January 6th, 2014
A Cross-Section of CPR Training in U.S. Counties
CardioExchange’s John Ryan interviews Monique L. Anderson about her research group’s study, published in JAMA Internal Medicine, of CPR training rates in the United States.
In a cross-sectional ecologic study, researchers used CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute to analyze rates of CPR training in all U.S. counties from July 2010 through June 2011. County-based rates of CPR training were <1.29% of the population in the lowest tertile, 1.29% to 4.07% in the middle tertile, and >4.07% in the highest tertile. Compared with the two highest tertiles (combined), counties in the lowest tertile were significantly more to have a higher proportion of rural areas, black and Hispanic residents, a lower median household income, and a higher median age. Counties in the South, Midwest, and West were more likely to have rates of CPR training in the lowest tertile, compared with the Northeast.
Ryan: What are the causes of the lower rates of CPR training in the South, in low-income and rural areas, and in African American and Hispanic communities?
Anderson: CPR training may be occurring primarily in high-demand markets, related, for example, to healthcare- and job-related OSHA requirements. There may not be sufficient markets in rural, low-income, and high-density minority counties. For the community-based training, it may be some combination of (1) awareness of the need and value of CPR training, (2) expense, and (3) travel time for residents. As we note, this was a cross-sectional ecologic study, so we don’t know for sure who precisely is being trained in these counties.
Ryan: The highest tertile for CPR training was >4% of the population. To you, what is the ideal percentage of CPR-trained people in a community? Is it 100%?
Anderson: To start to answer this question, we would need a study to assess the association of CPR training with bystander CPR use and outcomes after out-of-hospital cardiac arrest (OHCA). If the higher rates of CPR training are correlated with bystander CPR use and outcomes, then I think there is an argument for consistent yearly CPR training in all U.S. counties (perhaps starting with a goal of >4%).
Ryan: How can CPR training rates be improved? And how will you measure the success of those efforts in altering CPR outcomes?
Anderson: We can start by following the Denmark example. A study recently highlighted the impact of a national initiative to improve cardiac arrest management and outcomes. Mandatory CPR training was implemented in elementary schools and for people who want to acquire a driver’s license, along with other efforts to increase the number of citizens available to perform CPR. The country experienced significant improvement in bystander CPR rates (from 22.1% to 44.9%) and survival from 2001 to 2010.
Implementation of two related requirements — CPR certification to qualify for a high school diploma and a driver’s license — can have a profound effect on the number of Americans with CPR training. Legislation is pending in some geographic areas — for example, North Carolina recently passed a law requiring CPR certification before high school graduation. In addition, dispatch-assisted CPR should be used by all emergency response systems in the United States. Finally, CPR training organizations should develop low-cost programs to improve training in geographic areas that have low overall rates of training.
Registries such as the Resuscitation Outcomes Registry, AED Registry, and CARES registry will be critical in measuring the success of efforts to increase CPR training, bystander CPR, and outcomes after OHCA. These registries collect comprehensive data on cardiac arrest characteristics, use of bystander CPR and AEDs, other treatments, and field and hospital outcomes.
The HeartRescue Initiative is a Medtronic-funded effort to improve outcomes after cardiac arrest. It involves seven academic centers with systems of care and/or OHCA expertise, has set a goal to increase survival after OHCA to more than 50% over a 5-year period. The mission is “developing and expanding SCA response systems by coordinating measurement, education, training and the application of evidence-based best practices among the general public, first responders, emergency medical services and hospitals.”
In short, the goal to improve survival after OHCA will require the collective and coordinated efforts of academic investigators, policy makers, CPR training organizations, and community leaders and citizens.
What insights do you gain from the study conducted by Dr. Anderson and her colleagues?