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Bias Takes a Deadly Turn – the Impact of Race in the Administration of Bystander CPR

By Rohan D. ‘25

Disparities in access to healthcare have long been documented across a broad swathe of interventions, expensive and cheap, new and old. However, a recent landmark study in the New England Journal of Medicine recently extended this idea into a shocking new realm: the administration of CPR to patients experiencing cardiac arrest outside of a hospital.

Approximately 356,000 non-traumatic cardiac arrests outside the hospital occur each year (Sudden Cardiac Arrest Foundation). According to the American Heart Association, receiving bystander CPR immediately after a cardiac arrest can double or triple the victim’s chances of survival. 

Prior to the publication of this study, it was known that there were disparities in the administration of immediate CPR by bystanders, but the effect of the victim’s race was unclear.  One article, “Association of Neighborhood Characteristics with Bystander-Initiated CPR,” written by Dr. Comilla Sasson and colleagues in the New England Journal of Medicine in 2012 explored the differences in the administration of bystander CPR as a function of demographic characteristics of the neighborhood where the cardiac arrest occurred. The authors concluded that  “patients who had an out-of-hospital cardiac arrest in low-income Black neighborhoods were less likely to receive bystander-initiated CPR than those in high-income white neighborhoods.” 

The new study, entitled “Racial and Ethnic Differences in Bystander CPR for Witnessed Cardiac Arrest,” was published in the New England Journal of Medicine on October 27, 2022. The investigators attack the question of race directly in their study. The authors coupled information from the CARES database, one of the largest cardiac arrest databases in the United States, with census tract information. By pairing cardiac arrest patient demographic information with granular data about the location where the arrest occurred, the authors were able to interrogate whether the victim’s race mattered for receiving bystander CPR, even after correcting for factors like neighborhood income or distribution of race within the neighborhood. 

The results were astonishing. In public locations, Black and Latinx persons had a 45% chance of receiving bystander CPR during a cardiac arrest, while White people had a 60% of receiving bystander CPR during a cardiac arrest. The effect was preserved across different neighborhoods regardless of racial or economic profiles. Even in majority-Black and Latinx neighborhoods, White victims fared better than Black or Latinx victims. In an interview with the Gazette, Dr. Paul Chan, the senior author of the paper and a Professor of Medicine at the University of Missouri-Kansas City School of Medicine, stated, “If there is some implicit bias and conscious racism that causes us to hesitate to respond to somebody of color, then it’s not just relegated to White communities. It’s pervasive in how people respond.” 

Some critiques can be applied to the study. First, although the CARES database is the largest out-of-hospital cardiac arrest registry in the United States, it only accounts for about half of all cardiac arrests in the country. Furthermore, a number of events in the database were excluded (for example, 21% of witnessed cardiac arrests were not included in the analysis because the victim’s race was unknown). Thus, it will be important to see if further studies replicate the findings using alternative data sources. Second, there is some uncertainty about whether the race of victims is accurate because the race data entered into the CARES database is based on the Emergency Medical Services (EMS) team’s guesses on the victim’s race. Third, the quality of the CPR that was provided by bystanders is unknown and recognized to vary greatly among non-healthcare providers. 

Black victims compared to White patients tended to have relatively more events in the street – but the general rate of bystander CPR is lowest in the street compared to other public locations like a gym or workplace. This raises the possibility that the disparity in Black versus White access may be partially confounded by a difference in where events tend to occur for members of different races. Dr. Saket Girotra, an Associate Professor in the Department of Internal Medicine at the University of Texas Southwestern Medical Center and co-author of the study, said in an interview with the Gazette, “Across different public locations, the disparities between Black or Hispanic vs. White bystander CPR rates were present. But they were so much smaller if the cardiac arrest occurred at a workplace where presumably bystanders were your colleagues and they knew you. However, if the cardiac arrest occurred in an airport or in the street or in the gym, where the bystanders may not know you very well, the difference in bystander CPR rates between Black or Hispanic vs. White individuals was as high as 50%. That guides the point of implicit bias among bystanders who may be strangers and may not know the victim- their reluctance to perform bystander CPR based on what the victim may be perceived as.” Additional research is required to understand whether the low rate of bystander CPR in the street may be due to the potentially lowest social proximity between arrest victims and bystanders.

Credit: Chan et al., “Racial and Ethnic Differences in Bystander CPR for Witnessed Cardiac Arrest, New England Journal of Medicine, 2022, Oct 27;387(17):1569-1578.

A critical question that the study does not address is the race of bystanders that witness the event. Further studies will be required to address this.

The study has ignited interest among different stakeholders in potential solutions. One proposal is making access to CPR training more accessible and affordable. Currently, CPR training, which is usually conducted by the American Red Cross and the American Heart Association, requires several hours and a monetary fee. Dr. Aaron Cohen, a cardiology fellow at the University of Massachusetts Medical School, stated to the Gazette, “We need to do more about educating everybody; the work that we have to do is more universal than we thought.” The nature of CPR training itself may have to be reimagined. “The images of CPR examples are of White people and White manikins. It doesn’t reflect diversity because Black and Hispanic people cannot relate as much,” stated Dr. Chan. 

Unfortunately, a sobering conclusion of the study is that even in areas where access to CPR training is presumably high, Black and Latinx victims still receive less CPR than their white counterparts. Therefore, providing additional training in CPR, in particular to Black and Latinx populations, is actionable, but not necessarily enabling for addressing the divide in access. Fundamentally addressing this disparity in access will likely require transforming a pervasive implicit racial bias that we now recognize was deadlier than ever before.

Categories: News, Science & Tech

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