The Effect of Building-Level Socioeconomic Status on Bystander Cardiopulmonary Resuscitation: A Retrospective Cohort Study

Abstract

Objective

Understanding the social determinants of bystander cardiopulmonary resuscitation (CPR) receipt can inform the design of public health interventions to increase bystander CPR. The association of socioeconomic status with bystander CPR is generally poorly understood. We evaluated the relationship between socioeconomic status and bystander CPR in cases of out-of-hospital cardiac arrest (OHCA).

Methods

This was a retrospective cohort study based on the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study registry between 2010 and 2018. We categorized patients into low, medium, and high Singapore Housing Index (SHI) levels—a building-level index of socioeconomic status. The primary outcome was receipt of bystander CPR. The secondary outcomes were prehospital return of spontaneous circulation and survival to discharge.

Results

A total of 12,730 OHCA cases were included, the median age was 71 years, and 58.9% were male. The bystander CPR rate was 56.7%. Compared to patients in the low SHI category, those in the medium and high SHI categories were more likely to receive bystander CPR (medium SHI: adjusted odds ratio [aOR] 1.48, 95% CI 1.30–1.69; high SHI: aOR 1.93, 95% CI 1.67–2.24). High SHI patients had higher survival compared to low SHI patients on unadjusted analysis (OR 1.79, 95% CI 1.08–2.96), but not adjusted analysis (adjusted for age, sex, race, witness status, arrest time, past medical history of cancer, and first arrest rhythm). When comparing high with low SHI, females had larger increases in bystander CPR rates than males.

Conclusions

Lower building-level socioeconomic status was independently associated with lower rate of bystander CPR, and females were more susceptible to the effect of low socioeconomic status on lower rate of bystander CPR.

Acknowledgments

The authors would like to thank the late Ms Susan Yap from Department of Emergency Medicine, Singapore General Hospital; Ms Nurul Asyikin, Ms Liew Le Xuan, Ms Noor Azuin, and Ms Joann Poh from Unit for Prehospital Emergency Care, Singapore General Hospital; Ms Woo Kai Lee from Department of Cardiology, National University Heart Centre Singapore; and Ms Charlene Ong previously from Accident & Emergency, Changi General Hospital for their contributions and support to the Singapore OHCA registry.

Authors’ Contributions

Andrew Ho: Conceptualization, methodology, investigation, resources, writing—review & editing Priscilla Tin, Jamie Ho: Investigation, data curation, formal analysis, writing—original draft Stephanie Fook-Chong: Investigation, data curation, formal analysis, writing—review & editing Nur Shahidah: Investigation, resources, writing—review & editing Pin Pin Pek, Nan Liu, Seth Teoh En: Investigation, validation, data curation, writing—review & editing Ching-Hui Sia, Daniel Lim: Investigation, data curation, writing—review & editing Shir Lynn Lim, Ting Hway Wong, Marcus Ong: Supervision, conceptualization, methodology, data curation, writing—review & editing

Disclosure Statement

MEH Ong reports funding from the Zoll Medical Corporation for a study involving mechanical cardiopulmonary resuscitation devices; grants from the Laerdal Foundation, Laerdal Medical, and Ramsey Social Justice Foundation for funding of the Pan-Asian Resuscitation Outcomes Study; an advisory relationship with Global Healthcare SG, a commercial entity that manufactures cooling devices; and funding from Laerdal Medical on an observation program to their Community CPR training Center Research Program in Norway. MEH Ong has a licensing agreement and patent filed (Application no: 13/047,348) with ZOLL Medical Corporation for a study titled “Method of predicting acute cardiopulmonary events and survivability of a patient. He is also the co-founder and scientific advisor of TIIM Healthcare, a commercial entity which develops real-time prediction and risk stratification solutions at triage. All other authors have no interests to declare.

Singapore PAROS Investigators

Han Nee Gan (Changi General Hospital, Singapore); Ling Tiah (Changi General Hospital, Singapore); Michael YC Chia (Tan Tock Seng Hospital, Singapore); Desmond R Mao (Khoo Teck Puat Hospital, Singapore); Wei Ming Ng (Ng Teng Fong General Hospital, Singapore); Wei Ling Tay (Ng Teng Fong General Hospital, Singapore); Si Oon Cheah (Urgent Care Clinic International, Singapore); Benjamin SH Leong (National University Hospital, Singapore); Lai Peng Tham (KK Women’s & Children’s Hospital, Singapore); Gayathri Nadarajan (Singapore General Hospital, Singapore); Nausheen Edwin Doctor (Sengkang General Hospital, Singapore); Shalini Arulanandam (previous Chief Medical Officer at Singapore Civil Defence Force, Singapore)

Additional information

Funding

A.F.W.H was supported by the Estate of Tan Sri Khoo Teck Puat (Khoo Clinical Scholars Programme), Khoo Pilot Award (KP/2019/0034), Duke-NUS Medical School and National Medical Research Council (NMRC/CS_Seedfd/012/2018). This work was supported by the National Medical Research Council, Clinician Scientist Awards, Singapore (NMRC/CSA/024/2010, NMRC/CSA/0049/2013 and NMRC/CSA-SI/0014/2017) and Ministry of Health, Health Services Research Grant, Singapore (HSRG/0021/2012).