Racial or ethnic differences in hospitalization for heart failure among elderly adults: Medicare, 1990 to 2000

Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction

BACKGROUND

Hispanics are the fastest growing segment of the US population and have a higher prevalence of cardiovascular risk factors than non-Hispanic whites. However, little is known about whether elderly Hispanics have higher readmission rates for heart failure (HF) and acute myocardial infarction (AMI) than whites and whether this is due to site of care.

METHODS

We examined hospitalizations for Medicare patients with a primary discharge diagnosis of HF and AMI in 2006 to 2008. We categorized hospitals in the top decile of proportion of Hispanic patients as "Hispanic serving" and used logistic regression to examine the relationship between patient ethnicity, hospital Hispanic-serving status, and readmissions.

RESULTS

Hispanic patients had higher risk-adjusted readmission rates than whites for both HF (27.9% vs 25.9%, odds ratio [OR] 1.11, 95% CI 1.07-1.14, P < .001) and AMI (23.0% vs 21.0%, OR 1.12, 95% CI 1.07-1.18, P < .001). Similarly, Hispanic-serving hospitals had higher readmission rates than non-Hispanic-serving hospitals for both HF (27.4% vs 25.8%, OR 1.09, 95% CI 1.06-1.12, P < .001) and AMI (23.0% vs 20.8%, OR 1.13, 95% CI 1.09-1.18, P < .001). In analyses considering ethnicity and site of care simultaneously, both Hispanics and whites had higher readmission rates at Hispanic-serving hospitals.

CONCLUSIONS

Elderly Hispanic patients are more likely to be readmitted for HF and AMI than whites, partly due to the hospitals where they receive care. Our findings suggest that targeting the site of care and these high-risk patients themselves will be necessary to reduce disparities in readmissions for this growing group of patients.

Future of personalized pharmacotherapy in chronic heart failure patients

There is a significant amount of diversity among heart failure (HF) patients. Contemporary HF regimens often do not take into consideration many of the factors that might influence an individual’s response to treatment. Clinical recommendations based on trial data derived from mainly younger Caucasian male study populations have, in most cases, been applied equally to women and African–Americans. Subgroup analyses of randomized HF trials and results of retrospective cohort studies have been used for customizing HF regimens in women and African–Americans. Pharmacogenetics is an emerging strategy for personalizing HF therapy. Genetic biomarkers may play an important role in predicting a patient’s response to treatment and in predicting those at risk of toxicity. HF pharmacotherapy has improved over the last two decades; however, substantial work remains in order to personalize HF management and maximize the benefit of pharmacologic interventions, while limiting adverse events.

The causes, consequences, and treatment of left or right heart failure

Chronic heart failure (HF) is a cardiovascular disease of cardinal importance because of several factors: a) an increasing occurrence due to the aging of the population, primary and secondary prevention of cardiovascular events, and modern advances in therapy, b) a bad prognosis: around 65% of patients are dead within 5 years of diagnosis, c) a high economic cost: HF accounts for 1% to 2% of total health care expenditure. This review focuses on the main causes, consequences in terms of morbidity, mortality and costs and treatment of HF.

Racial differences in incident heart failure during antihypertensive therapy

BACKGROUND

Blacks have a higher prevalence of heart failure (HF) than nonblacks, possibly reflecting a greater burden of HF risk factors, including hypertension. Although HF incidence is significantly higher in blacks during long-term follow-up of young adults, the relationship of incident HF to race in hypertensive patients undergoing treatment is unclear.

METHODS AND RESULTS

Incident HF was evaluated in 497 black and 8199 nonblack hypertensive patients with no history of HF randomly assigned to losartan- or atenolol-based treatment. During 4.7±1.1 years mean follow-up, HF hospitalization occurred in 265 patients (3.0%); 5-year HF incidence was significantly greater in black than nonblack patients (7.0 versus 3.1%, P<0.001). In Cox multivariate analyses adjusting for randomized treatment, age, sex, the presence of the strain pattern on the baseline ECG, and other HF risk factors treated as standard covariates, and for incident myocardial infarction, in-treatment QRS duration, diastolic and systolic pressure, Cornell product, and Sokolow-Lyon voltage criteria for left ventricular hypertrophy (LVH) treated as time-varying covariates, black race remained associated with a 130% increased risk of developing new HF (hazard ratio 2.30, 95% confidence interval 1.24 to 4.28).

CONCLUSIONS

Incident HF is substantially more common among black than nonblack hypertensive patients. The increased risk of developing new HF in blacks persists after adjusting for the higher prevalence of HF risk factors in blacks, for treatment effects and in-treatment blood pressure, and for the known predictive value of the ECG strain pattern and in-treatment ECG LVH and QRS duration for incident HF in this population. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00338260.

Disparity of care in the acute care of patients with heart failure

OBJECTIVES

It has been well documented that screening, prevention, and treatment disparities in cardiovascular care exist. Most studies have focused on the outpatient setting. The purpose of the present analysis was to assess if a disparity of care exists in the care of emergency department (ED) patients with acute heart failure in a secondary analysis of the Heart Failure and Audicor Technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational study.

METHODS

Only patients with an adjudicated diagnosis of acute heart failure were included in this analysis. Racial groups included in this analysis were limited to white and African American or black patients, due to their predominance in the cohort. Logistic regression including clinically relevant demographics, past medical history, exam, diagnostic tests, and adjudicated diagnosis of acute heart failure as covariates was performed to assess the association of race with treatment with a diuretic or nitroglycerin and 30-day death or readmission.

RESULTS

Of the cohort, 418 of 1,076 (38.8%) were included in the analysis. Median age was 69 years (interquartile range [IQR]=55-79 years), 49% were white, and 51% were African American or black. There was no difference in the correct admitting diagnosis in the two groups (p=0.83). Multivariate adjustment revealed that African American or black race was not associated with treatment with diuretics (adjusted odds ratio [OR]=1.00, 95% confidence interval [CI]=0.55 to 1.82) or nitrates (adjusted OR=1.27, 95% CI=0.76 to 2.13) in the ED. In a separate regression analysis there was no association with African American or black race with 30-day adverse events (adjusted OR=1.22, 95% CI=0.68 to 2.16).

CONCLUSIONS

This secondary analysis of HEARD-IT data did not identify racial disparities in the treatment of adults with acute heart failure in the ED.

Left ventricular dysfunction as a risk factor for cardiovascular and noncardiovascular hospitalizations in African Americans

BACKGROUND

A substantial portion of the public health burden of heart failure is due to hospitalizations, many of which are for causes other than cardiovascular disease. We assessed whether left ventricular (LV) systolic dysfunction was associated with increased risk of both cardiovascular and noncardiovascular hospitalizations in a community sample of African Americans.

METHODS

African American participants from the Jackson, MS, site of the Atherosclerosis Risk in Communities (ARIC) study who underwent echocardiography were followed for 12 years. Hospitalization rates among individuals with and without LV systolic dysfunction were compared using negative binomial regression.

RESULTS

Among 2,416 participants with echocardiograms, LV systolic dysfunction was found in 61 (2.5%). Participants with LV dysfunction experienced 366 hospitalizations, a rate of 1.27 per person-year, compared with 0.25 per person-year among individuals without LV dysfunction. The incidence rate ratio adjusted for demographics, comorbidities, and other risk factors was 3.11 (95% CI 2.22-4.35). The adjusted rate ratios were 4.76 (95% CI 2.90-7.20) for cardiovascular and 2.67 (95% CI 1.82-3.90) for noncardiovascular diagnoses, with similar findings in the subset of individuals with asymptomatic LV dysfunction. The percentage attributable risks for hospitalizations were 87% and 74% for cardiovascular and noncardiovascular causes (79% and 63% after adjustment).

CONCLUSIONS

African American individuals with LV dysfunction are at an increased risk of hospitalization due to a wide range of causes, with noncardiovascular hospitalizations accounting for nearly half the increased risk. To the extent that estimates of risk focus on cardiovascular morbidity, they may underestimate the true health burden of LV dysfunction.

Race/ethnic disparities in left ventricular diastolic function in a triethnic community cohort

BACKGROUND

Racial-ethnic disparities exist in cardiovascular risk factors, morbidity, and mortality. Left ventricular diastolic dysfunction is a predictor of mortality and of cardiovascular outcome including incident heart failure. We sought to assess whether race-ethnic differences in diastolic function exist. Such differences may contribute to the observed disparities in cardiovascular outcomes.

METHODS

Two-dimensional echocardiography was performed in 760 participants (539 Hispanic, 117 non-Hispanic black, 104 non-Hispanic white) from the Cardiac Abnormalities and Brain Lesions study. Left ventricular diastolic function was assessed by standard Doppler flow profile and tissue Doppler imaging. Early (E) and late (A) transmitral diastolic flow, and mitral annulus early diastolic velocities (E') were recorded; and E/A and E/E' ratios were calculated.

RESULTS

Blacks and Hispanics had higher body mass index (P = .04, P < .01), higher prevalence of hypertension (both Ps

CONCLUSIONS

Differences in left ventricular diastolic function exist between race-ethnic groups. However, modifiable cardiovascular risk factors and sociodemographic variables, rather than intrinsic race-ethnic heterogeneity, seem to explain most of the observed differences.

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Key Words

• diastolic function
• race
• ethnicity
• risk factors
• echocardiography

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MESH Headings

• Black or African American
• Aged
• Body Mass Index
• Diastole
• Echocardiography, Doppler
• Female
• Hispanic or Latino
• Humans
• Male
• New York City/epidemiology
• Prevalence
• Risk Factors
• Survival Rate/trends
• Ventricular Dysfunction, Left/diagnostic imaging
• Ventricular Dysfunction, Left/ethnology
• Ventricular Dysfunction, Left/physiopathology
• Ventricular Function, Left/physiology
• White People

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Grants

• R56 NS029993 NINDS NIH HHS
• R37 NS029993 NINDS NIH HHS
• R01 NS029993-11 NINDS NIH HHS
• R01 NS036286-10 NINDS NIH HHS
• R01 NS036286 NINDS NIH HHS
• R01 NS36286 NINDS NIH HHS
• NS29993 NINDS NIH HHS
• R01 NS029993 NINDS NIH HHS

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Affiliation(s)

Cesare Russo Department of Medicine, Columbia University, New York, NY
Zhezhen Jin Department of Biostatistics, Columbia University, New York, NY
Shunichi Homma Department of Medicine, Columbia University, New York, NY
Tatjana Rundek Department of Neurology, University of Miami, Miami, FL
Mitchell S.V. Elkind Department of Neurology, Columbia University, New York, NY
Ralph L. Sacco Department of Neurology, University of Miami, Miami, FL Department of Epidemiology and Human Genetics, University of Miami, Miami, FL
Marco R. Di Tullio Department of Medicine, Columbia University, New York, NY

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Assessment of the clinical outcomes and cost-effectiveness of the management of systolic heart failure in Chinese patients using a home-based intervention

This study was designed to assess the clinical effect of a home-based telephone intervention in Chinese heart failure patients. A total of 550 Chinese heart failure patients were enrolled into either (i) a group that received the usual standard of care (UC group); or (ii) a group that received a home-based heart failure centre management programme using nursing specialist-led telephone consultations (HFC group). The impact of the home-based intervention on admission rate, admission length and medical costs over 6 months was measured. Although the mean left ventricular ejection fraction in HFC patients was 29.3% compared with 34.8% in UC patients, the home-based intervention resulted in a significantly lower all-cause admission rate per person (HFC 0.60 +/- 0.77 times/person; UC 0.96 +/- 0.85 times/person), a shorter all-cause hospital stay (reduced by 8 days per person) and lower total 6-month medical costs (reduced by US$2682 per patient). These results suggest that the home-based intervention with nursing specialist-led telephone consultations may improve the clinical outcome and provide cost-savings for Chinese patients with heart failure.

Mortality after hospitalization for heart failure in blacks compared to whites

Heart failure (HF) disproportionately affects black compared to white Americans, and overall mortality from HF is greater among blacks. Paradoxically, mortality rates after a hospitalization for HF are lower in black than in white patients. These racial differences might reflect hospital, physician, and patient factors and could have implications for comparative hospital profiles. We identified published studies reporting the posthospitalization mortality for black and white patients with a discharge diagnosis of HF and conducted random-effects meta-analyses with the outcome of all-cause mortality. We included 29 cohorts of hospitalized black and white patients with HF. The unadjusted mean mortality rate after HF hospitalization for black and white patients, respectively, was 6% and 9% for in-hospital, 6% and 10% for 30-day, 10% and 15% for 60- to 180-day, 28% and 34% for 1-year, and 41% and 47% for >1-year follow-up, respectively. The unadjusted combined odds ratios for mortality in black versus white patients ranged from 0.48 for in-hospital (95% confidence interval [CI] 0.45 to 0.51) to 0.77 after >1 year follow-up (95% CI 0.75 to 0.79). In meta-analyses using adjusted data, the combined odds ratio was 0.68 for short-term mortality (95% CI 0.63 to 0.74), and the combined hazard ratio was 0.84 for long-term mortality (95% CI 0.77 to 0.91). In conclusion, mortality after hospitalization for HF was 32% lower during short-term follow-up and 16% lower during long-term follow-up for black than for white patients. The mortality differences imply unmeasured differences by race in clinical severity of illness at hospital admission and might lead to biased hospital mortality profiles.

Characteristics associated with racial disparities in illness beliefs of patients with heart failure

African Americans have greater misperceptions about heart failure (HF) than Caucasians. We examined socioeconomic and medical history factors to determine if they explain differences in accuracy of HF illness beliefs by race. 519 patients completed an illness beliefs and socioeconomic status survey. After establishing univariate associations by race, linear regression with backward selection was used to identify factors associated with HF illness beliefs accuracy. HF illness beliefs were less accurate among African Americans (p < .01). In multivariate models, race remained a predictor of HF illness beliefs accuracy, as did education level and living status (all ps < or = .01). Illness beliefs of African Americans were inaccurate and independently associated with social support and education level. Health care providers must consider patient education processes as a possible cause of differences and focus on what and how they teach, literacy level, materials used, and family engagement and education.

Medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with heart failure

BACKGROUND

Rehospitalization rates are higher in African American than Caucasian patients with heart failure (HF). The reasons for the disparity in outcomes between African Americans and Caucasians may relate to differences in medication adherence. To determine whether medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with HF.

METHODS AND RESULTS

Medication adherence was monitored longitudinally in 135 HF patients using the Medication Event Monitoring System. Events (emergency department visits for HF exacerbation, HF and cardiac rehospitalization, and all-cause mortality) were obtained by interview and hospital data base review. A series of regression models and survival analyses was conducted to determine whether medication adherence mediated the relationship between ethnicity and event-free survival. Event-free survival was significantly worse in African Americans than Caucasians. Ethnicity was a predictor of medication adherence (P=.011). African Americans were 2.57 times more likely to experience an event than Caucasians (P=.026). Ethnicity was not a predictor of event-free survival after entering medication adherence in the model (P=.06).

CONCLUSIONS

Medication adherence was a mediator of the relationship between ethnicity and event-free survival in this sample. Interventions designed to reduce barriers to medication adherence may decrease the disparity in outcomes.

Long-term association between self-reported signs and symptoms and heart failure hospitalizations: the Atherosclerosis Risk In Communities (ARIC) Study

AIMS

Although studies of the accuracy of heart failure (HF) classification scoring systems are available, few have examined their performance when restricted to self-reported items.

METHODS AND RESULTS

We evaluated the association between a simplified version of the Gothenburg score, a validated HF score comprised of cardiac and pulmonary signs and symptoms and medication use, and incident HF hospitalizations in 15,430 Atherosclerosis Risk in Communities (ARIC) Study participants. Gothenburg scores (range: 0-3) were constructed using self-reported items obtained at study baseline (1987-89). Incident HF hospitalization over 14.7 years of follow-up was defined as the first identified hospitalization with an ICD-9 discharge code of 428 (n = 1,668). Self-reported Gothenburg scores demonstrated very high agreement with the original metric comprised of self-reported and clinical measures and were directly associated with incident HF hospitalizations: [score = 1: hazard rate ratio (HRR) = 1.23 (1.07-1.42); score = 2: HRR = 2.17 (1.92-2.43); score = 3: HRR = 3.98 (3.37-4.70)].

CONCLUSION

In a population-based cohort, self-reported Gothenburg criteria items were associated with hospitalized HF over a prolonged follow-up time. The association was also consistent across groups defined by sex and race, suggesting that this simple score deserves further study as a screening tool for the identification of individuals at high risk of HF in resource-limited settings.

Changes in cardiovascular hospitalization and comorbidity of heart failure in the United States: findings from the National Hospital Discharge Surveys 1980-2006

OBJECTIVE

This study aimed to update the long-term trend of coronary heart disease (CHD), cerebrovascular disease (CBVD), and heart failure (HF) hospitalization rates and HF comorbidity among adults aged 65 and older in the United States.

METHODS

Data from the National Hospital Discharge Surveys between 1980 and 2006 were used. CHD, CBVD, and HF were defined using the principal (first-listed) diagnosis of disease at hospital discharge according to the ICD-9-CM code. Census estimated population data (2000) were used to estimate age and gender-specific hospitalization rates.

RESULTS

Age-adjusted CHD and CBVD hospitalization rates have significantly decreased between 1980 and 2006, with an estimated annual decrease rate of 2.24% for CHD and 1.55% for CBVD in men, and 2.36% for CHD and 1.34% for CBVD in women. However, the absolute numbers of CHD and CBVD hospitalization continued to increase partly because of the aging population. Furthermore, HF hospitalization rates have significantly increased with an estimated annual rate increase of 1.20% in men and 1.55% in women between 1980 and 2006. Of six selected co-morbidities, about 50% in men and 40% in women with HF had a coexisting disease of CHD, followed by chronic obstructive pulmonary disease, diabetes mellitus, renal failure, and pneumonia.

CONCLUSIONS

While the burden of CHD and CBVD remains the major public health problem, HF has emerged as a new challenge in cardiovascular disease control, characterized by increased trends of HF hospitalization and increased comorbidities from major diseases.

Mortality and readmission for patients with heart failure among U.S. News & World Report's top heart hospitals

BACKGROUND

The rankings of "America's Best Hospitals" by U.S. News & World Report are influential, but the performance of ranked hospitals in caring for patients with routine cardiac conditions such as heart failure is not known.

METHODS AND RESULTS

Using hierarchical regression models based on medical administrative data from the period July 1, 2005, to June 30, 2006, we calculated risk-standardized mortality rates and risk-standardized readmission rates for ranked and nonranked hospitals in the treatment of heart failure. The mortality analysis examined 14 813 patients in 50 ranked hospitals and 409 806 patients in 4761 nonranked hospitals. The readmission analysis included 16 641 patients in 50 ranked hospitals and 458 473 patients in 4627 nonranked hospitals. Mean 30-day risk-standardized mortality rates were lower in ranked versus nonranked hospitals (10.1% versus 11.2%, P<0.01), whereas mean 30-day risk-standardized readmission rates were no different between ranked and nonranked hospitals (23.6% versus 23.8%, P=0.40). The 30-day risk-standardized mortality rates varied widely for both ranked and nonranked hospitals, ranging from 7.9% to 12.4% for ranked hospitals and from 7.1% to 17.5% for nonranked hospitals. The 30-day risk-standardized readmission rates also spanned a large range, from 18.7% to 29.3% for ranked hospitals and from 19.2% to 29.8% for nonranked hospitals.

CONCLUSIONS

Hospitals ranked by U.S. News & World Report as "America's Best Hospitals" in "Heart & Heart Surgery" are more likely than nonranked hospitals to have a significantly lower than expected 30-day mortality rate, but there was much overlap in performance. For readmission, the rates were similar in ranked and nonranked hospitals.

Quality of life in a diverse population of patients with heart failure: BASELINE FINDINGS FROM THE HEART FAILURE ADHERENCE AND RETENTION TRIAL (HART)

PURPOSE

The exact role of psychosocial status in quality of life (QOL) of patients with heart failure (HF) is not fully clarified. This report investigates the association of depression and social support in 2 subdomains of QOL, overall satisfaction with QOL (S-QOL) and limitations in physical functioning (PF-QOL) in a diverse group of HF patients.

METHODS

Baseline data were used from a behavioral clinical trial, with complete information on 695 HF patients, of whom 33% were black and 24% had diastolic dysfunction. Data were collected via structured questionnaires, medical record review, and a 6-minute walk test. QOL outcomes included the Quality of Life Index (QLI) as a measure of S-QOL and the 36-item Short-Form Health Survey Physical Functioning (SF-36 PF) scale as a measure of PF-QOL.

RESULTS

After adjustment for sociodemographic variables, clinical and functional characteristics of disease status accounted for 19% of the variance in the QLI. Depressive symptoms and social support were significantly associated with QLI scores (P < .001) and accounted for an additional 26% of the variance. Clinical and functional characteristics accounted for 33% of the variance in SF-36 PF scores, whereas depressive symptoms and social support accounted for an additional 1% of the variance.

CONCLUSION

Depression and social support play a substantially greater role in S-QOL than in perceived limitations in basic physical functions. Targeting depression and low social support may be more important to improve overall QOL, whereas medical management of HF symptoms and functional capacity may have a greater impact on reducing basic physical limitations.

Correlates of depression at baseline among African Americans enrolled in cardiac rehabilitation

PURPOSE

To compare baseline psychosocial characteristics of African Americans entering phase 2 cardiac rehabilitation who have depression symptoms at or above threshold (Center for Epidemiological Studies Depression Scale [CES-D] score >or=16) with those who do not (CES-D score <16).

METHODS

A nonrandom sample of 112 men and women (n = 78 without depression, n = 34 with depression) was recruited through local phase 2 cardiac rehabilitation programs. Data were obtained by a structured interview and brief physical examination using several reliable and valid instruments. Chi-square tests, Kruskal-Wallis 2-sample tests, Spearman rank correlation coefficients, and logistic regression models were used for analyses.

RESULTS

We found that 30% of the participants were above the depression symptom threshold. Demographic characteristics were not significantly different between individuals at or above threshold and those below threshold. However, depressed individuals above threshold were more likely to be dissatisfied with their neighborhoods (P = .01) and had lower optimism scores (P < .0001), higher stress scores (P < .0001), lower adaptive coping scores (P = .05), and higher problematic coping scores (P < .01) than their counterparts who were below threshold. In the logistic regression model, the odds of being above the depression symptom threshold increased with stress (P < .001) and decreased with optimism (P = .03); none of the other psychosocial characteristics had an independent effect on depression symptoms.

CONCLUSIONS

At baseline, African Americans starting phase 2 cardiac rehabilitation with depression symptoms at or above threshold had more stress and fewer stress resilience factors. Assessing depression and stress resilience factors is important and may lead to more active participation in cardiac rehabilitation once enrolled, as well as optimal cardiovascular health outcomes.

Current trends in heart failure readmission rates: analysis of Medicare data

BACKGROUND

Despite advances in optimal pharmacologic therapy, patients with heart failure (HF) continue to have significant rehospitalization rates.

HYPOTHESIS

We sought to provide current estimates on rates of readmission for Medicare patients with HF, and identify factors associated with an increased chance of readmission.

METHODS

We used Medicare data from the 5% sample Standard Analytical File Limited Data Set for the years 2002 through 2004 to calculate readmission rates for HF. Clinical factors associated with readmission rates were identified using multivariate logistic regression.

RESULTS

We identified 28,919 patients accounting for 38,849 HF hospitalizations in the 5% sample for 2003. These numbers project to an estimated 578,380 patients with 776,980 HF hospitalizations. In-hospital mortality was 4.4% with an average length of stay of 5.5 +/- 5.4 d. In the 6-9 mo following the initial HF admission, 60% of patients had 1 or more readmissions for any cause. Heart failure accounted for 28% of all readmissions. Factors associated with readmission for HF after the initial HF hospitalization included age < 65 y, geographic location, previous hospitalization, length of stay of initial HF hospitalization > 7 d, not receiving a cardiac device implant at the time of initial HF hospitalization, and history of comorbidities including diabetes, myocardial infarction, peripheral vascular disease, and stroke.

CONCLUSIONS

Medicare patients with HF continue to have significant morbidity and one of the highest in-hospital mortality rates of any HF patient population. Factors associated with worse outcomes after an initial HF hospitalization can be used to identify patients who require aggressive therapy and follow-up.

Impact of overweight and obesity on hospitalization: race and gender differences

OBJECTIVE

To examine associations between weight status and number of all-cause and cause-specific hospitalizations overall, and by race and gender.

DESIGN

Longitudinal cohort study.

SUBJECTS

White and black adults (n=15 355) from the Atherosclerosis Risk in Communities Study who were normal weight (body mass index: >or=18.5 to <25.0 kg m(-2); n=4997), overweight (>or=25.0 to <30.0 kg m(-2); n=6100), or obese (>or=30.0 kg m(-2); n=4258) at baseline.

MEASUREMENTS

Information on hospitalizations was collected using community and cohort surveillance methods. Negative binomial models adjusted for race, gender, field center, age, physical activity, education level, smoking status, alcoholic beverage consumption and health insurance at baseline. Adjusted numbers of hospitalizations were calculated after setting covariates to the mean value (for continuous variables) or to the average distribution (for categorical variables) observed in the entire cohort and are expressed as the number of hospitalizations per 1000 adults followed over a period of 13 years.

RESULTS

The covariate-adjusted average number of all-cause hospitalizations was 1316 per 1000 normal weight, 1543 per 1000 overweight and 2025 per 1000 obese. Normal weight women had significantly fewer hospitalizations than normal weight men (1173 versus 1515 per 1000), but the increase associated with being obese on the number of all-cause hospitalizations was larger in women than men (791 versus 589 per 1000). There was no significant difference detected between the number of hospitalizations in normal weight whites and blacks, and the increase in hospitalizations with overweight or obesity was also not different. Effects of weight status on several primary causes of hospitalization differed by gender and race group.

CONCLUSION

Our work suggests that obesity prevention may reduce hospitalizations, a major component of rising healthcare costs. The impact of successful obesity prevention is likely to be larger in women than in men, and similar in blacks and whites.

Heart failure-related hospitalization in the U.S., 1979 to 2004

OBJECTIVES

The purpose of this study was to determine hospitalizations for heart failure in the U.S. during the past 26 years.

BACKGROUND

Heart failure increased in the U.S.; however, little is known about the long-term trends in diseases leading to hospitalizations among patients with heart failure.

METHODS

Using National Hospital Discharge Survey data from 1979 to 2004, we assessed trends in hospitalizations for heart failure as either a first-listed or additional (2nd to 7th) diagnosis. Among hospitalizations with any mention of heart failure, we assessed the distribution of first-listed diagnoses.

RESULTS

The number of hospitalizations with any mention of heart failure tripled from 1,274,000 in 1979 to 3,860,000 in 2004; 65% to 70% of admissions were patients with additional diagnoses of heart failure. Heart failure hospitalization rates increased sharply with age. More than 80% of hospitalizations were among patients of at least 65 years and were paid by Medicare/Medicaid. Age-adjusted hospitalization rates between 1979 and 2004 increased for heart failure as either the first-listed or additional diagnosis. Whereas heart failure was the first-listed diagnosis for 30% to 35% of these hospitalizations, the proportion with respiratory diseases and noncardiovascular, nonrespiratory diseases as the first-listed diagnoses increased. Heart failure hospitalizations that resulted in transfers to long-term care facilities increased, and in-hospital mortality and length of hospital stay declined.

CONCLUSIONS

With the increased aging of the U.S. population and advanced therapeutic interventions that improve survival, it is expected that heart failure hospitalizations at older ages and the associated economic burden to Medicare will continue to increase in the future.

Short-term mortality and cost associated with cardiac device implantation in patients hospitalized with heart failure

BACKGROUND

The use of implantable cardiac devices in the management of heart failure has increased, but patient selection and inhospital outcomes in clinical practice have not been critically explored. Therefore, we evaluated the inhospital mortality and costs associated with patients with heart failure who received an implantable cardioverter defibrillator, cardiac resynchronization device, or device lead.

METHODS

We analyzed admissions with International Classification of Diseases, Ninth Revision, procedure codes for implantation/revision of cardioverter defibrillator or cardiac resynchronization device and a primary or secondary diagnosis code for heart failure in a prospective hospital database from 2004 to 2005. Odds ratios were calculated to quantify risk for mortality. Average accumulated costs over time were calculated before and after day of first device implant procedure.

RESULTS

Among 27,907 hospitalizations, inhospital mortality varied based on day of device implantation and use of intravenous inotropic therapy. Mortality was 0.3% for patients who did not require inotropic drugs versus 3.3%, 6.6%, and 15.2% for patients who required initiation of drug before, on the day of, or after device implantation, respectively. Logistic regression demonstrated that the most potent risk for inhospital mortality was the use of inotropic drugs. Similar trends were observed for any vasoactive therapy. There was a marked increase in costs associated with these admissions.

CONCLUSIONS

Implantation of cardiac devices during a hospitalization for heart failure may be associated with significant inhospital mortality if patients require intravenous vasoactive therapy. Risk stratification methodology that incorporates ongoing/anticipated need for these drugs will likely improve clinical decision making.

Resource utilization in patients hospitalized with heart failure: insights from a contemporary national hospital database

BACKGROUND

Heterogeneity of disease severity and clinical trajectory has been described among patients hospitalized with heart failure (HF). However, little is known about the variability in and contributors to costs associated with HF hospitalizations. We examined the distribution of costs associated with a HF diagnosis in a large contemporary hospital database.

METHODS

Diagnosis and procedure codes were systematically used to identify primary inpatient HF admissions to hospitals participating in the PREMIER database 2004-2005. Average costs per day and division of costs among hospital departments were evaluated based on patient and hospitalization characteristics.

RESULTS

Total number of hospitalizations was 278,214; 36% had a length of stay (LOS) >5 days. There was a clear association between type of intravenous therapy, LOS, inhospital mortality, and cost. For example, patients initiated on a single intravenous inotrope had a longer mean LOS (9.6 days), greater inhospital mortality rate (14.7%), and higher mean total cost ($18,411) than any other medical therapy administered during hospitalization. The single largest contributor to cost was room and board. Forty-six percent of hospitalizations with diagnosis-related group code 127 (n = 234,204) exceeded average Medicare reimbursement. Variables on admission associated with highest cost hospitalizations were age <75 years, non-black race, male sex, and urban teaching hospital status.

CONCLUSIONS

Length of stay is the determinant of cost for HF hospitalizations. Use of vasoactive therapy is a marker for longer LOS, higher mortality, and greater costs. Improved reimbursement rates or improved therapeutic options that lessen LOS are required if the costs of HF care are to be minimized.

Race and the natural history of chronic heart failure: a propensity-matched study

BACKGROUND

Racial differences in the epidemiology and outcomes of heart failure are well known. However, the association of race with the natural history of heart failure has not been previously studied in a propensity-matched population of chronic heart failure in which all measured baseline patient characteristics are well-balanced between the races.

METHODS AND RESULTS

Of the 7788 patients with chronic systolic and diastolic heart failure in the Digitalis Investigation Group trial, 1128 were nonwhites. Propensity scores for being nonwhite were calculated for each patient and were used to match 1018 pairs of white and nonwhite patients. Matched Cox regression analyses were used to estimate associations of race with outcomes during 38 months of median follow-up. All-cause mortality occurred in 34% (rate, 1180/10000 person-years) of whites and 33% (rate, 1130/10000 person-years) of nonwhite patients (hazard ratio when nonwhite patients were compared with whites, 0.95, 95% confidence interval, 0.80-1.14; P = .593). All-cause hospitalization occurred in 63% (rate, 3616/10000 person-years) of whites and 65% (rate, 3877/10000 person-years) of nonwhite patients (hazard ratio, 1.03, 95% confidence interval, 0.90-1.18; P = .701). Respective hazard ratios (95% confidence intervals) for other outcomes were: 0.95 (0.75-1.12) for cardiovascular mortality, 0.82 (0.60-1.11) for heart failure mortality, 1.05 (0.91-1.22) for cardiovascular hospitalization, and 1.17 (0.98-1.39) for heart failure hospitalization.

CONCLUSIONS

In a propensity-matched population of heart failure patients where whites and nonwhites were balanced in all measured baseline characteristics, there were no racial differences in major natural history end points.

Pacific Islanders' perspectives on heart failure management

OBJECTIVE

To identify the health beliefs, attitudes, practices, and social and family relations important in heart failure treatment among Pacific Islanders.

METHODS

Four focus groups were convened with 36 Native Hawaiians and Samoans with heart failure and their family caregivers. Thematic data analysis was used to categorize data into four domains: health beliefs and attitudes, preferred health practices, social support systems, and barriers to heart failure care.

RESULTS

Common coping styles and emotional experiences of heart failure in this population included avoidance or denial of illness, hopelessness and despair, and reliance on spiritual/religious beliefs as a means of support. Among study participants, more Samoans preferred to be treated by physicians whereas more Native Hawaiians preferred traditional Hawaiian methods of healing. Two types of social support (informational and tangible-instrumental) were identified as important in heart failure care. Barriers to heart failure care included poor knowledge of heart failure, lack of trust in physicians' care, poor physician-patient relations, finances, dietary changes, and competing demands on time.

CONCLUSION

The recruitment, retention, and adherence of Pacific Islanders to heart failure interventions is affected by an array of psychosocial and socio-cultural factors.

PRACTICE IMPLICATIONS

Interventions might be improved by offering participants accurate and detailed information about heart failure and its treatment, engaging the extended family in providing necessary supports, and providing tools to facilitate physician-patient relationships, among others, within the context of a larger socio-cultural system.

Physician attitudes toward end-stage heart failure: a national survey

BACKGROUND

Despite recent improvements in medical therapies, heart failure remains a prevalent condition that places significant burdens on providers, patients, and families. However, there is a paucity of data published describing physician beliefs about heart failure management, especially in its advanced stages.

METHODS

In order to better understand physician decision-making in end-stage heart failure, we used a stratified random sampling of physicians obtained from the Master File of the American Medical Association to survey cardiologists (n=600), geriatricians (n=250), and internists/family practitioners (n=600).

RESULTS

Response rate was 59.6% (highest among geriatricians). The vast majority (>90%) of respondents cited similarities between the clinical trajectory of end-stage heart failure and lung cancer or chronic obstructive pulmonary disease; however, only 15.7% stated that they could predict death at 6 months "most of the time" or "always." Inpatient volume was a predictor of confidence in predicting mortality (odds ratio=1.38, 95% confidence interval, 1.36-1.40). Less than one quarter of respondents formally measure quality of life. The experience with deactivation of implantable cardioverter defibrillators was limited: 59.8% of cardiologists, 88.0% of geriatricians, and 95.1% of internal medicine/family practice physicians have had 2 or fewer conversations with patients and families about this option.

CONCLUSIONS

Significant gaps in knowledge about and experience with end-stage heart failure exist among a large proportion of physicians. The growing prevalence and highly symptomatic nature of heart failure highlight the need to further evaluate and improve the way in which care is delivered to patients dying from the disease.

Cardiovascular health disparities: a systematic review of health care interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.

Association of African American race with elevated pulmonary artery diastolic pressure: data from the Heart and Soul Study

BACKGROUND

Whether increased severity of heart failure in African Americans is a result of differences in cardiac physiology is uncertain. The end-diastolic pulmonary regurgitation (EDPR) gradient is associated with abnormal cardiac physiology. We hypothesized that African American race is associated with an elevated EDPR gradient that may partially predispose African Americans to heart failure.

METHODS

The Heart and Soul Study prospectively assessed the EDPR gradient in 480 patients with coronary disease. We used multivariable linear regression to investigate the independent association of African American race with EDPR gradient.

RESULTS

Compared with 393 non-African Americans, the 87 African Americans had similar indices of left ventricular systolic and diastolic function, left ventricular mass index, mitral regurgitation, peak tricuspid regurgitation gradient, and pulmonary velocity time integral. However, the EDPR gradient was significantly higher in African Americans (4.2 +/- 3.3 mm Hg) than in Caucasians (3.1 +/- 2.5 mm Hg) or other racial groups (3.5 +/- 2.7 mm Hg) (P = .008). In a multivariable model, African American race was a significant predictor of elevated EDPR gradient (beta coefficient 0.75, P = .03).

CONCLUSION

African American race is independently associated with an elevated EDPR gradient in patients with coronary artery disease.

Chronic inotropic therapy in end-stage heart failure

BACKGROUND

Interventions in advanced heart failure that provide symptom relief and decrease hospital readmission are important. Chronic intravenous inotropic therapy represents a pharmacologic approach that has been advocated for palliative treatment. However, little is known about associated mortality and cost. Therefore, we sought to describe the impact of chronic infusions on resource use and survival.

METHODS

Data were reviewed for a 17-state Medicare region from 1995 to 2002. We obtained hospital and outpatient expenditures accrued up to 180 days before and after the initiation of chronic infusions. Health care use was defined by dollars reimbursed for drug and hospitalizations per beneficiary. Average accumulated cost curves were generated for dollars reimbursed for drug and for hospitalizations by days at risk.

RESULTS

The mean age of the cohort (n = 331) was 69.1 +/- 11.3 years. Mortality exceeded 40% at 6 months. Reductions in hospital days were observed at all time points. The amounts reimbursed at 30 and 60 days before and after initiation of inotrope favor drug therapy; however, at six months, the amounts reimbursed were greater due to the cost of milrinone.

CONCLUSIONS

Chronic intravenous inotrope use was associated with a high mortality. The cost for milrinone was significant, but there was a decrease in expenditures for subsequent hospitalizations. In the absence of appropriately designed clinical trials, the data suggest that the decision to use inotropes, the choice of inotrope, and the duration of treatment should reflect the impact on resource use.

Association of race, heart failure and chronic kidney disease

Heart failure and kidney disease are two important emerging epidemics. The importance of pre-end stage kidney disease was introduced in the 2002 publication of the National Kidney Foundation's Chronic Kidney Disease Guidelines. One in nine US adults has some degree of kidney disease, many of whom also have heart failure. Among all patients with heart failure, approximately half have significant kidney disease. The distribution of etiologies of these conditions varies among races; blacks tend to have heart and kidney disease predominantly due to hypertension, while whites tend to be affected by ischemic heart disease and Hispanics by diabetic kidney disease. The burden of disease is disproportionately borne by minorities, the cause of which remains to be fully elucidated. The bulk of knowledge of these diseases is based on studies involving predominantly white subjects. Recent studies have suggested that there are racial differences in patients' responsiveness to various classes of drugs. Designs of future studies should take into account these differences.