Pay Stub May Predict In-Hospital Cardiac Arrest Tx, Outcomes

Disparities in cardiac arrest survival plagued even events that occurred in hospitals with universal healthcare coverage, Swedish researchers found.

Delays in CPR were significantly less likely for highly educated and high income patients (odds ratio 0.89 and OR 0.98, respectively), reported Jens Agerström, of Linnaeus University in Kalmar, and colleagues in the European Heart Journal.

High income was also significantly linked with surviving CPR (OR 1.02), while both high education and high income were significant predictors of hospital discharge with good neurological outcome (OR 1.27 and OR 1.06) and survival to 30 days (OR 1.21 and OR 1.05).

Secondary analyses suggested a mediating factor in that high socioeconomic status (SES) patients got more prophylactic heart rhythm monitoring before the cardiac arrest (OR 1.16 and OR 1.02), which seemed to partially explain the disparity in CPR delay, according to the researchers.

"In fact, we found that patients from high socioeconomic backgrounds were more likely to be monitored even if their health status was better than patients from low socioeconomic backgrounds," Agerström said in a press release.

That the findings were independent of age, gender, ethnicity, comorbidity, heart rhythm, and etiology of cardiac arrest suggested the presence of treatment bias or discrimination, they wrote. "Such bias, where patients are treated differently due to their SES, may stem from prejudiced attitudes among hospital staff."

His own experience at medical visits was part of the motivation to look at the issue, Agerström noted in the press release: "I got the impression that the staff often became more thorough after they had asked me about my profession."

Disparities have also been seen in out-of-hospital cardiac arrest survival, Agerström's group noted.

While the associations were fairly small, the researchers projected that approximately 280 people in 1,000 from a low socioeconomic background versus 320 of 1,000 who are better off would survive to 30 days.

Notably, healthcare staff didn't report lower treatment satisfaction for the lower socioeconomic status patients, which could indicate they are unconscious of the differences in care and outcomes, or that they have lower standards for good care, or even that they don't want to appear prejudiced, the researchers suggested.

The group wrote that "hospitals may consider enrolling their [cardiac arrest] teams in equality training programmes. The focus of such programmes could be on awareness training where teams become mindful of their own bias and learn how SES-related prejudice might translate into discriminatory treatment."

The study included 24,217 patients, ages 40 and older, with an in-hospital cardiac arrest recorded in the Swedish Register of Cardiopulmonary Resuscitation, which covered all but one of the emergency hospitals in that country from 2005 to 2018. Complete information on education level was available for all of the participants, with income data for 18,771 as well.

Among the patients, 59% had no delay from discovery of the patient to start of CPR and 52% survived CPR, while 23% survived to discharge with good neurologic outcome and 29% survived to 30 days.

Study limitations included inclusion of only cases where resuscitation was started in the registry, which likely made it a "conservative test of discrimination because it probed for discrimination in a sample where the first decision to treat had already been made," the researchers noted. "It is possible that most discrimination occurs earlier, during the decision-making process itself."

As far as generalizability to other countries, the group wrote, "since Sweden is regarded to be at the forefront of equality, the observed group differences may be larger in other countries."

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