# A Moderated Mediation Analysis of Timely EMS Activation and Bystander CPR in the Association Between Regional Deprivation and Outcomes Following Out-of-Hospital Cardiac Arrest

## TL;DR

This study shows that regional deprivation worsens outcomes after cardiac arrest, partly due to slower emergency response times, especially when bystander CPR is provided.

## Contribution

The study introduces a moderated mediation analysis to show how EMS activation delays mediate the effect of deprivation on OHCA outcomes, modified by bystander CPR.

## Key findings

- Deprived areas had lower rates of bystander CPR and timely EMS activation.
- Regional deprivation was linked to worse neurological recovery and survival outcomes.
- EMS activation delays explained a small but significant portion of the deprivation effect, especially in cases with bystander CPR.

## Abstract

Background/Objectives: Out-of-hospital cardiac arrest (OHCA) outcomes remain poor and vary widely across communities with socioeconomic deprivation. This study examines whether delays in emergency medical services (EMS) activation, the earliest link in the Chain of Survival, mediate the association between regional deprivation and OHCA outcomes, and whether this effect is modified by bystander cardiopulmonary resuscitation (CPR) status. Methods: We analyzed adult patients (aged 18–80 years) with witnessed, EMS-treated OHCA of presumed cardiac etiology from the Korean nationwide OHCA registry (2015–2022). Regional deprivation was defined by the Regional Deprivation Index and dichotomized into deprived (top 20%) vs. non-deprived areas. Timely EMS activation, defined as collapse to EMS activation, was measured as an awareness time interval (ATI) < 5 min. Outcomes were good neurological recovery (CPC 1–2) and survival to discharge. Causal mediation analysis within the counterfactual framework quantified the proportion of the association mediated by timely EMS activation, with stratification by bystander CPR status. Results: Among 43,032 patients, 6.1% resided in deprived areas. Deprived areas had lower bystander CPR (22.6% vs. 36.3%) and timely EMS activation (67.8% vs. 75.6%) (p < 0.05 for all). Regional deprivation was associated with poorer outcomes (good neurological prognosis: aOR 0.46, 95% CI 0.39–0.55; survival: aOR 0.65, 95% CI 0.57–0.73). Mediation analysis showed that ATI < 5 min accounted for 3.7% of the total deprivation effect on good neurological outcome and 7.9% on survival, with stronger mediation among patients receiving bystander CPR (7.9% and 14.7%, respectively). Conclusions: Regional deprivation is significantly associated with poorer OHCA outcomes, partly mediated by delays in EMS activation, particularly among patients who received bystander CPR. Interventions to enhance early recognition, rapid EMS activation, and bystander CPR in deprived communities are critical to improving survival equity after OHCA.