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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.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.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.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.

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.

There are conflicting data regarding the benefit of compression-only bystander cardiopulmonary resuscitation (CO-CPR) compared with CPR with rescue breathing (RB-CPR) after pediatric out-of-hospital cardiac arrest (OHCA).This study sought to test the hypothesis that RB-CPR is associated with improved neurologically favorable survival compared with CO-CPR following pediatric OHCA, and to characterize age-stratified outcomes with CPR type compared with no bystander CPR (NO-CPR).Analysis of the CARES registry (Cardiac Arrest Registry to Enhance Survival) for nontraumatic pediatric OHCAs (patients aged ≤18 years) from 2013-2019 was performed. Age groups included infants (1 year), children (1 to 11 years), and adolescents (≥12 years). The primary outcome was neurologically favorable survival at hospital discharge.Of 13,060 pediatric OHCAs, 46.5% received bystander CPR. CO-CPR was the most common bystander CPR type. In the overall cohort, neurologically favorable survival was associated with RB-CPR (adjusted OR: 2.16; 95% CI: 1.78-2.62) and CO-CPR (adjusted OR: 1.61; 95% CI: 1.34-1.94) compared with NO-CPR. RB-CPR was associated with a higher odds of neurologically favorable survival compared with CO-CPR (adjusted OR: 1.36; 95% CI: 1.10-1.68). In age-stratified analysis, RB-CPR was associated with better neurologically favorable survival versus NO-CPR in all age groups. CO-CPR was associated with better neurologically favorable survival compared with NO-CPR in children and adolescents, but not in infants.CO-CPR was the most common type of bystander CPR in pediatric OHCA. RB-CPR was associated with better outcomes compared with CO-CPR. These results support present guidelines for RB-CPR as the preferred CPR modality for pediatric OHCA.

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. 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.

Background The Utstein population is defined by non-traumatic, bystander-witnessed out-of-hospital cardiac arrest (OHCA) presenting with ventricular fibrillation (VF). It is used to compare resuscitation performance across emergency medical services (EMS) systems. We hypothesized a system-specific survival correlation between the current Utstein population and other VF populations defined by unwitnessed VF OHCA and VF OHCA after EMS arrival (EMS-witnessed). Expanding performance metrics to this more comprehensive population would make the Utstein definition more representative of the actual community burden and response to VF OHCA. Methods We performed a cohort investigation of all non-traumatic, VF OHCA in the Cardiac Arrest Registry to Enhance Survival from 1/1/2013-12/31/2018 among EMS agencies that treated > = 100 VF OHCA. We evaluated sample size and survival with the addition of the new VF populations. We used Pearson coefficient to assess whether there was a correlation of agency-specific survival outcomes between the current Utstein population and unwitnessed and EMS-witnessed VF OHCA. Results A total of 107 EMS agencies treated 38,836 VF arrests: 22,918 current Utstein, 11,297 unwitnessed VF, and 4621 EMS-witnessed VF OHCA. Overall, survival was 29.8% (11,567/38,836): 33.9% (7774/22,918) among current Utstein, 17.2% (1942/11,297) among unwitnessed VF, and 40.1% (1851/4621) among EMS-witnessed VF. For agency-specific survival outcome, the Pearson correlation was 0.52 between the current Utstein population versus combined unwitnessed and EMS-witnessed groups. For survival with Cerebral Performance Category 1–2, the Pearson correlation was 0.61. Conclusion Expanding the Utstein population to include unwitnessed and EMS-witnessed VF OHCA achieves a simpler, more inclusive case definition that minimizes variability in case determination and increases the number of survivors and eligible population by ∼50%, while still achieving a distinguishing metric of system-specific performance.

In-hospital cardiac arrest (IHCA) is a common clinical event with poor outcomes. Former IHCA registries in China were local, inconsistent in data reporting, and lacked attention to the process of care. Therefore, we designed and implemented the BASeline Investigation of In-hospital Cardiac Arrest (BASIC-IHCA), the first national IHCA registry in China.BASIC-IHCA is a prospective, multicenter, observational study with a nationwide surveillance network covering urban and rural hospitals from seven geographic regions of China. IHCA patients were enrolled continuously, and data were collected from medical records by investigators at participating hospitals. Key variables referring to the updated Utstein Template included patient information, event variables, process of care, and outcomes. Follow-up was conducted by telephone interview to obtain details on long-term survival and neurological status.Thirty-two urban hospitals and eight rural hospitals from twenty-nine provinces in seven geographic regions of China participated in BASIC-IHCA. The starting time of enrollment ranged from July 1, 2019, to January 1, 2020. By December 31, 2020, 35,451 IHCAs were enrolled in all participating hospitals, of which 19,493 (55%) received CPR, with a predominance of males (65%) and a median age of 65 years.BASIC-IHCA is the first national registry for IHCA in China. It will describe the epidemiology and outcomes of IHCA from a nationwide perspective, with a particular focus on details of the process of care for quality improvement. Meanwhile, it will help to facilitate the standardization of IHCA-related data reporting in China.

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.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.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).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.

Everyday, nearly 1000 U.S. adults experience out-of-hospital cardiac arrest (OHCA). Survival to hospital discharge varies across many factors, including sociodemographics, location of arrest, and whether bystander intervention was provided. The current study examines recent trends in OHCA survival by location of arrest using a cohort of emergency medical service (EMS) agencies that contributed data to the Cardiac Arrest Registry to Enhance Survival.The 2015 CARES cohort (N = 122,613) includes EMS agencies contributing data across five consecutive years, 2015-2019. We assessed trends in EMS-attended OHCA survival for the 2015 CARES cohort by location of arrest - public, residential, nursing home. Unadjusted and adjusted percentages were estimated using 3-level hierarchical logistic regression models among cases aged 18-65 years.Overall, survival from EMS-attended OHCA significantly increased from 12.5% in 2015 to 13.8% in 2019 (p = 0.001). Survival from bystander witnessed arrests also increased significantly from 17.8% in 2015 to 19.7% in 2019 (p = 0.004). The trend for survival increased overall and for bystander witnessed OHCAs occurring in public places and nursing homes.Increasing trends for EMS-attended OHCA survival were observed in the overall and bystander witnessed groups. No change in the trend for survival was observed among OHCAs in the groups most likely to have a desirable outcome - bystander witnessed, with a shockable rhythm, and receiving bystander intervention. Reporting and monitoring of OHCA may be an important first step in improving outcomes. Additional community interventions focused on bystander CPR and AED use may be warranted.

Background: Bystander cardiopulmonary resuscitation (CPR) is associated with a better survival outcome in patients with out-of-hospital cardiac arrest (OHCA). However, there may be cultural barriers in performing high-quality bystander CPR in women in some non-Western countries and the effect of bystander CPR on survival outcomes may differ by patients’ sex. Methods: Using data between 2012-2018 from a national OHCA registry from the Republic of Korea, we identified adult patients with OHCA of presumed cardiac etiology. The main exposures were bystander CPR and patients’ sex. The primary outcome was survival discharge and the secondary outcome was favorable neurological survival. Multivariable logistic regression evaluated the association between bystander CPR and survival, adjusted for patients’ age, sex, socio-economic status, year of arrest, witnessed arrest status, initial OHCA rhythm, location of arrest, urbanization level of arrest location, and type of bystander. The interaction between bystander CPR and sex was explicitly evaluated in the models. Results: Of 101,505 patients with OHCA in the cohort, 34,124 (33.6 %) were women and 67,381 (64.4 %) were men. Bystander CPR was performed on 18,481 (54.2%) women and 35,904 (53.3%) men (p=0.07). Unadjusted rates of survival discharge were 4.5% in women and 9.5 % in men (p Conclusions: In a national registry of OHCA from the Republic of Korea, men who received bystander CPR were more likely to survive whereas women who received bystander CPR were not.

Background: Given the diversity of patients resuscitated from out-of-hospital cardiac arrest (OHCA) complicated by STEMI, adequate risk adjustment is needed to account for potential differences in case-mix to reflect the quality of percutaneous coronary intervention. Objectives: We sought to build a risk-adjustment model of in-hospital mortality outcomes for patients with OHCA and STEMI requiring emergent angiography. Methods: Within the Cardiac Arrest Registry to Enhance Survival, we included adult patients with OHCA and STEMI who underwent angiography within 2 hours from January 2013 to December 2019. Using pre-hospital patient and arrest characteristics, multivariable logistic regression models were developed for in-hospital mortality. We then described model calibration, discrimination, and variability in patients’ unadjusted and adjusted mortality rates. Results: Of 2,999 hospitalized patients with OHCA and STEMI who underwent emergent angiography (mean age 61.2 ±12.0, 23.1% female, 64.6% white), 996 (33.2%) died. The final risk-adjustment model for mortality included higher age, unwitnessed arrest, non-shockable rhythms, not having sustained return of spontaneous circulation upon hospital arrival, and higher total resuscitation time on scene ( C -statistic, 0.804 with excellent calibration). The risk-adjusted proportion of patients died varied substantially and ranged from 7.8% at the 10 th percentile to 74.5% at the 90 th percentile (Figure). Conclusions: Through leveraging data from a large, multi-site registry of OHCA patients, we identified several key factors for better risk-adjustment for mortality-based quality measures. We found that STEMI patients with OHCA have highly variable mortality risk and should not be considered as a single category in public reporting. These findings can lay the foundation to build quality measures to further optimize care for the patient with OHCA and STEMI.

Background Approximately 1000 out-of-hospital cardiac arrest (OHCA) occur each day in the United States. Although sex differences exist for other cardiovascular conditions such as stroke and acute myocardial infarction, they are less well understood for OHCA. Specifically, the extent to which neurological and survival outcomes after OHCA differ between men and women remains poorly characterized in the U.S. Methods and results Within the national Cardiac Arrest Registry to Enhance Survival (CARES) registry, we identified 326,138 adults with an OHCA from 2013 to 2019. Using multivariable logistic regression, we evaluated for sex differences in rates of survival to hospital admission, survival to hospital discharge, and favorable neurological survival (i.e., without severe neurological disability), adjusted for demographics, cardiac arrest characteristics and bystander interventions. Overall, 117,281 (36%) patients were women. Median age was 62 and 65 years for men and women, respectively. An initial shockable rhythm (25.1% vs 14.7%, standardized difference of 0.26) and an arrest in a public location (22.2% vs. 11.3%; standardized difference of 0.30) were more common in men, but there were no meaningful sex differences in rates of witnessed arrests, bystander cardiopulmonary resuscitation, intra-venous access, or use of mechanical devices for delivering cardiopulmonary resuscitation. Overall, the unadjusted rates of all survival outcomes were similar between men and women: survival to hospital admission (27.0% for men vs. 27.9% for women, standardized difference of −0.02), survival to hospital discharge (10.5% for men vs. 8.6% for women, standardized difference of 0.07), and favorable neurological survival (9.0% for men vs. 6.6% for women, standardized difference of 0.09). After multivariable adjustment, however, men were less likely to survive to hospital admission (adjusted OR = 0.75, 95% CI: 0.73, 0.77), survive to hospital discharge (adjusted OR = 0.83, 95% CI: 0.80, 0.85), or have favorable neurological survival (adjusted OR = 0.88, 95% CI: 0.85, 0.91). Conclusions Compared to women, men with OHCA have more favorable cardiac arrest characteristics but were less likely to survive to hospital admission, survive to discharge, nor have favorable neurological survival.

Objective To estimate the annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest (OHCA) in the United States (U.S.). Methods All adult (age ≥ 18 years) non-traumatic EMS-treated OHCA with complete data for age, sex, race, and survival outcomes from the CARES database for 2013–2018 were included. Annual and lifetime labor productivity values, based on age and gender, were obtained from previously published national economic data. Productivity losses for OHCA events were calculated by year in U.S. dollars. Productivity losses for survivors were assigned by cerebral performance category score (CPC): CPC 1 and 2 = 0% productivity loss; CPC 3–5 = 100% productivity loss. Sensitivity analyses were performed assigning CPC 2 varying productivity losses (0–100%) based on CPC score and discharge location. Lifetime productivity values assumed 1% annual growth and 3% discount rate and were adjusted for inflation based on 2016 values. Results were extrapolated to annual U.S. population estimates for the study period. Results A total of 338,492 (96.5%) cases met inclusion criteria. The mean annual and lifetime productivity losses per OHCA in 2018 were $48,224 and $638,947 respectively. The total annual economic productivity loss due to OHCA in the U.S. increased from $7.4B in 2013 to $11.3B in 2018. Lifetime economic productivity loss increased from $95.2B in 2013 to $150.2B in 2018. Sensitivity analyses yielded similar findings. Per annual death, OHCA ranked third ($10.2B) in annual economic productivity loss in the U.S. behind cancer ($22.9B) and heart disease ($20.3B) in 2018. Conclusion Adult non-traumatic OHCA events are associated with significant annual and lifetime economic productivity losses and should be the focus of public health resources to improve preventative measures and survival outcomes.

Background: Left heart catheterization (LHC) and TTM are proven beneficial after OHCA. Detroit CARES data found a strong, though insignificant, trend for LHC rate and survival (p = 0.1). In 2018, the rate of patients with LHC and good CPC nearly doubled, despite an overall decrease in LHC rate. Therefore, we hypothesize LHC is performed later (after second day of hospitalization) nationwide and a good CPC is likely associated with selection of patients expected to survive. Methods: We analyzed the national CARES registry (2013 - 2018) to investigate whether delayed LHC after OHCA was occurring nationally. Included were patients 18 or older, non-skilled care facility patients and surviving to admission. The primary outcome was the CPC dichotomized into good (1 or 2) and poor (3 - 5). A propensity score was derived to predict early LHC that incorporated factors associated with LHC and outcome. A multi-level logistic regression analyses was fit using inverse weighted propensity scores. The primary predictor of interest was early LHC relative to no or late LHC. Also examined were TTM, year of cardiac arrest, and other predictors. Results reported are odds ratios (OR) and the corresponding 95% confidence intervals (95% CI). Results: 62,195 individual cases were identified; the median age was 61, (IQR-16), 62% male, 32% unwitnessed, 37% bystander CPR, and 35% initial shockable rhythm. 29% had good outcome and 22% received early LHC, 6% late LHC and 72% no LHC. 13% of patients receiving early LHC and 23% with no or late LHC had a good outcome. OR and 95% CI for good outcome were: 2.4 (2.2-2.7) for early LHC, 3.6 (3.3-3.8) for shockable rhythm, 1.9 (1.7-2.0) for public location and 2.0 (1.8-2.2) for witnessed arrest. Over the five-year period, no change in the total LHC occurred and a slight decrease in early LHC, (25%-23%), (Fig 1). Conclusion: Early LHC was associated with good outcome (CPC) at hospital discharge. The overall LHC rate is unchanged from 2013-18 with a slight decrease in early LHC.

Objective: To estimate the annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest (OHCA) in the United States (U.S.) over a 5-year study period between 2013-2018. Methods: All adult (age≥ 18 years) non-traumatic EMS-treated OHCA with complete data for age, sex, race, and survival outcomes from the CARES database for the most recently available 5-year period were included. Annual and lifetime labor productivity values, based on age and gender, were obtained from previously published national economic data. Productivity losses for OHCA events were calculated by year. Productivity losses for survivors were assigned by cerebral performance category score (CPC): CPC 1 and 2 = 0% productivity loss; CPC 3-5 = 100% productivity loss. Sensitivity analyses were performed assigning CPC 2 varying productivity losses (0-100%). Lifetime productivity values assumed 1% annual growth and 3% discount rate. Productivity data are presented in U.S. dollars and adjusted for inflation based on 2016 values. Results were extrapolated to the annual U.S. population. Results: A total of 338,492 (96.5%) cases met inclusion criteria. The mean annual and lifetime productivity losses per OHCA in 2018 were $48,224 and $638,947 respectively. Total annual and lifetime productivity losses for the study population in 2018 were $3.8 billion and $50.6 billion, respectively. Sensitivity analyses assigning CPC 2 varying productivity losses yielded similar findings. Males had a much larger lifetime productivity loss to approximately age 65 years compared to females (FIGURE 1). For the U.S. population in 2018, the total annual and lifetime productivity losses due to OHCA were $11.3 billion and $150.2 billion, respectively. Conclusion: Adult non-traumatic OHCA events are associated with significant annual and lifetime economic productivity losses and should be the focus of public health resources to improve preventative measures and survival outcomes.

Background: The Utstein population is defined by non-traumatic, bystander-witnessed out-of-hospital cardiac arrest (OHCA) presenting with ventricular fibrillation (VF). It is used to compare resuscitation performance across emergency medical services (EMS) systems. We hypothesized there being a system-specific survival correlation between the current Utstein and other VF populations inclusive of unwitnessed and EMS-witnessed VF OHCA that supports expanding performance metrics to this more comprehensive population that is more representative of the actual community burden of VF OHCA. Methods: We performed a cohort investigation of all non-traumatic, VF OHCA in the Cardiac Arrest Registry to Enhance Survival from 1/1/2013-12/31/2018 among EMS agencies that treated >=100 VF OHCA. We evaluated sample size and survival with the addition of the new VF populations. We used the Pearson coefficient to assess the correlation of agency-specific survival between the current Utstein population and unwitnessed and EMS-witnessed VF OHCA. Results: A total of 107 EMS agencies treated 38,836 VF arrests: 22,918 current Utstein, 11,297 unwitnessed VF, and 4621 EMS-witnessed VF OHCA. Overall, survival was 29.8% (11,567/38,836): 33.9% (7,774/22,918) among current Utstein, 17.2% (1942/11,297) among unwitnessed VF, and 40.1% (1851/4621) among EMS-witnessed VF. For agency-specific survival outcome, the Pearson correlation was 0.52 between current the Utstein population versus combined unwitnessed and EMS-witnessed groups. For survival with Cerebral Performance Category 1-2, the Pearson correlation was 0.61. Conclusion: Expanding the Utstein population to include unwitnessed and EMS-witnessed VF OHCA achieves a simpler, more inclusive case definition that minimizes variability in case determination and increases the number of survivors and eligible population by ~50%, while still achieving a distinguishing metric of system-specific performance.

Introduction: Bystander CPR (B-CPR) and defibrillation for sudden cardiac arrest (SCA) vary by gender with females being less likely to receive these interventions. Despite known differences by race and ethnicity, it is unknown whether gender disparities in B-CPR and defibrillation persist by neighborhood race and ethnicity. Objectives: We examined the likelihood of receiving B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition. We hypothesized that in public locations within Black neighborhoods, females will have a lower likelihood of receiving B-CPR compared to males. Methods: We conducted a retrospective cohort study using data from the US Cardiac Arrest Registry to Enhance Survival (CARES) registry. Neighborhoods were classified by census tract based on percent of Black or Hispanic residents using the threshold in the definition of “White flight” where Whites leave a neighborhood when it exceeds >30% of a minority population. We independently modeled the likelihood of receipt of B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition controlling for confounding variables. Results: From 2013-2018, CARES collected 350,722 US arrests; after excluding pediatric arrests, those witnessed by EMS, or those that occurred in a healthcare facility, 214,464 were included. Mean age was 64±16 and 65% were male; 39% received B-CPR, 9% received bystander defibrillation prior to 9-1-1 responders arrival, and 18% occurred in the public. In Black neighborhoods, females who had SCA in public locations were 22% less likely to receive B-CPR (OR: 0.78 (0.64-0.95), p=0.01) and 42% less likely to receive defibrillation (OR: 0.58 (0.45-0.74), p Conclusion: Females with public SCA have a decreased likelihood of receiving B-CPR and defibrillation, and these findings persist in Black and Hispanic neighborhoods. This has implications for strategies to reduce disparities around bystander response to SCA.

Introduction: Pre-hospital capabilities are minimally developed in Vietnam; therefore, the prognosis of OHCA might differ from that of other countries. The aim of this study was to investigate survival rate from OHCA and potential determinants of the chain of survival following an OHCA in a developing country. Hypothesis: Understanding the country-specific etiologies and the disease risk and prognosis of OHCA are crucial for reducing mortality in Vietnam, as well as in other countries that face challenges in clinical practice owing to limited medical resources. Methods: This is a multi-center prospective observational study of OHCA patients (age>18 years) presenting to the ED of three tertiary hospitals from February 2014 to December 2018. Factors associated with survival following OHCA were collected and compared among types of pre-hospital care transportation and between survival and non-survival to admission. Factors for survival to admission were assessed using logistic regression analysis. Results: Among 590 OHCA patients (male, 74.6%; age, 56.1±17.2 years), we observed low rates of survival to admission (24.2%) and discharge (14.1%). Of total patients, 67.8% occurred at home, 79.4% witnessed by bystanders, 124/555 (22.3%) received bystander CPR, a minority of patients (8.64%) was conveyed by EMS, and 49/152 (32.2%) received pre-hospital defibrillation. Multivariate analysis revealed that past medical history (PMH) of respiratory disease (OR, 3.128; 95% CI, 1.197-8.173), pre-hospital defibrillation (OR, 3.904; 95% CI, 1.540-9.898), pre-hospital advanced airway (OR, 3.441; 95% CI, 1.203-9.844) and ROSC at ED (OR, 2.891; 95% CI, 1.030-8.115) were independent factors for survival to admission. Following OHCA with cardiac etiology, EMS use (OR, 0.203; 95% CI, 0.044-0.935) was also an independent factor for survival to admission. Conclusions: This was a highly selected cohort of OHCA patients presenting to the ED. Many OHCA victims in Vietnam do not come to the ED. PMH of respiratory disease, pre-hospital defibrillation and advanced airway, and ROSC at ED were independent factors predicting survival to admission. EMS use was also an inverse and independent predictor of survival to admission among patients following OHCA with cardiac etiology.

IMPORTANCE: Recent reports from communities severely affected by the coronavirus disease 2019 (COVID-19) pandemic found lower rates of sustained return of spontaneous circulation (ROSC) for out-of-hospital cardiac arrest (OHCA). Whether the pandemic has affected OHCA outcomes more broadly is unknown. OBJECTIVE: To assess the association between the COVID-19 pandemic and OHCA outcomes, including in areas with low and moderate COVID-19 disease burden. DESIGN, SETTING, AND PARTICIPANTS: This study used a large US registry of OHCAs to compare outcomes during the pandemic period of March 16 through April 30, 2020, with those from March 16 through April 30, 2019. Cases were geocoded to US counties, and the COVID-19 mortality rate in each county was categorized as very low (0-25 per million residents), low (26-100 per million residents), moderate (101-250 per million residents), high (251-500 per million residents), or very high (>500 per million residents). As additional controls, the study compared OHCA outcomes during the prepandemic period (January through February) and peripandemic period (March 1 through 15). EXPOSURE: The COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: Sustained ROSC (≥20 minutes), survival to discharge, and OHCA incidence. RESULTS: A total of 19 303 OHCAs occurred from March 16 through April 30 in both years, with 9863 cases in 2020 (mean [SD] age, 62.6 [19.3] years; 6040 men [61.3%]) and 9440 in 2019 (mean [SD] age, 62.2 [19.2] years; 5922 men [62.7%]). During the pandemic, rates of sustained ROSC were lower than in 2019 (23.0% vs 29.8%; adjusted rate ratio, 0.82 [95% CI, 0.78-0.87]; P

Aim To estimate and trend disability-adjusted life years (DALY) following adult out-of-hospital cardiac arrest (OHCA) over time, and to compare OHCA DALY to other leading causes of death and disability in the U.S. Methods DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) database for 2013–2018 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total U.S. DALY. Data were reported as DALY total and rate. Data were compared to the top 10 causes of DALY in the U.S. Results 337,991 OHCA met study inclusion criteria. Total U.S. OHCA DALY increased from 3,005,308 in 2013 to 4,326,745 in 2018. The DALY rate increased from 950.9 per 100,000 individuals to 1322.4 per 100,000 individuals. OHCA DALY ranked fifth in the U.S. behind ischemic heart disease (2470), drug use disorders (1703), chronic obstructive pulmonary disease (1449), and back pain (1336). OHCA represented the largest percent increase in DALY rate (40.3%) over the study period. Conclusion Adult non-traumatic OHCA is a leading cause of DALY in the U.S. and the burden of disease due to OHCA has increased rapidly over time. These findings are likely due to more precise national OHCA surveillance, and suggest that the public health impact of OHCA is larger than previously described.

Background The natural cycle of large‐scale wildfires is accelerating, increasingly exposing both rural and populous urban areas to wildfire emissions. While respiratory health effects associated with wildfire smoke are well established, cardiovascular effects have been less clear. Methods and Results We examined the association between out‐of‐hospital cardiac arrest and wildfire smoke density (light, medium, heavy smoke) from the National Oceanic Atmospheric Association's Hazard Mapping System. Out‐of‐hospital cardiac arrest data were provided by the Cardiac Arrest Registry to Enhance Survival for 14 California counties, 2015–2017 (N=5336). We applied conditional logistic regression in a case‐crossover design using control days from 1, 2, 3, and 4 weeks before case date, at lag days 0 to 3. We stratified by pathogenesis, sex, age (19–34, 35–64, and ≥65 years), and socioeconomic status (census tract percent below poverty). Out‐of‐hospital cardiac arrest risk increased in association with heavy smoke across multiple lag days, strongest on lag day 2 (odds ratio, 1.70; 95% CI, 1.18–2.13). Risk in the lower socioeconomic status strata was elevated on medium and heavy days, although not statistically significant. Higher socioeconomic status strata had elevated odds ratios with heavy smoke but null results with light and medium smoke. Both sexes and age groups 35 years and older were impacted on days with heavy smoke. Conclusions Out‐of‐hospital cardiac arrests increased with wildfire smoke exposure, and lower socioeconomic status appeared to increase the risk. The future trajectory of wildfire, along with increasing vulnerability of the aging population, underscores the importance of formulating public health and clinical strategies to protect those most vulnerable.

Background Cardiac arrest is the leading cause of death among patients receiving hemodialysis. Despite guidelines recommending CPR training and AED presence in dialysis clinics, rates of CPR and AED use by dialysis staff are suboptimal. Given that racial disparities exist in bystander CPR administration in non-healthcare settings, we examined the relationship between patient race/ethnicity and staff-initiated CPR and AED application within dialysis clinics. Methods We analyzed data prospectively collected in the Cardiac Arrest Registry to Enhance Survival across the U.S. from 2013 to 2017 and the Centers for Medicare & Medicaid Services dialysis facility database to identify outpatient dialysis clinic cardiac arrest events. Using multivariable logistic regression models, we examined relationships between patient race/ethnicity and dialysis staff-initiated CPR and AED application. Results We identified 1568 cardiac arrests occurring in 809 hemodialysis clinics. The racial/ethnic composition of patients was 31.3% white, 32.9% Black, 10.7% Hispanic/Latinx, 2.7% Asian, and 22.5% other/unknown. Overall, 88.0% of patients received CPR initiated by dialysis staff, but rates differed by race: 91% of white patients, 85% of black patients, and 77% of Asian patients (p = 0.005). After adjusting for differences in patient and clinic characteristics, black (OR = 0.41, 95% CI 0.25–0.68) and Asian patients (OR = 0.28, 95% CI 0.12–0.65) were significantly less likely than white patients to receive staff-initiated CPR. No significant difference between staff-initiated CPR rates among white, Hispanic/Latinx, and other/unknown patients was observed. An AED was applied by dialysis staff in 62% of patients. In adjusted models, there was no relationship between patient race/ethnicity and staff AED application. Conclusions Black and Asian patients are significantly less likely than white patients to receive CPR from dialysis staff. Further understanding of practices in dialysis clinics and increased awareness of this disparity are necessary to improve resuscitation practices.

Background For individuals with an out‐of‐hospital cardiac arrest (OHCA), survival may be influenced by the neighborhood in which the arrest occurs. Methods and Results Within the national CARES (Cardiac Arrest Registry to Enhance Survival) registry, we identified 169 502 patients with OHCA from 2013 to 2017. On the basis of census tract data, OHCAs were categorized as occurring in predominantly white (>80% white), majority black (>50% black), or integrated (neither of these 2) neighborhoods and in low‐income (median household $80 000) neighborhoods. With hierarchical logistic regression, the association of neighborhood race and income on overall survival was assessed. Overall, 37.5%, 16.6%, and 45.9% of people had an OHCA in predominantly white, majority black, and integrated neighborhoods, and 30.1%, 53.4%, and 16.5% in low‐, middle‐, and high‐income neighborhoods, respectively. Compared with OHCAs occurring in predominantly white neighborhoods, those in majority black neighborhoods were 12% less likely (6.9% versus 10.6%; adjusted odds ratio 0.88; 95% CI 0.82‐0.95; P P =0.93). Compared with high‐income neighborhoods, those in middle‐income neighborhoods were 11% (10.1% versus 11.3%; adjusted odds ratio 0.89; 95% CI 0.8‐0.94; P P Conclusions OHCAs in majority black and non–high‐income neighborhoods have lower survival rates, and these differences were not explained by differential bystander cardiopulmonary resuscitation rates.

Objective: This study aimed to explore significant pre-hospital factors affecting the survivability of Out-of-Hospital Cardiac Arrest (OHCA) patients in countries with developing EMS systems. Method: A retrospective cohort study was conducted examining data from January 1, 2017 to December 31, 2020 from Utstein Registry databases in Thailand, collected through Pan-Asian Resuscitation Outcomes Study (PAROS). Data were collected from three centres, including regional, suburban-capital, and urban-capital hospitals. The primary endpoint of this study was 30-day survival or discharged alive after an OHCA event. The multivariable risk regression was done by modified Poisson regression with robust error variance to explore the association between 30-day survival and pre-hospital factors with potential confounders adjustments. Findings: Of 1,240 OHCA cases transferred by Emergency Medical Services (EMS), 42 patients (3.4%) were discharged alive after 30 days, including 22 (8.6%), 8 (3.0%), and 12 (1.7%) from regional, suburban-capital, and urban-capital centres, respectively. The initial arrest rhythm was 89.7% unshockable, with no significant variations across the three centres. Overall, bystander Cardiopulmonary Resuscitation (CPR) was 40.4%. However, bystander CPR with Automated External Defibrillator (AED) application was 0.8%. Bystander CPR significantly increased 30-day survival probability (aRR 1.88, 95% CI 1.01 to 3.51; p 0.049). Additionally, reducing the EMS response time by one minute significantly increased OHCA survivability (aRR 1.12, 95% CI 1.04 to 1.20; p 0.001). Conclusions: Response time and bystander CPR are the factors that improve the 30-day survival outcomes of OHCA patients. In contrast, scene time, transport time, and pre-hospital advanced airway management didn’t improve 30-day OHCA survival.

Background: The highest achievable survival rate following out-of-hospital cardiac arrest is unknown. Data from airports serving international destinations (international airports) provide the opportunity to evaluate the success of pre-hospital resuscitation in a relatively controlled but real-life environment. Methods: This retrospective cohort study included all cases of out-of-hospital cardiac arrest at international airports with resuscitation attempted between January 1st, 2013 and December 31st, 2015. Crude incidence, patient, event characteristics and survival to hospital discharge/survival to 30 days (survival) were calculated. Mixed effect logistic regression analyses were performed to identify predictors of survival. Variability in survival between airports/countries was quantified using the median odds ratio. Results: There were 800 cases identified, with an average of 40 per airport. Incidence was 0.024/100,000 passengers per year. Percentage survival for all patients was 32%, and 58% for patients with an initial shockable heart rhythm. In adjusted analyses, initial shockable heart rhythm was the strongest predictor of survival (odds ratio, 36.7; 95% confidence interval [CI], 15.5–87.0). In the bystander-witnessed subgroup, delivery of a defibrillation shock by a bystander was a strong predictor of survival (odds ratio 4.8; 95% CI, 3.0–7.8). Grouping of cases was significant at country level and survival varied between countries. Conclusions: In international airports, 32% of patients survived an out-of-hospital cardiac arrest, substantially more than in the general population. Our analysis suggested similarity between airports within countries, but differences between countries. Systematic data collection and reporting are essential to ensure international airports continually maximise activities to increase survival.

To compare odds of survival to hospital discharge among pediatric out-of-hospital cardiac arrest (OHCA) patients receiving either bag-valve-mask ventilation (BVM), supraglottic airway (SGA) or endotracheal intubation (ETI), after adjusting for the propensity to receive a given airway intervention.Retrospective cohort study using the Cardiac Arrest Registry to Enhance Survival (CARES) database from January 1 201-December 31, 2015. The CARES registry includes data on cardiac arrests from 17 statewide registries and approximately 55 additional US cities. We included patients less than18 years of age who suffered a non-traumatic OHCA and received a resuscitation attempt by Emergency Medical Services (EMS). The key exposure was the airway management strategy (BVM, ETI, or SGA). The primary outcome was survival to hospital discharge.Of the 3793 OHCA cases included from 405 EMS agencies, 1724 cases were analyzed after limiting the analysis to EMS agencies that used all 3 devices. Of the 1724, 781 (45.3%) were treated with BVM only, 727 (42.2%) ETI, and 215 (12.5%) SGA. Overall, 20.7% had ROSC and 10.9% survived to hospital discharge. After using a propensity score analysis, the odds ratio for survival to hospital discharge for ETI compared to BVM was 0.39 (95%CI 0.26-0.59) and for SGA compared to BVM was 0.32 (95% CI 0.12-0.84). These relationships were robust to the sensitivity analyses including complete case, EMS-agency matched, and age-stratified.BVM was associated with higher survival to hospital discharge compared to ETI and SGA. A large randomized clinical trial is needed to confirm these findings.

Introduction: Survival from out-of-hospital cardiac arrest (OHCA) remains low and with major regional variation. This study explored differences in patients, care, and survival in patients with OHCA in North Carolina (NC), Washington State (WA), and Denmark. Methods: We identified a total of 17,277 adult patients with OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) registry and the Danish Cardiac Arrest Register of presumed cardiac cause from 2013-2014. Patients were categorized into three regions: two states in the United States (NC, 9.1 million inhabitants, WA, 7.5 million inhabitants) and the country of Denmark (5.8 million inhabitants). Outcomes of cardiopulmonary resuscitation (CPR) and defibrillation performed by either professional first responder or lay bystanders prior to emergency medical service (EMS) arrival, as well as overall survival. Data were analyzed using multivariable logistic regression analyses adjusted for age, sex, calendar year, location of arrest and witnessed status. Results: Patients in NC and WA were younger and had more racial variation compared to Denmark. Survival was 9.3% in NC, 14.5% in WA and 13.3% in Denmark. Using the Danish cohort as reference, the odds for bystander CPR and defibrillation in NC (CPR: OR 0.41, 95%CI 0.38-0.44; defibrillation: OR 0.30, 95%CI 0.23-0.38) and WA (CPR: OR 0.71, 95%CI 0.65-0.77; defibrillation: OR 0.41, 95%CI 0.31-0.53) were lower, respectively. CPR and defibrillation performed by either a bystander or a professional first responder prior to EMS arrival were higher in NC (CPR: OR 2.67, 95%CI 2.43-2.93; defibrillation: OR 2.72 95%CI 2.30-3.21), but not in WA (CPR: OR 1.01, 95%CI 0.92-1.11; defibrillation OR 0.73, 95%CI 0.58-0.90), respectively. Compared with Denmark, survival was lower in NC (OR 0.39, 95%CI 0.34-0.45) and WA (OR 0.83, 95%CI 0.72-0.95). Conclusion: Survival following OHCA was higher in Denmark and WA than in NC, and was associated with higher rates of bystander CPR and defibrillation. However, CPR and defibrillation prior to EMS arrival, mainly from professional first responders, was significantly higher in NC. A combination of both bystander and first responder interventions may be the optimal approach to improve outcomes of cardiac arrest.

Background: Cardiac arrest (CA) is a leading cause of disability-adjusted life years (DALY) in the United States (U.S.). The National Institutes of Health (NIH) does not report annual research funding for CA. Our objective was to calculate and compare the NIH research investment for CA to other leading causes of DALY in the U.S. Methods: A search within NIH RePORTER for the year 2016 was performed using the following terms: cardiac arrest, cardiopulmonary resuscitation, heart arrest, circulatory arrest, pulseless electrical activity, ventricular fibrillation, or resuscitation. Grants were individually reviewed and categorized as CA research (yes/no) using predefined criteria and the sum of funding for grants meeting inclusion criteria were tabulated. DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD) using all adult non-traumatic EMS-treated out-of-hospital CA (OHCA) from the CARES database for 2016. Total DALY for the study population were extrapolated to a national level. The leading causes of DALY were obtained from the Global Burden of Disease study. Funding data were extracted from the 2016 NIH Categorical Spending Report. Research funding were compared using U.S. dollars invested per DALY as the outcome measure. Results: The search yielded 285 NIH-funded grants, of which 65 (22.8%) were classified as CA research. Total NIH funding for CA research in 2016 was $28.5M. A total of 59,752 cases from CARES met study inclusion criteria for the DALY analysis. The total DALY following adult OHCA in the U.S. were 4,354,192 (YLL 4,350,825; YLD 3,365). Per annual DALY, the NIH invested $284 for diabetes, $89 for stroke, $53 for ischemic heart disease, and $7 for CA research in 2016 (FIGURE). Conclusion: The NIH investment into CA research is less than other leading causes of death and disability in the U.S. These results should help inform the debate regarding how to best utilize limited resources to improve public health.

Introduction: Approximately 1,000 out-of-hospital cardiac arrest (OHCA) occur per day in the United States. Although survival rates remains low, the extent to which OHCA neurological outcomes differ between men and women remains poorly characterized. Methods: Within the national Cardiac Arrest Registry to Enhance Survival (CARES) registry, we identified 195,722 adult individuals with an OHCA between 2013-2017. Using multi-variable logistic regression models, we evaluated for sex differences in rates of survival to hospital discharge and favorable neurological outcome (survival with discharge CPC score of 1 or 2), adjusted for cardiac arrest characteristics, race, location, year of arrest, age, and use of targeted temperature management (TTM) and coronary angiography. Results: Overall, 70,767 (31%) patients were women. Median age was 64 and 62 years for women and men, respectively. An initial shockable rhythm (14.9% vs. 25.7%) and a witnessed arrest (40.9% vs. 45.6%) was more common in men. Bystander CPR was provided to 37% of women and 39% of men. Men were less likely to survive to hospital discharge than women (8.7% vs. 10.9%; adjusted OR 0.75, 95% CI 0.73, 0.78). Similarly, men were less likely to have favorable neurological outcome (6.6% vs. 9.2% for women; adjusted OR 0.78, 95% CI 0.74, 0.82). Further interaction analysis for the pre-hospital elements found small, but statistically significant sex differences in favorable neurological survival for witnessed status (among female OR 2.29, 95% CI 2.10, 2.49; among males OR 2.07, 95% CI 1.92, 2.23, p= 0.04) and for bystander CPR (among females OR 1.20, 95% CI 1.11, 1.29; among males OR 1.34, 95% CI 1.27, 1.42, p= 0.01). Interaction of sex with the hospital level variables of TTM and coronary angiography, for the subset of patients that survived to hospital admission, had no sex differences in favorable neurological outcome. Conclusion: Our analysis shows that for OHCA in the United States, women have better survival outcomes than men. There was a sex differences in the pre-hospital variable of BCPR, but not in the other modifiable variables of TTM and coronary angiography. Further study is needed to better understand sex differences in overall survival and neurological outcomes.

Background:\ud Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.\ud \ud Methods:\ud We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.\ud \ud Results:\ud Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0 to 97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1% to 79.0% in all registries and 2.0% to 37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1% to 20.4% across all registries. Favourable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8% to 18.2%. Survival to hospital discharge or 30-day survival after bystander witnessed shockable OHCA ranged from 11.7% to 47.4% and favourable neurological outcome from 9.9% to 33.3%.\ud \ud Conclusion:\ud This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.

AIM: We examined overall and temporal differences in out-of-hospital cardiac arrest (OHCA) care and outcomes by urban versus non-urban setting separately for North Carolina (NC) and Washington State (WA) during HeartRescue initiatives and associations of urban/non-urban settings with outcome by state.METHODS: OHCAs of presumed cardiac etiology from counties with complete registry enrollment in NC during 2010-2014 (catchment population = 3,143,809) and WA during 2011-2014 (catchment population = 3,653,506) were identified. Geospatial arrest location data and US Census classification were used to categorize urban areas with ≥50,000 versus non-urban RESULTS: Included were 7731 NC cases (78.9% urban) and 4472 WA cases (85.8% urban). Bystander cardiopulmonary resuscitation (CPR) increased from 36.9% (2010) to 50.3% (2014) in NC non-urban areas versus 58.2% (2011) to 69.2% (2014) in WA; and from 39.3% to 51.1% in NC urban areas versus 52.4% to 61.8% in WA. Crude discharge survival odds ratio (OR) was 2.49 (95%CI 1.96-3.16) for urban versus non-urban NC cases not declared dead in field (N = 4241). Adjusted for age, sex, public location, bystander-witness status, time between emergency call and emergency medical service (EMS) arrival, calendar-year, bystander and first-responder CPR and defibrillation and direct PCI-center transport, OR was 1.30 (95%CI 0.98-1.73). In WA, corresponding crude and adjusted ORs were 1.38 (95%CI 0.99-1.93) and 1.46 (95%CI 1.00-2.13). In both states, bystander and first-responder CPR and defibrillation and direct PCI-hospital transport were associated with increased survival.CONCLUSIONS: During HeartRescue initiatives, bystander CPR increased in urban and non-urban locations. Bystander and first-responder interventions and direct PCI-hospital transport were associated with improved outcomes, including in non-urban areas.

Background Disability-adjusted life years (DALY) are a common public health metric used to consistently estimate and compare health loss because of both fatal and nonfatal disease burden. The annual number of DALY because of adult out-of-hospital cardiac arrest (OHCA) in the United States is unknown. Our objective was to estimate the DALY after adult nontraumatic, emergency medical services–treated OHCA, and to compare OHCA DALY to other leading causes of death and disability in the US. Methods and Results The DALY were calculated as the sum of years of life lost and years lived with disability. The years of life lost were calculated using all adult nontraumatic emergency medical services–treated OHCA with complete data from the national Cardiac Arrest Registry to Enhance Survival database for 2016, and actuarial data for remaining life expectancy at the age of death. Cerebral performance category scores from the Cardiac Arrest Registry to Enhance Survival database and previously established disability weights were used to estimate years lived with disability. The cohort’s calculated DALY were extrapolated to a national level to estimate total US DALY. Data were reported as total, mean, and DALY per 100 000 individuals. A total of 59 752 OHCA met study inclusion criteria. The DALY for the study population were 1 194 993 (years of life lost, 1 194 069; years lived with disability, 924) in 2016. The estimated total DALY following adult nontraumatic emergency medical services–treated OHCA in the US were 4 354 192 (years of life lost, 4 350 825; years lived with disability, 3365) for the index year 2016. The rate of OHCA DALY were 1347 per 100 000 population, which ranked third in the US behind ischemic heart disease (2447) and low back and neck pain (1565). Sensitivity analyses yielded similar findings. Conclusions Adult nontraumatic OHCA is a leading cause of annual DALY in the US and should be a focus of public health policy and resources.

Automated external defibrillators (AEDs) are critical in the chain of survival following out-of-hospital cardiac arrest (OHCA), yet few studies have reported on AED use and outcomes among pediatric OHCA. This study describes the association between bystander AED use, neighborhood characteristics and survival outcomes following public pediatric OHCA.Non-traumatic OHCAs among children less than18 years of age in a public setting between from January 1, 2013 through December 31, 2017 were identified in the CARES database. A neighborhood characteristic index was created from the addition of dichotomous values of 4 American Community Survey neighborhood characteristics at the Census tract level: median household income, percent high school graduates, percent unemployment, and percent African American. Multivariable logistic regression models assessed the association of OHCA characteristics, the neighborhood characteristic index and outcomes.Of 971 pediatric OHCA, AEDs were used by bystanders in 10.3% of OHCAs. AEDs were used on 2.3% of children ≤1 year (infants), 8.3% of 2-5 year-olds, 12.4% of 6-11 year-olds, and 18.2% of 12-18 year-olds (p 0.001). AED use was more common in neighborhoods with a median household income of$50,000 per year (12.3%; p = 0.016),10% unemployment (12.1%; p = 0.002), and80% high school education (11.8%; p = 0.002). Greater survival to hospital discharge and neurologically favorable survival were among arrests with bystander AED use, varying by neighborhood characteristics.Bystander AED use is uncommon in pediatric OHCA, particularly in high-risk neighborhoods, but improves survival. Further study is needed to understand disparities in AED use and outcomes.

Background Firefighter first responders dispatched in parallel with emergency medical services ( EMS ) personnel for out‐of‐hospital cardiac arrests ( OHCA ) can provide early defibrillation to improve survival. We examined whether survival following first responder defibrillation differed according to driving distance from nearest fire station to OHCA site. Methods and Results From the CARES (Cardiac Arrest Registry to Enhance Survival) registry, we identified non‐ EMS witnessed OHCA s of presumed cardiac cause from 2010 to 2014 in Durham, Mecklenburg, and Wake counties, North Carolina. We used logistic regression to estimate the association between calculated driving distances (≤1, 1–1.5, 1.5–2, and >2 miles) and survival to hospital discharge following first responder defibrillation compared with defibrillation by EMS personnel. In total, 5020 OHCA s were included in the study. First responders more often applied the first automated external defibrillators at the shortest distances (≤1 mile) versus longest distances (>2 miles) (53.4% versus 46.6%, respectively, P EMS defibrillation, first responder defibrillation within 1 mile and 1 to 1.5 miles of the nearest fire station was associated with increased survival to hospital discharge (odds ratio 2.01 [95% confidence interval 1.46–2.78] and odds ratio 1.61 [95% confidence interval 1.10–2.35], respectively). However, at the longest distances (1.5–2.0 and >2.0 miles), survival following first responder defibrillation did not differ from EMS defibrillation (odds ratio 0.77 [95% confidence interval 0.48–1.21] and odds ratio 0.97 [95% confidence interval 0.67–1.41], respectively). Conclusions Shorter driving distance from nearest fire station to OHCA location was associated with improved survival following defibrillation by first responders. These results suggest that the location of first responder units should be considered when organizing prehospital systems of OHCA care.

Background: Disability-adjusted life years (DALY) are a common public health metric used to consistently estimate and compare disease burden. The impact of bystander interventions on DALY following out-of-hospital cardiac arrest (OHCA) is unknown. Our objective was to estimate the effect of bystander CPR (B-CPR) and bystander AED (B-AED) application on DALY following OHCA in the United States (U.S.). Methods: DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD) using all adult non-traumatic EMS-treated OHCA from the national CARES database for 2016. A multivariable linear regression model was constructed for effect estimation with DALY values as the outcome and standard Utstein variables as independent variables. Marginal effect estimates for B-CPR and B-AED were derived in models that used all independent variables as main effects. A sensitivity analysis included interaction terms. The analysis for B-CPR was limited to bystander witnessed events. The B-AED analysis was limited to public OHCA events. The marginal effects on DALY were used to derive national estimates of life years saved. Results: A total of 19,324 OHCA cases met study inclusion criteria. The provision of B-CPR was associated with an absolute mean decrease of -0.36 DALY; 95% CI (-0.44, -0.27) per OHCA, when compared to cases without B-CPR (p Conclusion: Bystander interventions are associated with a decrease in DALY following adult OHCA. These results highlight the importance of national bystander CPR and AED education and surveillance.

Introduction: Thirty eight states have laws requiring education of high school students on cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AED). No study has measured the association of these laws and outcomes. Hypothesis: Out of hospital cardiac arrests (OHCAs) occurring in states with CPR high school education laws will have higher bystander CPR, survival, and favorable neurological survival than states without such laws. Methods: We conducted an analysis of the Cardiac Arrest Registry to Enhance Survival database and included all nontraumatic OHCAs with at least 50% population catchment from 1/2013-12/2017 in all ages. We excluded OHCAs witnessed by 911 responders, in healthcare facilities, or nursing homes. Outcomes were bystander CPR, survival to hospital discharge and neurologically favorable survival (Cerebral Performance Category score of 1 or 2 at hospital discharge). Chi-square tests were used to assess associations. Results: The 110,902 subjects with OHCA included Male, 64.0%; 50 yrs. (38.9% vs. 40.7% for ≤50 yrs.), Black and Hispanic subjects (25.7% and 34.9%, respectively, vs. 42.4% for Whites) (p Conclusions: Bystander CPR, survival to hospital discharge, and neurologically favorable survival was higher in states that had CPR high school education laws.

Introduction: Automated external defibrillators (AEDs) are an important link in the chain of survival following out-of-hospital cardiac arrest (OHCA). While the use of AEDs are clearly beneficial for OHCA in adults, there are few data on the overall use and outcomes of public AED use in children. Hypothesis: AED use is uncommon in children and associated with neurologically favorable survival. Methods: We conducted an analysis of the Cardiac Arrest Registry to Enhance Survival database. Inclusion criteria were age ≤ 18 years of age, public arrests, and non-traumatic OHCA from January 1, 2013 through December 31, 2017. Neurologically favorable survival was defined as a Cerebral Performance Category Scale of 1 or 2 at hospital discharge. Results: Of 971 public pediatric OHCA (66% male, 32% white), AEDs were used by bystanders in 117 (10.3%). AEDs were used among 2.3% of children aged ≤ 1 year (infants), 8.3% of 2-5 year-olds, 12.4% of 6-11 year-olds, and 18.2% of 12-18 year-olds (p Conclusions: AED use is uncommon in children suffering OHCA but is associated with improved neurologically favorable survival. The benefit of AEDs was evident mostly for adolescents and white children. Further study is needed to understand these disparities in AED use and outcomes after AED use.

Background The Institute of Medicine has called for actions to understand and target sex‐related differences in care and outcomes for out‐of‐hospital cardiac arrest patients. We assessed changes in bystander and first‐responder interventions and outcomes for males versus females after statewide efforts to improve cardiac arrest care. Methods and Results We identified out‐of‐hospital cardiac arrests from North Carolina (2010–2014) through the CARES (Cardiac Arrest Registry to Enhance Survival) registry. Outcomes for men versus women were examined through multivariable logistic regression analyses adjusted for (1) nonmodifiable factors (age, witnessed status, and initial heart rhythm) and (2) nonmodifiable plus modifiable factors (bystander cardiopulmonary resuscitation and defibrillation before emergency medical services), including interactions between sex and time (ie, year and year 2 ). Of 8100 patients, 38.1% were women. From 2010 to 2014, there was an increase in bystander cardiopulmonary resuscitation (men, 40.5%–50.6%; women, 35.3%–51.8%; P for each P =0.007; women, 8.5%–23.7%, P =0.004). From 2010 to 2014, the unadjusted predicted probability of favorable neurologic outcome was higher and increased more for men (men, from 6.5% [95% confidence interval (CI), 5.1–8.0] to 9.7% [95% CI, 8.1–11.3]; women, from 6.3% [95% CI, 4.4–8.3] to 7.4% [95% CI, 5.5–9.3%]); while adjusted for nonmodifiable factors, it was slightly higher but with a nonsignificant increase for women (from 9.2% [95% CI, 6.8–11.8] to 10.2% [95% CI, 8.0–12.5]; men, from 5.8% [95% CI, 4.6–7.0] to 8.4% [95% CI, 7.1–9.7]). Adding bystander cardiopulmonary resuscitation and defibrillation before EMS (modifiable factors) did not substantially change the results. Conclusions Bystander and first‐responder interventions increased for men and women, but outcomes improved significantly only for men. Additional strategies may be necessary to improve survival among female cardiac arrest patients.

Background: Despite evidence that therapeutic hypothermia improves patient outcomes for out-of-hospital cardiac arrest, use of this therapy remains low. It is unknown if the use of therapeutic hypothermia and patient outcomes have changed following publication of a trial that supported more lenient temperature management. Methods: In the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 45,935 U.S. patients who experienced out-of-hospital cardiac arrest and survived to admission at 649 hospitals between 2013 and 2016. Using segmented hierarchical logistic regression, we determined risk-adjusted trends in the use of therapeutic hypothermia overall and stratified by presenting rhythm of ventricular tachycardia or ventricular fibrillation (VT/VF) vs pulseless electrical activity or asystole (PEA/asystole). We used mediation analysis to assess the impact of temporal trends in the use of therapeutic hypothermia on risk-adjusted survival trends at a patient- and hospital-level. Results: Overall use of therapeutic hypothermia was 46.4%. In unadjusted analyses, the use of therapeutic hypothermia dropped from 52.5% in the last quarter of 2013 to 46.0% in the first quarter of 2014 after publication of a trial that supported more lenient temperature management. Use of therapeutic hypothermia remained at or below 46.5% through 2016. After risk-adjustment, these trends in use persisted (see Figure). Compared with the last quarter of 2013, the risk-adjusted odds of therapeutic hypothermia was 18% lower in the first quarter of 2014 (OR 0.82, 95% CI 0.71, 0.94, P=0.006). Similar findings were observed in analyses stratified by presenting rhythm (see Figure). Overall risk-adjusted patient survival was 36.9% in 2013, 37.5% in 2014, 34.8% in 2015, and 34.3% in 2016 (P for trend Conclusions: In a U.S. registry of out-of-hospital cardiac arrest, the use of therapeutic hypothermia decreased after publication of a study supporting more lenient temperature thresholds. Concurrent to this change, overall risk-adjusted survival of cardiac arrest decreased, but was not attributed to lower use of therapeutic hypothermia.

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents’ assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system−treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.

Importance Little is known about the influence of comprehensive public health initiatives according to out-of-hospital cardiac arrest (OHCA) location, particularly at home, where resuscitation efforts and outcomes have historically been poor.Objective To describe temporal trends in bystander cardiopulmonary resuscitation (CPR) and first-responder defibrillation for OHCAs stratified by home vs public location and their association with survival and neurological outcomes.Design, Setting, and Participants This observational study reviewed 8269 patients with OHCAs (5602 [67.7%] at home and 2667 [32.3%] in public) for whom resuscitation was attempted using data from the Cardiac Arrest Registry to Enhance Survival (CARES) from January 1, 2010, through December 31, 2014. The setting was 16 counties in North Carolina.Exposures Patients were stratified by home vs public OHCA. Public health initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in the use of automated external defibrillators, teaching first responders about team-based CPR (eg, automated external defibrillator use and high-performance CPR), and instructing dispatch centers on recognition of cardiac arrest.Main Outcomes and Measures Association of resuscitation efforts with survival and neurological outcomes from 2010 through 2014.Results Among home OHCA patients (n = 5602), the median age was 64 years, and 62.2% were male; among public OHCA patients (n = 2667), the median age was 68 years, and 61.5% were male. After comprehensive public health initiatives, the proportion of patients receiving bystander CPR increased at home (from 28.3% [275 of 973] to 41.3% [498 of 1206], P

Background The HeartRescue Project is a multistate public health initiative focused on establishing statewide out‐of‐hospital cardiac arrest (OHCA) systems of care to improve case capture and OHCA care in the community, by emergency medical services (EMS), and at hospital level. Methods and Results From 2011 to 2015 in the 5 original HeartRescue states, all adults with EMS–treated OHCA due to a presumed cardiac cause were included. In an adult population of 32.8 million, a total of 64 988 OHCAs—including 10 046 patients with a bystander‐witnessed OHCA with a shockable rhythm—were treated by 330 EMS agencies. From 2011 to 2015, the case‐capture rate for all‐rhythm OHCA increased from an estimated 39.0% (n=6762) to 89.2% (n=16 103; P P P P P Conclusions In the initial 5 years, the HeartRescue Project developed a population‐based OHCA registry and improved statewide case‐capture rates and some processes of care, although there were no early temporal changes in survival. The observed survival variation across states and EMS systems presents a future challenge to elucidate the characteristics of high‐performing systems with the goal of improving OHCA care and survival.

Background— Practice guidelines recommend regional systems of care for out-of-hospital cardiac arrest. However, whether emergency medical services should bypass nonpercutaneous cardiac intervention (non-PCI) facilities and transport out-of-hospital cardiac arrest patients directly to PCI centers despite longer transport time remains unknown. Methods and Results— Using the Cardiac Arrest Registry to Enhance Survival with geocoding of arrest location, we identified out-of-hospital cardiac arrest patients with prehospital return of spontaneous circulation and evaluated the association between direct transport to a PCI center and outcomes in North Carolina during 2012 to 2014. Destination hospital was classified according to PCI center status (catheterization laboratory immediately accessible 24/7). Inverse probability-weighted logistic regression accounting for age, sex, emergency medical services response time, clustering of county, transport time to nearest PCI center, initial heart rhythm, and prehospital ECG information was performed. Of 1507 patients with prehospital return of spontaneous circulation, 1359 (90.2%) were transported to PCI centers, of whom 873 (57.9%) bypassed the nearest non-PCI hospital and 148 (9.8%) were transported to non-PCI hospitals. Discharge survival was higher among those transported to PCI centers (33.5% versus 14.6%; adjusted odds ratio, 2.47; 95% confidence interval, 2.08–2.92). Compared with patients taken to non-PCI hospitals, odds of survival were higher for patients taken to the nearest hospital with PCI center status (odds ratio, 3.07; 95% confidence interval, 1.90–4.97) and for patients bypassing closer hospitals to PCI centers (odds ratio, 3.02; 95% confidence interval, 2.01–4.53). Adjusted survival remained significantly better across transport times of 1 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 minutes. Conclusions— Direct transport to a PCI center is associated with better outcomes for out-of-hospital cardiac arrest patients, even when bypassing nearest hospital and regardless of transport time.

Background Bystander cardiopulmonary resuscitation ( CPR ) is associated with increased survival from cardiac arrest, yet bystander CPR rates are low in many communities. The overall prevalence of CPR training in the United States and associated individual‐level disparities are unknown. We sought to measure the national prevalence of CPR training and hypothesized that older age and lower socioeconomic status would be independently associated with a lower likelihood of CPR training. Methods and Results We administered a cross‐sectional telephone survey to a nationally representative adult sample. We assessed the demographics of individuals trained in CPR within 2 years (currently trained) and those who had been trained in CPR at some point in time (ever trained). The association of CPR training and demographic variables were tested using survey weighted logistic regression. Between September 2015 and November 2015, 9022 individuals completed the survey; 18% reported being currently trained in CPR , and 65% reported training at some point previously. For each year of increased age, the likelihood of being currently CPR trained or ever trained decreased (currently trained: odds ratio, 0.98; 95% CI, 0.97–0.99; P OR , 0.99; 95% CI , 0.98–0.99; P =0.04). Furthermore, there was a greater then 4‐fold difference in odds of being currently CPR trained from the 30–39 to 70–79 year old age groups (95% CI , 0.10–0.23). Factors associated with a lower likelihood of CPR training were lesser educational attainment and lower household income ( P Conclusions A minority of respondents reported current training in CPR . Older age, lesser education, and lower income were associated with reduced likelihood of CPR training. These findings illustrate important gaps in US CPR education and suggest the need to develop tailored CPR training efforts to address this variability.

Background— Despite intensive efforts over many years, the United States has made limited progress in improving rates of survival from out-of-hospital cardiac arrest. Recently, national organizations, such as the American Heart Association, have focused on promoting bystander cardiopulmonary resuscitation, use of automated external defibrillators, and other performance improvement efforts. Methods and Results— Using the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective clinical registry, we identified 70 027 U.S. patients who experienced an out-of-hospital cardiac arrest between October 2005 and December 2012. Using multilevel Poisson regression, we examined temporal trends in risk-adjusted survival. After adjusting for patient and cardiac arrest characteristics, risk-adjusted rates of out-of-hospital cardiac arrest survival increased from 5.7% in the reference period of 2005 to 2006 to 7.2% in 2008 (adjusted risk ratio, 1.27; 95% confidence interval, 1.12–1.43; P P P for interaction=0.22) and was also accompanied by better neurological outcomes among survivors ( P for trend=0.01). Improved survival was attributable to both higher rates of prehospital survival, where risk-adjusted rates increased from 14.3% in 2005 to 2006 to 20.8% in 2012 ( P for trendP for trend=0.015). Rates of bystander cardiopulmonary resuscitation and automated external defibrillator use modestly increased during the study period and partly accounted for prehospital survival trends. Conclusions— Data drawn from a large subset of U.S communities suggest that rates of survival from out-of-hospital cardiac arrest have improved among sites participating in a performance improvement registry.

Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared OHCA outcomes between patients receiving endotracheal intubation (ETI) versus supraglottic airway (SGA), and between patients receiving [ETI or SGA] and those receiving no advanced airway.We studied adult OHCA in the Cardiac Arrest Registry to Enhance Survival (CARES). Primary exposures were ETI, SGA, or no advanced prehospital airway placed. Primary outcomes were sustained ROSC, survival to hospital admission, survival to hospital discharge, and neurologically-intact survival to hospital discharge (cerebral performance category 1-2). Propensity scores characterized the probability of receiving ETI, SGA, or no advanced airway. We adjusted for Utstein confounders. Multivariable random effects regression accounted for clustering by EMS agency. We compared outcomes between (1) ETI vs. SGA, and (2) [no advanced airway] vs. [ETI or SGA].Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC (OR 1.35; 95%CI 1.19-1.54), survival to hospital admission (1.36; 1.19-1.55), hospital survival (1.41; 1.14-1.76) and hospital discharge with good neurologic outcome (1.44; 1.10-1.88). Compared with [ETI or SGA], patients receiving no advanced airway attained higher survival to hospital admission (1.31; 1.16-1.49), hospital survival (2.96; 2.50-3.51) and hospital discharge with good neurologic outcome (4.24; 3.46-5.20).In CARES, survival was higher among OHCA receiving ETI than those receiving SGA, and for patients who received no advanced airway than those receiving ETI or SGA.

Background— 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. Methods and Results— 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 Conclusions— 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.

Background Most studies on out‐of‐hospital cardiac arrest have focused on immediate survival. However, little is known about long‐term outcomes and resource use among survivors. Methods and Results Within the national CARES registry, we identified 16 206 adults 65 years or older with an out‐of‐hospital cardiac arrest between 2005 and 2010. Among 1127 patients who were discharged alive, we evaluated whether 1‐year mortality, cumulative readmission incidence, and follow‐up inpatient costs differed according to patients’ race, sex, initial cardiac arrest rhythm, bystander delivery of cardiopulmonary resuscitation, discharge neurological status, and functional status (hospital discharge disposition). Overall 1‐year mortality after hospital discharge was 31.8%. Among survivors, there were no long‐term mortality differences by sex, race, or initial cardiac arrest rhythm, but worse functional status and severe neurological disability at discharge were associated with higher mortality. Moreover, compared with first responders, cardiopulmonary resuscitation delivered by bystanders was associated with 23% lower mortality (hazard ratio 0.77 [confidence interval 0.58–1.02]). Besides mortality, 638 (56.6%) patients were readmitted within the first year, and the cumulative readmission incidence was 197 per 100 patient‐years. Mean 1‐year inpatient costs were $23 765±41 002. Younger age, black race, severe neurological disability at discharge, and hospital disposition to a skilled nursing or rehabilitation facility were each associated with higher 1‐year inpatient costs ( P for all Conclusion Among elderly survivors of out‐of‐hospital cardiac arrest, nearly 1 in 3 patients die within the first year. Long‐term mortality and inpatient costs differed substantially by certain demographic factors, whether cardiopulmonary resuscitation was initiated by a bystander, discharge neurological status, and hospital disposition.