Effects of Socioeconomic Status and Hospital Characteristics on Out-of-Hospital Cardiac Arrest Outcomes with Emergency Medical Service and Bystander Administered Cardiopulmonary Resuscitation in Houston, TX

Abstract

Background: Out-of-hospital cardiac arrest (OHCA) is a major public health concern in the US with an 8% survival rate and 424,000 affected annually. OHCA studies are often conducted at the national and state level; local level studies may identify health disparities at the neighborhood level and thus help to target interventions towards the most affected population. This OHCA study is focused on the fourth largest US city, Houston, TX.

Purpose: To identify OHCA in Houston, TX, and to evaluate the association of age, gender, race/ethnicity, zip code level Socioeconomic Status (SES), with OHCA, survival to hospital admission, survival to hospital discharge and hospital teaching status.

Methods: Data for this retrospective OHCA study from 2010 to 2019 in Houston, TX, is achieved from the Cardiac Arrest Registry to Enhance Survival (CARES) database. Deidentified data is used, and duplicates are eliminated with unique identifiers. CARES 2019 Data Dictionary defines and describes OHCA variables. Hospital characteristics and teaching status are achieved from SouthEast Texas Regional Advisory Council (SETRAC). Houston residents ≥18 years, non-dead-on-arrival are included in the study. Zip code level SES is obtained from the American Community Survey (US Census Bureau, ACS, 2017). Binary logistic regression is conducted using IBM SPSS (Statistical Package for the Social Science) Statistics version 26. Variables studied are considered statistically significant with p < .05 (2-sided) value. A positive or negative coefficient βeta is directly proportional to an increase or decrease respectively in the outcome. OHCA are geocoded using ArcGIS version 10. For this study: Blacks, Hispanics and Asians are compared to Whites; males are compared to females; SES Levels 1, 2 and 4 are compared to SES Level 3, teaching hospital is compared to nonteaching hospital.

Results: OHCA for the 10-year period in Houston, TX is n= 18,262. OHCA is highest at SES level 3 at 41% (n= 7796), followed by SES level 2 at 30% (n= 5492). Bystander CPR is at 46% (n= 8343). Survival to hospital admission is at 30% (n= 5486) and survival to hospital discharge is 10% (n= 1820).

i. Age disparity is noticed. Increasing age corresponds to negative OHCA survival outcomes.

ii. Gender disparity is seen. Males affected with OHCA are at 60% (n= 11,013); with mean age of 63 years in comparison to females at 40% (n= 7249); with mean age of 67 years. No gender disparity is evident with respect to EMS CPR; further, males in comparison to females are 55.4% (95% CI: 0.339 to 0.588; p <.001) less likely to sustain ROSC, with a 54.7% (95% CI: 0.340 to 0.604; p < .001) decrease in the odds of attaining survival to hospital admission.

iii. Race / ethnicity disparity is evident. OHCA among Blacks is at 44% (n= 8105), followed by Whites at 31% (n= 5664), Hispanics at 19% (n = 3550) and Asians at 3% (n = 573). Blacks are 97.2% (95% CI: 1.450 to 2.681; p < .001) less likely to achieve Bystander CPR in comparison to Whites. Furthermore, Blacks are 48.2% (95% CI: 0.379 to 0.709; p < .001) less likely to sustain ROSC; also 48.2% (95% CI: 0.373 to 0.718; p < .001) less likely to achieve survival to hospital admission with a 49.7% (95% CI: 0.313 to 0.809; p = .005) decrease in achieving survival to hospital.

Hospital teaching status and survival outcomes: a 45.1% (95% CI: 1.024 – 2.057; p = 0.036) increase in the odds of obtaining survival to hospital admission with respect to a teaching hospital in comparison to nonteaching hospital is seen. No statistical significance is seen in obtaining survival to hospital discharge with respect to a hospital teaching status.

Conclusions: This 10-year OHCA study offers a tool to target interventions at the neighborhood level for the population most affected. Prioritizing Bystander CPR trainings for Houston’s Black community may improve overall OHCA survival rates.