Race and Survival After Out-of-Hospital Cardiac Arrest in a Suburban Community

doi:10.1016/S0196-0644(98)70257-4

Annals of Emergency Medicine

Volume 31, Issue 4, April 1998, Pages 478-482

Presented at the Society for Academic Emergency Medicine Annual Meeting, Denver, Colorado, May 1996.

https://doi.org/10.1016/S0196-0644(98)70257-4 Get rights and content

Abstract

Study objective: To determine whether race, when controlled for income, is an independent predictor of survival to hospital discharge after out-of-hospital cardiac arrest (OHCA). Methods: Prospective OHCA data were collected over 4 years (1991–1994) from a convenience sample of OHCA patients transported to nine hospitals in three suburban counties. Race was determined from hospital and vital statistics records. The average household income was identified from ZIP codes and used as a marker of socioeconomic status. Demographic data and known predictors of survival were compared between blacks and whites. A logistic regression analysis was used to assess the association between race, income, and survival. Results: Of the 1,690 patients, 223 (13%) were blacks and 1,467 (87%) were whites. Average household income was less for blacks than for whites ($40,225 versus $46,193; P<.001), but both populations were affluent by national standards (national percentile ranks were 73% and 88%, respectively). The populations were no different in percentage of witnessed arrests (57% versus 61%; P=.465). Blacks were younger (mean±SD, 62±16 versus 68±15 years; P<.001); less frequently received bystander CPR (11% versus 20%; P=.002); less often had ventricular tachycardia or ventricular fibrillation (37% versus 50%; P<.001); and had a shorter advanced life support call-response interval (median, 4 versus 6 minutes; P<.001). The odds ratio for survival (white/black) was .931 (95% confidence interval, .446 to 1.945). Conclusion: Race was not found to predict adverse OHCA outcomes in this affluent population. [Chu K, Swor R, Jackson R, Domeier R, Sadler E, Basse E, Zaleznak H, Gitlin J: Race and survival after out-of-hospital cardiac arrest in a suburban community. Ann Emerg Med April 1998;31:478-482.]

Section snippets

INTRODUCTION

Previous studies have found that outcome after out-of-hospital cardiac arrest (OHCA) is worse for blacks than for whites.1, 2 Similarly, Valenzuela³ identified worse outcome in Hispanic-surnamed patients. These studies controlled for other factors predictive of survival but did not control for markers of socioeconomic status (SES) other than race. The goal of our research was to determine whether race, adjusted for income, is an independent predictor of survival to hospital discharge after OHCA

MATERIALS AND METHODS

A prospective, cohort study was conducted in three suburban southeastern Michigan counties with nine participating hospitals—Beyer Hospital, Chelsea Community Hospital, McPherson Hospital, North Oakland Hospital, Providence Hospital, Saline Community Hospital, St Joseph Mercy Hospital, University of Michigan Medical Center, and William Beaumont Hospital. Oakland County is a 900-square-mile area with a population of 1 million (1990 census). The EMS system is a heterogenous one- and two-tiered

RESULTS

Of the original data set of 1,963 patients, 173 (9%) were excluded because data on outcome (33 patients) or on race (90 patients) were missing, because the patient's race was non-black and non-white, or because the cardiac arrest was not of primary cardiac origin. Of the 1,690 patients remaining for univariate analysis (Table 1), 223 (13%) were blacks and 1,467 (87%) were whites.

. Demographics of cardiac arrest patients according to race.

Characteristic	Blacks	Whites	Probability Values
No. of cases

DISCUSSION

Our study found that race was not an independent predictor of survival to hospital discharge after OHCA, when adjusted for income and other predictors of outcome, in our population of affluent blacks and whites. In this study blacks had a shorter ALS call-response interval, possibly because they tend to live in the more densely populated parts of the county. Blacks had a greater proportion of OHCA occurring outside the home, a factor that favors better outcome.⁶

However, blacks were about half

Acknowledgements

We acknowledge Anthony Sayegh for his contribution to the data collection.

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Cited by (53)

Racial and ethnic disparities in bystander resuscitation for out-of-hospital cardiac arrests
2024, Heart and Lung
Bystander-provided cardiopulmonary resuscitation (CRP) influences the survival rates of out-of-hospital cardiac arrests (OHCAs). Disparities on bystander resuscitation measures between Black, Hispanic, Asians and Non-Hispanic White OHCAs is unclear. Examining racial and ethnic differences in bystander resuscitations is essential to better target interventions.
15,542 witnessed OHCAs were identified between April 1, 2011, and June 30, 2015 using the Resuscitation Outcomes Consortium Epidemiologic Registry 3, a multi-center, controlled trial about OHCAs in the United States and Canada. Multivariable logistic regression model was used to analyze the differences in bystander resuscitation (bystander CRP [B-CPR], CPR plus ventilation, automated external defibrillators/defibrillator application [B-AED/D], or delivery of shocks) and clinical outcomes (death at the scene or en route, return of spontaneous circulation upon first arrival at the emergency department [ROSC-ED], survival until ED discharge [S-ED], survival until hospital discharge [S-HOS], and favorable neurological outcome at discharge) between Black, Hispanic, or Asian victims and Non-Hispanic White victims.
Compared to OHCA victims in Non-Hispanic Whites, Black, Hispanic, and Asians were less likely to receive B-CPR (adjusted OR: 0.79; 95 % CI: 0.63–0.99), and B-AED/D (adjusted OR: 0.80; 95 % CI: 0.65–0.98) in public locations. And, Black, Hispanic, and Asian OHCAs were less likely to receive bystander resuscitation in street/highway locations and public buildings, and less likely to have better clinical outcomes, including ROSC-ED, S-ED and S-HOS.
Black, Hispanic and Asian victims with witnessed OHCAs are less likely to receive bystander resuscitation and more likely to get worse outcomes than Non-Hispanic White victims.
Outcomes after out-of-hospital cardiac arrest in immigrants vs natives in Denmark
2023, Resuscitation
Ethnic disparities subsist in out-of-hospital cardiac arrest (OHCA) outcomes in the US, yet it is unresolved whether similar inequalities exist in European countries. This study compared survival after OHCA and its determinants in immigrants and non-immigrants in Denmark.
Using the nationwide Danish Cardiac Arrest Register, 37,622 OHCAs of presumed cardiac cause between 2001 and 2019 were included, 95% in non-immigrants and 5% in immigrants. Univariate and multiple logistic regression was used to assess disparities in treatments, return of spontaneous circulation (ROSC) at hospital arrival, and 30-day survival.
Immigrants were younger at OHCA (median 64 [IQR 53–72] vs 68 [59–74] years; p < 0.05), had more prior myocardial infarction (15% vs 12%, p < 0.05), more diabetes (27% vs 19%, p < 0.05), and were more often witnessed (56% vs 53%; p < 0.05). Immigrants received similar bystander cardiopulmonary resuscitation and defibrillation rates to non-immigrants, but more coronary angiographies (15% vs 13%; p < 0.05) and percutaneous coronary interventions (10% vs 8%, p < 0.05), although this was insignificant after age-adjustment. Immigrants had higher ROSC at hospital arrival (28% vs 26%; p < 0.05) and 30-day survival (18% vs 16%; p < 0.05) compared to non-immigrants, but adjusting for age, sex, witness status, first observed rhythm, diabetes, and heart failure rendered the difference non-significant (odds ratios (OR) 1.03, 95% confidence interval (CI) 0.92–1.16 and OR 1.05, 95% CI 0.91–1.20, respectively).
OHCA management was similar between immigrants and non-immigrants, resulting in similar ROSC at hospital arrival and 30-day survival after adjustments.
Racial Disparity in Outcomes of Out-of-Hospital Cardiac Arrest (OHCA): A Systematic Review and Meta-Analysis
2023, Current Problems in Cardiology
Out-of-hospital Cardiac Arrest (OHCA) is the abrupt cessation of cardiac function outside of a hospital setting. With limited research into the presence of racial disparities among outcomes of OHCA patients, this systematic review and meta-analysis was conducted. PubMed, Cochrane, and Scopus were searched from inception to March 2023. This analysis includes a total of 53,507 black patients, and 185,173 white patients, resulting in the pooling of 238,680 patients in this meta-analysis. It was observed that the black population was associated with significantly worsened survival to hospital discharge (OR: 0.81; 95% CI: 0.68, 0.96, P = 0.01), return of spontaneous circulation (OR: 0.79; 95% CI: 0.69, 0.89, P = 0.0002), and neurological outcomes (OR: 0.80; 95% CI: 0.68, 0.93; P = 0.003) when compared to their white counterparts. However, there were no differences found with respect to mortality. To the best of our knowledge, this is the most comprehensive meta-analysis assessing racial disparities in OHCA outcomes that have never been explored before. Increased awareness programs, and greater racial inclusivity in the field of cardiovascular medicine is encouraged. Further studies are needed in order to arrive at a robust conclusion.
The effect of ethnicity and socioeconomic status on outcomes after resuscitated out-of-hospital cardiac arrest – Findings from a tertiary centre in South London
2023, Resuscitation Plus
Out-of-hospital cardiac arrest is a common cause of morbidity and mortality, and ethnic variation in outcomes is recognised. We investigated ethnic and socioeconomic differences in arrest circumstances, rates of coronary artery disease, treatment, and outcomes in resuscitated OOHCA.
Patients with resuscitated OOHCA of suspected cardiac aetiology were included in the King’s Out-of-Hospital Cardiac Arrest Registry between 1-May-2012 and 31-December-2020.
Of 526 patients (median age 62.0 years, IQR 21.1, 74.1% male), 414 patients (78.7%) were White, 35 (6.7%) were Asian, and 77 (14.6%) were Black. Black patients had more co-existent hypertension (p = 0.007) and cardiomyopathy (p = 0.003), but less prior coronary revascularisation (p = 0.026) compared with White/Asian patients. There were no ethnic differences in location, witnesses, or bystander CPR, but Black patients had more non-shockable rhythms (p < 0.001). Black patients received less immediate coronary angiography (p < 0.001) and percutaneous coronary intervention (p < 0.001) but had lower rates of CAD (p = 0.004) than White/Asian patients. All-cause mortality at 12 months was highest amongst Black patients, followed by Asian and then White patients (57.1% vs 48.6% vs 41.3%, p = 0.032). In Black patients, excess mortality was driven by higher rates of multi-organ dysfunction but lower cardiac death than White/Asian patients, with cardiac death highest amongst Asian patients (p = 0.009). Socioeconomic status had no effect on mortality, and in a multivariable logistic regression, age, location, witnesses, and Black compared to White ethnicity were independent predictors of mortality, whilst social deprivation was not.
In this single-centre study, Black patients had higher mortality after resuscitated OOHCA than White/Asian patients. This may be in part due to differing underlying aetiology rather than differences in arrest circumstances or social deprivation.
Associations of Race and Ethnicity With Presentation and Outcomes of Hypertrophic Cardiomyopathy: JACC Focus Seminar 6/9
2021, Journal of the American College of Cardiology
Citation Excerpt :
In patients with out-of-hospital cardiac arrest, the age-adjusted incidence per 10,000 adults was 10.1 among Black subjects, 6.5 among Hispanic subjects, and 5.8 among White subjects, and age-adjusted survival to 30 days’ postdischarge was more than twice as poor for Black subjects as for White subjects (53). Several studies have shown that the prevalence of bystander cardiopulmonary resuscitation is lower for Black patients than for White patients (54,55). These studies suggest that racial/ethnic disparities in the circumstances of out-of-hospital cardiac arrest partially explain racial/ethnic disparities in survival.
Significant racial and ethnicity-based disparities in clinical presentation, management, and outcome of hypertrophic cardiomyopathy (HCM) are reported. Black patients with HCM are more likely to present with heart failure but are less commonly referred for symptom management, sudden cardiac death stratification, surgical septal myectomy, or for implantable cardioverter-defibrillators, all interventions that increase survival. Prevalence of bystander cardiopulmonary resuscitation is lower for Black patients than for White patients. Black patients with HCM have decreased survival after hospital discharge following out-of-hospital cardiac arrest. Biomedical and social interventions are urgently needed to reduce ethnicity-based disparities, which have an impact on outcomes in HCM and other cardiovascular diseases. There is also a need to focus on implementation science to support durable adoption of evidence-based therapies in Black patients and communities.
Association of measures of socioeconomic position with survival following out-of-hospital cardiac arrest: A systematic review
2020, Resuscitation
Survival following out-of-hospital cardiac arrest (OHCA) is low, and poor survival appears associated with low socioeconomic position (SEP). We aimed to synthesise the evidence regarding association of specific SEP measures with OHCA survival, as well as effect modification and potential mediators, with the goal of informing efforts to improve survival by highlighting characteristics of populations requiring additional resources, and identifying modifiable factors.
MEDLINE and Embase databases were searched on 23 May 2019. Quantitative primary studies considering the association of any SEP measure with any OHCA survival measure were eligible. SEP could be measured at the level of the patient, their residential area, or OHCA location. Data on study characteristics and outcomes were extracted and a narrative review performed; this considered the evidence for overall SEP-survival association, variation in association of different SEP measures with survival, effect modification, and mediation.
Twenty-three studies were included. These were highly heterogeneous, particularly regarding SEP measures and eligibility criteria. Several studies report a SEP-survival association, with this being almost exclusively in the direction of lower survival with lower SEP. There is some indication that the education-survival association is particularly consistent but further work is needed to increase confidence here. No evidence of effect modification by age, sex or other factors was seen, although few studies considered this. No mediators were conclusively identified.
Low SEP is associated with poorer OHCA survival in at least some settings. It may be appropriate to consider populations’ socioeconomic characteristics when targeting interventions to improve OHCA survival.

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^☆: From the Departments of Emergency Medicine at William Beaumont Hospital, Royal Oak^*; St Joseph's Mercy Hospital, Ann Arbor^‡; William Beaumont Hospital, Troy^§; North Oakland Medical Center, Pontiac^∥; and Providence Hospital, Southfield, MI.^¶

^☆☆: Funded in part by Grant No. 92.03 from Beaumont Foundation.

^★: Address for reprints: Dr Robert Swor, DO, Department of Emergency Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, Michigan 48073, 248-551-2015, Fax 248-551-2017, E-mail [email protected]

^★★: 47/1/88627

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Race and Survival After Out-of-Hospital Cardiac Arrest in a Suburban Community☆,☆☆,★,★★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Ann Emerg Med

Ann Emerg Med

Am J Prev Med

Racial differences in the incidence of cardiac arrest and subsequent survival

N Engl J Med

Out-of-hospital cardiac arrest: Racial differences in outcome in Seattle

Am J Public Health

Survival of Hispanics After Cardiac Arrest

Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein style

Ann Emerg Med

The Source Book of Zip Code Demographics