Black and Hispanic adults who go into cardiac arrest in public are less likely to receive CPR from anyone standing by before a medical team arrives, a new study finds.
Overall, the relative likelihood of getting bystander CPR at home was 26% lower for Black and Hispanic people than for Whites, and the likelihood of bystander CPR for cardiac arrests in public was 37% lower for Blacks and Hispanics than for Whites, according to the study, published Thursday in the New England Journal of Medicine.
“These results were important to understand and likely emblematic of other larger social issues that affect health care and treatment,” Dr. Paul Chan, the study’s senior author and cardiologist at Saint Luke’s Mid America Heart Institute in Missouri, said in a news release.
“In cardiac arrest, you depend on bystanders to respond. Without them, the likelihood of surviving before first responders and paramedics arrive are substantially lower,” he said. “That’s why this study really brings to light challenges with structural and individual bias that we, as a society, have to confront that may not be as prominent with other medical conditions.”
Disparities at home, and in public
The researchers – from Saint Luke’s Mid America Heart Institute, the University of Missouri-Kansas City and other US institutions – analyzed data from the national Cardiac Arrest Registry to Enhance Survival on 110,054 people in the United States who had cardiac arrests outside of a hospital setting between 2013 and 2019. The researchers examined data on the race and ethnicity of people who went into cardiac arrest but did not have race data for the bystanders.
The researchers found that 45.6% of Blacks and Hispanics received bystander CPR when cardiac arrests happened in public locations compared with 60% of Whites.
Specifically, Black and Hispanic people were less likely than Whites to receive bystander CPR in every public location category, including in workplace settings, at 53.2% vs. 61.8%; recreational facilities, at 55.8% vs. 74.4%; and public transportation centers, at 48.3% vs. 69.6%, according to the data.
“Racial and ethnic differences in bystander CPR in public locations raise additional concerns about implicit and explicit biases in layperson response to out-of-hospital cardiac arrests,” the researchers wrote.
The data also showed that 38.5% of Blacks and Hispanics received bystander CPR when the cardiac arrest happened at home, compared with 47.4% of Whites.
“Several factors could explain the lower incidence of bystander CPR among Black and Hispanic persons as compared with White persons in arrests that occurred at home,” the researchers wrote. “CPR training is less commonly conducted in Black and Hispanic communities, and dispatcher-assisted bystander CPR may not be as readily available.”
The lower likelihood of bystander CPR being performed on Black and Hispanic people continued even in majority Black and Hispanic neighborhoods, the researchers noted.
“Black and Hispanic persons were less likely than White persons to receive potentially lifesaving bystander CPR at home and in public locations, regardless of the racial or ethnic makeup or income level of the neighborhood where the cardiac arrest occurred,” the researchers wrote.
The study findings suggest that these differences in how likely someone is to receive CPR from a bystander contribute to how Black people may be less likely to survive an out-of-hospital cardiac arrest.
‘Disappointing’ but not surprising
The study findings were “troubling” but not surprising to Dr. Georges Benjamin, executive director of the American Public Health Association.
“For me personally, it’s disappointing that we haven’t fixed this over all these years – because we’ve known this for some time,” said Benjamin, who used to organize CPR training programs as chief of emergency medicine at Walter Reed Army Medical Center.
Benjamin, who was not involved in the new study, agreed with the authors that part of the reason for the racial disparity for bystander CPR could be a lack of training in Black and Brown communities. He added that not receiving bystander CPR during a cardiac arrest can have “significant clinical outcomes” for the person whose heart stopped pumping.
“Bystander CPR ensures some level of blood circulation, oxygenation of the brain and other vital organs,” Benjamin said. “So the earlier you can get blood circulated, even at a low level, the much more likely that person is to get enough oxygen to keep brain functioning going at some level” until the person can get hospital care.
The study findings were also no surprise to Dr. Jayne Morgan, a cardiologist and executive director of health and community education at Piedmont Healthcare/Hospital System in Atlanta, who was not involved in the new paper.
“No I am not particularly surprised with the findings as socioeconomic infrastructure impacts all areas of life of those impacted in negative and compounding ways,” Morgan wrote in an email to CNN on Thursday.
“Certainly time to intervention is critical, and bystander CPR and defibrillator access and use is a part of that,” she said, adding that disparities in how much CPR training is conducted in communities also plays a role in the likelihood of someone receiving bystander CPR.
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The study findings on disparities can be used to help improve the likelihood of bystander CPR for anyone with cardiac arrest, Dr. Walter Clair, of Vanderbilt University Medical Center, wrote in an editorial published alongside the study on Thursday.
“When interpreting their results, the authors have appropriately focused on the role that implicit bias may have played in the observed racial and ethnic disparities. The overall incidence of bystander CPR for witnessed out-of-hospital cardiac arrest in this study is disappointing, and there is a suggestion in these data that a hesitancy among bystanders to provide CPR may be having a greater effect in Black and Hispanic communities than in White communities,” Clair wrote.
“We need to use what we learn about disparities to help improve the likelihood of bystander CPR for everyone. This study reminds us that our efforts to decrease cardiovascular morbidity may be complicated to some extent by a legacy of structural racism that has left many of our communities segregated and with inequitable social determinants of sudden cardiac death.”