Disentangling the Complex Web of Out-of-Hospital Cardiac Arrest Socioeconomic Disparities

Abstract

Out-of-hospital cardiac arrest (OHCA) is a time sensitive and highly mortal condition with substantial variation in survival rates globally. 1 Optimizing OHCA outcomes requires complex coordination of multiple care systems and treatment modalities. Many aspects in the cascade of cardiac arrest care, from prevention to hospital-based postarrest care, are attributed to these variations in outcomes.Patient race, ethnicity, and socioeconomic position (SEP) 2 are also all associated with unacceptable disparities in OHCA outcomes. Attempting to disentangle the interconnectedness of cardiac arrest care modalities with SEP is undeniably complex, but Choi et al 3 present a unique, eloquent, and meaningful approach to isolating factors that might be associated with SEP-related disparities in OHCA outcomes.Choi et al 3 performed a retrospective study of the Korean nationwide OHCA registry, which is linked to a national health insurance database. The authors defined SEP on the basis of insurance premiums, a surrogate for patient income that is frequently used in other studies 2,4,5 that examine SEP and OHCA. The authors 3 evaluated the association between SEP and the care and outcomes of patients who experienced OHCA using logistic regression models. One approach infrequently used in prior studies is the use of mediation analysis and structural equation modeling to investigate possible mediating factors between SEP and OHCA outcome disparities.Consistent with prior research, patients from the lowest SEP group (medical aid) had poorer OHCA outcomes. Less than one-half of patients with OHCA in the medical aid group survived with good neurological recovery in comparison with the highest SEP group (first quartile). Interestingly though, outcome rates were similar between the 4 higher SEP groups (first through fourth quartiles).These findings somewhat differ from other studies of SEP, 4,5 where there is a more consistent linear association between SEP and survival outcomes. Witnessed arrest, bystander cardiopulmonary resuscitation (CPR), initial shockable rhythm, sustained return of spontaneous circulation, emergency department (ED) level of care, coronary angiography, and targeted temperature management (TTM) were all identified as mediators between lower SEP and poorer OHCA outcomes.In their attempt to quantify mediation proportion, they found that witness status (11.8%), initial rhythm (56.2%), coronary angiography (20.2%), TTM (4.2%), and ED level of care (10.7%) to have the largest independent mediation proportions among patients who survived to hospital admission.These findings shed important light on modifiable factors amenable to public health interventions to mitigate disparities in OHCA outcomes. As an example, the authors 3 state that witness status may be a product of the lower rate of cardiac arrests in public locations for the lowest SEP group. Public safety net programs are proposed as an intervention to decrease the rates of unwitnessed cardiac arrest, but what cost would be necessary to ensure the presence of an ...

The Association of Racial Residential Segregation and Survival After Out-of-Hospital Cardiac Arrest in the United States

“…Neighborhood racial composition and socioeconomic status have been shown to be associated with differences in rates of bystander CPR, leading to disparities in survival to discharge and survival with good neurological status. 3,[10][11][12] In our prior OHCA research, we found that measures of racial and economic segregation are predictors of disparities in outcomes; Medicare beneficiaries residing in more highly segregated Black population and lower income ZIP codes had decreased likelihood of survival to discharge and survival at one year, as well as increased risk of readmission at 30 days. 13,14 However, prehospital predictors are not available in claims data, such as initial rhythm or the presence of a bystander CPR (B-CPR).…”