Historical neighborhood redlining and bystander CPR disparities in out-of-hospital cardiac arrest

Abstract

Background: Out-of-hospital cardiac arrest (OHCA) is associated with low survival rates. Bystander cardiopulmonary resuscitation (CPR) is essential for improving outcomes, but its utilization remains limited, particularly among racial and ethnic minorities. Historical redlining, a practice that classified neighborhoods for mortgage risk in 1930s, may have lasting implications for social and health outcomes. This study sought to investigate the influence of redlining on the provision of bystander CPR during witnessed OHCA.

Methods: We conducted an analysis using data from the comprehensive Cardiac Arrest Registry to Enhance Survival (CARES), encompassing 736,066 non-traumatic OHCA cases across the United States. The Home Owners' Loan Corporation (HOLC) map shapefiles were utilized to categorize census tracts of arrests into four grades (A signifying "best", B "still desirable", C "declining", and D "hazardous"). Multivariable hierarchical logistic regression models were employed to predict the likelihood of CPR provision, adjusting for various factors including age, sex, race/ethnicity, arrest location, calendar year, and state of occurrence. Additionally, we accounted for the percentage of Black residents and residents below poverty levels at the census tract level.

Results: Among the 43,186 witnessed cases of OHCA in graded HOLC census tracts, 37.2% received bystander CPR. The rates of bystander CPR exhibited a gradual decline across HOLC grades, ranging from 41.8% in HOLC grade A to 35.8% in HOLC grade D. In fully adjusted model, we observed significantly lower odds of receiving bystander CPR in HOLC grades C (OR 0.89, 95% CI 0.81-0.98, p = 0.016) and D (OR 0.86, 95% CI 0.78-0.95, p = 0.002) compared to HOLC grade A.

Conclusion: Redlining, a historical segregation practice, is associated with reduced contemporary rates of bystander CPR during OHCA. Targeted CPR training in redlined neighborhoods may be imperative to enhance survival outcomes.

Keywords: Bystander Cardiopulmonary Resuscitation; Cardiac Arrest Registry to Enhance Survival; Out-of-hospital cardiac arrest; Racial Disparities.

Fig. 1 –

Study Flow Chart.

Fig. 2 –

Map of Home Owner Loan Corporation (HOLC) in major cities in the US that are part of the Cardiac Arrest Registry to Enhance Survival (CARES).

Fig. 3 –

Absolute Rates of Bystander CPR by Individual and Neighborhood Characteristics, stratified by HOLC grade.

Fig. 4 –

Forest plot depicting Odds Ratio (OR) of bystander cardiopulmonary resuscitation (CPR) according to HOLC grade in unadjusted and fully adjusted models.