In the first study of its kind, researchers have found that those who suffer cardiac arrests in upper income, white neighborhoods are nearly twice as likely to get cardiopulmonary resuscitation (CPR) than people who collapse in low-income, black neighborhoods.
"If you drop in a neighborhood that is 80 percent white with a median income over $40,000 a year, you have a 55 percent chance of getting CPR," said study author Comilla Sasson, MD, an emergency room physician at the University of Colorado Hospital. "If you drop in a poor, black neighborhood you have a 35 percent chance. Life or death can literally be determined by what side of the street you drop on."
The study was published October 24 in the New England Journal of Medicine.
Sasson, an assistant professor in the Department of Emergency Medicine at the University of Colorado School of Medicine, analyzed data from 14,225 patients who suffered cardiac arrests in 29 cities from 2005-2009. She and her colleagues used census data to determine which neighborhood the event took place in, its racial make-up and median household income. Low-income was considered at or below $40,000 a year.
"We found a direct relationship between the median household income and racial composition of a neighborhood and the probability that a person whose heart had stopped would have a bystander perform CPR," the study said. "This association was most apparent in low-income black neighborhoods where the odds of receiving bystander- initiated CPR were approximately 50 percent lower than in high-income, nonblack neighborhoods."
A number of reasons were identified for this disparity. One is the cost of CPR training. Another is a lack of outreach to minority neighborhoods by organizations that promote CPR. And there are also language barriers and cultural issues surrounding the learning and performance of CPR.
Part of the study involved conducting focus groups in poor neighborhoods. In one area of Columbus, OH residents had median incomes of $20,000.
"If they paid $250 for a CPR class you are talking about 15 percent of their salary," Sasson said. "When you look at the competing economic interests -- am I going to eat tonight or attend a CPR class? -- the answer is obvious."
Yet the consequences are also obvious.
According to the study, there are 300,000 out-of-hospital cardiac arrests each year with survival rates that vary wildly from 0.2 percent in Detroit to 16 percent in Seattle. The difference can be explained in large part to intervention with CPR.
"For every 20 who get CPR you get one life saved," Sasson said. "So you are talking about thousands of lives being saved here."
The problem isn't only about income. Even in wealthier black neighborhoods, those who had cardiac arrest were 23 percent less likely to receive CPR than in high-income nonblack neighborhoods.
And the study showed that regardless of the neighborhood where a cardiac arrest occurs, blacks and Hispanics were 30 percent less likely than whites to receive CPR from a bystander.
"This suggests that, neighborhood effects, though important, do not fully account for observed racial differences," the study said.
Sasson called for more targeted, low-cost CPR training efforts based on the income and racial composition of neighborhoods. She is also working on creating public health programs aimed at increasing bystander-given CPR in specific communities.
As a doctor who once practiced in a level one trauma center in Atlanta, Sasson has witnessed first-hand the human toll of this inequity.
"I would see African-Americans coming in and dying from cardiac arrests after having laid there for 10 minutes with no one delivering CPR," she said. "There is no reason in 2012 that this kind of disparity exists -- that you live or die depending on what side of the street you drop on. It is simply unacceptable."
- Comilla Sasson, David J. Magid, Paul Chan, Elisabeth D. Root, Bryan F. McNally, Arthur L. Kellermann, Jason S. Haukoos. Association of Neighborhood Characteristics with Bystander-Initiated CPR. New England Journal of Medicine, 2012; 367 (17): 1607 DOI: 10.1056/NEJMoa1110700
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