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Larsson JE, Kristensen SL, Deis T, Warming PE, Graversen PL, Schou M, Køber L, Rossing K, Gustafsson F. Influence of socioeconomic status on rates of advanced heart failure therapies. J Heart Lung Transplant 2024; 43:920-930. [PMID: 38408549 DOI: 10.1016/j.healun.2024.02.1452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/15/2024] [Accepted: 02/18/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Socioeconomic deprivation is associated with a lower likelihood of referral for advanced heart failure (HF) evaluation, but it is not known whether it influences rates of advanced HF therapies independently of key hemodynamic measures and comorbidity following advanced HF evaluation in a universal healthcare system. METHODS We linked data from a single-center Danish clinical registry of consecutive patients evaluated for advanced HF with patient-level information on socioeconomic status. Patients were divided into groups based on the level of education (low, medium, and high), combined degree of socioeconomic deprivation (low, medium, and high), and household income quartiles. Rates of the combined outcome of left ventricular assist device implantation or heart transplantation (advanced HF therapy) with death as a competing risk were estimated with cumulative incidence functions, and Cox proportional hazards models adjusted for age, sex, central venous pressure, cardiac index, and comorbidities. RESULTS We included 629 patients, median age 53 years, of whom 77% were men. During a median follow-up of 5 years, 179 (28%) underwent advanced HF therapy. The highest level of education was associated with higher rates (high vs low, adjusted HR 1.81 95% CI 1.14-2.89, p = 0.01), whereas household income quartile groups (Q4 vs Q1, adjusted HR 1.37 95% CI 0.76-2.47, p = 0.30) or groups of combined socioeconomic deprivation (high vs low degree of deprivation, adjusted HR 0.86 95% CI 0.50-1.46, p = 0.56) were not significantly associated with rates of advanced HF therapy. CONCLUSIONS Patients with a lower level of education might be disfavored for advanced HF therapies and could require specific attention in the advanced HF care center.
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Affiliation(s)
- Johan E Larsson
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Søren Lund Kristensen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Tania Deis
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peder E Warming
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter L Graversen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Chehade M, Murali KP, Dickson VV, McCarthy MM. Intersection of social determinants of health with ventricular assist device therapy: An integrative review. Heart Lung 2024; 66:56-70. [PMID: 38583277 DOI: 10.1016/j.hrtlng.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/15/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Social determinants of health (SDOH) may influence the clinical management of patients with heart failure. Further research is warranted on the relationship between SDOH and Ventricular Assist Device (VAD) therapy for heart failure. OBJECTIVES The purpose of this integrative review was to synthesize the state of knowledge on the intersection of SDOH with VAD therapy. METHODS Guided by Whittemore and Knafl's methodology, this literature search captured three concepts of interest including VAD therapy, SDOH, and their domains of intersection with patient selection, decision-making, treatment outcome, and resource allocation. CINAHL, Embase, PsycINFO, PubMed, and Web of Science were searched in March 2023. Articles were included if they were peer-reviewed publications in English, published between 2006 and 2023, conducted in the United States, and examined VAD therapy in the context of adult patients (age ≥ 18 years). RESULTS 22 quantitative studies meeting the inclusion criteria informed the conceptualization of SDOH using the Healthy People 2030 framework. Four themes captured how the identified SDOH intersected with different processes relating to VAD therapy: patient decision-making, healthcare access and resource allocation, patient selection, and treatment outcomes. Most studies addressed the intersection of SDOH with healthcare access and treatment outcomes. CONCLUSION This review highlights substantial gaps in understanding how SDOH intersect with patient and patient selection for VAD. More research using mixed methods designs is warranted. On an institutional level, addressing bias and discrimination may have mitigated health disparities with treatment outcomes, but further research is needed for implementing system-wide change. Standardized assessment of SDOH is recommended throughout clinical practice from patient selection to outpatient VAD care.
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Affiliation(s)
- Mireille Chehade
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States.
| | - Komal Patel Murali
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
| | - Victoria Vaughan Dickson
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
| | - Margaret M McCarthy
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
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Minhas AMK, Fudim M, Garan AR, Davis JD, Fonarow GC, Antoine SM, Fedson S, Nambi V, Abramov D. Socioeconomic status and in-hospital outcomes for patients undergoing heart transplantation or ventricular assist device implantation. Clin Transplant 2023; 37:e15093. [PMID: 37548056 DOI: 10.1111/ctr.15093] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/19/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Although lower socioeconomic status (SES) has been associated with worse in-hospital outcomes among patients with heart failure, the in-hospital outcomes for patients undergoing durable Left Ventricular Assist Device (LVAD) implantation or Heart Transplantation (HT) based on SES have not been well characterized. METHODS We analyzed data from the National Inpatient Sample of hospitalizations between January 2016 and December 2020 of patients aged 18 and over who underwent a HT or newly implanted LVAD. Quartile classification of the median household income of the patient's residential zip code was used to estimate SES. Multivariable analyses with logistic and linear regression were used to evaluate the effects of SES on inpatient outcomes including inpatient mortality, length of stay, and key inpatient complications. RESULTS A total of 16,265 weighted hospitalizations for new LVAD implantation and 14,320 weighted hospitalizations for HT were identified. In multivariable analysis, among patients undergoing HT or LVAD implantation respectively, there were no significant differences between the lowest and highest SES quartiles among important in-hospital outcomes including length of stay (adj B-coeff .56, (-3.59)-(4.71), p = .79 and adj B-coeff 2.40, (-.21)-(5.02), p = .07) and mortality (aOR 1.02, .61-1.70, p = .94 and aOR 1.08, .72-1.62, p = .73). There were also no differences based on SES quartile in important inpatient complications including stroke and cardiac arrest. CONCLUSION In this analysis from the National Inpatient Sample, we demonstrate that SES, evaluated by median zip code income, was not associated with important in-hospital metrics including mortality and length of stay among patients undergoing LVAD or HT.
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Affiliation(s)
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan D Davis
- Department of Medicine, Division of Cardiology, University of San Francisco, San Francisco, California, USA
| | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Steve M Antoine
- Michael E DeBakey Veterans Affairs Hospital and Baylor College of Medicine, Center for Cardiovascular Disease Prevention, Houston, Texas, USA
| | - Savitri Fedson
- Michael E DeBakey Veterans Affairs Hospital and Baylor College of Medicine, Center for Cardiovascular Disease Prevention, Houston, Texas, USA
| | - Vijay Nambi
- Michael E DeBakey Veterans Affairs Hospital and Baylor College of Medicine, Center for Cardiovascular Disease Prevention, Houston, Texas, USA
| | - Dmitry Abramov
- Department of Medicine, Division of Cardiology, Loma Linda Medical Center, Loma Linda, California, USA
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Cascino TM, Colvin M, Lanfear DE, Richards B, Khalatbari S, Mann DL, Taddei-Peters WC, Jeffries N, Watkins DC, Stewart GC, Aaronson KD. Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study. Circ Heart Fail 2023; 16:e009745. [PMID: 36259388 PMCID: PMC9851944 DOI: 10.1161/circheartfailure.122.009745] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/24/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Racial disparities in access to advanced therapies for heart failure (HF) patients are well documented, although the reasons remain uncertain. We sought to determine the association of race on utilization of ventricular assist device (VAD) and transplant among patients with access to care at VAD centers and if patient preferences impact the effect. METHODS We performed an observational cohort study of ambulatory chronic systolic HF patients with high-risk features and no contraindication to VAD enrolled at 21 VAD centers and followed for 2 years in the REVIVAL study (Registry Evaluation of Vital Information for VADs in Ambulatory Life). We used competing events cause-specific proportional hazard methodology with multiple imputation for missing data. The primary outcomes were (1) VAD/transplant and (2) death. The exposures of interest included race (Black or White), additional demographics, captured social determinants of health, clinician-assessed HF severity, patient-reported quality of life, preference for VAD, and desire for therapies. RESULTS The study included 377 participants, of whom 100 (26.5%) identified as Black. VAD or transplant was performed in 11 (11%) Black and 62 (22%) White participants, although death occurred in 18 (18%) Black and 36 (13%) White participants. Black race was associated with reduced utilization of VAD and transplant (adjusted hazard ratio, 0.45 [95% CI, 0.23-0.85]) without an increase in death. Preferences for VAD or life-sustaining therapies were similar by race and did not explain racial disparities. CONCLUSIONS Among patients receiving care by advanced HF cardiologists at VAD centers, there is less utilization of VAD and transplant for Black patients even after adjusting for HF severity, quality of life, and social determinants of health, despite similar care preferences. This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01369407.
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Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | | | - Blair Richards
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | - Shokoufeh Khalatbari
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | | | | | - Neal Jeffries
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
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Jones-Ungerleider KC, Rose A, Knott K, Comstock S, Haft JW, Pagani FD, Tang PC. Sex-based considerations for implementation of ventricular assist device therapy. Front Cardiovasc Med 2022; 9:1011192. [DOI: 10.3389/fcvm.2022.1011192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Women with advanced heart failure receive advanced surgical therapies such as durable left ventricular assist device (LVAD) implantation or heart transplantation at a rate much lower compared to males. Reasons for this discrepancy remain largely unknown. Much of what is understood reflects outcomes of those patients who ultimately receive device implant or heart transplantation. Females have been shown to have a higher mortality following LVAD implantation and experience higher rates of bleeding and clotting phenomena and right ventricular failure. Beyond outcomes, the literature is limited in the identification of pre-operative factors that drive lower than expected LVAD implant rates in this population. More focused research is needed to define the disparities in advance heart failure therapy delivery in women and other underserved populations.
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Disparities in Practice Patterns by Sex, Race, and Ethnicity in Patients Referred for Advanced Heart Failure Therapies. Am J Cardiol 2022; 185:46-52. [DOI: 10.1016/j.amjcard.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/29/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
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Cascino TM, Somanchi S, Colvin M, Chung GS, Brescia AA, Pienta M, Thompson MP, Stewart JW, Sukul D, Watkins DC, Pagani FD, Likosky DS, Aaronson KD, McCullough JS. Racial and Sex Inequities in the Use of and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2223080. [PMID: 35895063 PMCID: PMC9331085 DOI: 10.1001/jamanetworkopen.2022.23080] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/20/2022] [Indexed: 11/14/2022] Open
Abstract
Importance While left ventricular assist devices (LVADs) increase survival for patients with advanced heart failure (HF), racial and sex access and outcome inequities remain and are poorly understood. Objectives To assess risk-adjusted inequities in access and outcomes for both Black and female patients and to examine heterogeneity in treatment decisions among patients for whom clinician discretion has a more prominent role. Design, Setting, and Participants This retrospective cohort study of 12 310 Medicare beneficiaries used 100% Medicare Fee-for-Service administrative claims. Included patients had been admitted for heart failure from 2008 to 2014. Data were collected from July 2007 to December 2015 and analyzed from August 23, 2020, to May 15, 2022. Exposures Beneficiary race and sex. Main Outcomes and Measures The propensity for LVAD implantation was based on clinical risk factors from the 6 months preceding HF admission using XGBoost and the synthetic minority oversampling technique. Beneficiaries with a 5% or greater probability of receiving an LVAD were included. Logistic regression models were estimated to measure associations of race and sex with LVAD receipt adjusting for clinical characteristics and social determinants of health (eg, distance from LVAD center, Medicare low-income subsidy, neighborhood deprivation). Next, 1-year mortality after LVAD was examined. Results The analytic sample included 12 310 beneficiaries, of whom 22.9% (n = 2819) were Black and 23.7% (n = 2920) were women. In multivariable models, Black beneficiaries were 3.0% (0.2% to 5.8%) less likely to receive LVAD than White beneficiaries, and women were 7.9% (5.6% to 10.2%) less likely to receive LVAD than men. Individual poverty and worse neighborhood deprivation were associated with reduced use, 2.9% (0.4% to 5.3%) and 6.7% (2.9% to 10.5%), respectively, but these measures did little to explain observed disparities. The racial disparity was concentrated among patients with a low propensity score (propensity score <0.52). One-year survival by race and sex were similar on average, but Black patients with a low propensity score experienced improved survival (7.2% [95% CI, 0.9% to 13.5%]). Conclusions and Relevance In this cohort study of Medicare beneficiaries hospitalized for HF, disparities in LVAD use by race and sex existed and were not explained by clinical characteristics or social determinants of health. The treatment and post-LVAD survival by race were equivalent among the most obvious LVAD candidates. However, there was differential use and outcomes among less clear-cut LVAD candidates, with lower use but improved survival among Black patients. Inequity in LVAD access may have resulted from differences in clinician decision-making because of systemic racism and discrimination, implicit bias, or patient preference.
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Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Sriram Somanchi
- University of Notre Dame, Mendoza College of Business, Department of IT Analytics and Operations, Notre Dame, Indiana
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Grace S. Chung
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
| | | | - Michael Pienta
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | | | - James W. Stewart
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | - Devraj Sukul
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | | | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Jeffrey S. McCullough
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
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Ebner B, Karetnick M, Grant J, Vincent L, Maning J, Olarte N, Olorunfemi O, Rosario C, Chaparro S. Comparison of household income in in-hospital outcomes after implantation of left ventricular assist device. Int J Artif Organs 2021; 45:379-387. [PMID: 34719291 DOI: 10.1177/03913988211056960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Due to the inability to keep up with the demand for heart transplantation, there is an increased utilization of left ventricular assist devices (LVAD). However, paucity of data exists regarding the association of household income with in-hospital outcomes after LVAD implantation. METHODS Retrospective cohort study using the NIS to identify all patients ⩾18 years who underwent LVAD implantation from 2011 to 2017. Statistical analysis was performed comparing low household income (⩽50th percentile) and high income (>50th percentile). RESULTS A total of 25,503 patients underwent LVAD implantation. The low-income group represented 53% and the high-income group corresponded to 47% of the entire cohort. The low-income group was found to be younger (mean age 55 ± 14 vs 58 ± 14 years), higher proportion of females (24% vs 22%), and higher proportion of blacks (32% vs 16%, p < 0.001 for all). The low-income group was found to have higher prevalence of hypertension, chronic pulmonary disease, smoking, dyslipidemia, obesity, and pulmonary hypertension (p < 0.001 for all). However, the high-income cohort had higher rate of atrial tachyarrhythmias and end-stage renal disease (p < 0.001). During hospitalization, patients in the high-income group had increased rates of ischemic stroke, acute kidney injury, acute coronary syndrome, bleeding, and need of extracorporeal membrane oxygenation (p < 0.001 for all). We found that the unadjusted mortality had an OR 1.30 (CI 1.21-1.41, p < 0.001) and adjusted mortality of OR 1.14 (CI 1.05-1.23, p = 0.002). CONCLUSION In patients undergoing LVAD implantation nationwide, low-income was associated with increased comorbidity burden, younger age, and fewer in-hospital complications and all-cause mortality.
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Affiliation(s)
- Bertrand Ebner
- University of Miami Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | | | - Jelani Grant
- University of Miami Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Louis Vincent
- University of Miami Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Jennifer Maning
- University of Miami Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Neal Olarte
- University of Miami Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | | | - Colombo Rosario
- University of Miami Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Sandra Chaparro
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Coral Gables, FL, USA
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Gilotra NA, Pamboukian SV, Mountis M, Robinson SW, Kittleson M, Shah KB, Forde-McLean RC, Haas DC, Horstmanshof DA, Jorde UP, Russell SD, Taddei-Peters WC, Jeffries N, Khalatbari S, Spino CA, Richards B, Yosef M, Mann DL, Stewart GC, Aaronson KD, Grady KL. Caregiver Health-Related Quality of Life, Burden, and Patient Outcomes in Ambulatory Advanced Heart Failure: A Report From REVIVAL. J Am Heart Assoc 2021; 10:e019901. [PMID: 34250813 PMCID: PMC8483456 DOI: 10.1161/jaha.120.019901] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Heart failure (HF) imposes significant burden on patients and caregivers. Longitudinal data on caregiver health-related quality of life (HRQOL) and burden in ambulatory advanced HF are limited. Methods and Results Ambulatory patients with advanced HF (n=400) and their participating caregivers (n=95) enrolled in REVIVAL (Registry Evaluation of Vital Information for VADs [Ventricular Assist Devices] in Ambulatory Life) were followed up for 24 months, or until patient death, left ventricular assist device implantation, heart transplantation, or loss to follow-up. Caregiver HRQOL (EuroQol Visual Analog Scale) and burden (Oberst Caregiving Burden Scale) did not change significantly from baseline to follow-up. At time of caregiver enrollment, better patient HRQOL by Kansas City Cardiomyopathy Questionnaire was associated with better caregiver HRQOL (P=0.007) and less burden by both time spent (P<0.0001) and difficulty (P=0.0007) of caregiving tasks. On longitudinal analyses adjusted for baseline values, better patient HRQOL (P=0.034) and being a married caregiver (P=0.016) were independently associated with better caregiver HRQOL. Patients with participating caregivers (versus without) were more likely to prefer left ventricular assist device therapy over time (odds ratio, 1.43; 95% CI, 1.03-1.99; P=0.034). Among patients with participating caregivers, those with nonmarried (versus married) caregivers were at higher composite risk of HF hospitalization, death, heart transplantation or left ventricular assist device implantation (hazard ratio, 2.99; 95% CI, 1.29-6.96; P=0.011). Conclusions Patient and caregiver characteristics may impact their HRQOL and other health outcomes over time. Understanding the patient-caregiver relationship may better inform medical decision making and outcomes in ambulatory advanced HF.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences National Heart, Lung, and Blood Institute Bethesda MD
| | - Neal Jeffries
- Division of Cardiovascular Sciences National Heart, Lung, and Blood Institute Bethesda MD
| | - Shokoufeh Khalatbari
- University of MichiganMichigan Institute for Clinical and Health Research Ann Arbor MI
| | | | - Blair Richards
- University of MichiganMichigan Institute for Clinical and Health Research Ann Arbor MI
| | - Matheos Yosef
- University of MichiganMichigan Institute for Clinical and Health Research Ann Arbor MI
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Wang X, Luke AA, Vader JM, Maddox TM, Joynt Maddox KE. Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes. Circ Cardiovasc Qual Outcomes 2020; 13:e006284. [DOI: 10.1161/circoutcomes.119.006284] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Left ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor. We aimed to determine whether there is an association between sex, race/ethnicity, insurance coverage, and neighborhood income and access to/outcomes of LVAD implantation. We further analyzed whether access to LVAD improved in states that did versus did not expand Medicaid.
Methods and Results:
Retrospective cohort study using State Inpatient Databases to identify patients 18 to 85 years of age admitted for heart failure, cardiogenic shock, or LVAD implantation from 2012 to 2015. Logistic regression analyses adjusting for age, all the sociodemographic factors above, medical comorbidities, and a hospital random effect were used to quantify odds of receipt of LVADs, as well as outcomes conditional on receiving an LVAD, for the sociodemographic groups of interest. A total of 925 770 patients were included; 3972 (0.43%) received LVADs. After adjusting for age, comorbidities, and hospital effects, women (adjusted odds ratio [aOR], 0.45 [0.41–0.49]), black patients (aOR, 0.83 [0.74–0.92]), and Hispanic patients (aOR, 0.74 [0.64–0.87]) were less likely to receive LVADs than whites. Medicare (aOR, 0.79 [0.72–0.86]), Medicaid (aOR, 0.52 [0.46–0.58]), and uninsured patients (aOR, 0.17 [0.11–0.25]) were less likely to receive LVADs than the privately insured, and patients in low-income ZIP codes were less likely than those in higher income areas (aOR, 0.71 [0.65–0.77]). Among those who received LVADs, women (aOR, 1.78 [1.38–2.30]), patients of unknown race or race other than white, black, or Hispanic (aOR, 1.97 [1.42–2.74]), and uninsured patients (aOR, 4.86 [1.92–12.28]) had higher rates of in-hospital mortality. Medicaid expansion was not associated with an increase in LVAD implantation.
Conclusions:
There are meaningful sociodemographic disparities in access and outcomes for LVAD implantation. Medicaid expansion was not associated with an increase in LVAD rates.
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Affiliation(s)
- Xiaowen Wang
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (X.W.)
| | - Alina A. Luke
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
| | - Justin M. Vader
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
| | - Thomas M. Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
- Healthcare Innovation Lab, BJC HealthCare/Washington University School of Medicine, St. Louis, MO (T.M.M.)
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO (K.E.J.M.)
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