Disparities in CPR Training and. Survival

Transcription

1 Disparities in CPR Training and Survival Monique L. Anderson, MD, MHS Assistant Professor of Medicine Division of Cardiology Duke Clinical Research Institute Duke University School of Medicine November 14, 2016

2 Objectives Review literature on racial/ethnic disparities in treatment and outcomes of OHCA. Describe barriers to performing bystander CPR in high-risk communities. Present opportunities for closing the gap in treatment and outcomes of OHCA.

3 Introduction More than 350,000 Americans experience cardiac arrest per year. 1 Regional variation in treatment and outcome of OHCA across the United States. 2 Bystander CPR rate of 31-33% in large multisite databases. 2,3 A majority of observational studies confirm the benefits of timely bystander CPR. Every persons who receive CPR, 1 life saved. 4 1.Circulation. 2015;132. 2/ JAMA MMWR Surveill Summ ;60(8): Circ Q&O 2010, 3(1):63-81.

4 Becker LB et al. NEJM 1993; 329:600-6

5 1980s: Out-Of-Hospital Cardiac Arrest: Racial Differences in Treatment and Outcome in Seattle Survival to discharge 17.1% for whites versus 9.1% for blacks, p<0.05 Cowie MR et al. Am J Public Health. 1993;83:

6 Systematic Review and Meta-analysis of OHCA and Race or Ethnicity: Black US Populations Fare Worse Shah, K SV et al. Eur J of Prev Card 2014, Vol 21(5)

7 Racial/Ethnic Differences in Bystander CPR in Los Angeles, California Paucity of studies among Hispanic/Latino populations. In LA, nearly ½ of population is Latino. Cardiac Arrest Resuscitation Evaluation (CARE-LA) Database 899 people with cardiac arrest Bystander CPR in 13% Latino, 13% black, and 24% whites. Probability of Receiving Bystander CPR Variable Race/Ethnicity White Black Latino Other Witnessed Yes No Location Home Private Percentage (%) Adjusted OR (0.38, 1.16) 0.46 (0.23, 0.92) 1.01 (0.49, 2.08) (2.13, 4.97) (1.07, 2.72) Adjusted for sex, age, SES. None were significant. Benson et al. Ethn Dis Autumn;19(4):401-6.

8 Association of Neighborhood Characteristics with Bystander-Initiated CPR Sasson C et al. NEJM2012;367:

9 Rates of CPR Training in the United States Anderson, ML. JAMA Intern Med Feb 1;174(2):

10 Rates of CPR Training in the US Anderson, ML. JAMA Intern Med Feb 1;174(2):

11 Neighborhood Matters: Disparities in Treatment and Outcomes for Out-of-Hospital Cardiac Arrest in the Resuscitation Outcomes Consortium Initial Shockable Rhythm <25% Black 25%-50% Black 50%-75% Black >75% Black Public Location Witnessed Status Bystander EMS Median Income 43,324 35,507 28,185 21,563 College Education P<0.001 for all comparisons Anderson ML et al, Unpublished

12 Neighborhood Matters: Disparities in Treatment and Outcomes for OHCA in the Resuscitation Outcomes Consortium P<0.001 Anderson ML et al, Unpublished

13 Neighborhood Matters: Disparities in Process and Outcomes for OHCA the Resuscitation Outcomes Consortium Neighborhood Race Quar les [vs Q1 (<25% Blacks)] Q2 (25-50%) Q3 (50-75%) Q4 (>75%) Rhythm vs Asystole VT/VF PEA No-shock, no-strip Cannot Determine Male Gender Witnessed Event Bystander Witnessed EMS Witnessed Median Income, per $10K Public Loca on 1st Agency Arrival Time 6 min Age vs Age <40 Age Age >65 Less likely to survive More likely to survive * p<0.001 for all comparisons Odds Ra o (95% CI) for Survival Individual race did not change the relationship between neighborhood race and outcomes, interaction-p value=0.7 Anderson ML et al, Unpublished

14 Disparities in Bystander CPR Provision and Survival from OHCA according to Neighborhood Ethnicity 30.2% of Arizona population is Hispanic. Examined 4821 cardiac arrests over a 2 year period ( ) in census tracts based on proportion of Hispanics residents. Hispanic=>80% Hispanic Integrated = less than 80% Hispanics or whites Non-Hispanic White= greater than 80% whites Bystander CPR 43.8%, 42.7%, and 28.6% in white, integrated, and Hispanic neighborhoods (p=0.003). Survival 10.8, 10.7, and 4.9% in white, integrated, and Hispanic neighborhoods (p=0.13). Moon, et al. Am J Emerg Med Sep;32(9):1041-5

15 Barriers to Learning and Performing CPR Learning CPR Financial Childcare Transportation Lack of Information What is CPR Where are courses No internet Lack of Spanish speaking resources Motivation Not required Financial disincentive to learn Performing CPR Consequences Emotion disconnection (lack of community cohesion) Knowledge Fear of doing it incorrectly Confusion re guidelines Risk to personal health Language Barriers and Immigration Status Lack of recognition of cardiac arrest Distrust of law enforcement Sasson, C et al. Circ Q&) 2013;6: Sasson, C et al May;65(5):

16 CPR Legislation for High Schools Across the United States

17 High Arrest Neighborhoods to Decrease Disparities in Survival Sasson C et al. Academic Emer Med; 2014;21: Hands-OnlyCPRProgram/UCM_476671_CPR-In-Schools-Program.jsp

18 CPR Training for High-Risk Populations At Hospital Discharge PCORI funding to examine optimal methods for CPR training of highrisk individuals and family members during hospitalization. Goals are to: 1) measure the ability of family members to learn and retain CPR skills 2) measure secondary CPR training after discharge 3) assess family perspectives on CPR training efforts. -cardiac-patients-hospital-discharge-comparing-methods

19 JAMA Cardiol Jun 1;1(3): Resuscitation 85 (2014) 34-41

20 Exploration of Mobile Technology to Improve Bystander CPR rates Ringh M et al. NEJM 2015; 372: demographic-tables/

21 Conclusions Significant disparities remain in cardiac resuscitation for minority and low-income communities. Blacks and Hispanics have lower bystander CPR, lower AED rates, and lower CPR training. Blacks and Hispanics have lower survival Addressing Gaps CPR training requirements for high school students Funding to explore CPR training for high risk cardiovascular patients Targeted tailored training by the AHA in high risk communities Research on innovative implementation efforts and privateacademic-government partnerships needed to mobilize the community and move the needle in this field.

22 Thank You My dad is why. Myocardial Infarction when I was 8 years. Dancing at my wedding 4 days after anterior STEMI.

23 Eight Americas: Investigating Mortality Disparities across Race, Counties, and Race Counties in the US --- Asian --- Northland Low Income Whites --- Middle America (98% white) --- Low-Income Whites (Appalachia/MS Valley) --- Western Native American --- Black Middle America --- Southern Lowincome Rural black --- High-risk Urban Black Murray, C.J.L et al. PLoS Med 2006; 3(9): e260. doi: /journal.pmed

24 Probability of Death by Specific Age Ranges in the US 1 Asian 2 Northland Low Income Whites 3 Middle America (98% white) 4 Low-Income Whites (Appalachia/MS Valley) 5 Western Native American 6 Black Middle America 7 Southern Low-income Rural black 8 High-risk Urban Black Murray, C.J.L et al. PLoS Med 2006; 3(9): e260. doi: /journal.pmed

25 Distinctive Clinical Profile of Blacks Versus Whites Presenting with Sudden Cardiac Arrest 7 Reinier et al. Circulation 2015; 132: