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Introduction: Survival to discharge after out-of-hospital cardiac arrest (OHCA) exhibits significant regional variability across communities in the US with differences in outcomes following arrest between rural, suburban, and urban communities. We examined the relationship between urban-rural residential county classification and survival following OHCA to determine if racial composition of a county and community health indicators contribute to improved outcomes following OHCA. Methods: Utilizing age-eligible Medicare fee-for-service claims data from January 2013 - December 2014, we identified OHCA patients by ICD-9-CM diagnosis code 427.5 and determined survival to discharge and at 30 days. Additional data sources included the 2013 National Center for Health Statistics (NCHS) urban-rural classification, US Census data, and County Health Rankings. Mixed effect logistic regression was used to determine the association of OHCA outcomes and NCHS classified residence, when accounting for individual age, sex, and race, county-level racial composition, poverty status, and community health measures. Results: 256,107 cases of OHCA were identified with a mean age of age of 78.7 (SD 8.5) years, 22.8% nonwhite, 47.5% female. Overall survival to discharge was 21.8% and survival at 30 days was 15.1%. Patients living in the most rural counties had increased likelihood of initial survival (aOR1.1, CI 1.0-1.1), but were associated with lower survival at 30 days (aOR 0.9, CI 0.8-0.9). Nonwhite patient race and residing in a majority nonwhite county were associated with significant decreases in the likelihood of survival to discharge and at 30 days (7% and 11%, respectively). Conclusions: Among Medicare beneficiaries, survival to discharge after OHCA was higher if residing in a non-urban community but did not persist at 30 days. OHCA patients residing in majority non-white counties were significantly less likely to survive the initial hospitalization and to 30-days post discharge. More study is needed to elucidate these disparities and determine if modifiable county level health factors exist that could contribute to improvements in OHCA survival.

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Background Racial residential segregation in the US is associated with poor health outcomes across multiple chronic conditions including cardiovascular disease. However, the national impact of racial residential segregation on out-of-hospital cardiac arrest (OHCA) outcomes after initial resuscitation remains poorly understood. We sought to characterize the association between measures of racial and economic residential segregation at the ZIP code level and long-term survival after OHCA among Medicare beneficiaries. Methods In this retrospective cohort study, utilizing Medicare fee-for-service claims data from 2013-2015, our primary predictor was the index of concentration at the extremes (ICE), a measure of racial and economic segregation. The primary outcomes were death at 1 and 3 years. Using random-effects Cox proportional hazards models, including a shared frailty term to account for clustering at the hospital level, we estimated hazard ratios across all three types of ICE measures for each outcome while adjusting for beneficiary demographics, treating hospital characteristics, and index hospital procedures. Results We identified 29,847 OHCA claims for beneficiaries who survived to discharge after an OHCA. Mean beneficiary age was 75 years (SD 8); 40.1% were female, 80% White and 15.2% Black. Overall crude survival for the cohort was 54% (n=16,129) at 1 year and 40.8% (n= 12,189) at 3 years. In fully adjusted models we found a decreased hazard of death in beneficiaries residing in the most racially and economically privileged ZIP codes (Q5) compared to the least privileged areas (Q1) across all three ICE measures (race: HR:0.84; CI 0.79-0.88, income: HR 0.76; CI 0.73-0.81, race + income: HR 0.78; CI 0.74-0.83) Conclusion We found a decreased hazard of death for those residing in predominately White and higher income ZIP codes as compared to majority Black and lower income ZIP codes when using validated measures of racial and economic segregation. Future work will need to more closely examine the causal pathways and mechanisms related to disparities in outcomes after OHCA to better understand the impacts of spatial and living environments on long-term outcomes.

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