Accepted Manuscript Title: SOCIOECONOMIC FACTORS ASSOCIATED WITH OUTCOME AFTER CARDIAC ARREST IN PATIENTS UNDER THE AGE OF 65 Author: Thomas Uray Florian B. Mayr James Fitzgibbon Jon C. Rittenberger Clifton W. Callaway Tomas Drabek Anthony Fabio Derek C. Angus Patrick M. Kochanek Cameron Dezfulian PII: DOI: Reference:
S0300-9572(15)00198-7 http://dx.doi.org/doi:10.1016/j.resuscitation.2015.04.032 RESUS 6401
To appear in:
Resuscitation
Received date: Revised date: Accepted date:
13-11-2014 1-3-2015 29-4-2015
Please cite this article as: Uray T, Mayr FB, Fitzgibbon J, Rittenberger JC, Callaway CW, Drabek T, Fabio A, Angus DC, Kochanek PM, Dezfulian C, SOCIOECONOMIC FACTORS ASSOCIATED WITH OUTCOME AFTER CARDIAC ARREST IN PATIENTS UNDER THE AGE OF 65, Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.04.032 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 2
SOCIOECONOMIC FACTORS ASSOCIATED WITH OUTCOME AFTER CARDIAC ARREST IN PATIENTS UNDER THE AGE OF 65
3 Thomas Uray, MD, MPH1,2,3; Florian B. Mayr, MD, MPH2; James Fitzgibbon1;
5
Jon C. Rittenberger, MD, MS4; Clifton W. Callaway, MD, PhD1,4; Tomas Drabek, MD, PhD1,5;
6
Anthony Fabio, PhD, MPH6; Derek C. Angus, MD, MPH2; Patrick M. Kochanek, MD, MCCM1,2;
7
Cameron Dezfulian, MD1,2,7
cr
8 1Safar
Center for Resuscitation Research, University of Pittsburgh School of Medicine
us
9
ip t
4
2Department
of Critical Care Medicine, University of Pittsburgh School of Medicine
11
3Department
of Emergency Medicine, Medical University of Vienna, Austria
12
4Department
of Emergency Medicine, University of Pittsburgh School of Medicine
13
5Department
of Anesthesiology, University of Pittsburgh School of Medicine
14
6Department
of Epidemiology, Graduate School of Public Health, University of Pittsburgh
15
7Vascular
M
an
10
d
Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
te
16 Correspondence:
18
Cameron Dezfulian, MD
19
Safar Center for Resuscitation Research
20
Department of Critical Care Medicine
21
University of Pittsburgh School of Medicine
22
3434 Fifth Avenue
23
Pittsburgh, PA 15260, USA
24
Telephone: +1-412-383-3128
25
Email: [email protected]
Ac ce p
17
26 27
Total word count: 3072
28
Subject codes:
29
[8] Epidemiology, [25] CPR and emergency cardiac care;
30
1
Page 1 of 27
30
Abstract
32
Aim
33
In a prior study of seven North American cities Pittsburgh had the highest crude rate of
34
cardiac arrest deaths in patients 18 to 64 years of age, particularly in neighborhoods
35
with lower socioeconomic status (SES). We hypothesized that lower SES, associated
36
poor health behaviors (e.g., illicit drug use) and pre-existing comorbid conditions
37
(grouped as socioeconomic factors [SE factors]) could affect the type and severity of
38
cardiac arrest, thus outcomes.
39
Methods
40
We retrospectively identified patients aged 18 to 64 years treated for in-hospital (IHCA)
41
and out-of hospital arrest (OHCA) at two Pittsburgh hospitals between January 2010
42
and July 2012. We abstracted data on baseline demographics and arrest characteristics
43
like place of residence, insurance and employment status. Favorable cerebral
44
performance category [CPC] (1 or 2) was our primary outcome. We examined the
45
associations between SE factors, cardiac arrest variables and outcome as well as post-
46
resuscitation care.
47
Results
48
Among 415 subjects who met inclusion criteria, unfavorable CPC were more common
49
in patients who were unemployed, had a history of drug abuse or hypertension. In
50
OHCA, favorable CPC was more often associated with presentation with ventricular
Ac ce p
te
d
M
an
us
cr
ip t
31
2
Page 2 of 27
fibrillation/tachycardia (OR 3.53, 95% CI 1.43-8.74, p=0.006) and less often associated
52
with non-cardiovascular arrest etiology (OR 0.22, 95% CI 0.08-0.62, p=0.004). We found
53
strong associations between specific SE factors and arrest factors associated with
54
outcome in OHCA patients only. Significant differences in post-resuscitation care
55
existed based on injury severity, not on SES.
56
Conclusions
57
SE factors strongly influence type and severity of OHCA but not IHCA resulting in an
58
association with outcomes.
an
us
cr
ip t
51
M
59 Key words:
61
cardiac arrest; young; socioeconomic position; outcome; survival;
te Ac ce p
62
d
60
3
Page 3 of 27
62 63
Introduction Sudden cardiac arrest is a leading cause of death in the United States.1 Every
65
year, approximately 300,000 out-of hospital cardiac arrests (OHCA)2 and 200,000 in-
66
hospital cardiac arrests (IHCA) 3 occur in the US with an overall survival rate ranging
67
from 8 to 22%.2,4,5 Socioeconomic status (SES) affects outcomes after cardiac arrest. The
68
annual incidence of cardiac arrests is approximately two-fold higher in poor vs. wealthy
69
neighborhoods across seven large North American regions.6,7 This discrepancy was
70
most pronounced in patients 18 to 64 years of age with the lowest quartile household
71
income7 suggesting that poorer SES may contribute to poorer health in this adult cohort,
72
which does not qualify for universal health care programs like Medicare.7 Disparities in
73
access to health care or differential delivery of services after admission could be
74
influenced by lack of insurance or economic means which could impact outcomes after
75
both IHCA and OHCA.
cr
us
an
M
d
te
Ac ce p
76
ip t
64
Lower SES may also be associated with other factors that would influence
77
outcomes after OHCA but not IHCA. Drug abuse and obesity incidence is higher in
78
areas with more poverty8, which could predispose to asphyxial OHCA (eg from drug
79
overdose). Lower SES is often associated with lower employment and marriage rates.9
80
This could increase the likelihood of social isolation and delay activation of the chain-
81
of-survival with lower rates of witnessed arrest and bystander cardiopulmonary
82
resuscitation (CPR)10-12 resulting in more severe brain injury and coma on
83
presentation11. Non-cardiac etiology of cardiac arrest, such as asphyxia from drug
4
Page 4 of 27
overdose, and higher rates of coma are both associated with worse outcomes after
85
cardiac arrest13 suggesting an indirect means whereby socioeconomic factors (SE
86
factors), which we define broadly as the sum of SES and associated behaviors and
87
comorbidities, may alter outcomes after OHCA but not IHCA. On the other hand non-
88
white race, also associated with lower SES 6,7,14,15 has been linked to decreased survival
89
post-arrest but this effect has been ascribed to differences in quality of care at the
90
treating center.16,17
cr
us
91
ip t
84
The aim of this study was to describe the association between SE factors and outcomes of younger adults treated after cardiac arrest. We restricted the study to
93
persons
S0300-9572(15)00198-7 http://dx.doi.org/doi:10.1016/j.resuscitation.2015.04.032 RESUS 6401
To appear in:
Resuscitation
Received date: Revised date: Accepted date:
13-11-2014 1-3-2015 29-4-2015
Please cite this article as: Uray T, Mayr FB, Fitzgibbon J, Rittenberger JC, Callaway CW, Drabek T, Fabio A, Angus DC, Kochanek PM, Dezfulian C, SOCIOECONOMIC FACTORS ASSOCIATED WITH OUTCOME AFTER CARDIAC ARREST IN PATIENTS UNDER THE AGE OF 65, Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.04.032 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 2
SOCIOECONOMIC FACTORS ASSOCIATED WITH OUTCOME AFTER CARDIAC ARREST IN PATIENTS UNDER THE AGE OF 65
3 Thomas Uray, MD, MPH1,2,3; Florian B. Mayr, MD, MPH2; James Fitzgibbon1;
5
Jon C. Rittenberger, MD, MS4; Clifton W. Callaway, MD, PhD1,4; Tomas Drabek, MD, PhD1,5;
6
Anthony Fabio, PhD, MPH6; Derek C. Angus, MD, MPH2; Patrick M. Kochanek, MD, MCCM1,2;
7
Cameron Dezfulian, MD1,2,7
cr
8 1Safar
Center for Resuscitation Research, University of Pittsburgh School of Medicine
us
9
ip t
4
2Department
of Critical Care Medicine, University of Pittsburgh School of Medicine
11
3Department
of Emergency Medicine, Medical University of Vienna, Austria
12
4Department
of Emergency Medicine, University of Pittsburgh School of Medicine
13
5Department
of Anesthesiology, University of Pittsburgh School of Medicine
14
6Department
of Epidemiology, Graduate School of Public Health, University of Pittsburgh
15
7Vascular
M
an
10
d
Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
te
16 Correspondence:
18
Cameron Dezfulian, MD
19
Safar Center for Resuscitation Research
20
Department of Critical Care Medicine
21
University of Pittsburgh School of Medicine
22
3434 Fifth Avenue
23
Pittsburgh, PA 15260, USA
24
Telephone: +1-412-383-3128
25
Email: [email protected]
Ac ce p
17
26 27
Total word count: 3072
28
Subject codes:
29
[8] Epidemiology, [25] CPR and emergency cardiac care;
30
1
Page 1 of 27
30
Abstract
32
Aim
33
In a prior study of seven North American cities Pittsburgh had the highest crude rate of
34
cardiac arrest deaths in patients 18 to 64 years of age, particularly in neighborhoods
35
with lower socioeconomic status (SES). We hypothesized that lower SES, associated
36
poor health behaviors (e.g., illicit drug use) and pre-existing comorbid conditions
37
(grouped as socioeconomic factors [SE factors]) could affect the type and severity of
38
cardiac arrest, thus outcomes.
39
Methods
40
We retrospectively identified patients aged 18 to 64 years treated for in-hospital (IHCA)
41
and out-of hospital arrest (OHCA) at two Pittsburgh hospitals between January 2010
42
and July 2012. We abstracted data on baseline demographics and arrest characteristics
43
like place of residence, insurance and employment status. Favorable cerebral
44
performance category [CPC] (1 or 2) was our primary outcome. We examined the
45
associations between SE factors, cardiac arrest variables and outcome as well as post-
46
resuscitation care.
47
Results
48
Among 415 subjects who met inclusion criteria, unfavorable CPC were more common
49
in patients who were unemployed, had a history of drug abuse or hypertension. In
50
OHCA, favorable CPC was more often associated with presentation with ventricular
Ac ce p
te
d
M
an
us
cr
ip t
31
2
Page 2 of 27
fibrillation/tachycardia (OR 3.53, 95% CI 1.43-8.74, p=0.006) and less often associated
52
with non-cardiovascular arrest etiology (OR 0.22, 95% CI 0.08-0.62, p=0.004). We found
53
strong associations between specific SE factors and arrest factors associated with
54
outcome in OHCA patients only. Significant differences in post-resuscitation care
55
existed based on injury severity, not on SES.
56
Conclusions
57
SE factors strongly influence type and severity of OHCA but not IHCA resulting in an
58
association with outcomes.
an
us
cr
ip t
51
M
59 Key words:
61
cardiac arrest; young; socioeconomic position; outcome; survival;
te Ac ce p
62
d
60
3
Page 3 of 27
62 63
Introduction Sudden cardiac arrest is a leading cause of death in the United States.1 Every
65
year, approximately 300,000 out-of hospital cardiac arrests (OHCA)2 and 200,000 in-
66
hospital cardiac arrests (IHCA) 3 occur in the US with an overall survival rate ranging
67
from 8 to 22%.2,4,5 Socioeconomic status (SES) affects outcomes after cardiac arrest. The
68
annual incidence of cardiac arrests is approximately two-fold higher in poor vs. wealthy
69
neighborhoods across seven large North American regions.6,7 This discrepancy was
70
most pronounced in patients 18 to 64 years of age with the lowest quartile household
71
income7 suggesting that poorer SES may contribute to poorer health in this adult cohort,
72
which does not qualify for universal health care programs like Medicare.7 Disparities in
73
access to health care or differential delivery of services after admission could be
74
influenced by lack of insurance or economic means which could impact outcomes after
75
both IHCA and OHCA.
cr
us
an
M
d
te
Ac ce p
76
ip t
64
Lower SES may also be associated with other factors that would influence
77
outcomes after OHCA but not IHCA. Drug abuse and obesity incidence is higher in
78
areas with more poverty8, which could predispose to asphyxial OHCA (eg from drug
79
overdose). Lower SES is often associated with lower employment and marriage rates.9
80
This could increase the likelihood of social isolation and delay activation of the chain-
81
of-survival with lower rates of witnessed arrest and bystander cardiopulmonary
82
resuscitation (CPR)10-12 resulting in more severe brain injury and coma on
83
presentation11. Non-cardiac etiology of cardiac arrest, such as asphyxia from drug
4
Page 4 of 27
overdose, and higher rates of coma are both associated with worse outcomes after
85
cardiac arrest13 suggesting an indirect means whereby socioeconomic factors (SE
86
factors), which we define broadly as the sum of SES and associated behaviors and
87
comorbidities, may alter outcomes after OHCA but not IHCA. On the other hand non-
88
white race, also associated with lower SES 6,7,14,15 has been linked to decreased survival
89
post-arrest but this effect has been ascribed to differences in quality of care at the
90
treating center.16,17
cr
us
91
ip t
84
The aim of this study was to describe the association between SE factors and outcomes of younger adults treated after cardiac arrest. We restricted the study to
93
persons
