The past, present, and future of the Cardiac Arrest Registry to Enhance Survival (CARES).

Background: The Cardiac Arrest Registry to Enhance Survival (CARES) was created in 2004 in collaboration with the Centers for Disease Control and Prevention (CDC) and Emory University School of Medicine's Department of Emergency Medicine. The registry allows local communities to benchmark their performance, enhance the quality of care, and increase survival rates for out-of-hospital cardiac arrest (OHCA). Methods/design: CARES enrolls patients who experience a non-traumatic, EMS-treated OHCA. For each case, data is collected from three sources: 911 call center data, EMS data, and hospital data. CARES data is de-identified and stored in a secured web-based cloud platform and maintains confidentiality throughout the process. CARES data is subjected to an internal auditing system that oversees both local and regional levels. The variables in CARES adhere with the Utstein style reporting system and the National EMS Information System (NEMSIS) standard. Discussion: As of 2023, CARES captures data from a population base of over 178 million people which accounts for 53% of the total U.S. population. Over the past two decades, CARES has consistently been a part of public health surveillance for OHCA and serves as a quality improvement tool to improve cardiac arrest outcomes. Moreover, CARES commits to facilitate observational research on OHCA, continues to modernize its software platform, and comprehensively expands its coverage for the entire U.S.

Towards advancing Out-of-Hospital cardiac arrest (OHCA) registries globally: Considerations from the global OHCA registry (GOHCAR) collaborative.

A growing number out-of-hospital cardiac arrest (OHCA) registries have been developed across the globe. A few of these are national, while others cover larger geographical regions. These registries have common objectives; continuous quality improvement, epidemiological research and providing infrastructure for clinical trials. OHCA registries make performance comparison across Emergency Medical Services systems possible for benchmarking, hypothesis generation and further research. Changes in OHCA incidence and outcomes provide insights about the effects of secular trends or health services interventions. These registries, therefore, have become a mainstay of OHCA management and research. However, developing and maintaining these registries is challenging. Coordination of different service providers to support data collection, sustainable resourcing, data quality and data security are the key challenges faced by these registries. Despite all these challenges, noteworthy progress has been made and further standardization and co-ordination across registries can result in great international benefit. In this paper we present a 'why' and 'how to' model for setting up OHCA registries, and suggestions for better international co-ordination through a Global OHCA Registries Collaborative (GOHCAR). We draw together the knowledge of a cohort of international researchers, with experience and expertise in OHCA registry development, management, and data synthesis.

Sex Differences in Receipt of Bystander Cardiopulmonary Resuscitation Considering Neighborhood Racial and Ethnic Composition.

BACKGROUND: Bystander cardiopulmonary resuscitation (B-CPR) and defibrillation for out-of-hospital cardiac arrest (OHCA) vary by sex, with women being less likely to receive these interventions in public. It is unknown whether sex differences persist when considering neighborhood racial and ethnic composition. We examined the odds of receiving B-CPR stratified by location and neighborhood. We hypothesized that women in predominantly Black neighborhoods will have a lower odds of receiving B-CPR. METHODS AND RESULTS: We conducted a retrospective study using the Cardiac Arrest Registry to Enhance Survival (CARES). Neighborhoods were classified by census tract. We modeled the odds of receipt of B-CPR (primary outcome), automatic external defibrillation application, and survival to hospital discharge (secondary outcomes) by sex. CARES collected 457 621 arrests (2013-2019); after appropriate exclusion, 309 662 were included. Women who had public OHCA had a 14% lower odds of receiving B-CPR (odds ratio [OR], 0.86 [95% CI, 0.82-0.89]), but effect modification was not seen by neighborhood (P=not significant). In predominantly Black neighborhoods, women who had public OHCA had a 13% lower odds of receiving B-CPR (adjusted OR, 0.87 [95% CI, 0.76-0.98]) and 12% lower odds of receiving automatic external defibrillation application (adjusted OR, 0.88 [95% CI, 0.78-0.99]). In predominantly Hispanic neighborhoods, women who had public OHCA were less likely to receive B-CPR (adjusted OR, 0.83 [95% CI, 0.73-0.96]) and less likely to receive automatic external defibrillation application (adjusted OR, 0.74 [95% CI, 0.64-0.87]). CONCLUSIONS: Women with public OHCA have a decreased likelihood of receiving B-CPR and automatic external defibrillation application. Findings did not differ significantly according to neighborhood composition. Despite this, our work has implications for considering strategies to reduce disparities around bystander response.

Rural cardiac arrest care and outcomes in Texas.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) victims in rural communities have worse outcomes despite higher rates of bystander cardiopulmonary resuscitation (CPR) than urban communities. In this retrospective cohort study we attempt to evaluate selected aspects of the continuum of care, including post-arrest care, for rural OHCA victims, and we investigated factors that could contribute to rural areas having higher rates of bystander CPR. METHODS: We analyzed 2014-2020 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) data for adult OHCAs. We linked TX-CARES data to census tract data and stratified OHCAs into urban and rural events. We created a mixed-model logistic regression to compare cardiac arrest characteristics, pre-hospital care, and post-arrest care between rural and urban settings. We adjusted for confounders and modeled census tract as a random intercept. We then compared different regression models evaluating the association between response time and bystander CPR. RESULTS: We included 1202 rural and 28,288 urban cardiac arrests. Comparing rural to urban OHCAs, rates of bystander CPR were significantly higher in rural communities (49.6% v 40.6%, aOR 1.3 95% CI 1.1-1.5). The median response time for rural (11.5 min) was longer than urban (7.3 min). The occurrence of an ambulance response time of <10 min was notably less common in rural communities when compared to urban areas (aOR 0.2, 95% CI 0.2-0.2). For post-arrest care the rates of percutaneous coronary intervention (PCI) were higher in rural than urban communities (aOR 1.7, 95% CI 1.01-2.8). The rates of AED and TTM were similar between urban and rural communities. Survival to hospital discharge was significantly lower in rural communities than urban communities (aOR 0.6, 95% CI 0.4-0.7). Although not significant, rural communities had lower rate of survival with a cognitive performance score (CPC) of 1 or 2 (aOR 0.7, 05% CI 0.6-1.003). We identified no association between response time and bystander CPR. CONCLUSION: Patients in rural areas of Texas have lower survival after OHCA compared to patients in urban areas, despite having significantly greater rates of bystander CPR and PCI. We did not find a link between response time and bystander CPR rates.

The impact of COVID-19 pandemic on out-of-hospital cardiac arrest: An individual patient data meta-analysis.

AIM: Prior studies have reported increased out-of-hospital cardiac arrests (OHCA) incidence and lower survival during the COVID-19 pandemic. We evaluated how the COVID-19 pandemic affected OHCA incidence, bystander CPR rate and patients' outcomes, accounting for regional COVID-19 incidence and OHCA characteristics. METHODS: Individual patient data meta-analysis of studies which provided a comparison of OHCA incidence during the first pandemic wave (COVID-period) with a reference period of the previous year(s) (pre-COVID period). We computed COVID-19 incidence per 100,000 inhabitants in each of 97 regions per each week and divided it into its quartiles. RESULTS: We considered a total of 49,882 patients in 10 studies. OHCA incidence increased significantly compared to previous years in regions where weekly COVID-19 incidence was in the fourth quartile (>136/100,000/week), and patients in these regions had a lower odds of bystander CPR (OR 0.49, 95%CI 0.29-0.81, p = 0.005). Overall, the COVID-period was associated with an increase in medical etiology (89.2% vs 87.5%, p < 0.001) and OHCAs at home (74.7% vs 67.4%, p < 0.001), and a decrease in shockable initial rhythm (16.5% vs 20.3%, p < 0.001). The COVID-period was independently associated with pre-hospital death (OR 1.73, 95%CI 1.55-1.93, p < 0.001) and negatively associated with survival to hospital admission (OR 0.68, 95%CI 0.64-0.72, p < 0.001) and survival to discharge (OR 0.50, 95%CI 0.46-0.54, p < 0.001). CONCLUSIONS: During the first COVID-19 pandemic wave, there was higher OHCA incidence and lower bystander CPR rate in regions with a high-burden of COVID-19. COVID-19 was also associated with a change in patient characteristics and lower survival independently of COVID-19 incidence in the region where OHCA occurred.

Association Between Delays in Time to Bystander CPR and Survival for Witnessed Cardiac Arrest in the United States.

BACKGROUND: Prompt initiation of bystander cardiopulmonary resuscitation (CPR) is critical to survival for out-of-hospital cardiac arrest (OHCA). However, the association between delays in bystander CPR and OHCA survival is poorly understood. METHODS: In this observational study using a nationally representative US registry, we identified patients who received bystander CPR from a layperson for a witnessed OHCA from 2013 to 2021. Hierarchical logistic regression was used to estimate the association between time to CPR (<1 minute versus 2-3, 4-5, 6-7, 8-9, and ≥10-minute intervals) and survival to hospital discharge and favorable neurological survival (survival to discharge with cerebral performance category of 1 or 2 [ie, without severe neurological disability]). RESULTS: Of 78 048 patients with a witnessed OHCA treated with bystander CPR, the mean age was 63.5±15.7 years and 25, 197 (32.3%) were women. The median time to bystander CPR was 2 (1-5) minutes, with 10% of patients having a≥10-minute delay before initiation of CPR. Overall, 15 000 (19.2%) patients survived to hospital discharge and 13 159 (16.9%) had favorable neurological survival. There was a graded inverse relationship between time to bystander CPR and survival to hospital discharge (P for trend <0.001). Compared with patients who received CPR within 1 minute, those with a time to CPR of 2 to 3 minutes were 9% less likely to survive to discharge (adjusted odds ratio, 0.91 [95% CI, 0.87-0.95]) and those with a time to CPR 4 to 5 minutes were 27% less likely to survive (adjusted odds ratio, 0.73 [95% CI, 0.68-0.77]). A similar graded inverse relationship was found between time to bystander CPR and favorable neurological survival (P for trend <0.001). CONCLUSIONS: Among patients with witnessed OHCA, there was a dose-response relationship between delays in bystander initiation of CPR and lower survival rates.

Bystander CPR and Long-Term Survival in Older Adults With Out-of-Hospital Cardiac Arrest.

BACKGROUND: Most studies on bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) have focused on in-hospital or short-term survival. OBJECTIVES: The purpose of this study was to examine the association between bystander CPR and long-term survival outcomes for OHCA. METHODS: Within the Cardiac Arrest Registry to Enhance Survival, we identified 152,653 patients with OHCA ≥65 years of age or older. Using multivariable hierarchical logistic regression, we first examined the association between bystander CPR and in-hospital survival. Then, among those surviving to discharge and linked to Medicare files, we evaluated the association between bystander CPR and long-term mortality over 5 years using multivariable Cox regression. RESULTS: Overall, 58,464 (38.3%) received bystander CPR. Patients receiving bystander CPR were more likely to have an OHCA that was witnessed, in a public location, and with an initial shockable rhythm. Bystander CPR was associated with a 24% higher likelihood of surviving to hospital discharge (10.2% vs 5.5%; adjusted relative risk: 1.24 [95% CI: 1.19-1.29]; P < 0.001), and this survival benefit was similar (interaction P = 0.24) for those who were 65 to 74, 75 to 84, and ≥85 years of age. Among patients surviving to hospital discharge (median follow-up of 31 months), bystander CPR was additionally associated with lower long-term mortality vs those without bystander CPR (adjusted hazard ratio: 0.78 [95% CI: 0.73-0.84]; P < 0.001), and this benefit was also consistent across age groups (interaction P = 0.13). CONCLUSIONS: In older adults with OHCA, bystander CPR was associated with higher rates of in-hospital survival. This survival benefit was not attenuated by competing mortality risks but increased in magnitude after hospital discharge.

Impact of Receiving Hospital on Out-of-Hospital Cardiac Arrest Outcome: Racial and Ethnic Disparities in Texas.

Background Factors associated with out-of-hospital cardiac arrest (OHCA) outcome disparities remain poorly understood. We evaluated the role of receiving hospital on OHCA outcome disparities. Methods and Results We studied people with OHCA who survived to hospital admission from TX-CARES (Texas Cardiac Arrest Registry to Enhance Survival), 2014 to 2021. Using census data, we stratified OHCAs into majority (>50%) strata: non-Hispanic White race and ethnicity, non-Hispanic Black race and ethnicity, and Hispanic or Latino ethnicity. We stratified hospitals into performance quartiles based on the primary outcome, survival with good neurologic outcome. We evaluated the association between race and ethnicity and care at higher-performance hospitals. We compared 3 models evaluating the association between race and ethnicity and outcome: (1) ignoring hospital, (2) adjusting for hospital as a random intercept, and (3) adjusting for hospital performance quartile. We adjusted models for possible confounders. We included 10 434 OHCAs. Hospital performance quartile outcome rates ranged from 11.3% (fourth) to 37.1% (first). Compared with OHCAs in neighborhoods of majority White race, those in neighborhoods of majority Black race (odds ratio [OR], 0.1 [95% CI, 0.1-0.1]) and Hispanic or Latino ethnicity (OR, 0.2 [95% CI, 0.2-0.2]) were less likely to be cared for at higher-performing hospitals. Compared with White neighborhoods (30.1%) and ignoring hospital, outcomes were worse in Black neighborhoods (15.4%; adjusted OR [aOR], 0.5 [95% CI, 0.4-0.5]) and Hispanic or Latino neighborhoods (19.2%; aOR, 0.6 [95% CI, 0.5-0.7]). Adjusting for hospital as a random intercept, outcomes improved for Black neighborhoods (aOR, 0.9 [95% CI, 0.7-1.05]) and Hispanic or Latino neighborhoods (aOR, 0.9 [95% CI, 0.8-0.99]). Adjusting for hospital performance quartile, outcomes improved for Black neighborhoods (aOR, 0.8 [95% CI, 0.7-1.01]) and Hispanic or Latino neighborhoods (aOR, 0.9 [95% CI, 0.8-0.996]). Conclusions In Black and Hispanic or Latino communities, OHCAs were less likely to be cared for at higher-performing hospitals, and adjusting for receiving hospital improved OHCA outcome disparities.

Survey of resuscitation practices at emergency medical service agencies in the U.S.

Background: Survival for out-of-hospital cardiac arrest (OHCA) varies across emergency medical service (EMS) agencies. Yet, little is known about resuscitation response and quality improvement activities at EMS agencies. We describe herein a novel survey to EMS agencies in a U.S. registry for OHCA. Methods: Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 577 EMS agencies with ≥10 OHCA cases annually between 2015 and 2019 that remained active in CARES. We administered a survey to EMS directors regarding agency characteristics, cardiac arrest response, relationships with first responders and dispatchers, quality improvement activities and perceived barriers in the community. Results: Of eligible EMS agencies, 470 (81.5%) completed the survey. The high completion rate was likely due to frequent personalized emails and phone calls, liaising with CARES state coordinators to encourage survey response, and multiple periodic drawings of an automated external defibrillator during the survey period for participating EMS agencies. The survey examined rates of resuscitation training modalities; use of resuscitation equipment and devices in the field; frequency of simulation; non-EMS stakeholder response to OHCA (dispatchers, fire, police); quality improvement; and community factors affecting bystander response to OHCA. Conclusions: In this study design paper on the RED-CASO survey, we provide summary data on EMS agency characteristics in the U.S. Upon linkage to CARES patient-level data, this survey will provide critical insights into 'best practices' at EMS agencies with the highest OHCA survival rates as well as provide insights into current disparities in outcomes.

Cardiac Arrest Survival at Emergency Medical Service Agencies in Catchment Areas With Primarily Black and Hispanic Populations.

Importance: Black and Hispanic patients are less likely to survive an out-of-hospital cardiac arrest (OHCA) than White patients. Given the central importance of emergency medical service (EMS) agencies in prehospital care, a better understanding of OHCA survival at EMS agencies that work in Black and Hispanic communities and White communities is needed to address OHCA disparities. Objective: To examine whether EMS agencies serving catchment areas with primarily Black and Hispanic populations (Black and Hispanic catchment areas) have different rates of OHCA survival than agencies serving catchment areas with primarily White populations (White catchment areas). Design, Setting, and Participants: A cohort study including adults with nontraumatic OHCA from January 1, 2015, to December 31, 2019, in the Cardiac Arrest Registry to Enhance Survival was conducted. Data analysis was conducted from August 17, 2022, to July 7, 2023. Exposure: Emergency medical service agencies, categorized as working in catchment areas where the combination of Black and Hispanic residents made up more than 50% of the population or where White residents made up more than 50% of the population. Main Outcomes and Measures: The unit of analysis was the EMS agency. The primary outcome was agency-level risk-standardized survival rates (RSSRs) to hospital admission for OHCA at each EMS agency, which were calculated using hierarchical logistic regression and compared between agencies serving Black and Hispanic and White catchment areas. Whether differences in OHCA survival were explained by EMS and first responder measures was evaluated with additional adjustment for these factors. Results: Among 764 EMS agencies representing 258 342 OHCAs, 82 EMS agencies (10.7%) had a Black and Hispanic catchment area. Overall median age of the patients was 63.0 (IQR, 52.0-75.0) years, 36.1% were women, and 63.9% were men. Overall, the mean (SD) RSSR was 27.5% (3.6%), with lower survival at EMS agencies with Black and Hispanic catchment areas (25.8% [3.6%]) compared with agencies with White catchment areas (27.7% [3.5%]; P < .001). Among the 82 EMS agencies with Black and Hispanic catchment areas, a disproportionately higher number (32 [39.0%]) was in the lowest survival quartile, whereas a lower number (12 [14.6%]) was in the highest survival quartile. Additional adjustment for EMS response times, EMS termination of resuscitation rates, and first responder rates of initiating cardiopulmonary resuscitation or applying an automated external defibrillator before EMS arrival did not meaningfully attenuate differences in RSSRs between agencies with Black and Hispanic compared with White catchment areas (mean [SD] RSSRs after adjustment, 25.9% [3.3%] vs 27.7% [3.1%]; P < .001). Conclusions and Relevance: Risk-standardized survival rates for OHCA were 1.9% lower at EMS agencies working in Black and Hispanic catchment areas than in White catchment areas. This difference was not explained by EMS response times, rates of EMS termination of resuscitation, or first responder rates of initiating cardiopulmonary resuscitation or applying an automated external defibrillator. These findings suggest there is a need for further assessment of these discrepancies.

Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is an important global public health issue, but its epidemiology and outcomes in low-income and middle-income countries remain largely unknown. We aim to comprehensively describe the incidence, process of care, and outcomes of OHCA in China. METHODS: In the prospective, multicentre, population-based Baseline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA) registry study, participating sites were selected from both urban and rural areas in all seven geographical regions across China. All patients with OHCA assessed by emergency medical service (EMS) staff were consecutively enrolled from Aug 1, 2019, to Dec 31, 2020. Patients with suspected cardiac arrest assessed by bystanders whose return of spontaneous circulation was achieved without the need for defibrillation or EMS personnel cardiopulmonary resuscitation were excluded. Patients with all key variables missing were excluded, including resuscitation attempt, age, sex, witnessed status, cause, all process of care indicators, and all outcome measures. In this analysis, we included data for EMS agencies serving 25 monitoring sites (20 urban and five rural) that included the entire serving population, data for the whole of 2020, and at least 50 OHCA patients in 2020. Data were collected and reported using the Utstein template. We calculated the crude incidence of EMS-assessed OHCA in 2020. We also report data on baseline characteristics (including sex, cause, location of OHCA, and presence of shockable rhythm), process of care (including EMS response time, cardiopulmonary resuscitation, defibrillation, and advanced life support), and outcomes of non-traumatic OHCA between Aug 1, 2019, and Dec 31, 2020, including survival and survival with favourable neurological outcomes at discharge or 30 days, and at 6 and 12 months. FINDINGS: Of 115·1 million people served by the 25 participating sites, 132 262 EMS-assessed patients with OHCA were enrolled, and resuscitation was attempted for 42 054 (31·8%) patients between Aug 1, 2019, and Dec 31, 2020. The crude incidence of EMS-assessed OHCA was 95·7 per 100 000 population (95% CI 95·6-95·8) in 2020. Among 38 227 individuals with non-traumatic OHCA, 25 958 (67·9%) were male, 30 282 (79·2%) had a cardiac arrest at home, 32 523 (85·1%) had a presumed cardiac cause, and 2297 (6·0%) presented with an initial shockable rhythm. 4049 (11·5%) of 35 090 patients with an unwitnessed or bystander-witnessed OHCA received dispatcher-assisted cardiopulmonary resuscitation and 7121 (20·3%) received bystander cardiopulmonary resuscitation; only 14 (<0·1%) patients were assessed by bystanders with an automated external defibrillator. The median EMS response time was 12 min (IQR 9-16). At hospital discharge or 30 days, 441 (1·2%) of 38 227 survived, 304 (0·8%) survived up to 6 months, and 269 (0·7%) up to 12 months. At hospital discharge or 30 days, 309 (0·8%) survived with favourable neurological outcomes, 257 (0·7%) had favourable neurological outcomes at 6 months, and 236 (0·6%) at 12 months. INTERPRETATION: Our findings revealed a high burden of EMS-assessed OHCA with a low proportion of resuscitation attempts. The suboptimal implementation of chain of survival and unsatisfactory prognosis call for national efforts to improve the care and outcomes of patients with OHCA in China. FUNDING: The National Science & Technology Fundamental Resources Investigation Program of China, the State Key Program of the National Natural Science Foundation of China, Taishan Pandeng Scholar Program of Shandong Province, the Key Research & Development Program of Shandong Province, the Interdisciplinary Young Researcher Groups Program of Shandong University, the Clinical Research Center of Shandong University, the ECCM Program of Clinical Research Center of Shandong University, and the Natural Science Foundation of Shandong Province.

Fine and coarse particulate air pollution and out-of-hospital cardiac arrest onset: a nationwide case-crossover study in China.

Out-of-hospital cardiac arrest (OHCA) is a global public health concern. Nationwide studies on the effects of short-term exposure to particulate matter (PM) on OHCA risk are rare in regions with high PM levels, and evidence for coarse PM (PM2.5-10) is limited and inconsistent. To evaluate the associations between fine PM (PM2.5) and PM2.5-10 and OHCA onset, a time-stratified case-crossover study was conducted on 77,261 patients with cardiac OHCA in 26 cities across China in 2020. Daily PM2.5 and PM2.5-10 concentrations were assessed with high-resolution and full-coverage PM estimations. Conditional logistic regression models were applied in analyses. Each interquartile range of PM increase in 3-day moving average was associated with an increased risk of cardiac OHCA onset of 2.37% (95% CI, 1.20-3.56%) for PM2.5 and 2.12% (95% CI, 0.70-3.56%) for PM2.5-10. Stratified analyses showed higher susceptibility in patients over 75 years for PM2.5 exposure and with diabetes for PM2.5-10. This first nationwide study in region with high PM levels and great PM variability found not only PM2.5 but also PM2.5-10 were associated with a higher risk of OHCA onset, which could add powerful epidemiological evidence to this field and provide new evidence for the formulation of air quality guidelines.

Three-year trends in out-of-hospital cardiac arrest across the world: Second report from the International Liaison Committee on Resuscitation (ILCOR).

BACKGROUND: The International Liaison Committee on Resuscitation (ILCOR) Research and Registries Working Group previously reported data on systems of care and outcomes of out-of-hospital cardiac arrest (OHCA) in 2015 from 16 national and regional registries. To describe the temporal trends with updated data on OHCA, we report the characteristics of OHCA from 2015 through 2017. METHODS: We invited national and regional population-based OHCA registries for voluntary participation and included emergency medical services (EMS)-treated OHCA. We collected descriptive summary data of core elements of the latest Utstein style recommendation during 2016 and 2017 at each registry. For registries that participated in the previous 2015 report, we also extracted the 2015 data. RESULTS: Eleven national registries in North America, Europe, Asia, and Oceania, and 4 regional registries in Europe were included in this report. Across registries, the estimated annual incidence of EMS-treated OHCA was 30.0-97.1 individuals per 100,000 population in 2015, 36.4-97.3 in 2016, and 40.8-100.2 in 2017. The provision of bystander cardiopulmonary resuscitation (CPR) varied from 37.2% to 79.0% in 2015, from 2.9% to 78.4% in 2016, and from 4.1% to 80.3% in 2017. Survival to hospital discharge or 30-day survival for EMS-treated OHCA ranged from 5.2% to 15.7% in 2015, from 6.2% to 15.8% in 2016, and from 4.6% to 16.4% in 2017. CONCLUSION: We observed an upward temporal trend in provision of bystander CPR in most registries. Although some registries showed favourable temporal trends in survival, less than half of registries in our study demonstrated such a trend.

Efforts to Improve Survival Outcomes of Out-of-Hospital Cardiac Arrest in China: BASIC-OHCA.

BACKGROUND: Establishing registries to collect demographic characteristics, processes of care, and outcomes of patients with out-of-hospital cardiac arrest (OHCA) can better understand epidemiological trends, measure care quality, and identify opportunities for improvement. This study aimed to describe the design, implementation, and scientific significance of a nationwide registry-the BASIC-OHCA (Baseline Investigation of Out-of-Hospital Cardiac Arrest)-in China. METHODS: BASIC-OHCA was designed as a prospective, multicenter, observational, population-based study. The BASIC-OHCA registry was developed based on Utstein templates. BASIC-OHCA includes all OHCA patients confirmed by emergency medical services (EMS) personnel regardless of age, sex, or cause. Patients declared dead at the scene by EMS personnel for any reasons are also included. To fully characterize an OHCA event, BASIC-OHCA collects data from 3 sources-EMS, the receiving hospital, and patient follow-up-and links them to form a single record. Once data entry is completed and quality is checked, individual identifiers are stripped from the record. RESULTS: Currently, 32 EMS agencies in 7 geographic regions contribute data to BASIC-OHCA. They are distributed in the urban and rural areas, covering ≈9% of the population of mainland China. Data collection started on August 1, 2019. By July 31, 2020, a total of 92 913 EMS-assessed OHCA patients were enrolled. Among 28969 (31.18%) EMS-treated OHCAs, the mean age was 65.79±17.36 years, and 68.35% were males. The majority of OHCAs (76.85%) occurred at home or residence. A shockable initial rhythm was reported in 5.43% of patients. Any return of spontaneous circulation, survival to hospital discharge, and favorable neurological outcome at hospital discharge were 5.98%, 1.15%, and 0.83%, respectively. CONCLUSIONS: BASIC-OHCA is the first nationwide registry on OHCA in China. It can be used as a public health surveillance system and as a platform to produce evidence-based practices to help identify opportunities for improvement. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03926325.

Sex differences in the association between bystander CPR and survival for Out-of-Hospital cardiac arrest.

BACKGROUND: Prior studies have identified socio-cultural barriers in laypersons performing high-quality cardiopulmonary resuscitation (CPR) in women. Whether the effect of layperson bystander CPR on survival from out-of-hospital cardiac arrest (OHCA) differs by patients' sex is unknown. METHODS: Using data during 2013-2020 from an OHCA registry in the U.S., we identified adult patients with non-traumatic OHCA. The primary outcome was favorable neurological survival and the secondary outcome was survival to discharge. Multivariable logistic regression models evaluated the interaction between patients' sex and bystander CPR with survival, adjusted for patient and cardiac arrest characteristics. RESULTS: Of 420,671 patients with OHCA, 151,145 (35.9 %) occurred in women and 269,526 (64.1 %) in men. Rates of layperson bystander CPR were similar between women (38.3 %) and men (40.0 %). Rates of favorable neurological survival were 11.4 % in those with bystander CPR and 5.6 % in those without, but the association between bystander CPR and favorable neurological survival was weaker for women than men (women: adjusted OR, 1.33 [95 % CI: 1.27-1.39]; men: adjusted OR, 1.55 [95 % CI: 1.51-1.61]; interaction p < 0.001)]. Rates of survival to discharge were 13.1 % and 7.3 % in those with and without layperson bystander CPR, and the association between bystander CPR was weaker for women than men (women: adjusted OR, 1.21 [95 % CI: 1.16-1.26]; men: adjusted OR, 1.43 [95 % CI: 1.39-1.47]; interaction p < 0.001). CONCLUSIONS: For OHCA, bystander CPR was associated with higher survival in women and men. However, as currently practiced, the association between bystander CPR and higher survival was weaker for women as compared with men.

Alignment of targeted temperature management treatment with patients' mortality risk for out-of-hospital cardiac arrest.

OBJECTIVE: To examine whether TTM treatment was aligned with predicted mortality risk in patients with resuscitated OHCA during a period when it was a class I guideline-recommended therapy. METHODS: Within the Cardiac Arrest Registry to Enhance Survival for OHCA, we identified adult patients with OHCA who survived to hospital admission and were presumed eligible for TTM. Multivariable models were constructed using pre-hospital variables to predict in-hospital death in patients with shockable and non-shockable rhythms. Within each rhythm category, we divided patients into deciles of predicted mortality risk and examined TTM treatment rates across deciles. RESULTS: From 2013-2019, there were 25,882 successfully resuscitated patients with shockable rhythms and 43,414 patients with non-shockable rhythms presumed eligible for TTM. Of patients with shockable rhythms, predicted in-hospital mortality ranged from 16%-78% in deciles 1-10. TTM treatment increased from 44% in decile 1 to 59% in decile 10 (P for trend < 0.001), but over a third of patients in deciles 4-9 were not treated with TTM. Of patients with non-shockable rhythms, predicted mortality ranged from 48%-95% in deciles 1-10. Although TTM treatment rates increased from 36% in decile 1 to 43% in decile 10 (P for trend 0.003), TTM treatment rates were agnostic to mortality risk (44% to 47%) from decile 2-9. CONCLUSION: TTM treatment patterns were not well-aligned with patients' mortality risk during a period when it was a guideline-recommended treatment for OHCA. Identifying strategies to better align guideline-recommended treatments with patients' mortality risk is critical for efforts to improve OHCA survival.

Long-Term Outcomes for Out-of-Hospital Cardiac Arrest in Elderly Patients: An Analysis of Cardiac Arrest Registry to Enhance Survival Data Linked to Medicare Files.

BACKGROUND: Most studies on out-of-hospital cardiac arrest have primarily focused on in-hospital or short-term survival. Little is known about long-term outcomes and resource use among survivors of out-of-hospital cardiac arrest. METHODS: In this observationsl study, we describe overall long-term outcomes for patients from the national Cardiac Arrest Registry to Enhance Survival linked to Medicare files to create the Cardiac Arrest Registry to Enhance Survival: Mortality, Events, and Costs for Cardiac Arrest survivors dataset. Cardiac Arrest Registry to Enhance Survival data between 2013 and 2019 were linked to Medicare data using probabilistic matching algorithms. Overall long-term mortality, readmissions, and index hospitalization costs are reported for the overall cohort. RESULTS: Among 56 425 patients who were 65 years of age or older in Cardiac Arrest Registry to Enhance Survival who survived to hospital admission, 26 875 (47.6%) were successfully linked to Medicare files. Mean (+SD) cost of the index hospitalization was $23 262+$24 199 and the median cost was $14 636 (interquartile range, $9930-$30 033). Overall, 8676 (32.3%) survived to hospital discharge with 38.0% discharged home, 11.8% to hospice care, and the remaining 50.2% to other inpatient, skilled nursing care, or rehabilitation facilities. Mortality after discharge was initially high (27.0% at 3 months) and then increased gradually, with 1- and 3-year mortality of 37.1% and 50.1%, respectively. During the first year, 40.1% were readmitted at least once, with 19.7% readmitted on > 1 occasion. CONCLUSIONS: The Cardiac Arrest Registry to Enhance Survival: Mortality, Events, and Costs for Cardiac Arrest survivors registry includes rich data on postdischarge outcomes and resource utilization. Use of this dataset will enable future investigations on the long-term effectiveness, costs, and cost-effectiveness of various interventions for out-of-hospital cardiac arrest in elderly patients.

Racial and Ethnic Differences in Bystander CPR for Witnessed Cardiac Arrest.

BACKGROUND: Differences in the incidence of cardiopulmonary resuscitation (CPR) provided by bystanders contribute to survival disparities among persons with out-of-hospital cardiac arrest. It is critical to understand whether the incidence of bystander CPR in witnessed out-of-hospital cardiac arrests at home and in public settings differs according to the race or ethnic group of the person with cardiac arrest in order to inform interventions. METHODS: Within a large U.S. registry, we identified 110,054 witnessed out-of-hospital cardiac arrests during the period from 2013 through 2019. We used a hierarchical logistic regression model to analyze the incidence of bystander CPR in Black or Hispanic persons as compared with White persons with witnessed cardiac arrests at home and in public locations. We analyzed the overall incidence as well as the incidence according to neighborhood racial or ethnic makeup and income strata. Neighborhoods were classified as predominantly White (>80% of residents), majority Black or Hispanic (>50% of residents), or integrated, and as high income (an annual median household income of >$80,000), middle income ($40,000-$80,000), or low income (<$40,000). RESULTS: Overall, 35,469 of the witnessed out-of-hospital cardiac arrests (32.2%) occurred in Black or Hispanic persons. Black and Hispanic persons were less likely to receive bystander CPR at home (38.5%) than White persons (47.4%) (adjusted odds ratio, 0.74; 95% confidence interval [CI], 0.72 to 0.76) and less likely to receive bystander CPR in public locations than White persons (45.6% vs. 60.0%) (adjusted odds ratio, 0.63; 95% CI, 0.60 to 0.66). The incidence of bystander CPR among Black and Hispanic persons was less than that among White persons not only in predominantly White neighborhoods at home (adjusted odds ratio, 0.82; 95% CI, 0.74 to 0.90) and in public locations (adjusted odds ratio, 0.68; 95% CI, 0.60 to 0.75) but also in majority Black or Hispanic neighborhoods at home (adjusted odds ratio, 0.79; 95% CI, 0.75 to 0.83) and in public locations (adjusted odds ratio, 0.63; 95% CI, 0.59 to 0.68) and in integrated neighborhoods at home (adjusted odds ratio, 0.78; 95% CI, 0.74 to 0.81) and in public locations (adjusted odds ratio, 0.73; 95% CI, 0.68 to 0.77). Similarly, across all neighborhood income strata, the frequency of bystander CPR at home and in public locations was lower among Black and Hispanic persons with out-of-hospital cardiac arrest than among White persons. CONCLUSIONS: In witnessed out-of-hospital cardiac arrest, Black and Hispanic persons were less likely than White persons to receive potentially lifesaving bystander CPR at home and in public locations, regardless of the racial or ethnic makeup or income level of the neighborhood where the cardiac arrest occurred. (Funded by the National Heart, Lung, and Blood Institute.).

Management of Out-of-Hospital Cardiac Arrest during COVID-19: A Tale of Two Cities.

Variations in the impact of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) have been reported. We aimed to, using population-based registries, compare community response, Emergency Medical Services (EMS) interventions and outcomes of adult, EMS-treated, non-traumatic OHCA in Singapore and metropolitan Atlanta, before and during the pandemic. Associations of OHCA characteristics, pre-hospital interventions and pandemic with survival to hospital discharge were analyzed using logistic regression. There were 2084 cases during the pandemic (17 weeks from the first confirmed COVID-19 case) and 1900 in the pre-pandemic period (corresponding weeks in 2019). Compared to Atlanta, OHCAs in Singapore were older, received more bystander interventions (cardiopulmonary resuscitation (CPR): 65.0% vs. 41.4%; automated external defibrillator application: 28.6% vs. 10.1%), yet had lower survival (5.6% vs. 8.1%). Compared to the pre-pandemic period, OHCAs in Singapore and Atlanta occurred more at home (adjusted odds ratio (aOR) 2.05 and 2.03, respectively) and were transported less to hospitals (aOR 0.59 and 0.36, respectively) during the pandemic. Singapore reported more witnessed OHCAs (aOR 1.96) yet less bystander CPR (aOR 0.81) during pandemic, but not Atlanta (p < 0.05). The impact of COVID-19 on OHCA outcomes did not differ between cities. Changes in OHCA characteristics and management during the pandemic, and differences between Singapore and Atlanta were likely the result of systemic and sociocultural factors.

Race and ethnicity data in the cardiac arrest registry to enhance survival: Insights from medicare self-reported data.

BACKGROUND: For out-of-hospital cardiac arrest (OHCA), assignment of race/ethnicity data can be challenging. Validation of race/ethnicity in registry data with patients' self-reported race/ethnicity would provide insights regarding misclassification. METHODS: Using recently linked 2013-2019 Cardiac Arrest Registry to Enhance Survival (CARES) data with Medicare files, we examined the concordance of race/ethnicity in CARES with self-reported race/ethnicity in Medicare. Among patients with unknown race/ethnicity in CARES, race/ethnicity data from Medicare files were reported. RESULTS: Of 26,875 patients in the linked data, 5757 (21.4%) had unknown race/ethnicity in CARES. Of the remaining 21,118 patients, 14,284 (67.6%) were identified in CARES as non-Hispanic White, 4771 (22.6%) as non-Hispanic Black, 1213 (5.7%) as Hispanic, 760 (3.6%) as Asian or Pacific Islander, and 90 (0.4%) as American Indian or Alaskan Native. The concordance rate for race/ethnicity between CARES and Medicare was 93.4% for patients reported as non-Hispanic White in CARES, 89.1% for non-Hispanic Blacks, 74.6% for Hispanics, 69.6% for Asians and Pacific Islanders, and 37.8% for American Indian or Alaskan Natives. For the 5757 patients with unknown race/ethnicity in CARES, 3973 (69.0%) self-reported in Medicare as non-Hispanic White, 617 (10.7%) as non-Hispanic Black, 425 (7.4%) as Hispanic, 491 (8.5%) as Asian or Pacific Islander, and 52 (0.9%) as American Indian or Alaskan Native. Race/ethnicity remained unknown in 199 (3.5%) of patients. CONCLUSION: Race/ethnicity in CARES was highly concordant with self-reported race/ethnicity in Medicare, especially for non-Hispanic White and Black individuals. For patients with unknown race/ethnicity data in CARES, the vast majority were of White race.