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Existing risk-adjustment models, however, do not account for urbanization-related heterogeneity, which may contribute to systematic urbanization-stratified miscalibration, bias cross-system benchmarking, and misdirect quality improvement. We developed and validated an urbanization-adjusted ROSC after cardiac arrest (URACA) by incorporating Eurostat\u2019s Degree of Urbanisation (DEGURBA) into RACA and assessed whether it improves calibration across urbanization levels without compromising discrimination.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using 2014\u20132023 German Resuscitation Registry data, we identified 145,780 adult (\u226518\u2009years) out-of-hospital cardiac arrests and randomly split cases into development and validation cohorts. DEGURBA was recoded as metropolises (\u2265500,000 inhabitants), cities (&lt;500,000), and non-urban areas (all others). We refitted RACA and fitted URACA using logistic regression with multiple imputation for missing values. In validation, we assessed calibration (calibration belts), discrimination (area under receiver operating characteristic curve; AUROC), prediction error (Brier score), and reclassification (continuous net reclassification improvement; cNRI).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Refitted RACA exhibited urbanization-stratified miscalibration, overpredicting in non-urban areas and underpredicting in metropolises and cities. URACA reduced these systematic deviations: in non-urban areas, predicted ROSC closely matched observed ROSC across the full risk range, and in metropolises and cities, the mid-range underprediction was resolved. Discrimination and overall accuracy were unchanged (AUROC 0.735 vs 0.737; Brier 0.202 for both), while reclassification improved (cNRI 9.4%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>URACA mitigates urbanization-stratified calibration bias while preserving discrimination, enhancing the comparability of risk-adjusted ROSC benchmarking across EMS systems.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12873-026-01715-4","type":"journal-article","created":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T11:35:38Z","timestamp":1786361738000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Spatial heterogeneity in risk-adjusted return of spontaneous circulation after out-of-hospital cardiac arrest: the urbanization-adjusted RACA model"],"prefix":"10.1186","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0580-2710","authenticated-orcid":false,"given":"Dokyeong","family":"Lee","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Bender","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eiko","family":"Spielmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ulrike","family":"Grittner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christof","family":"Prugger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Friebel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,10]]},"reference":[{"key":"1715_CR1","doi-asserted-by":"crossref","unstructured":"Berg KM, Cheng A, Panchal AR, et al. 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Scand J Trauma Resusc Emerg Med. 2015;23(1):43. https:\/\/doi.org\/10.1186\/s13049-015-0124-0.","journal-title":"Scand J Trauma Resusc Emerg Med"}],"container-title":["BMC Emergency Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12873-026-01715-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12873-026-01715-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12873-026-01715-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T04:45:48Z","timestamp":1786509948000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12873-026-01715-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,10]]},"references-count":45,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["1715"],"URL":"https:\/\/doi.org\/10.1186\/s12873-026-01715-4","relation":{},"ISSN":["1471-227X"],"issn-type":[{"value":"1471-227X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,10]]},"assertion":[{"value":"7 April 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"31 July 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 August 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"This study was approved by the Ethics Commission of Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin (EA2\/025\/24) and was conducted in accordance with the Declaration of Helsinki. Given the fully anonymized nature of the GRR data, informed consent was neither obtainable nor required.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"220"}}