title: Regional Variation in Out-of-Hospital Cardiac Arrest Survival in the United States.
abstract: Although previous studies have shown marked variation in out-of-hospital cardiac arrest survival across US regions, factors underlying this survival variation remain incompletely explained.
  
  
  
  Using data from the Cardiac Arrest Registry to Enhance Survival, we identified 96 662 adult patients with out-of-hospital cardiac arrest in 132 US counties. We used hierarchical regression models to examine county-level variation in rates of survival and survival with functional recovery (defined as Cerebral Performance Category score of 1 or 2) and examined the contribution of demographics, cardiac arrest characteristics, bystander cardiopulmonary resuscitation, automated external defibrillator use, and county-level sociodemographic factors in survival variation across counties. A total of 9317 (9.6%) patients survived to discharge, and 7176 (7.4%) achieved functional recovery. At a county level, there was marked variation in rates of survival to discharge (range, 3.4%-22.0%; median odds ratio, 1.40; 95% confidence interval, 1.32-1.46) and survival with functional recovery (range, 0.8%-21.0%; median odds ratio, 1.53; 95% confidence interval, 1.43-1.62). County-level rates of bystander cardiopulmonary resuscitation and automated external defibrillator use were positively correlated with both outcomes (P<0.0001 for all). Patient demographic and cardiac arrest characteristics explained 4.8% and 27.7% of the county-level variation in survival, respectively. Additional adjustment of bystander cardiopulmonary resuscitation and automated external defibrillator explained 41% of the survival variation, and this increased to 50.4% after adjustment of county-level sociodemographic factors. Similar findings were noted in analyses of survival with functional recovery.
  
  
  
  Although out-of-hospital cardiac arrest survival varies significantly across US counties, a substantial proportion of the variation is attributable to differences in bystander response across communities.
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.). saket-girotra@uiowa.edu.
authors.forename: Saket
authors.initials: S
authors.lastname: Girotra
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Sean
authors.initials: S
authors.lastname: van Diepen
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Margaret
authors.initials: M
authors.lastname: Carrel
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Kimberly
authors.initials: K
authors.lastname: Vellano
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Monique L
authors.initials: ML
authors.lastname: Anderson
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Bryan
authors.initials: B
authors.lastname: McNally
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Abella
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Comilla
authors.initials: C
authors.lastname: Sasson
authors.affiliation: From Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.); Division of Critical Care and Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Center for Clinical Management Research, Ann Arbor VA Medical Center, & Department of Internal Medicine, University of Michigan Medical School (B.K.N.); Department of Geographic and Sustainability Sciences, University of Iowa College of Liberal Arts and Sciences (M.C.); Department of Emergency Medicine, Emory University, Atlanta, GA (K.V., B.M.); Rollins School of Public Health, Atlanta, GA (B.M.); Department of Medicine, Duke Clinical Research Institute, Durham, NC (M.L.A.); Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.S.A); Department of Emergency Medicine, University of Colorado, Aurora & American Heart Association (C.S.); and Saint Luke's Mid America Heart Institute and University of Missouri-Kansas, Kansas City, MO (P.S.C.).
authors.forename: Paul S
authors.initials: PS
authors.lastname: Chan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation / Q000401:mortality*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D012042:Registries; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: cardiopulmonary resuscitation; heart arrest