Dillan Meghan M, Piktel Joseph, Curtis Kristen K, Thomas Charles, Wilson Lance
Department of Emergency Medicine, MetroHealth Campus, Case Western Reserve University, Cleveland, OH, USA.
Department of Emergency Medicine, MetroHealth Campus, Case Western Reserve University, Cleveland, OH, USA.
Resuscitation. 2024 Sep;202:110328. doi: 10.1016/j.resuscitation.2024.110328. Epub 2024 Jul 24.
Understanding the impact of social determinants of health (SDOH) on CA, including access to care pre-cardiac arrest (CA) can improve outcomes. Large databases, such as Epic Cosmos, can help identify trends in patient demographics and SDOH that identify gaps in care. The purpose of this study was to determine the incidence of CA and subsequent mortality in a large national database across patient demographics and social determinants and characterize pre-arrest care patterns.
This was a retrospective cohort study using a large national deidentified electronic health database (Epic Cosmos) with 227 million patients. Inclusion criteria was ED encounter for CA (ICD-10-CM: I46). Patient demographics and social determinants included age, sex, race, ethnicity, social vulnerability index (SVI, a composite measure with greater SVI representing more vulnerability). The primary outcome was difference in CA incidence between groups, reported as odds ratios (ORs). The secondary outcomes were 1) incidence of pre-arrest care within 30 days and 2) post-arrest mortality at 7,30, and 180 days. Statistical analysis was performed using Chi-squared analysis (unadjusted OR) and aggregated logistic procedure (adjusted OR).
There were 201,846 ED visits for CA between April 20, 2020, and April 19, 2023 (0.11% incidence). For all ages, males had a higher incidence of CA (OR 1.76, p < 0.0001). Black, Native Hawaiian or Pacific Islander, and American Indian or Alaska Native had a higher OR of CA while Asian patients were less likely than White patients (adjusted OR 1.85, 1.44,1.51, and 0.81 respectively, all p < 0.0001). Hispanic/Latino patients had a lower OR of CA (adjusted OR 0.72, p < 0.0001). CA was more common in the highest SVI quartile compared to the lowest (adjusted OR 1.71, p < 0.0001). Significant heterogeneities were identified in pre-arrest care across patient demographics and social determinants, where ED visits were more common than office visits among male patients, patients in the highest SVI, Hispanic/Latino, and minority patients, except for Asian patients. Post-arrest mortality after 30 days was highest in females, Black patients, and patients in the highest SVI.
SDOH have a significant impact on the risk of CA, pre-arrest care patterns, and post-arrest mortality. Determining the impact that SDOH have on the CA care continuum provides can provide actionable targets to prevent CA and subsequent mortality.
了解健康的社会决定因素（SDOH）对心脏骤停（CA）的影响，包括心脏骤停前的就医机会，有助于改善治疗结果。大型数据库，如Epic Cosmos，可帮助识别患者人口统计学和SDOH方面的趋势，从而发现护理方面的差距。本研究的目的是确定一个大型全国数据库中，不同患者人口统计学和社会决定因素下CA的发病率及后续死亡率，并描述心脏骤停前的护理模式。
这是一项回顾性队列研究，使用了一个拥有2.27亿患者的大型全国性匿名电子健康数据库（Epic Cosmos）。纳入标准为因CA就诊于急诊科（国际疾病分类第十版临床修正版：I46）。患者人口统计学和社会决定因素包括年龄、性别、种族、民族、社会脆弱性指数（SVI，一种综合指标，SVI越高表示越脆弱）。主要结局是组间CA发病率的差异，以比值比（OR）表示。次要结局为：1）30天内心脏骤停前护理的发生率；2）心脏骤停后7天、30天和180天的死亡率。采用卡方分析（未调整OR）和汇总逻辑程序（调整OR）进行统计分析。
在2020年4月20日至2023年4月19日期间，有201,846例因CA就诊于急诊科（发病率为0.11%）。在所有年龄段中，男性CA发病率较高（OR 1.76，p < 0.0001）。黑人、夏威夷原住民或太平洋岛民以及美洲印第安人或阿拉斯加原住民CA的OR较高，而亚洲患者比白人患者发病可能性小（调整后OR分别为l.85、1.44、1.51和0.81，均p < 0.0001）。西班牙裔/拉丁裔患者CA的OR较低（调整后OR 0.72，p < 0.0001）。与最低SVI四分位数相比，CA在最高SVI四分位数中更常见（调整后OR 1.71，p < 0.0001）。在不同患者人口统计学和社会决定因素的心脏骤停前护理中发现了显著的异质性，其中男性患者、SVI最高的患者、西班牙裔/拉丁裔患者和少数族裔患者（亚洲患者除外）中，急诊科就诊比门诊就诊更常见。30天后心脏骤停后的死亡率在女性、黑人患者和SVI最高的患者中最高。
SDOH对CA风险、心脏骤停前护理模式和心脏骤停后死亡率有显著影响。确定SDOH对CA护理连续过程的影响可为预防CA及后续死亡率提供可采取行动的目标。
