When Laws Save Lives: Impact of Legislation RequiringCardiopulmonary Resuscitation Education in High Schools

onSurvival after Sudden Cardiac Arrest

Victoria L. Vetter, M.D., MPHProfessor of Pediatrics

Perelman School of Medicine at the University of PennsylvaniaMedical Director, Youth Heart Watch

Division of Cardiology, The Children’s Hospital of Philadelphia

Co Investigators: Katherine F Dalldorf, Joseph Rossano, Heather Griffis, Maryam Y Naim, Andrew C Glatz (CHOP/UPenn)

Kimberly Vellano, Bryan McNally, (Emory Univ School of Med/CARES)

When Laws Save LivesBackground

• Sudden cardiac arrest is a major public health problem.• SCA affects >350,000 adults and 7000 children each year.• Survival rates after out-of-hospital cardiac arrest (OHCA) are low.

• Adults: 10.4%• 9.0% Neurologically Favorable Survival

• Children: 10.7% • 8.2% Neurologically Favorable Survival

• Mortality is decreased by early CPR and AED use and increased by delays.

• Trained bystanders willing to perform CPR and use AEDs with access to AEDs are critical factors for improving survival from OHCA.

When Laws Save LivesBackground

• While there are data showing that survival rates are higher when CPR is performed and an AED is used, it is unclear if laws mandating CPR/AED training in schools impact bystander CPR and survival rates.

• Even in states that have laws, there are inconsistencies in implementation that could result in disparities in specific populations.

When Laws Save LivesStates with Laws

• Requirements for CPR/AED training in schools are determined at the state level, leading to nationwide variations in legislative mandates.

• While mandates for CPR/AED education have been present since as early as 1984, there has been a recent upsurge in the number of states requiring CPR/AED training.

• Currently, 38 of 50 US states plus the District of Columbia require CPR and AED training be in the curriculum for high school students, while the remaining states have no legislation. cpr.heart.org

Research Proposal: When Laws Save Lives

CARES (Cardiac Arrest Registry to Enhance Survival) Data Sharing Committee

Aim: To determine and compare the effect on victims of sudden cardiac arrest (SCA) of statewide legislation requiring cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) education in high schools.

• On bystander CPR rates, AED use rates, survival, and favorable neurological outcomes

• Between states with and without legislation• Noting differences from years 2013 through 2017• By age, sex, race, ethnicity, location of arrest, urbanicity, and

neighborhood SES

When Laws Save LivesMethods

Outcomes of Interest

• Bystander CPR rates• Bystander AED use rates• Overall survival rates• Survival rates with favorable

neurological outcomes

Variables of Interest

• Victim’s age, sex, race/ethnicity

• Arrest witnessed or not• Arrest date and location• Urbanicity/Population density

and neighborhood SES• Bystander CPR• Bystander AED used

When Laws Save LivesMethods

• Inclusion CriteriaAll nontraumatic out-of-hospital cardiac arrest (OHCA) Cases submitted to CARES Registry during study period (2013-2017)In states with 50% state-level CARES population catchment

• Exclusion CriteriaOHCA that occurred in medical facilities or nursing homesTraumatic arrests Arrests with missing values on any variables of interest

• Statistical AnalysisDescriptive statistics (Chi-square tests)Multivariable logistic regression

CARES OHCA Study Population and Status of Laws

Total, 149,453

With Exclusions,

109,668

0

20000

40000

60000

80000

100000

120000

140000

160000

Population

Laws Passed, 66%

Laws Enacted, 59%

54

56

58

60

62

64

66

68

Law Status

Results: General Characteristics

24.0%, 26,173

76.0%, 83,495

1.8%, 1989

1.0%, 1050

0.4%,485

7.4%, 8167

13.2%, 14,482

31.1%, 34,13929.0%, 31,804

16.0%, 17,155

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

Population by Age Distribution

<50 >50 <1 1 to 12 13-17 18-34 35-49 50-64 65-69 80+

{ 3.2%

General Characteristics

Male, 64%

Female, 36%

White, 49.4%

Black, 19.1%

Hispanic, 2.3% Other, 2.9%

Unknown, 26.4%

0

10

20

30

40

50

60

70

Gender Race/Ethnicity

Perc

enta

ge

General Characteristics

Public, 18.2%

Home/Res, 81.8%

BystanderWitnessed, 44.3%

Shockable Rhythm, 21.6%

Bystander CPR, 44.3%

AED Used, 2.9%

0

10

20

30

40

50

60

70

80

90

Arrest Location Event

Perc

enta

ge

Intervention

Overall OutcomesHospital Discharge

10.3%Neurologically Favorable

Survival, 8.7%

0

2

4

6

8

10

12

Outcomes

Bystander CPR by Age

40.638.7

44.9

50.5 52.0

40.3 39.3 40.5 39.1

34.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Perc

enta

ge

<50 >50 <1 1 to 12 13-17 18-34 35-49 50-64 65-69 80+

p<0.001{

Bystander CPR by Gender and Race/Ethnicity

Male, 40.1%Female, 37.6%

White, 42.3%

Black, 25.6%

Hispanic, 31.8%

Other, 42.7%Unknown, 43.6%

0

5

10

15

20

25

30

35

40

45

50p<0.001

Gender Race/Ethnicity

Perc

enta

ge

p<0.001

BCPR by Location and Event Characteristics

Public, BCPR 46.2%

Home/Res, BCPR 37.6%

Bystander Witnessed, BCPR, 47.5%

Not Witnessed, BCPR, 32.6%

0

10

20

30

40

50

Arrest Location Event Characteristics

Perc

enta

ge

p<0.001 p<0.001

Bystander CPR Outcomes

BCPR, Hospital Discharge , 14.5%

No BCPR,Hospital Discharge, 7.6%

BCPR, Neurologically Favorable survival, 13%

No BCPR, Neurologically Favorable survival, 6%

0

2

4

6

8

10

12

14

16

Perc

enta

ge

p<0.001

p<0.001

Effect of Laws EnactedBCPR, Hospital Discharge, Neurologically Favorable Survival

Laws Enacted, 41.3%

Laws Enacted, 11.3%Laws Enacted 9.5%

No Law Enacted, 36.1%

No Laws, 8.9%No Laws, 7.6%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

BCPR Hospital Discharge Neurologically Favorable Survival

p<0.001

Perc

enta

ge

Marginal Probabilities of Bystander CPR by Ageby Law Enacted Status

• BCPR is higher in states with Laws across all ages by 17-25%.

• Greatest increase in the 13-17 year age group (25.3%) in states with laws.

47.90%56.40%

50.40%59.10%

46.60%55.40%

38.20%46.40%

36.60%43.20%

35.60%43.40%

33.50%40.80%

31.10%37.10%

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

<1<1

1 to 121 to 12

13 to 1713 to 1718 to 3418 to 3435 to 4935 to 4950 to 6450 to 6465 to 7965 to 79

80+80+

Green= LAWRED= NO LAW

p<0.001

Hospital Discharge by Age

• Hospital discharge is higher across all ages in states with Laws.

• Greatest increase (32.4%) noted in the 1-12 year range with a discharge rate of 22.9%.

9.5%

11.9%

17.3%

22.9%

16.9%

20.6%

16.6%

21.3%

11.1%

14.1%

9.5%

12.1%

7.5%

9.1%

4.9%

5.2%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Law

Age

No <1

Yes

<1

No

1 to 12

Yes

1 to 12

No

13 to 17

Yes

13 to 17

No

18 to 34

Yes

18 to 34

No

35 to 49

Yes

35 to 49

No

50 to 64

Yes

50 to 64

No

65 to 79

Yes

65 to 79

No

80+

Yes

80+

p<0.001

Neurologically Favorable Survival by Age

• Neurologically favorable survival across all ages is higher in states with Laws.

• The highest NFS occurs between18 and 34 years at 19.4%.

7.9%

11.1%

15.8%

19.0%

15.1%

18.6%

15.6%

19.4%

9.8%

12.5%

8.2%

10.3%

6.0%

7.4%

3.6%

4.1%

Age

<1

<1

1 to 12

1 to 12

13 to 17

13 to 17

18 to 34

18 to 34

35 to 49

35 to 49

50 to 64

50 to 64

65 to 79

65 to 79

80+

80+

p<0.001

Green= LAWRED= NO LAW

Bystander CPR, Hospital DC and NFS by Gender

• BCPR, hospital discharge, and neurologically favorable survival are higher in both genders in states with Laws.

• BCPR and NFS are higher in females in states with laws

• Hospital discharge is higher in males in states with laws.

34.6%43.2%

35.1%41.7%

0 20 40 60

Female, no lawFemale, law

Male , no lawMale, law

Bystander CPRp<0.001

9.7%10.2%

8.7%10.7%

0 2 4 6 8 10 12

Female, no lawFemale, law

Male , no lawMale, law

Hospital Discharge

7.6%10.3%

7.4%9.2%

0 2 4 6 8 10 12

Female, no lawFemale, law

Male , no lawMale, law

Neurologically Favorable Survival

Bystander CPR, Hospital Discharge and NFS by Race/Ethnicity

• Bystander CPR, hospital discharge and NFS are higher in states with laws across all races.

• Largest race specific increases occurred in Hispanics and Blacks for BCPR.

39.5%

43.5

21.6%

28.5

26.9

33.9

44.5

41.1

36.7

51.6

0 10 20 30 40 50 60

White, no law

White, law

Black , no law

Black, law

Hispanic, no law

Hispanic, law

Other, no law

Other, law

Unknown, no law

Unknown, law

Percentage

Bystander CPR

p<0.001

Effect of Laws by Area on BCPRRural, Suburban, Urban

• BCPR, Hospital discharge and NFS rates are higher in states with laws regardless of area.

• The largest increase in BCPR (36.6%) occurred in Urban areas.

• Best BCPR rates occur in rural areas.

• Highest hospital discharge and best NFS rates are in suburban and urban areas, despite lower BCPR rates.

45.4%

47.0%

38.0%

42.6%

27.9%

38.1%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Law

No

Yes

No

Yes

No

Yes

Urb

ani

city

Rur

alR

ural

Subu

rba

nSu

bur

ban

Urb

anU

rban

Bystander CPR

Green= LAWRED= NO LAWp<0.001

Neighborhood Characteristics

• Social determinants have a significant effect on rates of bystander CPR.

• BCPR rates are higher in states with laws by multiple indicators that reflect SES.

• The greatest increase (43.9%) occurred in those with <80% high school education. 29.2

41.3

40.8

25.6

38.4

17.1

22.3

38.6

35.9

45.7

44.6

33.5

43.4

21.1

32.1

43.5

0 10 20 30 40 50

<$50,000/yr

>$50,000/yr

<10% Unemployment

>10% Unemployment

Black <80%

Black >80%

HS Education <80%

HS Education >80%

Bystander CPR

Green= LAWRED= NO LAW

p<0.001

When Laws Save LivesConclusions

• Bystander CPR, hospital discharge and neurologically favorable survival are higher in states with CPR and AED education laws.

• This effect prevails across all ages, genders, racial and ethic groups, and geographical areas.

• Groups with lower SES have higher rates through all domains (income, education, race, and employment status) in states with laws.

When Laws Save LivesConclusions

• Assistance to schools to help with CPR/AED education in low SES, minority communities has the potential for the greatest benefit.

• States with laws passed should enact them in a uniform fashion as soon as is feasible.

• The 12 states that do not have laws passed or enacted should pass such laws to benefit all of their citizens. Alaska, California, Colorado, Florida, Hawaii, Maine, Massachusetts, Montana, Nebraska,

New Hampshire, Pennsylvania, and Wyoming

When Laws Save Lives

Thank you!

Longitudinal Outcomes by Year

• No significant differences in hospital discharge or neurologically favorable outcomes over the past 5 years.

• Short time interval with laws enacted at various times.• Catchment varies by time

intervals.2013 20132014 20142015 20152016 20162017 2017

0

2

4

6

8

10

12

Hopital Discharge Neuro Fav Outcome

2013 2014 2015 2016 2017

p=0.316p=0.712

Perc

enta

ge

AED Use in Public ArrestsAge (yrs) % p Race/Ethnicity % p

<1 2.7 <0.001 White 11.8 0.0011-12 8.9Black 9.713-17 20.0

18-34 9.4 Hispanic 8.235-49 9.9 Other 11.950-64 12.1

Unknown 12.165-79 12.1

Bystander witnessed % p80+ 12.1

Gender % n No 8.5 <0.001Yes 13.5Female 10.1

Male 11.9 0.001Bystander CPR %

pLaws Enacted % pNo 12.2 no 2.1 <0.001Yes 10.9 0.005 yes 22.3

Effect of Laws by Area on DischargeRural, Suburban, Urban

• Hospital discharge rates were higher in states with laws regardless of area.

• The largest increase (33%) occurred in Urban areas from 9 to 12%.

• Highest discharge are in suburban and urban areas, despite lower BCPR rates.

Discharge

8%

9%

10%

12%

9%

12%

0% 2% 4% 6% 8% 10% 12% 14%

Law

No

Yes

No

Yes

No

Yes

Urb

ani

city

Rur

alR

ural

Subu

rba

nSu

bur

ban

Urb

anU

rban

Green= LAWRED= NO LAW

p<0.001

Effect of Laws by Area on Neurologically Favorable Outcomes

Rural, Suburban, Urban

• Neurologically favorable outcomes in states are higher in states with laws regardless of area.

• The largest increase (41.1%) occurred in urban areas.

• Best neurologically favorable outcomes rates are seen in suburban and urban areas.

Neurologically Favorable Outcome

7.3%

8.0%

8.7%

10.5%

7.3%

10.3%

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0%

Law

No

Yes

No

Yes

No

Yes

Urb

anic

ityR

ural

Rur

alSu

burb

anSu

burb

anU

rban

Urb

an

Green= LAWRED= NO LAW

p<0.001

Cardiac Arrest Registry to Enhance Survival

• CARES was established in 2004 by the U.S. Centers for Disease Control and Prevention and Emory University to improve survival from cardiac arrest through out-of-hospital cardiac arrest (OHCA) data collection in the United States.

• Communities that join CARES enter cardiac arrest data from EMS agencies and hospitals into a national database to track their performance confidentially over time, improve the quality of patient care, and increase survival.

• State-wide registries in 23 states with 63 community sites in 18 additional states representing a catchment area of >115 million people with >405,000 patients in the Registry.

mycares.net

Bystander CPR by Law Status

Laws Passed, BPCR , 41.2%

No Laws Passed, BCPR, 35.3 %

Laws Enacted, 41.3%

No Laws Enacted, 36.1%

32

33

34

35

36

37

38

39

40

41

42

Perc

enta

ge

p<0.001 p<0.001