A multilevel analysis of absence of transport to a hospital before premature cardiac death

Prompt transportation to a hospital and aggressive medical treatment can often prevent acute cardiac events from becoming fatal. Consequently, lack of transport before death may represent lost opportunities for life-saving interventions. We investigated the effect of individual characteristics (age, sex, race/ethnicity, education, and marital status) and small-area factors (population density and social cohesion) on the probability of premature cardiac decedents dying without transport to a hospital. We analyzed death data for adults aged 25 to 69 years who resided in the Tampa, Florida, metropolitan statistical area and died from an acute cardiac event from 1998 through 2002 (N = 2,570). Geocoding of decedent addresses allowed the use of multilevel (hierarchical) logistic regression models for analysis. The strongest predictor of dying without transport was being unmarried (odds ratio, 2.13; 95% confidence interval, 1.79-2.52, P < .001). There was no effect of education; however, white race was modestly predictive of dying without transport. Younger decedent age was a strong predictor. Multilevel statistical modeling revealed that less than 1% of the variance in our data was found at the small-area level. Results contradicted our hypothesis that small-area characteristics would increase the probability of cardiac patients receiving transport before death. Instead we found that being unmarried, a proxy of living alone and perhaps low social support, was the most important predictor of people who died from a cardiac event dying without transport to a hospital.