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Journal Watch: Bystander CPR by Race and Neighborhood

Reviewed This Month

Race/Ethnicity and Neighborhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Study From CARES. 

Authors: Naim MY, Griffis HM, Burke RV, et al. 

Published in: J Am Heart Assoc, 2019 Jul 16; 8(14): e012637.  

Unfortunately, even with the increases in bystander CPR seen in some areas, only about 1 in 10 pediatric out-of-hospital cardiac arrest (OHCA) patients survives to hospital discharge. A 2017 study examining bystander CPR among pediatric patients identified racial and ethnic disparities. Specifically, black and Hispanic children were less likely to receive bystander CPR compared to white children. However, it was unknown if this disparity was based on race alone or a combination of socioeconomic status and/or neighborhood characteristics.  

This month we review a study that evaluated the relationship between the race/ethnicity of pediatric OHCA patients and neighborhood characteristics with the provision of bystander CPR. The authors hypothesized that the race/ethnicity of cardiac arrest victims and neighborhood racial and socioeconomic characteristics were associated with the provision of bystander CPR. 

To complete this study the authors used data from the Cardiac Arrest Registry to Enhance Survival (CARES) national database. CARES is a fantastic resource—it is an EMS-based registry of OHCA patients that combines data from 9-1-1 call centers, EMS providers, and receiving hospitals. CARES includes an overall catchment area of more than 115 million people in 41 states and captures all 9-1-1-activated nontraumatic cardiac arrest events. 

The authors analyzed all pediatric cases (18 years old or less) with nontraumatic OHCA submitted to CARES from January 1, 2013 through December 31, 2017. To ensure they could appropriately evaluate whether bystander CPR was performed, they excluded any arrests that occurred in medical facilities or nursing homes or were witnessed by emergency responders. 

To facilitate the analysis, they categorized race/ethnicity as white, black/African American, Hispanic/Latino, and other (American Indian/Alaskan, Asian, and Native Hawaiian/Pacific). In addition to race/ethnicity, the authors collected all the typical data elements you’d expect, including age, sex, bystander witness status, arrest location, initial rhythm, and AED use. 

Scoring Neighborhoods

One of the most interesting and novel parts of this study is how the authors evaluated neighborhoods. To do this they created neighborhood categories based on the geocoded OHCA event, 2010 U.S. Census Summary Files, and 2016 American Community Survey five-year estimates. The authors used this information to develop “neighborhood index scores.” Neighborhoods that had more than 80% of a specific race were categorized as predominantly of that race. Neighborhoods without a predominant racial composition were classified as integrated. 

To develop this index the authors also looked at median household income, high school graduations, and unemployment. Each neighborhood received a score of 0 or 1 for each characteristic. In other words, a neighborhood received a one point if it was more than 80% black and additional points if it had more than 10% unemployment, a high school graduation rate of less than 80%, or a median income of less than $50,000 (the median income for the USA). A neighborhood meeting all those criteria would have a total score of 4. Total neighborhood index scores summed those characteristic scores and therefore ranged from 0–4. It is unclear why the index only adjusted for neighborhoods that were more than 80% black rather than including other race/ethnicity categories. 

The outcome of interest was bystander CPR, defined as CPR administered by a lay family member, unrelated layperson, or person with medical training who was not part of the organized emergency response. 

The authors calculated descriptive statistics, which are frequencies and percentages, to describe the child and arrest characteristics as well as characteristics of the arrests with and with no bystander CPR. They also performed logistic regression to develop statistical models that investigated association of bystander CPR with race/ethnicity and neighborhood characteristics. Overall the analysis appears solid and appropriate to address the study hypothesis. 


The authors evaluated a total of 7,086 cardiac arrests. They noted a statistically significance difference when evaluating bystander CPR and race/ethnicity (p<0.01). Bystander CPR was performed in 48% of the arrests evaluated. It was more commonly performed in whites (56.9%) compared to blacks (39.3%), Hispanics (46.6%), children of other race/ethnicities (49.0%), and those with unknown race/ethnicity (40.9%). This relationship remained significant when adjusting for other important variables (age, sex, bystander witnessed status, arrest location, and AED use). Bystander CPR was also more common in high-income (54% vs. 43%, p<0.01), low-unemployment (53% vs. 40%, p<0.01), and high-education neighborhoods (52% vs. 39%, p<0.01). Bystander CPR was performed more often in predominantly white neighborhoods compared with those that were predominantly nonwhite (55% vs. 45%, p<0.01). 

Bystander CPR was performed significantly more in neighborhoods with an index score of 0 compared to every other index score. After adjustment for other variables, white children had higher rates of bystander CPR compared to black children for most neighborhood index scores, and the difference was pretty stark. A black child in a neighborhood with an index score of 0 (less than 80% black, less than 10% unemployment, greater than 80% high school graduation, and median household income greater than $50,000) was just as likely to receive bystander CPR compared to a white child in a neighborhood with an index score of 3 (predicted probability: 45.7% vs 45.2%). 

One of the most important limitations in this study is an inability to evaluate individual-level socioeconomic data. The authors had to use neighborhood characteristics as a proxy, and this may have led to misclassifications. It is also important to keep in mind that this is a retrospective study, and therefore we cannot determine causality with these results. 

This was nonetheless a well done and important study that concluded that race/ethnicity and neighborhood characteristics are associated with the provision of bystander CPR. The authors recommend targeting training in neighborhoods identified as less likely to have bystander CPR performed. EMS can certainly play a large role in this.    

Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.

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