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

Ádám Pál-Jakab; Bettina Nagy; Boldizsár Kiss; György Pápai; Nora Boussoussou; Béla Merkely; Miklós Constantinovits; Gábor Csató; Péter Sótonyi; Brigitta Szilágyi; Endre Zima

doi:10.1016/j.resplu.2025.101108

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

Resusc Plus. 2025 Sep 23:26:101108. doi: 10.1016/j.resplu.2025.101108. eCollection 2025 Nov.

Authors

Affiliations

¹ Heart and Vascular Centre, Semmelweis University, 1122 Budapest, Hungary.
² Hungarian National Ambulance Service (HNAS), Markó Street 22., 1055 Budapest, Hungary.
³ Budapest University of Technology and Economics, Műegyetem rkp. 3, 1111 Budapest, Hungary.
⁴ Corvinus University of Budapest, Fővám tér 8, 1093 Budapest, Hungary.
⁵ Anaesthesiology and Perioperative Care Institute, Semmelweis University, Hungary.

Abstract

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.

Keywords: Cardiac arrest (CA); Cardiopulmonary resuscitation (CPR); Emergency medical services (EMS); Out-of-hospital cardiac arrest (OHCA); Urban-rural disparity.