The vertical black line indicates the date of Michigan's stay-at-home order.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Nickles AV, Oostema A, Allen J, O’Brien SL, Demel SL, Reeves MJ. Comparison of Out-of-Hospital Cardiac Arrests and Fatalities in the Metro Detroit Area During the COVID-19 Pandemic With Previous-Year Events. JAMA Netw Open. 2021;4(1):e2032331. doi:10.1001/jamanetworkopen.2020.32331
It is difficult to overstate the impact of the coronavirus disease 2019 (COVID-19) pandemic. As of November 30, 2020, there were more than 63 million documented infections and approximately 1.5 million deaths worldwide.1 COVID-19 outbreaks have been especially acute in certain regions in the United States. In Michigan, 360 449 confirmed infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, have occurred since the first documented cases on March 10, 2020.2 Nearly 33% of these cases occurred in the metropolitan Detroit area (Macomb, Oakland, and Wayne counties), an area with a combined population of 3.9 million.2 Reports from Italy,3 France,4 and New York5 have documented marked increases in out-of-hospital cardiac arrests (OHCAs) attended by emergency medical services (EMS) in areas with significant COVID-19 burdens. We examined whether a similar phenomenon occurred in the metropolitan Detroit area during the peak of the outbreak by using data from the Michigan EMS Information System.
Nontraumatic OHCA calls in Macomb, Oakland, and Wayne counties between January 1 and May 31 of both 2019 and 2020 were identified from the Michigan EMS Information System. Basic Life Support and Medical First Response records were excluded to eliminate duplicate counting of events.
Weekly per capita OHCA incidence rates (events per 100 000 population) were calculated for each year. We also calculated weekly per capita SARS-CoV-2 incidence rates per 100 000 population for the 3 counties using the official count of confirmed cases from the Michigan Department of Health and Human Services.2 We used χ2 tests to compare demographic and clinical characteristics of OHCA events after Michigan’s stay-at-home order (March 23 through May 31, 2020) with the same period in 2019. This cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. Because this study was a public health surveillance activity authorized by a public health authority, it did not require institutional review board approval per 45 CFR 46.102(l)(2). Patient informed consent for this study was waived per the State of Michigan Public Health Code (Michigan Public Health Code Act, PA 368 of 1978 Sec. 1101). Two-sided P < .05 was used to test statistical significance. All analyses were performed using SAS statistical software, version 9.4 (SAS Institute Inc).
Between March 23 and May 31, 2019, there were 1162 OHCA calls identified from the Michigan EMS Information System. Of these, 451 OHCAs (38.8%) occurred in individuals aged 65 to 84 years, 662 (57.0%) occurred in men, and 626 (53.9%) occurred in White individuals (Table). During the same period in 2020, 1854 OHCA calls were identified. Of these, 735 OHCAs (39.6%) occurred in individuals aged 65 to 84 years, 1083 (58.4%) occurred in men, and 867 (46.8%) occurred in White individuals.
The Figure shows the incidence of OHCA events per capita from January through May of 2019 and 2020 along with the incidence of confirmed COVID-19 cases in 2020. Beginning in early March 2020 (week 12), a marked increase in the incidence of OHCAs was observed compared with the previous year. The spike in OHCAs lags slightly behind but closely mirrors the epidemic curve of COVID-19 (which represents the date of symptom onset for confirmed cases) during the same period.
The 1854 OHCA calls during the pandemic period studied (March 23 through May 31, 2020) represent a 60% increase compared with 1162 OHCA calls during the same period in 2019. The Table provides additional demographic characteristics and the presumed causes of cardiac arrest during the pandemic period compared with the same period in 2019. Out-of-hospital cardiac arrests increased across all demographic characteristics in 2020. However, the increases occurred disproportionately among elderly individuals 85 years or older (341 cases [18.4%] in 2020 vs 171 [14.7%] in 2019; P = .01) and Black individuals (724 cases [39.1%] in 2020 vs 353 [30.4%] in 2019; P < .001), consistent with data from New York City.5 In addition, a greater proportion of OHCA cases occurred at nursing facilities in 2020 (407 cases [22.0%] in 2020 vs 219 [18.8%] in 2019; P = .03). In 2020, patients with OHCAs were 53% less likely to receive an advanced airway device, such as intubation or placement of a supraglottic airway, compared with 2019 (397 patients [21.4%] in 2020 vs 529 [45.5%] in 2019; P < .001). The proportion of OHCA calls for patients who died in the field increased by 42% (1400 patients [75.5%] in 2020 vs 619 [53.3%] in 2019; P < .001).
Southeast Michigan experienced marked increases in both the number of OHCA calls and the prehospital fatality rates for OHCA. In 2020, OHCA disproportionately increased among older individuals, Blacks, and residents of skilled nursing facilities. This study was limited to prehospital records; definitive causes of death are not known and it is not clear from these data whether the increase arose as a direct effect of COVID-19 infection or from indirect effects of the pandemic on utilization of EMS.6 Further investigation is needed to characterize the phenomena underlying these associations to design interventions to mitigate the impacts of the ongoing COVID-19 pandemic.
Accepted for Publication: November 12, 2020.
Published: January 6, 2021. doi:10.1001/jamanetworkopen.2020.32331
Correction: This article was corrected on January 27, 2021, to fix an error in the Introduction, to fix a number and its percentage in the Results section as well as in the Table, and to add a caption for the Figure.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Nickles AV et al. JAMA Network Open.
Corresponding Author: Adrienne V. Nickles, MPH, Lifecourse Epidemiology and Genomics Division, Michigan Department of Health and Human Services, 333 S Grand Ave, Lansing, MI 48909 (email@example.com).
Author Contributions: Ms Nickles had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Nickles, Oostema, Demel, Reeves.
Acquisition, analysis, or interpretation of data: Nickles, Oostema, Allen, O’Brien.
Drafting of the manuscript: Nickles, Oostema.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Nickles, Allen.
Administrative, technical, or material support: Allen, Reeves.
Conflict of Interest Disclosures: Dr Demel reported receiving personal fees from the Michigan Public Health Institute as a physician advisor during the conduct of the study and personal fees from Genentech as a member of the Speakers Bureau outside the submitted work. No other disclosures were reported.