Association of Racial Residential Segregation With Long‐Term Outcomes and Readmissions After Out‐of‐Hospital Cardiac Arrest Among Medicare Beneficiaries

Abstract

Background The national impact of racial residential segregation on out‐of‐hospital cardiac arrest 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 and readmissions after out‐of‐hospital cardiac arrest among Medicare beneficiaries. Methods and Results In this retrospective cohort study, using Medicare claims data, our primary predictor was the index of concentration at the extremes, a measure of racial and economic segregation. The primary outcomes were death up to 3 years and readmissions. We estimated hazard ratios (HRs) across all 3 types of index of concentration at the extremes measures for each outcome while adjusting for beneficiary demographics, treating hospital characteristics, and index hospital procedures. In fully adjusted models for long‐term survival, we found a decreased hazard of death and risk of readmission for beneficiaries residing in the more segregated White communities and higher‐income ZIP codes compared with the more segregated Black communities and lower‐income ZIP codes across all 3 indices of concentration at the extremes measures (race: HR, 0.87 [95% CI, 0.81–0.93]; income: HR, 0.75 [95% CI, 0.69–0.78]; and race+income: HR, 0.77 [95% CI, 0.72–0.82]). Conclusions We found a decreased hazard of death and risk for readmission for those residing in the more segregated White communities and higher‐income ZIP codes compared with the more segregated Black communities and lower‐income ZIP codes when using validated measures of racial and economic segregation. Although causal pathways and mechanisms remain unclear, disparities in outcomes after out‐of‐hospital cardiac arrest are associated with the structural components of race and wealth and persist up to 3 years after discharge.

Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

“…There is considerable evidence that residential segregation drives variation in hospital racial composition, with several recent studies showing poor hospital quality in residentially segregated areas . This, in part, reflects the lower quality of hospitals located in largely Black communities.…”

“…Racial inequities in health outcomes can be, in part, attributed to disparities in treatment and utilization arising from geographic variation in clinical practices, historical and systemic racism, implicit bias, social determinants of health, and poor access to care . There has been increasing attention to the role of lower-quality care in segregated communities leading to poor health outcomes . In the case of Black patients, it is less well understood whether higher rates of patient admissions occur because hospitals’ markets comprise segregated communities, or because patients from the same communities are admitted to different hospitals.…”

“… 4 , 5 , 6 , 7 There has been increasing attention to the role of lower-quality care in segregated communities leading to poor health outcomes. 8 , 9 In the case of Black patients, it is less well understood whether higher rates of patient admissions occur because hospitals’ markets comprise segregated communities, or because patients from the same communities are admitted to different hospitals. Local patient sorting could be positive if patients disproportionately seek care at hospitals providing more affirming care, such as that captured in an index of hospital inclusivity.…”

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

“…This methodology has been previously applied in our research exploring both short and long-term outcomes in OHCA. 13,14 The ICE measure is considered a more methodologically robust method as compared with other measures such as the usage of racial of ethnic percentage composition of a given geographic area (census tract, county, ZIP code). ICE captures geographies where extreme differences in race, ethnicity, and economic segregation exist-factors that are potential drivers of disparities in health outcomes.…”

“…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). To better understand the association of measures of residential segregation with OHCA clinical outcomes while accounting for important prehospital variables, we utilized Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine if there are differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander CPR, using validated measures of racial, ethnic, and economic segregation.…”