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.