Saket Girotra1, Sean van Diepen2, Brahmajee K Nallamothu2, Margaret Carrel2, Kimberly Vellano2, Monique L Anderson2, Bryan McNally2, Benjamin S Abella2, Comilla Sasson2, Paul S Chan2. 1. From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.). saket-girotra@uiowa.edu. 2. From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
Abstract
BACKGROUND: Although previous studies have shown marked variation in out-of-hospital cardiac arrest survival across US regions, factors underlying this survival variation remain incompletely explained. METHODS AND RESULTS: Using data from the Cardiac Arrest Registry to Enhance Survival, we identified 96 662 adult patients with out-of-hospital cardiac arrest in 132 US counties. We used hierarchical regression models to examine county-level variation in rates of survival and survival with functional recovery (defined as Cerebral Performance Category score of 1 or 2) and examined the contribution of demographics, cardiac arrest characteristics, bystander cardiopulmonary resuscitation, automated external defibrillator use, and county-level sociodemographic factors in survival variation across counties. A total of 9317 (9.6%) patients survived to discharge, and 7176 (7.4%) achieved functional recovery. At a county level, there was marked variation in rates of survival to discharge (range, 3.4%-22.0%; median odds ratio, 1.40; 95% confidence interval, 1.32-1.46) and survival with functional recovery (range, 0.8%-21.0%; median odds ratio, 1.53; 95% confidence interval, 1.43-1.62). County-level rates of bystander cardiopulmonary resuscitation and automated external defibrillator use were positively correlated with both outcomes (P<0.0001 for all). Patient demographic and cardiac arrest characteristics explained 4.8% and 27.7% of the county-level variation in survival, respectively. Additional adjustment of bystander cardiopulmonary resuscitation and automated external defibrillator explained 41% of the survival variation, and this increased to 50.4% after adjustment of county-level sociodemographic factors. Similar findings were noted in analyses of survival with functional recovery. CONCLUSIONS: Although out-of-hospital cardiac arrest survival varies significantly across US counties, a substantial proportion of the variation is attributable to differences in bystander response across communities.
BACKGROUND: Although previous studies have shown marked variation in out-of-hospital cardiac arrest survival across US regions, factors underlying this survival variation remain incompletely explained. METHODS AND RESULTS: Using data from the Cardiac Arrest Registry to Enhance Survival, we identified 96 662 adult patients with out-of-hospital cardiac arrest in 132 US counties. We used hierarchical regression models to examine county-level variation in rates of survival and survival with functional recovery (defined as Cerebral Performance Category score of 1 or 2) and examined the contribution of demographics, cardiac arrest characteristics, bystander cardiopulmonary resuscitation, automated external defibrillator use, and county-level sociodemographic factors in survival variation across counties. A total of 9317 (9.6%) patients survived to discharge, and 7176 (7.4%) achieved functional recovery. At a county level, there was marked variation in rates of survival to discharge (range, 3.4%-22.0%; median odds ratio, 1.40; 95% confidence interval, 1.32-1.46) and survival with functional recovery (range, 0.8%-21.0%; median odds ratio, 1.53; 95% confidence interval, 1.43-1.62). County-level rates of bystander cardiopulmonary resuscitation and automated external defibrillator use were positively correlated with both outcomes (P<0.0001 for all). Patient demographic and cardiac arrest characteristics explained 4.8% and 27.7% of the county-level variation in survival, respectively. Additional adjustment of bystander cardiopulmonary resuscitation and automated external defibrillator explained 41% of the survival variation, and this increased to 50.4% after adjustment of county-level sociodemographic factors. Similar findings were noted in analyses of survival with functional recovery. CONCLUSIONS: Although out-of-hospital cardiac arrest survival varies significantly across US counties, a substantial proportion of the variation is attributable to differences in bystander response across communities.
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