Population density, call-response interval, and survival of out-of-hospital cardiac arrest

BACKGROUND Little is known about the effects of geographic variation on outcomes of out-of-hospital cardiac arrest (OHCA). The present study investigated the relationship between population density, time between emergency call and ambulance arrival, and survival of OHCA, using the All-Japan Utstein-style registry database, coupled with geographic information system (GIS) data. METHODS We examined data from 101,287 bystander-witnessed OHCA patients who received emergency medical services (EMS) through 4,729 ambulatory centers in Japan between 2005 and 2007. Latitudes and longitudes of each center were determined with address-match geocoding, and linked with the Population Census data using GIS. The endpoints were 1-month survival and neurologically favorable 1-month survival defined as Glasgow-Pittsburgh cerebral performance categories 1 or 2. RESULTS Overall 1-month survival was 7.8%. Neurologically favorable 1-month survival was 3.6%. In very low-density (<250/km(2)) and very high-density (≥10,000/km(2)) areas, the mean call-response intervals were 9.3 and 6.2 minutes, 1-month survival rates were 5.4% and 9.1%, and neurologically favorable 1-month survival rates were 2.7% and 4.3%, respectively. After adjustment for age, sex, cause of arrest, first aid by bystander and the proportion of neighborhood elderly people ≥65 yrs, patients in very high-density areas had a significantly higher survival rate (odds ratio (OR), 1.64; 95% confidence interval (CI), 1.44 - 1.87; p < 0.001) and neurologically favorable 1-month survival rate (OR, 1.47; 95%CI, 1.22 - 1.77; p < 0.001) compared with those in very low-density areas. CONCLUSION Living in a low-density area was associated with an independent risk of delay in ambulance response, and a low survival rate in cases of OHCA. Distribution of EMS centers according to population size may lead to inequality in health outcomes between urban and rural areas.