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Original Investigation |

Rates of Cardiopulmonary Resuscitation Training in the United States

Monique L. Anderson, MD1; Margueritte Cox, MS1; Sana M. Al-Khatib, MD, MHS1; Graham Nichol, MD, MPH, FRCP2; Kevin L. Thomas, MD1; Paul S. Chan, MD, MSc3; Paramita Saha-Chaudhuri, PhD1; Emil L. Fosbol, MD, PhD1; Brian Eigel, PhD4; Bill Clendenen, MBA5; Eric D. Peterson, MD, MPH1
[+] Author Affiliations
1Department of Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
2Department of General Internal Medicine, University of Washington–Harborview Center for Prehospital Emergency Care, University of Washington, Seattle
3Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
4American Heart Association, Dallas, Texas
5Health & Safety Institute, Eugene, Oregon
JAMA Intern Med. 2014;174(2):194-201. doi:10.1001/jamainternmed.2013.11320.
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Importance  Prompt bystander cardiopulmonary resuscitation (CPR) improves the likelihood of surviving an out-of-hospital cardiac arrest. Large regional variations in survival after an out-of-hospital cardiac arrest have been noted.

Objectives  To determine whether regional variations in county-level rates of CPR training exist across the United States and the factors associated with low rates in US counties.

Design, Setting, and Participants  We used a cross-sectional ecologic study design to analyze county-level rates of CPR training in all US counties from July 1, 2010, through June 30, 2011. We used CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute. Using multivariable logistic regression models, we examined the association of annual rates of adult CPR training of citizens by these 3 organizations (categorized as tertiles) with a county’s geographic, population, and health care characteristics.

Exposure  Completion of CPR training.

Main Outcome and Measures  Rate of CPR training measured as CPR course completion cards distributed and CPR training products sold by the American Heart Association, persons trained in CPR by the American Red Cross, and product sales data from the Health & Safety Institute.

Results  During the study period, 13.1 million persons in 3143 US counties received CPR training. Rates of county training ranged from 0.00% to less than 1.29% (median, 0.51%) in the lower tertile, 1.29% to 4.07% (median, 2.39%) in the middle tertile, and greater than 4.07% or greater (median, 6.81%) in the upper tertile. Counties with rates of CPR training in the lower tertile were more likely to have a higher proportion of rural areas (adjusted odds ratio, 1.12 [95% CI, 1.10-1.15] per 5–percentage point [PP] change), higher proportions of black (1.09 [1.06-1.13] per 5-PP change) and Hispanic (1.06 [1.02-1.11] per 5-PP change) residents, a lower median household income (1.18 [1.04-1.34] per $10 000 decrease), and a higher median age (1.28 [1.04-1.58] per 10-year change). Counties in the South, Midwest, and West were more likely to have rates of CPR training in the lower tertile compared with the Northeast (adjusted odds ratios, 7.78 [95% CI, 3.66-16.53], 5.56 [2.63-11.75], and 5.39 [2.48-11.72], respectively).

Conclusions and Relevance  Annual rates of US CPR training are low and vary widely across communities. Counties located in the South, those with higher proportions of rural areas and of black and Hispanic residents, and those with lower median household incomes have lower rates of CPR training than their counterparts. These data contribute to known geographic disparities in survival of cardiac arrest and offer opportunities for future community interventions.

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Figure 1.
Geographic Distribution of Counties by Tertiles of Cardiopulmonary Resuscitation (CPR) Training in the US Community CPR Training Cohort

This map shows the tertiles of CPR training levels for each county in the United States. Lower-tertile counties had rates of CPR training ranging from 0.00% to less than 1.29% (median, 0.51%); middle-tertile counties, from 1.29% to 4.07% (median, 2.39%); and upper-tertile counties, greater than 4.07% (median, 6.81%).

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Figure 2.
Spatial Clustering of Rates of Cardiopulmonary Resuscitation (CPR) Training in the United States

This map shows the clustering pattern of tertiles of CPR training categories. Spatial clustering is demonstrated with high values (“hot spots”) and low values (“cold spots”) on the map. The z scores, calculated with the Getis-Ord Gi* test,20 show the degree of clustering. Negative z scores indicate spatial clustering of low values (lowest tertile); positive z scores, spatial clustering of high values (upper tertile); and z scores ranging from −1.65 to 1.65, no statistically significant clustering in that area. The number of counties in Alaska and Hawaii is too small to calculate valid z scores. In the Figure key, the opening parenthesis indicates that the value is not included in the category and the closing bracket, that the number is included.

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