Urban-rural disparities in out-of-hospital cardiac arrest outcomes: a nationwide Hungarian study

Background

Out-of-hospital cardiac arrest (OHCA) outcomes often differ between urban and rural settings, but comprehensive nationwide data from Central-Eastern Europe using uniform data collection and modern confounding control remain limited. We investigated urban–rural disparities in OHCA outcomes in Hungary.

Methods

We analysed 130,258 OHCA cases (2018–2023) from the Hungarian National Ambulance Service registry, classified as urban (70.1 %) or rural (29.9 %) using national administrative categories. The primary outcome was on-scene return of spontaneous circulation (ROSC). We performed univariable and multivariable logistic regression, propensity score matching (PSM) and continuous response-time modeling using natural cubic splines.

Results

The overall ROSC rate was 9.1 % (urban: 9.4 %, rural: 8.3 %, p < 0.001). After PSM, urban location remained significantly associated with higher survival (OR = 1.26, 95 % CI 1.20–1.32, p < 0.001). EMS response times were significantly longer in rural areas (median 14.9 vs 9.8 min, p < 0.001). Urban survival advantage was most pronounced in cases with shockable rhythms (OR = 1.57, 95 % CI 1.43–1.72), medical-witnessed arrests (OR = 1.31, 95 % CI 1.20–1.42), and response times ≤8 min (OR = 1.59, 95 % CI 1.44–1.76).

Conclusions

Significant urban–rural disparities in OHCA on-scene ROSC persist even after accounting for patient and arrest characteristics. These findings highlight the need for targeted interventions to strengthen the Chain of Survival in rural communities.