Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Kidney360. 2022 Mar 11;3(6):1021-1030. doi: 10.34067/KID.0008092021. eCollection 2022 Jun 30.
Cardiac arrest occurs frequently in outpatient dialysis clinics, and immediate cardiopulmonary resuscitation (CPR) provision improves patient outcomes. However, Black patients in dialysis clinics receive CPR from clinic staff less often compared with White patients. We examined the role of dialysis facility resources and patient factors in the observed racial disparity in CPR receipt and automated external defibrillator application.
This was a retrospective cohort study linking the National Cardiac Arrest Registry to Enhance Survival and Medicare Annual Dialysis Facility Report registries from 2013 to 2017. We identified patients experiencing cardiac arrests within US outpatient dialysis clinics geolocation matching (=1554). Differences in facility size, quality, staffing, and patient-related factors were summarized and compared according to patient race. Multilevel multivariable logistic regression models including these factors were used to examine the influence of these factors on the observed disparity in CPR rates between Black and White patients.
Compared with White patients, Black cardiac arrest patients dialyzed in larger facilities (26 versus 21 dialysis stations; <0.001), facilities with fewer registered nurses per station (0.29 versus 0.33; <0.001), and facilities with lower quality scores (# citations 6.8 versus 6.3; =0.04). Facilities treating Black patients cared for a higher proportion of patients with a history of cardiac arrest (41% versus 35%; <0.001), HIV/hepatitis B, and Medicaid-enrolled patients (15% versus 11%; <0.001). Even after accounting for these differences and other covariates, the racial disparity for CPR in Black versus White patients persisted (OR=0.45; 95% CI, 0.27 to 0.75). The racial disparity in CPR was greater among older patients compared with younger patients (interaction =0.04).
The racial disparity in CPR delivery within dialysis clinics was not explained by differences in facility resources and quality. Reducing this disparity will require a multifaceted approach, including developing dialysis clinic-specific protocols for CPR and addressing potential implicit bias.
心脏骤停在门诊透析诊所中经常发生，立即进行心肺复苏（CPR）可改善患者预后。然而，与白人患者相比，透析诊所中的黑人患者接受诊所工作人员进行 CPR 的频率较低。我们研究了透析机构资源和患者因素在接受 CPR 和自动体外除颤器（AED）应用方面观察到的种族差异中的作用。
这是一项回顾性队列研究，将国家心脏骤停登记处与 2013 年至 2017 年的医疗保险年度透析机构报告登记处相链接。我们确定了在美国门诊透析诊所中经历心脏骤停的患者（通过地理位置匹配，共 1554 例）。根据患者种族，总结并比较了设施规模、质量、人员配备和患者相关因素的差异。使用包括这些因素的多水平多变量逻辑回归模型，研究这些因素对黑人与白人患者 CPR 率差异的影响。
与白人患者相比，黑人心脏骤停患者在更大的设施（26 个与 21 个透析站；<0.001）、每个站注册护士人数较少（0.29 与 0.33；<0.001）和质量评分较低的设施（#引文 6.8 与 6.3；=0.04）中接受治疗。治疗黑人患者的设施收治了更高比例有心脏骤停史（41%与 35%；<0.001）、HIV/乙型肝炎和医疗补助计划患者（15%与 11%；<0.001）的患者。即使考虑到这些差异和其他协变量，黑人与白人患者接受 CPR 的种族差异仍然存在（OR=0.45；95%CI，0.27 至 0.75）。与年轻患者相比，老年患者 CPR 种族差异更大（交互作用=0.04）。
透析诊所内 CPR 实施的种族差异不能用设施资源和质量的差异来解释。要缩小这一差距，需要采取多方面的方法，包括制定针对 CPR 的透析诊所特定方案，并解决潜在的隐性偏见问题。
