Your neighborhood matters: A machine-learning approach to the geospatial and social determinants of health in 9-1-1 activated chest pain

Social Determinants of Health and Emergency Medical Services: A Scoping Review

OBJECTIVES

Social determinants of health (SDOH) are the non-medical factors that affect people's health and quality of life. Emergency medical services (EMS) clinicians are in a unique position to recognize and respond to SDOH through their presence and responses in the communities they serve. The objective of this study was to generally explore the existing body of literature of SDOH within the context of EMS.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guided the analysis of peer-reviewed literature from PubMed, CINAHL, and Web of Science databases published between January 1960 and June 2024. Using Covidence software, titles and abstracts then, separately, full texts, were reviewed by two distinct researchers to include studies published in English that referenced SDOH and EMS. We later excluded articles that were published before 2010, when the SDOH term was made more popular by its inclusion in the Healthy People 2020 project. Reviewers then performed data extraction for qualitative analysis using a grounded theory approach.

RESULTS

Of the 1,503 records imported from the databases (PubMed n = 779, Web of Science n = 687, CINAHL n = 37), 1,164 unique manuscripts were screened, and 62 full texts were assessed for eligibility. Forty-two articles met inclusion criteria; 39 were EMS patient-centric and three were illustrative of EMS clinicians' SDOH, thus excluded from this analysis. Patient-related impact levels included individual characteristics, community characteristics, EMS clinicians' recognition of and response to SDOH, healthcare system factors, and social and cultural considerations. Articles were on the topic areas of medical conditions, EMS practice, trauma, pediatrics, and mental health. More than half (n = 24) of the manuscripts were from studies conducted in North America and a majority (n = 32) of the papers were published since 2020.

CONCLUSIONS

Research in SDOH and their association with EMS is rapidly growing. A deeper understanding of how the EMS system and EMS clinicians affect, recognize, and manage patients' SDOH insecurities can improve efforts toward health equity and improve patients' health outcomes.

Association of Racial Residential Segregation and Survival After Out-of-Hospital Cardiac Arrest in the United States

BACKGROUND

Social determinants of health such as residential segregation have been identified as drivers of disparities in health outcomes; however, this has been understudied for out-of-hospital cardiac arrest (OHCA). We sought to examine whether there were differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander cardiopulmonary resuscitation, using validated measures of racial, ethnic, and economic segregation.

METHODS

We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival data set. The primary predictor for this study was the Index of Concentration at the Extremes. The primary outcomes were survival to discharge and survival with good neurological status.

RESULTS

During the study period, 626 264 had an out-of-hospital cardiac arrest, and patients had a mean age of 62 years (SD 17.2 years). In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in more highly segregated predominately White population and higher-income census tracts as compared with more highly segregated and lower-income Black and Hispanic/Latinx population census tracts. We found that the magnitude of this disparity was 24% for the outcome of survival to discharge as compared with reference (relative risk,1.24 [95% CI, 1.20-1.28]).

CONCLUSIONS

This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for out-of-hospital cardiac arrest.

A Review of Racial Differences and Disparities in ECG

The electrocardiogram (ECG) is a widely used, non-invasive tool for diagnosing a range of cardiovascular conditions, including arrhythmia and heart disease-related structural changes. Despite its critical role in clinical care, racial and ethnic differences in ECG readings are often underexplored or inadequately addressed in research. Variations in key ECG parameters, such as PR interval, QRS duration, QT interval, and T-wave morphology, have been noted across different racial groups. However, the limited research in this area has hindered the development of diagnostic criteria that account for these differences, potentially contributing to healthcare disparities, as ECG interpretation algorithms largely developed from major population data may lead to misdiagnoses or inappropriate treatments for minority groups. This review aims to help cardiac researchers and cardiovascular specialists better understand, explore, and address the impact of racial and ethnic differences in ECG readings. By identifying potential causes-ranging from genetic factors to environmental influences-and exploring the resulting disparities in healthcare outcomes, we propose strategies such as the development of race-specific ECG norms, the application of artificial intelligence (AI) to improve diagnostic accuracy, and the diversification of ECG databases. Through these efforts, the medical community can advance toward more personalized and equitable cardiovascular care.

The Association of Racial Residential Segregation and Survival After Out-of-Hospital Cardiac Arrest in the United States

Background

Residential segregation has been identified as drivers of disparities in health outcomes, but further work is needed to understand this association with clinical outcomes for out-of-hospital cardiac arrest (OHCA). We utilized Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine if there are differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander CPR, using validated measures of racial, ethnic, and economic segregation.

Methods

We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine associations among adult OHCA patients. The primary predictor was the Index of Concentration at the Extremes (ICE), a validated measure that includes race, ethnicity, and income across three measures at the census tract level. The primary outcomes were survival to discharge and survival with good neurological status. A multivariable modified Poisson regression modeling approach with random effects at the EMS agency and hospital level was utilized.

Results

We identified 626,264 OHCA patients during the study period. The mean age was 62 years old (SD 17.2 years), and 35.7% (n =223,839) of the patients were female. In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in predominately White population census tracts and higher income census tracts as compared to lower income Black and Hispanic/Latinx population census tracts (RR 1.24, CI 1.20-1.28) and a 32% increased likelihood of receiving bystander CPR in higher income census tracts as compared to reference (RR 1.32, CI 1.30-1.34).

Conclusions

In this study examining the association of measures of residential segregation and OHCA outcomes, there was an increased likelihood of survival to discharge, survival with good neurological status, and likelihood of receiving B-CPR for those patients residing in predominately White population and higher income census tracts when compared to predominately Black and/or Hispanic Latinx populations and lower income census tracts. This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for OHCA.