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Letter to the Editor| Volume 185, 109730, April 2023

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Influence of population characteristics and use of emergency medical systems on the rate of asystolic out-of-hospital cardiac arrest for which resuscitation is attempted

  • Robert Larribau
    Correspondence
    Corresponding author at: Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva 14, Switzerland.
    Affiliations
    Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH 1211 Geneva 14, Switzerland
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  • Charles Payot
    Affiliations
    Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH 1211 Geneva 14, Switzerland
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  • Christelle Lardi
    Affiliations
    CURML, University Center of Legal Medicine, Geneva University Hospitals, Geneva, Switzerland
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  • Laurent Suppan
    Affiliations
    Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH 1211 Geneva 14, Switzerland
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  • Christophe Alain Fehlmann
    Affiliations
    Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH 1211 Geneva 14, Switzerland
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Published:February 09, 2023DOI:https://doi.org/10.1016/j.resuscitation.2023.109730
Influence of population characteristics and use of emergency medical systems on the rate of asystolic out-of-hospital cardiac arrest for which resuscitation is attempted
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      Abbreviations:

      OHCA (Out-of-hospital cardiac arrest), EMS (Emergency medical system), EP (Emergency physician)
      To the Editor,
      Three studies were recently published related to factors that may influence a physicians' decision to initiate advanced life support for asystolic out-of-hospital cardiac arrest (OHCA). As a result of these publications, there has been some debate, mainly between the Bologna study
      • Gamberini L.
      • Mazzoli C.A.
      • Allegri D.
      • et al.
      Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients.
      Resuscitation. 2022; 177: 19-27
      and the other studies conducted in Graz
      • Zajic P.
      • Zoidl P.
      • Deininger M.
      • et al.
      Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine.
      Sci Rep. 2021; 11: 5120
      and Geneva
      • Payot C.
      • Fehlmann C.A.
      • Suppan L.
      • et al.
      Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest.
      Int J Environ Res Public Health. 2021; 18
      , regarding the resuscitation rate attempted in asystolic OHCA, which was 11.8 % in Bologna, 65.0 % in Graz, and 76.4 % in Geneva.
      As authors of the Geneva study, we tried to understand why there was such a difference between these studies, which were carried out in overlapping years and which, at first sight, concerned emergency medical systems (EMSs) with a relatively similar organisation, in particular because the three systems practice the dispatch of emergency physicians (EPs) to the field for patients requiring resuscitation.
      We noticed that the annual number of asystolic OHCAs in Bologna appeared to be much higher than in either Geneva or Graz, which led us to wonder whether or not the study populations were the same. We therefore searched for population statistics covering the three regions concerned (Bologna in Italy

      Statistiche demografiche Bologna Guida ai Comuni, alle Province ed alle Regioni d'Italia: Gwind S.r.l.; [Statistics on the population of Bologna and neighbouring municipalities]. Available from: https://www.tuttitalia.it/emilia-romagna/32-bologna/statistiche/popolazione-andamento-demografico/ accessed 2023.01.29, 2023.

      , Graz in Austria

      Bevölkerung von Graz und Umgebung: Wirtschaftspolitisches Bericts - und Informations System (WIBIS); [Statistics on the population of the city of Graz and its surroundings]. Available from: https://wibis-steiermark.at/bevoelkerung/ accessed 2023.01.29, 2023.

      and Geneva in Switzerland

      Statistiques de la population - Statistiques cantonales - République et canton de Genève: Office cantonal de la statistique (OCSTAT); [Cantonal population statistics for Geneva]. Available from: https://statistique.ge.ch/domaines/welcome.asp?domaine=01 accessed 2023.01.29, 2023.

      ). For each region and from 2009 to 2020 (11 years), we looked for the annual number of inhabitants, those aged over 64, and the annual number of deaths. We were thus able to calculate the rate of inhabitants aged over 64 in each region and their respective annual incidence of deaths per 100,000 inhabitants. Finally, we measured and compared the median age of patients for each region who had experienced asystolic OHCA and for whom resuscitation had been withdrawn/withheld by the EP who had intervened in the field.
      We found that the annual incidence of death was about twice as high in Bologna as in Geneva or Graz (Table 1). We therefore considered that this was probably related to the fact that the resident population of Bologna was significantly older (25.5 % of the population > 64 years) than that of Geneva (16.1 % of the population > 64 years) or Graz (17.3 % of the population > 64 years). We also found that the overall average number of incidences of OHCA attended by EMS was three to four times higher in Bologna than in Graz or Geneva. The percentage of asystolic OHCAs expected by the EMSs was about three times higher in Bologna (23.3 %) than in Graz (8.6 %) or Geneva (8.2 %) compared to the number of deaths in each population. The consequence appears to be that the use of EMSs for asystolic OHCAs was significantly higher in Bologna than in Graz or Geneva. Not surprisingly, the age of patients with asystolic OHCA for whom resuscitation was withdrawn/withheld was also significantly higher in Bologna.
      Table 1Characteristics of the populations and asystolic out-of-hospital cardiac arrests attended.
      Eats of the greater Graz area

      (Austria)      		Canton of Geneva (Switzerland)Urban area of Bologna with Casalecchio and San Lazzaro

      (Italy)
      Study period2010–20182009–20162013–2019
      Resident population (inhabitants) served by EMS∼200,000475,000458,000
      Percentage of the population aged 64 + years17.3
      Data derived from the data of the city of Graz and the surroundings of Graz.
      		16.125.5
      Overall average incidence of death in the population, per 100,000 inhabitants per year863
      Data derived from the data of the city of Graz and the surroundings of Graz.
      		6751223
      Overall average incidence of OHCA attended by EMS, per 100,000 inhabitants per year9578N/A
      Overall average incidence of asystole attended by EMS, per 100,000 inhabitants per year7459233
      Percentage of OHCA in asystole attended by EMS / total death during the relevant period8.6 %8.2 %23.3 %
      Percentage of resuscitations withheld /withdrawn for patients with asystolic rhythm35.0 %

      (n = 278 / 794
      Exclusion of babies resuscitated at birth.
      )      		23.2 %

      (n = 185 / 796
      Exclusion of babies resuscitated at birth.
      )      		88.2 %

      (n = 2339/ 2653)
      Median of age of non-resuscitated patients (y [IQR])85 [73–90]

      (all rhythms)      		80 [66–87] (asystole)88 [82–92]

      (asystole)
      Percentage of return to spontaneous circulation for resuscitated asystole patientsN/A

      		31.3 %

      (n = 191 / 611)      		21.3 %

      (n = 67 / 314)
      EMS: Emergency Medical Service; OHCA: Out-of-Hospital Cardiac Arrest.
      * Data derived from the data of the city of Graz and the surroundings of Graz.
      ** Exclusion of babies resuscitated at birth.
      In conclusion, the rate of asystolic OHCA for which resuscitation is attempted must always be considered in relation to the age of the study population and EMS practices.

      Conflict of interest

      All authors declare no conflict of interest.

      Funding

      There is no funding source.

      References

        • Gamberini L.
        • Mazzoli C.A.
        • Allegri D.
        • et al.
        Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients.
        Resuscitation. 2022; 177: 19-27
        View in Article
        • Zajic P.
        • Zoidl P.
        • Deininger M.
        • et al.
        Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine.
        Sci Rep. 2021; 11: 5120
        View in Article
        • Payot C.
        • Fehlmann C.A.
        • Suppan L.
        • et al.
        Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest.
        Int J Environ Res Public Health. 2021; 18
        View in Article

      4. Statistiche demografiche Bologna Guida ai Comuni, alle Province ed alle Regioni d'Italia: Gwind S.r.l.; [Statistics on the population of Bologna and neighbouring municipalities]. Available from: https://www.tuttitalia.it/emilia-romagna/32-bologna/statistiche/popolazione-andamento-demografico/ accessed 2023.01.29, 2023.

        View in Article

      5. Bevölkerung von Graz und Umgebung: Wirtschaftspolitisches Bericts - und Informations System (WIBIS); [Statistics on the population of the city of Graz and its surroundings]. Available from: https://wibis-steiermark.at/bevoelkerung/ accessed 2023.01.29, 2023.

        View in Article

      6. Statistiques de la population - Statistiques cantonales - République et canton de Genève: Office cantonal de la statistique (OCSTAT); [Cantonal population statistics for Geneva]. Available from: https://statistique.ge.ch/domaines/welcome.asp?domaine=01 accessed 2023.01.29, 2023.

        View in Article

      Article info

      Publication history

      Published online: February 09, 2023
      Accepted: February 2, 2023
      Received: February 1, 2023

      Identification

      DOI: https://doi.org/10.1016/j.resuscitation.2023.109730

      Copyright

      © 2023 Elsevier B.V. All rights reserved.

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