Are lower Child Opportunity Index and Black/African American race associated with worse outcomes in pediatric out-of-hospital cardiac arrest, and does bystander CPR mediate this association?
Pediatric out-of-hospital cardiac arrests in lower opportunity neighborhoods and among Black/African American children have worse outcomes, which is partially mediated by lower rates of bystander CPR.
Introduction: Studies in adults and children have shown unacceptable disparities in out-of-hospital cardiac arrest (OHCA) risk, outcomes and bystander CPR (BCPR) provision. This study evaluated the association between the Child Opportunity Index (COI) and race and ethnicity and pediatric OHCA outcomes and the role of BCPR as a mediator. We hypothesized that arrests in lower COI neighborhoods are associated with worse outcomes, and that lower BCPR mediates this association. Methods: This is a retrospective cohort study using the Cardiac Arrest Registry to Enhance Survival (CARES) of children ≤18 years with OHCA. The exposures were COI quintiles (very low indicates the most disadvantaged neighborhoods) and race and ethnicity. The primary outcome was survival to hospital discharge with favorable neurological outcome (Pediatric Cerebral Performance Category ≤2). Associations of exposures with outcome were determined using logistic regression and mediation analysis was used to evaluate the indirect effect of BCPR. Results: Overall, 1654/17903 (9.24%) had a favorable outcome. Arrests in lower COI neighborhoods and in Black/African-American children occurred more frequently in infants and were less likely to be witnessed and to receive BCPR. Arrests in very low COI areas (vs very high COI, adjusted odds ratio aOR 0.68 95% CI 0.54-0.84, P<.001) and Black/African American race (vs non-Hispanic White, aOR 0.81 95% CI 0.69-0.96, P=.02) were independently associated with lower odds of a favorable outcome. Lower BCPR partially mediated worse outcomes associated with lower COI quintiles (adjusted percent mediated: 11.67% 95% CI 5.48-17.87, P<.001) and Black/African American race (15.57% 95% CI 7.54-23.61, P<.001). Conclusions: Arrests occurring in lower COI areas and among Black/African American children were associated with lower odds of a favorable outcome. Lower bystander response partially explained these associations. This is the first pediatric study to apply mediation analysis to explore mechanisms behind OHCA disparities, informing future research and policy. These data suggest a need to focus on arrest prevention and understand barriers and facilitators to improve bystander response.
Barreto et al. (Sun,) studied this question.