ACA Medicaid expansion cut disparities in cancer care for minorities, poor

September 26, 2017 – In non-expanded states, benefits were seen primarily in whites and higher-income patients.

States that fully expanded their Medicaid programs under the Affordable Care Act cut their rates of uninsured cancer patients by more than half between 2011 and 2014. Black patients and those living in the highest poverty areas saw the greatest benefit from Medicaid expansion, according to an analysis by DCRI and Duke Cancer Institute researchers.

Rates of uninsured cancer patients in states without Medicaid expansion also declined, but in these states, improvements appeared to primarily benefit white patients and residents of low-poverty areas, with a portion transitioning to non-Medicaid health insurance.

There were no improvements in uninsured rates for black patients and residents of high-poverty areas in states without Medicaid expansion. In fact, patients in these groups appeared to be losing insurance coverage, although this finding was not statistically significant, according to lead study author Fumiko Chino, MD, a radiation oncologist at Duke.

The data was presented Sept. 26 as part of the press program at an annual meeting of the American Society for Radiation Oncology (ASTRO) in San Diego. The analysis is based on the records of more than 197,000 people ages 18 to 64 in a National Cancer Institute database who received radiation for a cancer diagnosis between 2011 and 2014. The DCRI’s Yousuf Zafar, MD, was one of the study’s authors.

“The debate over health care reform is ongoing,” Chino said. “Our findings indicate that Medicaid expansion was effective at decreasing disparities and improving access to care for cancer patients receiving radiation, but some disparities still exist. In states without Medicaid expansion, the rates of uninsured patients went down, but those who benefited were white patients living in higher-income areas, for whom it might have been possible to purchase plans through the health care exchange.”

According to the study data, states with expanded Medicaid programs cut the rate of uninsured cancer patients receiving radiation from 4.4 percent to 2.1 percent. At the same time, the proportion of Medicaid recipients rose from 15.2 to 18 percent.

Inversely, in states without Medicaid expansion, Medicaid enrollment dropped from 15.9 to 14.9 percent for cancer patients receiving radiation, while the portion of these patients having non-Medicaid insurance coverage grew from 75.7 to 77.1 percent.

“This study is part of a developing body of research to quantify healthcare delivery changes under the ACA,” Chino said. “We now are assessing if these insurance changes translate to differences in patient survival.”

In addition to Chino and Zafar, study authors include Gita Suneja, Haley Moss, Laura Havrilesky and Junzo Chino.

DCRI researchers receive grant to study biomarkers linked to chronic low back pain

September 25, 2017 – The DCRI’s Adam Goode, DPT, PhD, and his team will collaborate with UNC-Chapel Hill on the project.

The National Institute of Arthritis, Musculoskeletal and Skin Diseases, part of the National Institutes of Health, has awarded a four-year, $2.4 million grant to a team of Duke researchers led by the DCRI’s Adam Goode, DPT, PhD. The grant will fund an analysis of biomarkers that could be used to better understand the nature of chronic low back pain.

Chronic low back pain affects more than 31 million Americans and costs the national healthcare system between $100 and $200 billion each year. The condition has several different causes, making it difficult for physicians to treat effectively.

Physicians often determine how to treat chronic lower back pain through diagnostic clinical imaging. With a limited understanding of the etiologies of low back pain, however, patients often receive interventions that are unnecessary or even dangerous.

“Not knowing the exact source of a patient’s back pain can really hamper clinical decision-making,” Goode said. “The hope is that we can reduce some of that confusion through the use of biochemical markers.”

Goode and his team, working in concert with the Thurston Arthritis Center and Department of Epidemiology at the University of North Carolina-Chapel Hill, will conduct longitudinal analyses of an ongoing population-based study investigating the incidence and progression of knee, hip and spine osteoarthritis to determine if biomarkers and other risk factors can predict the incidence and progression of intervertebral disc degeneration and facet joint osteoarthritis with and without low back symptoms.

The data will come from serum samples collected by the Johnston County Osteoarthritis Project, a community-based, longitudinal study of approximately 3,200 rural white and African American residents funded by the Centers for Disease Control and conducted by the University of North Carolina School of Medicine.  These samples will be validated against data collected from a second project, the Genetics of Generalized Osteoarthritis study. That study is cohort study designed to identify regions of the human genome associated with multi-joint osteoarthritis.

“We are very proud of Dr. Goode and his team for this important work,” said Benjamin A. Alman, MD, James Urbaniak Professor and Chair of the Department of Orthopaedic Surgery. “This research is directly applicable to healthcare and will not only strengthen and diversify our research portfolio, but also pave the way to improve the way we care for patients.”

Co-investigators on the study also include the DCRI’s Steven Z. George, PhD, and Duke’s Jun Chen, PhD.

DCRI’s Steven George receives funding for non-drug pain management research project

September 21, 2017 – The project, in addition to others announced this week, is intended to address the needs of current U.S. service members and veterans.

The U.S. Department of Health and Human Services, the U.S. Department of Defense (DoD), and the U.S. Department of Veterans Affairs (VA) announced this week a multi-component research project focusing on non-drug approaches for pain management addressing the needs of service members and veterans. Twelve research projects, totaling approximately $81 million over six years (pending available funds), will focus on developing, implementing, and testing cost-effective, large-scale, real-world research on nondrug approaches for pain management and related conditions in military and veteran health care delivery organizations. The National Institutes of Health (NIH) will be the lead HHS agency in this partnership.

One of these projects is led by the DCRI’s Steven George, PhD, along with co-PI Susan Nicole Hastings, MD; and Duke/DCRI faculty Chad Cook, PhD, MBA; Corey Simon, DPT, PhD; and Adam Goode, DPT, PhD. The goal of this planning and demonstration project is to improve access to recommended nondrug therapies for low-back pain in the Department of VA Health Care System and involves researchers from the DCRI, Department of Psychiatry and Behavioral Sciences, Durham VA Center for Health Services Research in Primary, and the UNC Thurston Arthritis Research Center.

“We are hoping to provide non-pharmacological, frontline options that provide optimal pain relief to veterans and prevent unnecessary surgery, injections or opioid prescriptions,” George said.

Benjamin A. Alman, MD, James Urbaniak Professor and Chair of the Department of Orthopaedic Surgery, said, “We are incredibly proud of the work Dr. George is doing for our veterans, as well as the broader implications his work could have on the way we treat patients with chronic low-back pain.”

“Finding solutions for chronic pain is of critical importance, especially for military personnel and veterans who are disproportionately affected,” said NIH Director Francis S. Collins, MD, PhD. “Bringing the science to bear through these real-world research projects will accelerate our search for pain management strategies for all Americans, especially as we work to address the nation’s opioid crisis.”

The National Center for Complementary and Integrative Health (NCCIH), part of NIH, is contributing more than half of the total funding, and it is the lead for this multi-agency initiative called the NIH-DoD-VA Pain Management Collaboratory, which is modeled on the successful NIH Health Care Systems Research Collaboratory. This initiative also addresses the need to focus on “advancing better practices for pain management,” which is outlined in HHS’ 5-point strategy to combat the opioid crisis.

Studies report nearly 45 percent of soldiers and 50 percent of veterans experience pain on a regular basis, and there is significant overlap among chronic pain, post-traumatic stress disorder (PTSD), and persistent post-concussive symptoms. Data from the National Health Interview Survey shows that American veterans experience a higher prevalence of pain and more severe pain than nonveterans. Although opioids are often prescribed to treat chronic pain, research has not shown them to be very effective, and there are many issues with long-term use. Thus, there is a need for nondrug approaches to complement current strategies for pain management and to reduce the need for, and hazards of, excessive reliance on opioids.

Seven of the 12 projects, including George’s, have been awarded by HHS/NIH. The remaining five will be announced by the DoD and VA in the coming months.

NIH Health Care Systems Research Collaboratory celebrates five years

September 19, 2017 – The NIH Collaboratory is celebrating five successful years of innovation in pragmatic clinical trials.

The Common Fund at the National Institutes of Health (NIH), which supports innovative endeavors with the potential for extraordinary impact, instituted the NIH Health Care Systems Research Collaboratory five years ago in 2012, with its coordinating center based at the DCRI. The goal of the program is to improve the way clinical trials are conducted by creating a new infrastructure for collaborative research with healthcare systems. At a time when reducing the cost of clinical trials and generating real-word knowledge is becoming progressively crucial, the NIH Collaboratory is leading the way in expanding the national capacity for pragmatic clinical research.

“The NIH Collaboratory embodies what makes clinical research exciting and simply fun,” said Adrian Hernandez, MD, one of three principal investigators of the NIH Collaboratory coordinating center at the DCRI. “We’ve learned together how to address challenges and then seeing how those solutions go forward to change how clinical trials should be done as opposed to how they are currently done.”

Providing national leadership and technical expertise in all aspects of research with healthcare systems, the DCRI has worked with the NIH and other coordinating centers at the Center for Medical Technology Policy, Harvard Pilgrim Health Care Institute, Group Health Research Institute, and Johns Hopkins Berman Institute of Bioethics over the last five years to produce, document, and disseminate standards for healthcare systems research. Together they have created an infrastructure to facilitate multi-center studies and the responsible use of electronic health data. They have also been able to establish a structure supporting research with healthcare systems as partners.

“The hallmark of the NIH Collaboratory over the last five years has been the spirit of collaboration and curiosity from all the investigators,” said DCRI’s Kevin Weinfurt, PhD, co-principal investigator (pictured left). “One of the most prominent accomplishments of the Collaboratory during this time is successfully planning 10 very complex pragmatic clinical trial Demonstration Projects spanning 12 NIH institutes and centers, 9 of which proceeded to full implementation.”

The NIH Collaboratory’s pragmatic clinical trial Demonstration Projects gather real-world evidence to answer clinical questions of major public health importance and engage healthcare delivery systems in research partnerships. Seven Core Working Groups of experts, each focused on a specific topic, support all of the Demonstration Projects and initiatives across the program, helping the research teams navigate issues of research embedded in clinical care, as well as collect knowledge gained throughout the process.

“All of us in the NIH Collaboratory have learned a tremendous amount about how to successfully embed pragmatic clinical trials in health care delivery systems,” said DCRI’s Lesley Curtis, PhD, co-principal investigator (pictured right). “What’s most exciting is the universal commitment to sharing successes, surprises, and missteps so that we build the evidence base about embedded research while the trials answer important questions.”

Knowledge sharing has been a key component of the NIH Collaboratory over the past half a decade. Weekly Grand Rounds, delivered in the form of webinars, have been highly successful and provide a forum for sharing the latest advances in pragmatic research. Attended by a large audience of researchers and others in the clinical research community, including representatives from NIH and the U.S. Food and Drug Administration, the Grand Rounds also serve as a platform to discuss how to successfully conduct pragmatic clinical trials within the current ethical and regulatory framework for research.

“Another noteworthy accomplishment of the Collaboratory in the last five years is the creation of the continuously evolving Living Textbook, which is an easily available online repository of the

Lesley Curtis

lessons learned from the Collaboratory,” said Weinfurt. “To support the wider conduct of pragmatic trials, the investigators put in a lot of effort to update the Living Textbook as experiences were accumulated.”

Together with the DCRI, the program built a Knowledge Repository, a publicly available archive of resources related to the conduct of pragmatic trials. In the same spirit, it also created the NIH Collaboratory Distributed Research Network, which facilitates multi-site research collaborations to allow researchers to query electronic health records of over 90 million individuals in a way that protects participant privacy. According to the investigators, this paves the way for standards in data sharing, data quality, and reuse of electronic health record data.

“It takes a village,” said Tammy Reece, Project Leader of the NIH Collaboratory at the DCRI. According to Reece, the success is in the numbers: with more than 500 resources achieved in the Knowledge Repository, more than 200 Grand Rounds held since inception along with over 70 conference presentations or symposia, more than 60 total publications, and more than 320 citations in peer-reviewed journals, and these numbers are still growing.

According to the investigators, the numbers from the last five years add up to success but there is still much to achieve for both the DCRI and the NIH Collaboratory.

“In the future, we would like to see the Collaboratory learn a bit more about how to implement pragmatic trials in less than optimal settings with a goal to empower all health systems to be able to conduct trials on a variety of different platforms,” said Weinfurt. “Empowering health systems is an important and unique feature of the Collaboratory as a network.”

EASD 2017: Study confirms safety of once-weekly exenatide in broad range of patients with diabetes

September 14, 2017 – A global team of researchers reported in the New England Journal of Medicine that the study did not meet its primary efficacy endpoint, but yielded important results for all-cause mortality.

Diabetes is a widespread and increasing problem currently affecting 30.3 million Americans, 4.5 million people living in the United Kingdom, and 422 million people worldwide. In 2015, an estimated 1.6 million deaths worldwide were directly caused by diabetes. There is a clear need to improve health outcomes, particularly for cardiovascular events, which represent the greatest burden in terms of morbidity and mortality.

The EXSCEL trial (EXenatide Study of Cardiovascular Event Lowering) was among the largest ever carried out in type 2 diabetes, setting out to evaluate the safety and efficacy of a once-weekly extended-release formulation of exenatide, a glucagon-like peptide-1 (GLP-1) receptor agonist. The drug works by mimicking a hormone in that reduces blood sugar levels after meals but its impact on heart disease is unknown.

Launched in 2009 and completed in April 2017, the EXSCEL trial was a Phase IIIB/IV, double-blind, placebo-controlled, global cardiovascular outcomes trial involving 14,752 patients with type 2 diabetes in 35 countries. Participants – who were eligible with or without additional cardiovascular risk factors or prior cardiovascular events – all received usual type 2 diabetes care and were randomized to receive subcutaneous injections of 2mg exenatide once-weekly, or a matching placebo. The trial compared the risk of major adverse cardiac events (MACE) – a composite endpoint of cardiovascular death, non-fatal myocardial infarction or non-fatal stroke – in the two groups of patients. The median length of follow-up was 3.2 years.

The trial met its primary safety objective of non-inferiority for MACE. The efficacy objective of a superior reduction in MACE did not reach statistical significance, although a prespecified analysis suggested all-cause mortality was lower with exenatide than placebo.

The results were presented today at the European Association for the Study of Diabetes (EASD) annual meeting in Lisbon, Portugal. They were also published simultaneously in the New England Journal of Medicine.

EXSCEL was run jointly by the DCRI and the University of Oxford Diabetes Trials Unit (DTU).

“The study results show that exenatide had no adverse effects on cardiovascular health, meaning that the drug can be used safely in people with type 2 diabetes who may have a wide range of existing cardiovascular conditions,” said the DTU’s Rury R. Holman, who co-led the study. “There did not seem to be any increase in the risk of hypoglycemia, acute pancreatitis, pancreatic cancer, or medullary thyroid carcinoma.”

“It’s encouraging for the field of diabetes to see these results in patients similar to what we see in clinical practice can have a potentially lower risk of death from all causes with the convenience of once-weekly dosing,” said the DCRI’s Adrian F. Hernandez, MD, MHS, Holman’s co-leader on the trial.

“This confirms the importance of carrying out large studies to evaluate impacts on cardiovascular outcomes. EXSCEL largely mirrored what we’ve learned from other studies of this class of medications – that they are safe and may have outcomes benefits.”

In addition to Holman and Hernandez, co-authors on the EXCSEL paper were Angelyn Bethel,MD, from the DTU, and Robert Mentz, MD; Vivian Thompson, MPH; Yuliya Lokhnygina, PhD; and Neha Pagidipati, MD, MPH, from Duke and DCRI.

Trial launches to learn how to prevent kidney stone recurrence

September 13, 2017 – The DCRI serves as the Scientific Data Research Center for the Urinary Stone Disease Research Network, whose researchers are conducting the study.

Researchers are recruiting participants for a two-year clinical trial to determine whether using a high-tech water bottle and encouraging people to drink more water, and therefore urinate, will reduce the recurrence of urinary stone disease, also known as kidney stones.

The trial, known as the Prevention of Urinary Stones with Hydration (PUSH) study, is being conducted as part of a five-year initiative by the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) to improve outcomes for patients with kidney stones.

The purpose of the initiative, the Urinary Stone Disease Research Network (USDRN), is to design and conduct clinical trials in adults and children who suffer from kidney stones. The DCRI serves as the network’s Scientific Data Research Center. Charles Scales, MD, and Hussein Al-Khalidi, PhD, serve as the research center’s principal investigators.

In addition to the data research center, the USDRN comprises clinical sites at the University of Pennsylvania, Children’s Hospital of Philadelphia, the University of Texas Southwestern Medical Center, the University of Washington at Seattle, and Washington University. Investigators at the DCRI and each clinical site will work collaboratively to plan, execute, and analyze USDRN studies.

Kidney stones are small, hard mineral deposits that form inside the kidneys and can cause kidney damage and excruciating pain. Kidney stones affect about 1 out of 11 Americans. The prevalence of kidney stones among Americans has nearly doubled in the last 15 years, and is increasing in both adults and children. According to the NIDDK, kidney stones cost an estimated $10 billion each year, making them the most expensive non-malignant urologic condition in the United States. A recent study estimates that the impact of obesity, diabetes and population rates will increase costs of kidney stones to $1.24 billion a year by 2030.

Kidney stones are a recurring condition for many patients. Data from the National Health and Nutrition Examination Survey show that 35 percent of participants had experienced two or more distinct episodes of urinary stones. Although the causes of kidney stone formation are relatively well understood, there has been little clinical emphasis on preventing recurrent kidney stones. Many physicians treat kidney stones as discrete events, rather than a chronic metabolic condition resulting in painful “stone attacks.”

“If we treated people with heart disease the way we treat patients with kidney stones, we would only be treating patients with chest pain or a heart attack,” Scales said. “We wouldn’t pay attention to risk factors like smoking or cholesterol. My hope is that through this research network, we can focus on stone prevention, and empower patients to make the necessary lifestyle changes to avoid recurrent kidney stones.”

PUSH will enroll 1,642 people, half in an intervention group and half in a control group. The study’s primary aim is to determine whether a program of financial incentives, receiving advice from a health coach, and using a smart water bottle called Hidrate Spark that monitors fluid consumption and connects to an app will result in reduced risk of USD recurrence over a two-year period.

Those in the intervention group will be asked to drink a specific quantity of fluids calculated based on each person’s urine output. They will also be given financial incentives if they achieve their fluid targets. They will also meet with a health coach who will help identify barriers to drinking more liquids, and help solve them. Study participants in both groups will receive the water bottles to monitor how much they drink and will be asked to try to achieve a goal of drinking enough to expel 2.5 liters of urine per day – about 10.5 cups.

“Urinary stones are painful and debilitating, and their treatment expensive. We hope that identifying the barriers to water intake, and helping people overcome those barriers individually, will be successful,” said Ziya Kirkali, MD, program director of urology clinical research and epidemiology, in NIDDK’s Division of Kidney, Urologic, and Hematologic Diseases. “If successful, the study could change management of kidney stones, and could result in healthcare systems incorporating problem solving and prevention strategies, perhaps using incentives to modify behavior in people with urinary stone disease.”

The study is supported by the NIDDK (DK110986).

A new approach to real-world evidence

September 8, 2017 – The Robert J. Margolis, MD, Center for Health Policy at Duke University has issued a white paper in advance of its upcoming one-day workshop on the use of real-world evidence.

Adrian Hernandez

As the demand for more use of real-evidence (RWE) grows, so does the need for a more nuanced and considered approach to it. That is the conclusion of a white paper issued by the Robert J. Margolis, MD, Center for Health Policy at Duke University in advance of its Sept. 13 workshop on real-world evidence.

The DCRI’s Adrian Hernandez, MD, MHS, is among the white paper’s authors.

In recent years the amount of patient data collected outside of clinical trials has become more plentiful and, with the advent of electronic health records, more easily accessible. Researchers and clinicians have recognized the potential uses of this information, but questions remain about how to best use it.

“Here, we advance the idea that RWE is the output from the combination of a variety of different RWD sources and methods for evidence development, and that the resultant applicability of RWE will necessarily vary across regulatory contexts of use,” the authors write. “Appropriately matching data and methods to potential uses will take time and input from all stakeholders involved in the development and use of medical products, but progress can be made if thoughtful and transparent collaborations can improve underlying challenges in data collection, study design, and shared infrastructure.”

The complete paper can be downloaded here.

Duke receives $12.5 million to study children with autism and ADHD

September 7, 2017 – The DCRI’s Scott Kollins, PhD, is a co-principal investigator for the trial.

Duke researchers will lead a $12.5 million, five-year program to study connections between autism and attention deficit and hyperactivity disorder (ADHD), joining five other universities as a National Institutes of Health Autism Center of Excellence.

Having both autism spectrum disorder (ASD) and ADHD can lead to more severe autism symptoms in young children, including tantrums, greater challenges at school and trouble making friends. There is little research on the estimated half of individuals with ASD who also have ADHD.

“Young children with autism who also have ADHD are diagnosed with autism at a much later age and have poorer outcomes,” said Geraldine Dawson, PhD, a co-principal investigator for the grant and director of the Duke Center for Autism and Brain Development. “Children with both conditions are 30 times more likely to receive a diagnosis of autism after age 6, which is a shame because we are able to diagnose autism reliably by 24 months. We want to understand why these children are being missed and help them get early interventions.”

Duke researchers across disciplines — including psychology, psychiatry, neuroscience, engineering, computer science and public policy — will launch three major projects designed to improve early detection and treatment of children with autism and ADHD.

The first project will follow about 9,000 infants and toddlers visiting Duke primary care clinics to identify those with symptoms of ASD, ADHD, or both. They will compare symptoms, progression and overall health outcomes, and test new screening tools. They will also probe racial and ethnic disparities in early diagnosis and strategies to reduce them.

A second effort will focus on understanding how brain dysfunction in ASD and ADHD are similar and how they differ. Researchers aim to identify signatures in brain activity or attention-related biomarkers that could predict risk for autism and ADHD in infancy.

The third project will evaluate a treatment that combines behavioral intervention and the use of Adzenys-XR-ODT, an FDA-approved ADHD drug. The researchers will study how the combined treatment affects autism and ADHD symptoms and patterns of brain activity.

“This research has the potential to significantly impact clinical practice,” said the DCRI’s Scott Kollins, PhD, co-principal investigator for the grant and director of the Duke ADHD Program (pictured). “We hope it will validate new approaches to early screening, specifically in pediatric primary care. It will also provide many children in North Carolina who have autism and ADHD with diagnostic and treatment services. We are grateful to NIH and to Duke for providing the opportunity to make a real difference both for families in our community and families everywhere.”

Data from Duke and all other Autism Centers of Excellence are included in a centralized NIH National Database for Autism Research, available to scientists and institutions around the world working to uncover the causes and develop the best treatments for ASD.

In addition to Dawson and Kollins, investigators leading the projects include Linmarie Sikich, Guillermo Sapiro, Scott Compton, Kenneth Dodge, Naomi Davis and Michael Murias.

NIH Health Care Systems Research Collaboratory launches comprehensive online resource on pragmatic clinical trials

September 5, 2017 – The new website shares the latest expert consensus on conducting efficient trials that generate evidence to improve healthcare.

The NIH Health Care Systems Research Collaboratory has launched a new website to serve as a primary resource for anyone wishing to learn how to conduct pragmatic clinical trials. Pragmatic trials are distinct from usual methods of research in that evidence is gathered from settings where healthcare is delivered every day, such as hospitals or clinics, often relying on electronic data that is already routinely captured. These trials have the opportunity to answer important research questions quickly and efficiently by applying novel research designs and tools—but employing new methods also comes with challenges.

Drawing on experiences from the NIH Collaboratory’s own pragmatic trials and community of experts, Rethinking Clinical Trials®: A Living Textbook of Pragmatic Clinical Trials explains how pragmatic trials are distinct and provides guidance on special considerations at each step of the research process, from trial design through applying results in the real world. The updated website can be accessed at www.rethinkingclinicaltrials.org.

“The new Living Textbook will help to change the way research is conducted by promoting best practices for pragmatic clinical trials. Easy access to this vast knowledge base will help expand the capabilities for conducting pragmatic research within health care systems, ultimately leading to advances in healthcare,” said the DCRI’s Kevin Weinfurt, PhD, editor-in-chief of the Living Textbook.

“The new website contains a wealth of knowledge from the past 5 years of conducting pragmatic trials in the NIH Collaboratory and will be continually updated as new information emerges. I look forward to seeing the impact the Living Textbook will have on the future of clinical research,” said the DCRI’s Adrian Hernandez, MD, MHS, who helps lead the NIH Collaboratory.

The NIH Collaboratory is supported by the National Institutes of Health Common Fund through a grant administered by the National Center for Complementary and Integrative Health (U54AT007748).

Cardiac arrests in black neighborhoods less likely to get CPR, defibrillation

August 30, 2017 – Study shows that delaying CPR is associated with worse survival.

Surviving cardiac arrest often seems like a matter of luck — whether a passerby knows CPR, or a defibrillator is close at hand or the ambulance arrives quickly.

But one surprising factor also plays a role: The racial makeup of your neighborhood.

Compared to people who live in predominantly white neighborhoods, those who live in predominantly black areas are much less likely to receive CPR or defibrillation from a bystander when their heart suddenly stops beating while they are at home or out in the community.

And that appears to translate into a worse chance of survival for people in black neighborhoods, according to a study published online Aug. 30 in JAMA Cardiology by researchers at the DCRI.

“We have known that there are differences in the rates of survival from cardiac arrest between blacks and whites, but it was surprising to see how the demographics of a neighborhood affected outcomes of residents who experience cardiac arrest,” said lead author Monique Starks, MD, a cardiologist and member of the DCRI. “This is absolutely a call to action to improve and expand CPR training and defibrillator access.”

Starks and colleagues — including senior author Graham Nichol, MD, director of the University of Washington-Harborview Center for Prehospital Emergency Care — analyzed cardiac arrest data from a registry that includes information from seven U.S. cities: Birmingham, Dallas-Fort Worth, Pittsburgh, Portland, Seattle, and Milwaukee. U.S. Census data were used to provide demographic information at the neighborhood level.

The researchers analyzed more than 22,000 cases in which cardiac arrest occurred in a non-hospital setting over a four-year period between 2008-11. Neighborhoods where out-of-hospital cardiac arrests occurred were classified by census tract, based on percentage of black residents, ranging from fewer than 25 percent, between 25–50 percent, between 51–75 percent, and more than 75 percent.

Compared with patients who experienced a cardiac arrest in mainly white neighborhoods, those in predominantly black neighborhoods were slightly younger, more frequently female, had lower rates of initial shockable rhythm, and less frequently experienced their heart event in a public location.

Overall, nearly 40 percent of people stricken with cardiac arrest outside of the hospital received bystander CPR. In primarily white neighborhoods, the rate was almost 47 percent, but in predominantly black neighborhoods, the rate was just 18 percent.

Use of an automated external defibrillator was similarly disproportionate by racial composition of the neighborhood. In mostly white neighborhoods, 4.5 percent of cardiac arrest victims received defibrillation from a bystander, compared to 0.9 percent in black neighborhoods.

Neighborhood make-up was also associated with survival. People with cardiac arrest in mixed- to majority- black neighborhoods had significantly lower adjusted survival rates at hospital discharge, the researchers found.

“We clearly see that treatments and outcomes for patients with cardiac arrest in black neighborhoods are worse than those in white neighborhoods. We then asked, does it matter if you were black or white within those neighborhoods?” Nichol said. “Our observations were reassuring. It actually does not matter if you are black or white within the neighborhood, but the neighborhood matters.”

That finding, the researchers noted, points to a lack of education about cardiac arrest and CPR in general among people living in black neighborhoods, along with a dearth of defibrillators in public spaces.

“This is something that can be addressed,” Starks said. “Organizations such as the American Heart Association and the American Red Cross, along with medical centers and public health departments, have a unique opportunity to address this issue with dedicated education programs that are particularly tailored for black neighborhood. This is a relatively low-cost solution that could save lives.”

In addition to Starks and Nichol, study authors include Robert H. Schmicker, Eric D. Peterson, Susanne May, Jason E. Buick, Peter J. Kudenchuk, Ian R. Drennan, Heather Herren, Jamie Jasti, Michael Sayre, Dion Stub, Gary M. Vilke, Shannon W.  Stephens, Anna M. Chang and Jack Nuttall on behalf of the Resuscitation Outcomes Consortium investigators.

The study was supported by the Resuscitation Outcomes Consortium, which was funded by the National Institutes of Health and American Heart Association. Starks also receives grant support from the National Institutes of Health Common Fund to promote diversity in health-related research (3U54AT007748-02S1).