Treatment of the african-american patient with congestive heart failure

Racial differences in clinical treatment and self-care behaviors of adults with chronic heart failure

BACKGROUND

In the United States, the highest prevalence of heart failure (HF) is in blacks followed by whites. Compared with whites, blacks have a higher risk of HF-related morbidity and mortality and HF-related hospitalization. Little research has focused on explaining the reasons for these disparities. The purpose of this study was to examine racial differences in demographic and clinical characteristics in blacks and whites with HF and to determine if these characteristics influenced treatment, or together with treatment, influenced self-care behaviors.

METHODS AND RESULTS

This was a secondary analysis of existing data collected from adults (n=272) with chronic HF enrolled from outpatient sites in the northeastern United States and followed for 6 months. After adjusting for sociodemographic and clinical characteristics within reduced (HFrEF) and preserved ejection fraction (HFpEF) groups, there were 2 significant racial differences in clinical treatment. Blacks with HFrEF were prescribed ACE inhibitors and hydralazine and isosorbide dinitrate (H-ISDN) more often than whites. In the HFpEF group, blacks were taking more medications and were prescribed digoxin and a diuretic when symptomatic. Deficits in HF knowledge and decreased medication adherence, objectively measured, were more prominent in blacks. These racial differences were not explained by sociodemographic or clinical characteristics or clinical treatment variables. Premorbid intellect and the quality of support received contributed to clinical treatment and self-care.

CONCLUSION

Although few differences in clinical treatment could be attributed solely to race, knowledge about HF and medication adherence is lower in blacks than whites. Further research is needed to explain these observations, which may be targets for future intervention research.

Hospice use among patients with heart failure

BACKGROUND

Hospices provide end-of-life care for heart failure (HF) patients, but hospice is underused for these patients, and its use has not been well described.

METHODS

We examined hospice use among 11,754 HF and 31,228 cancer patients. These patients were either discharged from hospice or died while in hospice between January 1, 2004, and June 30, 2005.

RESULTS

The percentages of patients with HF and cancer who received hospice care for </=7 days were similar (31.7% vs 30.8%; P = .08), but HF patients were significantly more likely to receive hospice care for >/=6 months (7.6% vs 1.1%; P < .001). Patients with HF were significantly more likely to be discharged from hospice alive (19.0% vs 11.3%; P < .001), as were African Americans with HF and those who were prescribed HF medications.

CONCLUSION

Our study provides detailed estimates of hospice use and identifies potential areas of hospice care that are unique to HF patients. Our findings generate hypotheses about the Medicare Hospice Benefit, specifically whether changes to the 6-month prognosis criterion for hospice eligibility would result in increased hospice use for HF patients. We hope that our results will stimulate additional studies to elucidate differences in hospice use between HF and cancer patients, including patient perspectives of hospice care and clinician referral patterns.