5)Private 3,486,694 1,310 3.8 (3.3-4.3)Self-pay 275,885 105 3.8 (2.5-5.8)No charge 23,915 20 8.4 (3.1-22.4)Other 307,400 105 3.4 (2.2-5.3)

Hospital ownershipPrivate non-profit 6,892,997 3,950 5.7 (5.3-6.2)Government, nonfederal 1,002,870 730 7.3 (6-8.8)Private invest-own 1,348,994 550 4.1 (3.3-5)

Patient county size Central metro > 1M 2,620,253 1,485 5.7 (5-6.4)Fringe metro > 1M 2,291,624 1,195 5.2 (4.5-6)250K-1M 1,961,169 1,060 5.4 (4.7-6.2)50-250K 865,904 540 6.2 (5.1-7.6)Micropolitan 857,625 530 6.2 (5.1-7.4)Other 648,285 420 6.5 (5.2-8.1)

Median zip code income percentile 0-25th 2,523,008 1,505 6 (5.3-6.8)26th-50th 2,351,304 1,330 5.7 (5-6.4)51th-75th 2,322,355 1,310 5.6 (4.9-6.4)76th-100th 2,048,194 1,085 5.3 (4.6-6.1)

Census Division New England 418,495 240 5.7 (3.8-8.7)Mid Atlantic 1,278,685 750 5.9 (4.8-7.1)East North Central 1,386,479 860 6.2 (5.2-7.3)West North Central 673,400 395 5.9 (4.6-7.4)South Atlantic 1,897,855 1,040 5.5 (4.8-6.2)East South Central 641,833 370 5.8 (4.4-7.6)West South Central 1,133,756 565 5 (4.1-6)Mountain 621,248 340 5.5 (4.2-7.2)Pacific 1,193,110 670 5.6 (4.6-6.9)

Hospital location Rural 620,225 270 4.4 (3.3-5.8)Urban nonteaching 2,245,902 910 4.1 (3.5-4.7)Urban teaching 6,378,734 4,050 6.3 (5.9-6.9)

Type of hospitalization Non-elective 4,462,317 3,395 7.6 (7-8.3)Elective 4,782,544 1,835 3.8 (3.4-4.3)

Month of admission January 750,640 470 6.3 (5.1-7.7)

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February 747,050 405 5.4 (4.4-6.7)March 786,505 505 6.4 (5.2-7.9)April 753,375 445 5.9 (4.7-7.4)May 773,780 455 5.9 (4.8-7.3)June 783,645 390 5 (4-6.2)July 748,260 425 5.7 (4.6-7)August 812,475 495 6.1 (5-7.4)September 762,555 360 4.7 (3.7-6)October 782,215 415 5.3 (4.3-6.6)November 772,685 375 4.9 (3.9-6.1)December 771,680 490 6.3 (5.2-7.8)

Admission day Weekday 8,006,702 4,365 5.5 (5.1-5.9)Weekend 1,238,159 865 7 (6-8.2)

Procedural risk Low 5,515,953 480 0.9 (0.7-1.1)High 3,728,908 4,750 12.7 (11.9-13.6)

ComorbiditiesCongestive heart failure 437,250 795 18.2 (15.5-21.3)Valvular disease 249,150 250 10 (7.5-13.4)Pulmonary circulation disorders 49,525 160 32.3 (22.8-45.8)Peripheral vascular disease 560,260 1,070 19.1 (16.6-22)Hypertension 4,325,779 3,335 7.7 (7.1-8.4)Paralysis 212,575 270 12.7 (9.7-16.6)Other neurological disorders 489,530 410 8.4 (6.8-10.4)Chronic pulmonary disease 1,404,484 1,060 7.5 (6.6-8.6)Diabetes without chronic complications 1,083,445 835 7.7 (6.7-8.9)Diabetes with chronic complications 828,410 955 11.5 (9.9-13.4)Hypothyroidism 995,745 590 5.9 (4.9-7.1)Renal failure 867,375 1,525 17.6 (15.6-19.8)Liver disease 252,015 280 11.1 (8.5-14.5)Chronic peptic ulcer disease 62,045 95 15.3 (9.8-23.9)HIV and AIDS 10,895 5 4.6 (0.6-32.6)Lymphoma 36,445 30 8.2 (3.7-18.2)Metastatic cancer 194,175 135 7 (4.7-10.3)Solid tumor without metastasis 139,145 170 12.2 (8.8-16.9)RA / collagen vascular diseases 242,150 100 4.1 (2.6-6.5)Coagulation deficiency 437,340 1,180 27 (23.6-30.9)Obesity 1,533,440 1,065 6.9 (6-8)Weight loss 348,305 495 14.2 (11.7-17.2)Fluid and electrolyte disorders 1,445,639 2,480 17.2 (15.6-18.8)Blood loss anemia 404,425 60 1.5 (0.8-2.6)Deficiency anemias 1,237,759 1,115 9 (7.9-10.3)Alcohol abuse 224,180 145 6.5 (4.5-9.4)Drug abuse 189,400 85 4.5 (2.8-7.2)Psychoses 187,305 65 3.5 (1.9-6.2)Depression 909,365 460 5.1 (4.1-6.2)

AIDS = acquired immune deficiency syndrome; HIV = human immunodeficiency virus; K = thousand; M = million; RA = rheumatoid arthritis.

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Supplementary Table 5. Adjusted Odds Ratios for In-Hospital Mortality, Full ModelCharacteristic Odds Ratio (95% CI) P valueIntraoperative cardiac arrest

No 1 [Reference]Yes 15.44 (12.74-18.7) < 0.001

Age, years18-39 1 [Reference]40-59 1.37 (1.29-1.46) < 0.00160-79 1.98 (1.85-2.12) < 0.00180+ 3.4 (3.15-3.67) < 0.001

SexMale 1 [Reference]Female 1 (0.97-1.03) 0.856

RaceWhite 1 [Reference]Black 0.93 (0.89-0.98) 0.01Hispanic 0.92 (0.87-0.98) 0.006Asian or Pacific Islander 1.03 (0.93-1.13) 0.606Native American 1.18 (0.99-1.42) 0.072Other 1.1 (1.01-1.2) 0.034Missing 1.34 (1.21-1.49) < 0.001

Payor statusMedicare 1 [Reference]Medicaid 1 (0.94-1.06) 0.976Private 0.82 (0.79-0.86) < 0.001Self-pay 1.27 (1.16-1.38) < 0.001No charge 0.97 (0.71-1.32) 0.837Other 1.06 (0.97-1.16) 0.181

Hospital ownershipPrivate non-profit 1 [Reference]Government, nonfederal 1.09 (1.01-1.18) 0.033Private invest-own 1.02 (0.95-1.09) 0.582

Patient county sizeCentral metro > 1M 1 [Reference]Fringe metro > 1M 0.99 (0.94-1.04) 0.737250K-1M 1.13 (1.07-1.2) < 0.00150-250K 1.13 (1.06-1.21) < 0.001Micropolitan 1.25 (1.17-1.34) < 0.001Other 1.17 (1.09-1.25) < 0.001

Median zip code income percentile0-25th 1 [Reference]26th-50th 0.94 (0.9-0.97) 0.00151th-75th 0.93 (0.9-0.98) 0.00276th-100th 0.88 (0.83-0.93) < 0.001

Census DivisionNew England 1 [Reference]Mid Atlantic 1.06 (0.96-1.17) 0.24East North Central 0.8 (0.73-0.89) < 0.001West North Central 0.86 (0.77-0.98) 0.018South Atlantic 0.9 (0.81-1) 0.046East South Central 1.07 (0.94-1.21) 0.326West South Central 0.97 (0.87-1.08) 0.603Mountain 0.94 (0.83-1.06) 0.292Pacific 1.04 (0.94-1.15) 0.412

Hospital locationRural 1 [Reference]Urban nonteaching 1.01 (0.92-1.11) 0.844Urban teaching 1.15 (1.05-1.27) 0.003

Type of hospitalizationNon-elective 1 [Reference]Elective 0.29 (0.28-0.3) < 0.001

Month of admissionJanuary 1 [Reference]

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February 1.02 (0.96-1.09) 0.487March 1.06 (1-1.13) 0.065April 0.96 (0.9-1.03) 0.235May 0.98 (0.92-1.05) 0.621June 0.95 (0.89-1.02) 0.155July 0.94 (0.88-1.01) 0.083August 0.93 (0.87-1) 0.038September 0.97 (0.91-1.03) 0.321October 0.92 (0.86-0.98) 0.008November 0.95 (0.89-1.02) 0.158December 1.04 (0.97-1.11) 0.282

Admission dayWeekday 1 [Reference]Weekend 1.13 (1.09-1.17) < 0.001

Number of OR procedures 1.06 (1.05-1.07) < 0.001Surgical subtype

Cardiac 1.63 (1.55-1.7) < 0.001Endocrine 0.8 (0.63-1.02) 0.07Intraabdominal general 1.21 (1.16-1.26) < 0.001Genitourinary 0.78 (0.73-0.84) < 0.001Gynecologic 0.52 (0.45-0.61) < 0.001Heart and lung transplant 0.3 (0.2-0.46) < 0.001Neurosurgery 2.31 (2.19-2.44) < 0.001Noncardiac transplant 0.11 (0.07-0.18) < 0.001Obstetric 0.06 (0.04-0.08) < 0.001Ophthalmologic 1.27 (0.93-1.74) 0.134Orthopedic 0.59 (0.57-0.62) < 0.001Otolaryngology 0.84 (0.75-0.95) 0.006Skin and subcutaneous tissue 0.9 (0.86-0.95) < 0.001Thoracic 2.29 (2.2-2.39) < 0.001Vascular 3.03 (2.9-3.15) < 0.001

ComorbiditiesCongestive heart failure 1.84 (1.76-1.92) < 0.001Valvular disease 1.09 (1.03-1.16) 0.005Pulmonary circulation disorders 1.83 (1.68-1.99) < 0.001Peripheral vascular disease 1.29 (1.24-1.34) < 0.001Hypertension 0.77 (0.74-0.79) < 0.001Paralysis 1.6 (1.51-1.69) < 0.001Other neurological disorders 1.1 (1.04-1.15) < 0.001Chronic pulmonary disease 1.01 (0.97-1.05) 0.595Diabetes without chronic complications 0.94 (0.9-0.98) 0.005Diabetes with chronic complications 0.8 (0.77-0.84) < 0.001Hypothyroidism 0.83 (0.8-0.87) < 0.001Renal failure 1.32 (1.27-1.37) < 0.001Liver disease 1.58 (1.49-1.67) < 0.001Chronic peptic ulcer disease 1.13 (1.03-1.24) 0.008HIV and AIDS 1.16 (0.87-1.54) 0.314Lymphoma 1.54 (1.37-1.73) < 0.001Metastatic cancer 2.21 (2.09-2.34) < 0.001Solid tumor without metastasis 1.35 (1.26-1.46) < 0.001RA / collagen vascular diseases 1.05 (0.97-1.13) 0.244Coagulation deficiency 2.28 (2.19-2.38) < 0.001Obesity 0.86 (0.83-0.9) < 0.001Weight loss 1.38 (1.32-1.45) < 0.001Fluid and electrolyte disorders 2.95 (2.83-3.07) < 0.001Blood loss anemia 0.75 (0.67-0.84) < 0.001Deficiency anemias 0.77 (0.74-0.8) < 0.001Alcohol abuse 1.05 (0.98-1.12) 0.152Drug abuse 0.77 (0.7-0.85) < 0.001Psychoses 0.89 (0.81-0.98) 0.014Depression 0.72 (0.69-0.76) < 0.001

AIDS = acquired immune deficiency syndrome; HIV = human immunodeficiency virus; K = thousand; M = million; OR = operating room; RA = rheumatoid arthritis.

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Supplementary Table 6. Linear Regression Coefficients for Length of Stay, Full Model

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Characteristic Days (95% CI) P valueIntraoperative cardiac arrest

No 1 [Reference]Yes -0.14 (-1.12-0.83) 0.772

Age, years18-39 1 [Reference]40-59 0.26 (0.22-0.31) < 0.00160-79 0.53 (0.47-0.6) < 0.00180+ 0.66 (0.58-0.74) < 0.001

SexMale 1 [Reference]Female -0.17 (-0.2--0.14) < 0.001

RaceWhite 1 [Reference]Black 0.48 (0.43-0.54) < 0.001Hispanic 0.09 (0.03-0.15) 0.003Asian or Pacific Islander 0.17 (0.06-0.27) 0.002Native American 0.15 (-0.05-0.35) 0.135Other 0.26 (0.15-0.37) < 0.001Missing 0.24 (0.09-0.38) 0.001

Payor statusMedicare 1 [Reference]Medicaid 0.64 (0.57-0.7) < 0.001Private 0.09 (0.04-0.14) < 0.001Self-pay 0.19 (0.09-0.28) < 0.001No charge 0.36 (0.11-0.6) 0.005Other 0.28 (0.19-0.38) < 0.001

Hospital ownershipPrivate non-profit 1 [Reference]Government, nonfederal 0.4 (0.25-0.54) < 0.001Private invest-own 0.02 (-0.07-0.11) 0.697

Patient county sizeCentral metro > 1M 1 [Reference]Fringe metro > 1M -0.02 (-0.08-0.04) 0.508250K-1M -0.03 (-0.11-0.05) 0.47450-250K -0.07 (-0.15-0.01) 0.078Micropolitan 0.01 (-0.08-0.09) 0.865Other -0.02 (-0.1-0.07) 0.712

Median zip code income percentile0-25th 1 [Reference]26th-50th -0.08 (-0.12--0.04) < 0.00151th-75th -0.07 (-0.12--0.03) < 0.00176th-100th -0.08 (-0.13--0.03) 0.002

Census DivisionNew England 1 [Reference]Mid Atlantic 0.24 (0.09-0.4) 0.002East North Central -0.46 (-0.61--0.31) < 0.001West North Central -0.28 (-0.46--0.11) 0.001South Atlantic 0.08 (-0.08-0.24) 0.323East South Central 0.13 (-0.12-0.37) 0.308West South Central -0.06 (-0.22-0.1) 0.453Mountain -0.41 (-0.61--0.22) < 0.001Pacific -0.24 (-0.39--0.08) 0.003

Hospital locationRural 1 [Reference]Urban nonteaching 0.07 (-0.03-0.16) 0.155Urban teaching 0.42 (0.32-0.52) < 0.001

Type of hospitalizationNon-elective 1 [Reference]Elective -1.42 (-1.47--1.36) < 0.001

Month of admissionJanuary 1 [Reference]February -0.06 (-0.1--0.02) 0.006March -0.11 (-0.15--0.07) < 0.001

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April -0.14 (-0.18--0.1) < 0.001May -0.17 (-0.21--0.13) < 0.001June -0.15 (-0.19--0.11) < 0.001July -0.18 (-0.22--0.13) < 0.001August -0.21 (-0.25--0.17) < 0.001September -0.19 (-0.23--0.15) < 0.001October -0.21 (-0.25--0.17) < 0.001November -0.17 (-0.22--0.13) < 0.001December -0.21 (-0.25--0.17) < 0.001

Admission dayWeekday 1 [Reference]Weekend -0.02 (-0.08-0.04) 0.508


Cardiac 1.21 (1.12-1.31) < 0.001Endocrine 0.59 (0.42-0.76) < 0.001Intraabdominal general 2.15 (2.07-2.22) < 0.001Genitourinary 0.94 (0.87-1.01) < 0.001Gynecologic -0.49 (-0.54--0.44) < 0.001Heart and lung transplant 20.44 (17.67-23.22) < 0.001Neurosurgery 0.95 (0.88-1.02) < 0.001Noncardiac transplant 7.09 (5.63-8.54) < 0.001Obstetric 1.66 (1.58-1.74) < 0.001Ophthalmologic 0.66 (0.27-1.06) 0.001Orthopedic 1.08 (1.02-1.15) < 0.001Otolaryngology 0.67 (0.47-0.87) < 0.001Skin and subcutaneous tissue 1.88 (1.8-1.96) < 0.001Thoracic 5.59 (5.4-5.77) < 0.001Vascular 3.31 (3.22-3.39) < 0.001

ComorbiditiesCongestive heart failure 1.81 (1.73-1.89) < 0.001Valvular disease 0.32 (0.24-0.39) < 0.001Pulmonary circulation disorders 4.59 (4.28-4.9) < 0.001Peripheral vascular disease 0.05 (-0.01-0.11) 0.101Hypertension -0.17 (-0.2--0.14) < 0.001Paralysis 3.35 (3.19-3.52) < 0.001Other neurological disorders 1.14 (1.06-1.21) < 0.001Chronic pulmonary disease -0.03 (-0.06-0) 0.097Diabetes without chronic complications -0.12 (-0.15--0.09) < 0.001Diabetes with chronic complications 0.59 (0.53-0.65) < 0.001Hypothyroidism -0.01 (-0.04-0.03) 0.698Renal failure 0.5 (0.43-0.56) < 0.001Liver disease 0 (-0.09-0.1) 0.929Chronic peptic ulcer disease 1.93 (1.72-2.14) < 0.001HIV and AIDS 0.8 (0.35-1.26) 0.001Lymphoma 1.23 (0.99-1.46) < 0.001Metastatic cancer 0.25 (0.14-0.36) < 0.001Solid tumor without metastasis 0.26 (0.16-0.37) < 0.001RA / collagen vascular diseases 0.15 (0.09-0.21) < 0.001Coagulation deficiency 1.85 (1.75-1.95) < 0.001Obesity 0.38 (0.35-0.41) < 0.001Weight loss 5.56 (5.34-5.77) < 0.001Fluid and electrolyte disorders 2.8 (2.72-2.87) < 0.001Blood loss anemia 0.22 (0.16-0.27) < 0.001Deficiency anemias 0.64 (0.58-0.69) < 0.001Alcohol abuse 0.61 (0.51-0.71) < 0.001Drug abuse 1.24 (1.13-1.35) < 0.001Psychoses 0.99 (0.89-1.1) < 0.001Depression 0.25 (0.21-0.29) < 0.001


Supplementary Table 7. Linear Regression Coefficients for Total Admission Costs, Full ModelCharacteristic Dollars (95% CI) P value

14

Intraoperative cardiac arrestNo 1 [Reference]Yes 13184 (9600-16769) < 0.001

Age, years18-39 1 [Reference]40-59 -34 (-244-177) 0.75360-79 472 (174-769) 0.00280+ -645 (-1025--264) 0.001

SexMale 1 [Reference]Female -872 (-974--769) < 0.001

RaceWhite 1 [Reference]Black 1372 (1098-1647) < 0.001Hispanic 588 (253-924) 0.001Asian or Pacific Islander 492 (48-935) 0.03Native American 848 (-864-2560) 0.331Other 1869 (1069-2668) < 0.001Missing 1457 (804-2111) < 0.001

Payor statusMedicare 1 [Reference]Medicaid 1334 (1121-1547) < 0.001Private 386 (230-541) < 0.001Self-pay -760 (-1120--400) < 0.001No charge -1059 (-1997--120) 0.027Other 1144 (718-1569) < 0.001

Hospital ownershipPrivate non-profit 1 [Reference]Government, nonfederal 2982 (2042-3922) < 0.001Private invest-own -1647 (-2143--1151) < 0.001

Patient county sizeCentral metro > 1M 1 [Reference]Fringe metro > 1M -267 (-687-153) 0.212250K-1M -760 (-1252--267) 0.00250-250K -344 (-858-171) 0.191Micropolitan -378 (-893-137) 0.15Other 261 (-292-813) 0.355

Median zip code income percentile0-25th 1 [Reference]26th-50th 318 (139-497) < 0.00151th-75th 879 (652-1105) < 0.00176th-100th 1603 (1258-1947) < 0.001

Census DivisionNew England 1 [Reference]Mid Atlantic -2985 (-4424--1545) < 0.001East North Central -3650 (-4959--2342) < 0.001West North Central -3876 (-5162--2591) < 0.001South Atlantic -3183 (-4478--1888) < 0.001East South Central -5235 (-6837--3633) < 0.001West South Central -3590 (-4934--2247) < 0.001Mountain -2681 (-4009--1353) < 0.001Pacific 3662 (2007-5316) < 0.001

Hospital locationRural 1 [Reference]Urban nonteaching -2144 (-2767--1521) < 0.001Urban teaching -997 (-1558--435) 0.001

Type of hospitalizationNon-elective 1 [Reference]Elective -749 (-962--536) < 0.001

Month of admissionJanuary 1 [Reference]February -18 (-160-124) 0.804March -68 (-202-65) 0.316April -219 (-356--81) 0.002

15

May -209 (-347--71) 0.003June -117 (-262-27) 0.111July -94 (-243-55) 0.217August -33 (-187-121) 0.675September -11 (-159-138) 0.888October 229 (82-376) 0.002November 307 (143-471) < 0.001December 115 (-30-260) 0.119

Admission dayWeekday 1 [Reference]Weekend 309 (179-440) < 0.001

Number of OR procedures 4247 (4091-4402) < 0.001Surgical subtype

Cardiac 15688 (15080-16295) < 0.001Endocrine 894 (293-1496) 0.004Intraabdominal general 3704 (3414-3993) < 0.001Genitourinary 2488 (2117-2859) < 0.001Gynecologic -4490 (-4716--4265) < 0.001Heart and lung transplant 149958 (133600-166316) < 0.001Neurosurgery 6783 (6393-7173) < 0.001Noncardiac transplant 95148 (83331-106964) < 0.001Obstetric -3474 (-3787--3160) < 0.001Ophthalmologic 2981 (931-5030) 0.004Orthopedic 5156 (4890-5421) < 0.001Otolaryngology 1535 (752-2318) < 0.001Skin and subcutaneous tissue 1233 (929-1538) < 0.001Thoracic 20546 (19633-21460) < 0.001Vascular 11323 (10869-11776) < 0.001

ComorbiditiesCongestive heart failure 3631 (3293-3968) < 0.001Valvular disease 241 (-44-526) 0.097Pulmonary circulation disorders 14674 (13545-15803) < 0.001Peripheral vascular disease 112 (-131-356) 0.366Hypertension -1089 (-1258--920) < 0.001Paralysis 8140 (7654-8626) < 0.001Other neurological disorders 2849 (2605-3092) < 0.001Chronic pulmonary disease -437 (-575--299) < 0.001Diabetes without chronic complications -732 (-858--606) < 0.001Diabetes with chronic complications -1387 (-1633--1140) < 0.001Hypothyroidism 129 (6-252) 0.04Renal failure 911 (645-1176) < 0.001Liver disease -59 (-412-295) 0.745Chronic peptic ulcer disease 6376 (5490-7262) < 0.001HIV and AIDS 2425 (787-4063) 0.004Lymphoma 3545 (2512-4579) < 0.001Metastatic cancer -2698 (-3437--1959) < 0.001Solid tumor without metastasis -1968 (-2356--1581) < 0.001RA / collagen vascular diseases 336 (116-555) 0.003Coagulation deficiency 10494 (9958-11030) < 0.001Obesity 1714 (1569-1859) < 0.001Weight loss 13541 (12575-14506) < 0.001Fluid and electrolyte disorders 8458 (8069-8847) < 0.001Blood loss anemia 1128 (959-1297) < 0.001Deficiency anemias -312 (-528--96) 0.005Alcohol abuse 987 (620-1355) < 0.001Drug abuse 1498 (1154-1842) < 0.001Psychoses 889 (557-1222) < 0.001Depression 162 (9-314) 0.038


Supplementary Table 8. Baseline Patient and Admission Characteristics Before and After Propensity Score MatchingBefore Propensity Score Matching After Propensity Score Matching

16

Characteristic No IOCANo. (%)(n = 9,239,631)

IOCANo. (%)(n = 5,230)

SMD, %

No IOCANo. (%)(n = 15,155)

IOCANo. (%)(n = 5,115)

SMD, %

Age, years 0.665 0.046

18-39 2699768 (29.2) 350 (6.7) 865 (5.7) 335 (6.5) 40-59 2287414 (24.8) 1180 (22.6) 3310 (21.8) 1165 (22.8) 60-79 3354459 (36.3) 2715 (51.9) 7980 (52.7) 2645 (51.7) 80+ 897990 (9.7) 985 (18.8) 3000 (19.8) 970 (19.0)

Sex 0.44 0.022Male 3,525,219 (38.2) 3120 (59.7) 9170 (60.5) 3040 (59.4)Female 5714412 (61.8) 2110 (40.3) 5985 (39.5) 2075 (40.6)

Race 0.187 0.046White 6152256 (66.6) 3500 (66.9) 10225 (67.5) 3455 (67.5) Black 1057475 (11.4) 750 (14.3) 2055 (13.6) 725 (14.2) Hispanic 972280 (10.5) 330 (6.3) 880 (5.8) 315 (6.2) Asian or Pacific Islander 275035 (3.0) 170 (3.3) 560 (3.7) 160 (3.1) Native American 46915 (0.5) 40 (0.8) 115 (0.8) 30 (0.6) Other 280895 (3.0) 115 (2.2) 330 (2.2) 115 (2.2) Missing 454776 (4.9) 325 (6.2) 990 (6.5) 315 (6.2)

Payor status 0.496 0.021Medicare 3575534 (38.7) 3255 (62.2) 9500 (62.7) 3180 (62.2) Medicaid 1571744 (17.0) 435 (8.3) 1295 (8.5) 425 (8.3) Private 3485384 (37.7) 1310 (25.0) 3735 (24.6) 1285 (25.1) Self-pay 275780 (3.0) 105 (2.0) 285 (1.9) 100 (2.0) No charge 23895 (0.3) 20 (0.4) 50 (0.3) 20 (0.4) Other 307295 (3.3) 105 (2.0) 290 (1.9) 105 (2.1)

Hospital ownership 0.146 0.019Private non-profit 6889046 (74.6) 3950 (75.5) 11435 (75.5) 3900 (76.2) Government, nonfederal 1002140 (10.8) 730 (14.0) 2050 (13.5) 675 (13.2) Private invest-own 1348444 (14.6) 550 (10.5) 1670 (11.0) 540 (10.6)

Patient county size 0.071 0.036Central metro > 1M 2618768 (28.3) 1485 (28.4) 4080 (26.9) 1440 (28.2) Fringe metro > 1M 2290429 (24.8) 1195 (22.8) 3575 (23.6) 1170 (22.9) 250K-1M 1960109 (21.2) 1060 (20.3) 3140 (20.7) 1040 (20.3) 50-250K 865364 (9.4) 540 (10.3) 1500 (9.9) 525 (10.3) Micropolitan 857095 (9.3) 530 (10.1) 1550 (10.2) 525 (10.3) Other 647865 (7.0) 420 (8.0) 1310 (8.6) 415 (8.1)

Median zip code income percentile

0.041 0.023

0-25th 2521503 (27.3) 1505 (28.8) 4265 (28.1) 1460 (28.5) 26th-50th 2349974 (25.4) 1330 (25.4) 3900 (25.7) 1325 (25.9) 51th-75th 2321045 (25.1) 1310 (25.0) 3755 (24.8) 1285 (25.1) 76th-100th 2047109 (22.2) 1085 (20.7) 3235 (21.3) 1045 (20.4)

Census Division 0.061 0.041New England 418255 (4.5) 240 (4.6) 655 (4.3) 235 (4.6) Mid Atlantic 1277935 (13.8) 750 (14.3) 2280 (15.0) 735 (14.4) East North Central 1385619 (15.0) 860 (16.4) 2550 (16.8) 845 (16.5) West North Central 673005 (7.3) 395 (7.6) 1165 (7.7) 390 (7.6) South Atlantic 1896815 (20.5) 1040 (19.9) 2865 (18.9) 1020 (19.9) East South Central 641463 (6.9) 370 (7.1) 1150 (7.6) 360 (7.0) West South Central 1133191 (12.3) 565 (10.8) 1685 (11.1) 560 (10.9) Mountain 620908 (6.7) 340 (6.5) 995 (6.6) 340 (6.6) Pacific 1192440 (12.9) 670 (12.8) 1810 (11.9) 630 (12.3)

Hospital location 0.192 0.032Rural 619955 (6.7) 270 (5.2) 840 (5.5) 270 (5.3) Urban nonteaching 2244992 (24.3) 910 (17.4) 2865 (18.9) 910 (17.8) Urban teaching 6374684 (69.0) 4050 (77.4) 11450 (75.6) 3935 (76.9)

Type of hospitalization 0.341 0.078Non-elective 4458922 (48.3) 3395 (64.9) 10405 (68.7) 3325 (65.0)Elective 4780709 (51.7) 1835 (35.1) 4750 (31.3) 1790 (35.0)

Month of admission 0.102 0.068January 750170 (8.1) 470 (9.0) 1385 (9.1) 460 (9.0)

17

February 746645 (8.1) 405 (7.7) 1190 (7.9) 390 (7.6) March 786000 (8.5) 505 (9.7) 1340 (8.8) 495 (9.7) April 752930 (8.1) 445 (8.5) 1350 (8.9) 430 (8.4) May 773325 (8.4) 455 (8.7) 1260 (8.3) 450 (8.8) June 783255 (8.5) 390 (7.5) 1140 (7.5) 370 (7.2) July 747835 (8.1) 425 (8.1) 1230 (8.1) 425 (8.3) August 811980 (8.8) 495 (9.5) 1380 (9.1) 495 (9.7) September 762195 (8.2) 360 (6.9) 1140 (7.5) 345 (6.7) October 781800 (8.5) 415 (7.9) 1100 (7.3) 415 (8.1) November 772310 (8.4) 375 (7.2) 1105 (7.3) 370 (7.2) December 771190 (8.3) 490 (9.4) 1535 (10.1) 470 (9.2)

Admission day 0.088 0.005Weekday 8,002,337 (86.6) 4,365 (83.5) 12655 (83.5) 4280 (83.7)Weekend 1237294 (13.4) 865 (16.5) 2500 (16.5) 835 (16.3)

Number of OR procedures* 1.76 (1.39) 2.85 (2.17) 0.598 2.59 (1.98) 2.77 (2.08) 0.085Surgical subtype

Cardiac 1059449 (11.5) 3205 (61.3) 1.21 9350 (61.7) 3095 (60.5) 0.024Endocrine 47040 (0.5) 35 (0.7) 0.021 80 (0.5) 35 (0.7) 0.02Intraabdominal general 1799429 (19.5) 1130 (21.6) 0.053 3230 (21.3) 1080 (21.1) 0.005Genitourinary 492424 (5.3) 235 (4.5) 0.039 660 (4.4) 225 (4.4) 0.002Gynecologic 836329 (9.1) 95 (1.8) 0.323 265 (1.7) 95 (1.9) 0.008Heart and lung transplant 4825 (0.1) 40 (0.8) 0.112 50 (0.3) 35 (0.7) 0.05Neurosurgery 915735 (9.9) 285 (5.4) 0.168 735 (4.8) 275 (5.4) 0.024Noncardiac transplant 7495 (0.1) 75 (1.4) 0.157 155 (1.0) 60 (1.2) 0.014Obstetric 1928343 (20.9) 20 (0.4) 0.705 30 (0.2) 20 (0.4) 0.036Ophthalmologic 13375 (0.1) 5 (0.1) 0.014 5 (0.0) 5 (0.1) 0.025Orthopedic 3646854 (39.5) 900 (17.2) 0.51 2130 (14.1) 885 (17.3) 0.089Otolaryngology 104090 (1.1) 65 (1.2) 0.011 165 (1.1) 65 (1.3) 0.017Skin and subcutaneous tissue 681149 (7.4) 400 (7.6) 0.01 990 (6.5) 385 (7.5) 0.039Thoracic 476619 (5.2) 990 (18.9) 0.433 2295 (15.1) 910 (17.8) 0.071Vascular 1305799 (14.1) 2690 (51.4) 0.866 7525 (49.7) 2575 (50.3) 0.014

ComorbiditiesCongestive heart failure 436455 (4.7) 795 (15.2) 0.355 2200 (14.5) 725 (14.2) 0.01Valvular disease 248900 (2.7) 250 (4.8) 0.11 735 (4.8) 235 (4.6) 0.012Pulmonary circulation disorders 49365 (0.5) 160 (3.1) 0.191 375 (2.5) 135 (2.6) 0.01Peripheral vascular disease 559190 (6.1) 1070 (20.5) 0.435 2885 (19.0) 1045 (20.4) 0.035Hypertension 4322444 (46.8) 3335 (63.8) 0.347 10070 (66.4) 3280 (64.1) 0.049Paralysis 212305 (2.3) 270 (5.2) 0.152 705 (4.7) 250 (4.9) 0.011Other neurological disorders 489120 (5.3) 410 (7.8) 0.103 1255 (8.3) 405 (7.9) 0.013Chronic pulmonary disease 1403424 (15.2) 1060 (20.3) 0.133 3185 (21.0) 1045 (20.4) 0.014Diabetes without chronic complications 1082610 (11.7) 835 (16.0) 0.123 2700 (17.8) 815 (15.9) 0.05Diabetes with chronic complications 827455 (9.0) 955 (18.3) 0.274 2840 (18.7) 940 (18.4) 0.009Hypothyroidism 995154 (10.8) 590 (11.3) 0.016 1745 (11.5) 585 (11.4) 0.002Renal failure 865850 (9.4) 1525 (29.2) 0.518 4140 (27.3) 1460 (28.5) 0.027Liver disease 251735 (2.7) 280 (5.4) 0.134 815 (5.4) 260 (5.1) 0.013Chronic peptic ulcer disease 61950 (0.7) 95 (1.8) 0.104 275 (1.8) 90 (1.8) 0.004HIV and AIDS 10890 (0.1) 5 (0.1) 0.007 25 (0.2) 5 (0.1) 0.019Lymphoma 36415 (0.4) 30 (0.6) 0.026 65 (0.4) 30 (0.6) 0.022Metastatic cancer 194039 (2.1) 135 (2.6) 0.032 370 (2.4) 135 (2.6) 0.013Solid tumor without metastasis 138975 (1.5) 170 (3.3) 0.115 440 (2.9) 165 (3.2) 0.019RA / collagen vascular diseases 242050 (2.6) 100 (1.9) 0.048 275 (1.8) 100 (2.0) 0.01Coagulation deficiency 436160 (4.7) 1180 (22.6) 0.538 2945 (19.4) 1090 (21.3) 0.047Obesity 1532375 (16.6) 1065 (20.4) 0.097 3120 (20.6) 1040 (20.3) 0.006Weight loss 347810 (3.8) 495 (9.5) 0.231 1295 (8.5) 465 (9.1) 0.019Fluid and electrolyte disorders 1443159 (15.6) 2480 (47.4) 0.728 6915 (45.6) 2385 (46.6) 0.02Blood loss anemia 404365 (4.4) 60 (1.1) 0.198 110 (0.7) 60.0 (1.2) 0.046Deficiency anemias 1236644 (13.4) 1115 (21.3) 0.211 3325 (21.9) 1115 (21.8) 0.003Alcohol abuse 224035 (2.4) 145 (2.8) 0.022 480 (3.2) 145 (2.8) 0.019Drug abuse 189315 (2.0) 85 (1.6) 0.032 215 (1.4) 85 (1.7) 0.02Psychoses 187240 (2.0) 65 (1.2) 0.062 170 (1.1) 65 (1.3) 0.014

18

Depression 908905 (9.8) 460 (8.8) 0.036 1380 (9.1) 460 (9.0) 0.004* Displayed as mean (standard deviation).AIDS = acquired immune deficiency syndrome; HIV = human immunodeficiency virus; K = thousand; M = million; OR = operating room; RA = rheumatoid arthritis.

19

Supplementary Table 9. Effect Estimates for Secondary Outcomes from Linear and Logistic Regression Models in the Propensity Score Matched CohortOutcome Effect Estimate

Odds Ratio P valueIn-hospital mortality 15.1 < 0.001

Coefficient P valueLength of stay, days -0.84 0.053Total cost of hospitalization, dollars 8,353 < 0.001

20

Supplementary Table 10. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Full ModelCharacteristic Odds Ratio (95% CI) P valueAge, years

18-39 1 [Reference]40-59 0.95 (0.7-1.29) 0.74360-79 1.05 (0.77-1.43) 0.76680+ 1.4 (1-1.98) 0.052

SexMale 1 [Reference]Female 0.97 (0.85-1.1) 0.608

RaceWhite 1 [Reference]Black 1.4 (1.15-1.7) 0.001Hispanic 0.82 (0.62-1.08) 0.165Asian or Pacific Islander 1.37 (0.96-1.97) 0.083Native American 1.69 (0.83-3.47) 0.15Other 0.81 (0.52-1.24) 0.326Missing 1.34 (1.01-1.77) 0.043

Payor statusMedicare 1 [Reference]Medicaid 0.73 (0.56-0.95) 0.019Private 0.9 (0.75-1.07) 0.23Self-pay 0.71 (0.44-1.12) 0.14No charge 1.35 (0.49-3.71) 0.557Other 0.65 (0.41-1.04) 0.071

Hospital ownershipPrivate non-profit 1 [Reference]Government, nonfederal 1.5 (1.24-1.82) < 0.001Private invest-own 0.88 (0.71-1.1) 0.273

Patient county sizeCentral metro > 1M 1 [Reference]Fringe metro > 1M 0.92 (0.76-1.1) 0.358250K-1M 0.97 (0.81-1.16) 0.7450-250K 1.09 (0.85-1.39) 0.496Micropolitan 0.97 (0.76-1.23) 0.798Other 0.99 (0.75-1.32) 0.96

Median zip code income percentile0-25th 1 [Reference]26th-50th 1 (0.83-1.2) 0.99251th-75th 1.05 (0.85-1.28) 0.66476th-100th 1.02 (0.82-1.27) 0.851

Census DivisionNew England 1 [Reference]Mid Atlantic 0.92 (0.58-1.45) 0.712East North Central 0.88 (0.57-1.37) 0.575West North Central 0.81 (0.5-1.3) 0.379South Atlantic 0.8 (0.52-1.25) 0.329East South Central 0.81 (0.49-1.35) 0.422West South Central 0.82 (0.52-1.31) 0.408Mountain 0.98 (0.59-1.62) 0.934Pacific 0.93 (0.59-1.46) 0.75


Type of hospitalizationNon-elective 1 [Reference]Elective 0.91 (0.78-1.06) 0.223

Month of admissionJanuary 1 [Reference]February 0.85 (0.63-1.14) 0.277March 1 (0.75-1.33) 0.993April 0.92 (0.68-1.25) 0.61

21

May 0.95 (0.71-1.27) 0.746June 0.82 (0.61-1.11) 0.195July 0.93 (0.7-1.24) 0.639August 1.01 (0.77-1.33) 0.95September 0.77 (0.57-1.04) 0.091October 0.84 (0.62-1.13) 0.246November 0.77 (0.57-1.05) 0.095December 1.03 (0.77-1.39) 0.824

Admission dayWeekday 1 [Reference]Weekend 1.04 (0.87-1.24) 0.654


Cardiac 7.44 (6.11-9.06) < 0.001Endocrine 1.76 (0.83-3.75) 0.143Intraabdominal general 1.17 (0.97-1.42) 0.094Genitourinary 1.03 (0.75-1.43) 0.849Gynecologic 0.93 (0.57-1.51) 0.765Heart and lung transplant 1.15 (0.57-2.34) 0.693Neurosurgery 1.07 (0.81-1.43) 0.624Noncardiac transplant 6.19 (3.36-11.4) < 0.001Obstetric 0.07 (0.03-0.21) < 0.001Ophthalmologic 0.69 (0.09-5.25) 0.723Orthopedic 0.93 (0.76-1.15) 0.529Otolaryngology 0.76 (0.44-1.31) 0.317Skin and subcutaneous tissue 1 (0.78-1.29) 0.998Thoracic 1.58 (1.32-1.89) < 0.001Vascular 1.77 (1.51-2.06) < 0.001

ComorbiditiesCongestive heart failure 1.97 (1.61-2.41) < 0.001Valvular disease 0.93 (0.67-1.28) 0.657Pulmonary circulation disorders 2.44 (1.67-3.57) < 0.001Peripheral vascular disease 1.47 (1.25-1.73) < 0.001Hypertension 0.81 (0.7-0.93) 0.004Paralysis 1.11 (0.83-1.48) 0.482Other neurological disorders 1.06 (0.84-1.33) 0.622Chronic pulmonary disease 0.89 (0.76-1.04) 0.144Diabetes without chronic complications 0.99 (0.83-1.17) 0.867Diabetes with chronic complications 0.87 (0.72-1.04) 0.124Hypothyroidism 0.89 (0.73-1.08) 0.228Renal failure 1.4 (1.2-1.64) < 0.001Liver disease 1.19 (0.87-1.62) 0.276Chronic peptic ulcer disease 1.25 (0.79-2) 0.345HIV and AIDS 0.56 (0.08-4.09) 0.568Lymphoma 0.88 (0.39-1.94) 0.743Metastatic cancer 1.17 (0.79-1.75) 0.434Solid tumor without metastasis 1.52 (1.06-2.17) 0.022RA / collagen vascular diseases 0.64 (0.4-1.02) 0.059Coagulation deficiency 1.54 (1.3-1.81) < 0.001Obesity 1.14 (0.97-1.33) 0.12Weight loss 0.88 (0.7-1.12) 0.3Fluid and electrolyte disorders 1.81 (1.57-2.09) < 0.001Blood loss anemia 0.77 (0.44-1.35) 0.359Deficiency anemias 0.94 (0.8-1.1) 0.446Alcohol abuse 0.76 (0.51-1.11) 0.154Drug abuse 0.78 (0.47-1.28) 0.32Psychoses 0.66 (0.37-1.19) 0.17Depression 0.91 (0.73-1.13) 0.389


22

Supplementary Table 11. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Subgroup AnalysesObstetric Surgery Admissions Excluded Cardiac Surgery Admissions Excluded

Characteristic Odds Ratio (95% CI) P value Odds Ratio (95% CI) P valueAge, years

18-39 1 [Reference] 1 [Reference]40-59 0.91 (0.68-1.22) 0.542 1.01 (0.64-1.61) 0.95460-79 1.01 (0.75-1.37) 0.924 1.26 (0.79-1.99) 0.33180+ 1.36 (0.97-1.89) 0.072 1.31 (0.76-2.25) 0.325

SexMale 1 [Reference] 1 [Reference]Female 0.97 (0.85-1.1) 0.608 0.96 (0.78-1.19) 0.72

RaceWhite 1 [Reference] 1 [Reference]Black 1.4 (1.15-1.71) 0.001 1.21 (0.91-1.63) 0.195Hispanic 0.81 (0.62-1.08) 0.235 0.81 (0.53-1.22) 0.308Asian or Pacific Islander 1.34 (0.93-1.92) 0.137 1.07 (0.55-2.11) 0.834Native American 1.71 (0.83-3.5) 0.073 1.4 (0.44-4.5) 0.569Other 0.81 (0.53-1.24) 0.245 1.05 (0.55-1.98) 0.891Missing 1.35 (1.02-1.79) 0.006 1.83 (1.17-2.87) 0.008

Payor statusMedicare 1 [Reference] 1 [Reference]Medicaid 0.73 (0.56-0.95) 0.011 0.62 (0.42-0.93) 0.02Private 0.9 (0.75-1.08) 0.291 0.99 (0.74-1.33) 0.956Self-pay 0.71 (0.45-1.13) 0.257 0.76 (0.36-1.58) 0.456No charge 1.36 (0.5-3.74) 0.462 0.96 (0.13-7.08) 0.97Other 0.66 (0.41-1.04) 0.118 1.21 (0.69-2.13) 0.498

Hospital ownershipPrivate non-profit 1 [Reference] 1 [Reference]Government, nonfederal 1.5 (1.24-1.81) < 0.001 1.52 (1.14-2.03) 0.004Private invest-own 0.89 (0.71-1.11) 0.293 0.74 (0.52-1.05) 0.093

Patient county sizeCentral metro > 1M 1 [Reference] 1 [Reference]Fringe metro > 1M 0.91 (0.75-1.09) 0.3 0.84 (0.62-1.14) 0.271250K-1M 0.96 (0.8-1.16) 0.691 1.1 (0.84-1.43) 0.49350-250K 1.08 (0.84-1.38) 0.551 0.99 (0.67-1.48) 0.972Micropolitan 0.97 (0.76-1.23) 0.78 0.96 (0.64-1.44) 0.838Other 0.99 (0.75-1.32) 0.948 0.79 (0.48-1.27) 0.328

Median zip code income percentile

0-25th 1 [Reference] 1 [Reference]26th-50th 1 (0.83-1.2) 0.984 1 (0.76-1.33) 0.97951th-75th 1.04 (0.85-1.28) 0.677 0.91 (0.67-1.23) 0.53176th-100th 1.03 (0.83-1.28) 0.801 0.73 (0.51-1.05) 0.092

Census DivisionNew England 1 [Reference] 1 [Reference]Mid Atlantic 0.91 (0.58-1.43) 0.688 0.97 (0.51-1.87) 0.93East North Central 0.88 (0.57-1.37) 0.575 0.95 (0.49-1.83) 0.881West North Central 0.79 (0.49-1.28) 0.345 0.77 (0.35-1.69) 0.515South Atlantic 0.8 (0.51-1.24) 0.317 0.99 (0.52-1.89) 0.967East South Central 0.81 (0.49-1.35) 0.417 0.9 (0.4-1.99) 0.786West South Central 0.82 (0.52-1.3) 0.405 0.84 (0.42-1.66) 0.606Mountain 0.96 (0.58-1.59) 0.878 0.95 (0.44-2.03) 0.888Pacific 0.93 (0.59-1.47) 0.763 0.93 (0.47-1.83) 0.833

Hospital locationRural 1 [Reference] 1 [Reference]Urban nonteaching 0.67 (0.47-0.94) 0.019 0.67 (0.41-1.1) 0.114Urban teaching 0.76 (0.55-1.05) 0.098 0.66 (0.42-1.05) 0.083

Type of hospitalizationNon-elective 1 [Reference] 1 [Reference]Elective 0.91 (0.78-1.06) 0.213 1.06 (0.82-1.37) 0.674

Month of admissionJanuary 1 [Reference] 1 [Reference]

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February 0.85 (0.63-1.14) 0.277 0.82 (0.5-1.35) 0.441March 1 (0.75-1.33) 0.995 1.14 (0.71-1.85) 0.583April 0.92 (0.68-1.25) 0.612 1.1 (0.69-1.75) 0.684May 0.94 (0.7-1.26) 0.693 1.45 (0.94-2.24) 0.095June 0.82 (0.61-1.11) 0.195 0.92 (0.55-1.52) 0.741July 0.92 (0.7-1.23) 0.583 1.04 (0.63-1.7) 0.877August 1.01 (0.77-1.33) 0.947 1.11 (0.69-1.78) 0.675September 0.77 (0.57-1.04) 0.092 0.86 (0.5-1.46) 0.567October 0.84 (0.62-1.13) 0.246 0.99 (0.6-1.61) 0.959November 0.76 (0.56-1.03) 0.08 1 (0.62-1.63) 0.985December 1.02 (0.76-1.37) 0.878 1.39 (0.88-2.18) 0.153

Admission dayWeekday 1 [Reference] 1 [Reference]Weekend 1.05 (0.88-1.25) 0.624 0.92 (0.7-1.23) 0.587

Number of OR procedures 1.15 (1.11-1.18) < 0.001 1.1 (1.05-1.16) 0Surgical subtype

Cardiac 7.37 (6.06-8.97) < 0.001 ExcludedEndocrine 1.76 (0.83-3.75) 0.142 2.33 (1.02-5.31) 0.044Intraabdominal general 1.17 (0.97-1.41) 0.111 1.26 (0.98-1.64) 0.076Genitourinary 0.99 (0.71-1.37) 0.944 0.98 (0.67-1.45) 0.938Gynecologic 0.89 (0.53-1.48) 0.646 1.42 (0.83-2.43) 0.196Heart and lung transplant 1.15 (0.57-2.34) 0.691 6.14 (0.86-43.85) 0.07Neurosurgery 1.07 (0.81-1.43) 0.632 1.1 (0.79-1.53) 0.565Noncardiac transplant 6.22 (3.38-11.45) < 0.001 7.28 (3.58-14.79) < 0.001Obstetric Excluded < 0.001 0.1 (0.03-0.37) 0.001Ophthalmologic 0.69 (0.09-5.23) 0.724 Excluded*Orthopedic 0.93 (0.75-1.15) 0.498 1.02 (0.78-1.31) 0.91Otolaryngology 0.76 (0.44-1.31) 0.316 0.69 (0.31-1.54) 0.369Skin and subcutaneous tissue 1 (0.78-1.29) 0.979 0.92 (0.66-1.28) 0.618Thoracic 1.58 (1.32-1.89) < 0.001 1.68 (1.26-2.25) < 0.001Vascular 1.76 (1.51-2.06) < 0.001 3.32 (2.57-4.29) < 0.001

ComorbiditiesCongestive heart failure 1.98 (1.62-2.42) < 0.001 2.02 (1.54-2.65) < 0.001Valvular disease 0.91 (0.66-1.26) 0.569 1.19 (0.77-1.83) 0.44Pulmonary circulation disorders 2.45 (1.68-3.58) < 0.001 2.39 (1.5-3.83) < 0.001Peripheral vascular disease 1.47 (1.25-1.73) < 0.001 1.95 (1.51-2.52) < 0.001Hypertension 0.81 (0.7-0.93) 0.003 0.92 (0.73-1.16) 0.486Paralysis 1.11 (0.83-1.48) 0.481 1.34 (0.91-1.99) 0.139Other neurological disorders 1.06 (0.84-1.33) 0.617 1.23 (0.9-1.68) 0.202Chronic pulmonary disease 0.89 (0.76-1.04) 0.151 0.85 (0.66-1.1) 0.219Diabetes without chronic complications 0.99 (0.83-1.18) 0.894 1.39 (1.06-1.82) 0.016Diabetes with chronic complications 0.87 (0.72-1.05) 0.139 0.92 (0.68-1.25) 0.597Hypothyroidism 0.89 (0.73-1.08) 0.238 0.99 (0.74-1.34) 0.971Renal failure 1.4 (1.2-1.64) < 0.001 1.7 (1.32-2.19) < 0.001Liver disease 1.19 (0.87-1.62) 0.273 1.07 (0.7-1.63) 0.761Chronic peptic ulcer disease 1.26 (0.79-2) 0.337 1.34 (0.73-2.47) 0.347HIV and AIDS 0.56 (0.08-4.09) 0.569 Excluded*Lymphoma 0.87 (0.39-1.94) 0.739 0.88 (0.28-2.77) 0.832Metastatic cancer 1.18 (0.79-1.76) 0.423 1.25 (0.79-1.98) 0.346Solid tumor without metastasis 1.52 (1.07-2.17) 0.021 0.89 (0.49-1.62) 0.697RA / collagen vascular diseases 0.64 (0.4-1.02) 0.059 0.43 (0.19-0.96) 0.041Coagulation deficiency 1.54 (1.31-1.82) < 0.001 2.08 (1.59-2.72) < 0.001Obesity 1.12 (0.96-1.32) 0.153 1.04 (0.81-1.34) 0.747Weight loss 0.89 (0.7-1.12) 0.311 0.79 (0.56-1.12) 0.182Fluid and electrolyte disorders 1.81 (1.57-2.09) < 0.001 2.29 (1.79-2.92) < 0.001Blood loss anemia 0.74 (0.41-1.34) 0.322 0.66 (0.29-1.5) 0.327Deficiency anemias 0.93 (0.79-1.1) 0.421 0.72 (0.55-0.92) 0.01Alcohol abuse 0.76 (0.52-1.11) 0.156 0.9 (0.52-1.55) 0.695

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Drug abuse 0.73 (0.44-1.21) 0.218 1.36 (0.76-2.44) 0.301Psychoses 0.67 (0.37-1.2) 0.173 0.47 (0.2-1.13) 0.092Depression 0.91 (0.73-1.13) 0.402 0.94 (0.69-1.28) 0.687

* Variable excluded due to perfectly collinearity with outcome within the subgroup.AIDS = acquired immune deficiency syndrome; HIV = human immunodeficiency virus; K = thousand; M = million; OR = operating room; RA = rheumatoid arthritis.

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Supplementary Table 12. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Elective Admissions with Procedures on Day 0Characteristic Odds Ratio (95% CI) P valueAge, years

18-39 1 [Reference]40-59 0.75 (0.4-1.38) 0.35360-79 0.97 (0.52-1.81) 0.92680+ 1.05 (0.53-2.08) 0.898






Median zip code income percentile0-25th 1 [Reference]26th-50th 0.94 (0.66-1.33) 0.71251th-75th 0.99 (0.69-1.42) 0.96276th-100th 0.87 (0.57-1.32) 0.503



Month of admissionJanuary 1 [Reference]February 0.56 (0.29-1.08) 0.085March 1.31 (0.77-2.23) 0.323April 0.91 (0.49-1.7) 0.763May 0.98 (0.55-1.74) 0.941June 0.98 (0.55-1.75) 0.958

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July 0.98 (0.55-1.73) 0.933August 1.03 (0.59-1.81) 0.916September 0.77 (0.41-1.42) 0.398October 0.78 (0.42-1.45) 0.431November 0.99 (0.55-1.77) 0.972December 1.26 (0.72-2.18) 0.415


Number of OR procedures 1.1 (1.02-1.19) 0.013Surgical subtype

Cardiac 9.77 (5.92-16.12) < 0.001Endocrine 1.51 (0.46-4.93) 0.494Intraabdominal general 1.98 (1.3-3.01) 0.002Genitourinary 1.44 (0.84-2.44) 0.183Gynecologic 1 (0.47-2.12) 0.997Heart and lung transplant ExcludedNeurosurgery 1.36 (0.89-2.1) 0.157Noncardiac transplant 4.17 (0.46-38.02) 0.206Obstetric 0.06 (0.01-0.54) 0.012Ophthalmologic 4.1 (0.43-38.78) 0.218Orthopedic 1.13 (0.69-1.82) 0.632Otolaryngology 1.27 (0.5-3.24) 0.62Skin and subcutaneous tissue 0.92 (0.52-1.65) 0.784Thoracic 1.07 (0.71-1.59) 0.752Vascular 1.88 (1.33-2.65) < 0.001

ComorbiditiesCongestive heart failure 2.58 (1.7-3.9) < 0.001Valvular disease 1.35 (0.77-2.38) 0.292Pulmonary circulation disorders 4 (1.63-9.86) 0.003Peripheral vascular disease 2.1 (1.57-2.8) < 0.001Hypertension 0.81 (0.62-1.06) 0.123Paralysis 1.49 (0.8-2.78) 0.207Other neurological disorders 1.45 (0.92-2.28) 0.113Chronic pulmonary disease 1.15 (0.85-1.55) 0.37Diabetes without chronic complications 1.16 (0.84-1.6) 0.383Diabetes with chronic complications 0.99 (0.67-1.45) 0.943Hypothyroidism 0.87 (0.61-1.24) 0.438Renal failure 1.74 (1.27-2.37) < 0.001Liver disease 0.89 (0.44-1.82) 0.757Chronic peptic ulcer disease 1 (0.3-3.29) 0.998HIV and AIDS Excluded*Lymphoma Excluded*Metastatic cancer 1.98 (1.01-3.89) 0.048Solid tumor without metastasis 2.37 (1.28-4.41) 0.006RA / collagen vascular diseases 0.33 (0.11-1.04) 0.058Coagulation deficiency 1.85 (1.34-2.56) < 0.001Obesity 1.23 (0.91-1.66) 0.179Weight loss 0.94 (0.54-1.63) 0.817Fluid and electrolyte disorders 2.27 (1.7-3.03) < 0.001Blood loss anemia 1.43 (0.56-3.63) 0.454Deficiency anemias 0.91 (0.65-1.27) 0.58Alcohol abuse 0.49 (0.16-1.57) 0.231Drug abuse 0.94 (0.22-3.93) 0.93Psychoses 0.25 (0.03-1.79) 0.167Depression 1.07 (0.73-1.59) 0.72

* Variable excluded due to no elective hospital admissions or perfectly collinearity with outcome within the subgroup.AIDS = acquired immune deficiency syndrome; HIV = human immunodeficiency virus; K = thousand; M = million; OR = operating room; RA = rheumatoid arthritis.

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Supplementary Table 13. Adjusted Odds Ratios for Intraoperative Cardiac Arrest, Exploratory Analysis, Selected CovarariatesCharacteristic Odds Ratio (95% CI) P valueCoronary artery disease 1.25 (1.05-1.50) 0.014Prior coronary revascularization 0.96 (0.80-1.16) 0.696History of stroke 0.80 (0.63-1.02) 0.071History of thromboembolic disease 0.93 (0.70-1.24) 0.622Active smoker 0.91 (0.75-1.10) 0.334Head or neck cancer 1.84 (0.94-3.62) 0.076Tracheal or laryngeal surgery 0.95 (0.68-1.34) 0.776

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Supplementary Table 14. Adjusted Odds Ratios for Mortality During Admissions with Intraoperative Cardiac Arrest, Full ModelCharacteristic Odds Ratio (95% CI) P valueAge, years

18-39 1 [Reference]40-59 0.63 (0.32-1.25) 0.18760-79 0.68 (0.34-1.35) 0.27180+ 1.45 (0.67-3.13) 0.342






Median zip code income percentile0-25th 1 [Reference]26th-50th 0.84 (0.55-1.29) 0.42751th-75th 0.84 (0.54-1.31) 0.44576th-100th 0.96 (0.58-1.6) 0.879



Type of hospitalizationNon-elective 1 [Reference]Elective 0.36 (0.25-0.51) < 0.001

Month of admissionJanuary 1 [Reference]February 0.98 (0.49-1.98) 0.954March 1.58 (0.82-3.05) 0.17

29

April 0.66 (0.32-1.39) 0.277May 0.75 (0.37-1.49) 0.407June 0.52 (0.27-1.02) 0.058July 0.57 (0.28-1.17) 0.125August 1.02 (0.52-2) 0.944September 0.76 (0.34-1.67) 0.49October 0.75 (0.37-1.53) 0.431November 0.95 (0.47-1.92) 0.893December 0.88 (0.46-1.68) 0.707


Number of OR procedures 1.02 (0.95-1.11) 0.554Surgical subtype

Cardiac 0.85 (0.57-1.27) 0.43Endocrine 0.34 (0.02-5.22) 0.442Intraabdominal general 1.03 (0.68-1.55) 0.893Genitourinary 0.8 (0.34-1.86) 0.602Gynecologic 0.42 (0.11-1.65) 0.215Heart and lung transplant 0.46 (0.08-2.57) 0.374Neurosurgery 0.99 (0.48-2.06) 0.985Noncardiac transplant 0.21 (0.05-0.85) 0.028Obstetric 15.05 (1.05-216.43) 0.046Ophthalmologic Excluded*Orthopedic 1.05 (0.68-1.63) 0.817Otolaryngology 0.33 (0.06-1.97) 0.224Skin and subcutaneous tissue 1.08 (0.6-1.95) 0.791Thoracic 1.31 (0.85-2.02) 0.223Vascular 1.51 (1.07-2.14) 0.019

ComorbiditiesCongestive heart failure 0.9 (0.58-1.4) 0.633Valvular disease 1.77 (0.84-3.75) 0.134Pulmonary circulation disorders 2.84 (1.23-6.58) 0.015Peripheral vascular disease 1.76 (1.16-2.65) 0.008Hypertension 0.83 (0.6-1.15) 0.273Paralysis 0.66 (0.32-1.36) 0.263Other neurological disorders 1.33 (0.79-2.24) 0.291Chronic pulmonary disease 1.14 (0.77-1.68) 0.522Diabetes without chronic complications 0.89 (0.58-1.36) 0.593Diabetes with chronic complications 0.89 (0.56-1.41) 0.618Hypothyroidism 1.34 (0.85-2.11) 0.212Renal failure 1.05 (0.73-1.53) 0.778Liver disease 3.34 (1.61-6.92) 0.001Chronic peptic ulcer disease 0.77 (0.27-2.21) 0.628HIV and AIDS Excluded*Lymphoma 1.98 (0.4-9.7) 0.401Metastatic cancer 1.4 (0.56-3.52) 0.468Solid tumor without metastasis 0.71 (0.26-1.94) 0.502RA / collagen vascular diseases 1.25 (0.49-3.23) 0.638Coagulation deficiency 1.02 (0.69-1.52) 0.903Obesity 0.96 (0.65-1.42) 0.83Weight loss 0.69 (0.4-1.21) 0.196Fluid and electrolyte disorders 1.22 (0.89-1.66) 0.216Blood loss anemia 0.08 (0.01-0.46) 0.005Deficiency anemias 1.03 (0.7-1.5) 0.892Alcohol abuse 0.74 (0.32-1.68) 0.466Drug abuse 0.2 (0.04-1.05) 0.057Psychoses 1.99 (0.63-6.35) 0.242Depression 0.47 (0.27-0.84) 0.01

* Variable excluded due to no elective hospital admissions or perfectly collinearity with outcome within the subgroup.AIDS = acquired immune deficiency syndrome; HIV = human immunodeficiency virus; K = thousand; M = million; OR = operating room; RA = rheumatoid arthritis.

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References

1. Beta Clinical Classifications Software (CCS) for ICD-10-CM/PCS. Healthcare Cost and Utilization Project (HCUP). October 2018. Agency for Healthcare Research and Quality, Rockville, MD.https://www.hcup-us.ahrq.gov/toolssoftware/ccs10/ccs10.jsp. Accessed November 5, 2018.

https://www.hcup-us.ahrq.gov/toolssoftware/ccs10/ccs10.jsp

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