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. 2025 Apr 1;8(4):e253435.
doi: 10.1001/jamanetworkopen.2025.3435.

Rurality and Area Deprivation and Outcomes After Out-of-Hospital Cardiac Arrest

Lakota Cheek  1 , Robert H Schmicker  2 , Remle Crowe  3 , Emily Goren  4 , Amanda West  1 , Jason McMullan  5 , Colin Raelson  6 , Jeanne Poole  7 , Karen Adams  8 , Antje Hoering  4 , Brent Myers  3 , Graham Nichol  8
Affiliations

Rurality and Area Deprivation and Outcomes After Out-of-Hospital Cardiac Arrest

Lakota Cheek et al. JAMA Netw Open. .

Abstract

Importance: Large regional variations in outcomes after out-of-hospital cardiac arrest (OHCA) exist.

Objective: To assess whether neighborhood rurality or economic deprivation where an OHCA occurred is associated with variation in emergency medical services (EMS) outcomes after OHCA.

Design, setting, and participants: This cohort study used data collated by ESO Inc on US adult patients (aged ≥18 years) with nontraumatic OHCA receiving chest compressions or defibrillation from EMS between January 1, 2022, and December 31, 2023.

Exposures: Rurality was assessed using Rural-Urban Commuting Area codes. Deprivation was assessed using the Area Deprivation Index. Both were derived from US Census data and grouped by EMS agency.

Main outcomes and measures: Outcomes were restoration of spontaneous circulation (ROSC) at emergency department (ED) arrival, survival to hospital discharge, and favorable discharge destination. Discharge outcomes were only available for patients transported to hospitals using health data exchange. Generalized estimating equations were used to account for correlated data.

Results: A total of 162 289 patients with OHCA had resuscitation attempted (median [IQR] age, 66 [53-76] years; 62.3% male). Overall, 28.1% of these patients lived in rural or suburban locations, 12.3% lived in areas with high deprivation, 18.7% had a first rhythm of ventricular tachycardia or ventricular fibrillation or shockable by automated external defibrillator rhythm, and 27.6% received bystander cardiopulmonary resuscitation. The mean (SD) EMS response time was 8.7 (5.6) minutes. Upon arrival at the ED, 23.7% of patients had ROSC. Compared with OHCAs in urban areas with low deprivation, those in rural areas with high deprivation (adjusted odds ratio [AOR], 0.81; 95% CI, 0.72-0.91), moderate deprivation (AOR, 0.75; 95% CI, 0.70-0.81), or low deprivation (AOR, 0.74; 95% CI, 0.62-0.88) had lower odds of ROSC at ED arrival. Among patients transported to hospitals using health data exchange, OHCAs in urban areas with high or moderate deprivation had lower odds of survival (AOR, 0.78 [95% CI, 0.68-0.90] and 0.82 [95% CI, 0.75-0.89], respectively) and favorable discharge destination (AOR, 0.65 [95% CI, 0.53-0.79] and 0.77 [95% CI, 0.69-0.87], respectively).

Conclusions and relevance: In this cohort study, OHCAs in rural areas of all levels of economic deprivation were associated with less ROSC at ED arrival vs urban areas with low deprivation, and OHCAs in urban areas with high or moderate deprivation are associated with less survival and less favorable discharge destination, suggesting worse neurologic outcomes. Care improvements alone may not reduce geographic differences in outcomes after OHCA.

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Conflict of interest statement

Conflict of Interest Disclosures: Mr Schmicker reported receiving grants from the University of Washington during the conduct of the study. Dr Myers reported holding stocks with ESO Inc outside the submitted work. Dr Nichol reported receiving salary support from the Medic One Foundation via the Leonard A. Cobb Medic One Foundation Endowed Chair in Prehospital Emergency Care at the University of Washington; research funding from Abiomed Inc, Johnson & Johnson MedTech, and ZOLL Medical; consulting fees from Celecor Inc and Orixha Inc; and an equipment loan from RCE Technologies Inc. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Flow Diagram
EMS indicates emergency medical services.
Figure 2.
Figure 2.. Associations Between Rurality or Deprivation and Outcomes
AOR indicates adjusted odds ratio; ED, emergency department; ROSC, restoration of spontaneous circulation.
See this image and copyright information in PMC

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