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Zhang DT, Onyebeke C, Nahid M, Balkan L, Musse M, Pinheiro LC, Sterling MR, Durant RW, Brown TM, Levitan EB, Safford MM, Goyal P. Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure. JAMA Netw Open 2023; 6:e2344070. [PMID: 37983029 PMCID: PMC10660170 DOI: 10.1001/jamanetworkopen.2023.44070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/10/2023] [Indexed: 11/21/2023] Open
Abstract
Importance Involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Objective To determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. Design, Setting, and Participants This retrospective cohort study used data from the Reasons for Geographic and Racial Difference in Stroke (REGARDS) cohort. Participants included adults who experienced an adjudicated hospitalization for HF between 2009 and 2017 in all 48 contiguous states in the US. Data analysis was performed from November 2022 to January 2023. Exposures A total of 9 candidate SDOH, aligned with the Healthy People 2030 conceptual model, were examined: Black race, social isolation, social network and/or caregiver availability, educational attainment less than high school, annual household income less than $35 000, living in rural area, living in a zip code with high poverty, living in a Health Professional Shortage Area, and living in a state with poor public health infrastructure. Main Outcomes and Measures The primary outcome was cardiologist involvement, defined as involvement of a cardiologist as the primary responsible clinician or as a consultant. Bivariate associations between each SDOH and cardiologist involvement were examined using Poisson regression with robust SEs. Results The study included 1000 participants (median [IQR] age, 77.8 [71.5-84.0] years; 479 women [47.9%]; 414 Black individuals [41.4%]; and 492 of 876 with low income [56.2%]) hospitalized at 549 unique US hospitals. Low annual household income (<$35 000) was the only SDOH with a statistically significant association with cardiologist involvement (relative risk, 0.88; 95% CI, 0.82-0.95). In a multivariable analysis adjusting for age, race, sex, HF characteristics, comorbidities, and hospital characteristics, low income remained inversely associated with cardiologist involvement (relative risk, 0.89; 95% CI, 0.82-0.97). Conclusions and Relevance This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.
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Affiliation(s)
- David T. Zhang
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | - Musarrat Nahid
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Lauren Balkan
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Laura C. Pinheiro
- Department of Health Policy and Management, Weill Cornell Medicine, New York, New York
| | | | - Raegan W. Durant
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Todd M. Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | | | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Program for the Care and Study of the Aging Heart, Weill Cornell Medicine, New York, New York
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Bolakale-Rufai IK, Knapp SM, Johnson AE, Brewer L, Mohammed S, Addison D, Mazimba S, Tucker-Edmonds B, Breathett K. Association Between Race, Cardiology Care, and the Receipt of Guideline-Directed Medical Therapy in Peripartum Cardiomyopathy. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01838-5. [PMID: 37870730 PMCID: PMC11035491 DOI: 10.1007/s40615-023-01838-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Black patients with peripartum cardiomyopathy (PPCM) have disproportionately worse outcomes than White patients, possibly related to variable involvement of cardiovascular specialists in their clinical care. We sought to determine whether race was associated with cardiology involvement in clinical care during inpatient admission and whether cardiology involvement in care was associated with higher claims of guideline-directed medical therapy (GDMT) a week after hospital discharge. METHODS Using Optum's de-identified Clinformatics® Data Mart (CDM), we included Black and White patients' first hospital admission for PPCM from 2008 to 2021. Cardiology involvement in clinical care was defined as the receipt of attending care from a cardiovascular specialist during admission. GDMT included beta-blockers (BB) for all patients and triple therapy (BB, angiotensin-responsive medications, and mineralocorticoid receptor antagonists) for non-pregnant patients. Logistic regression was used to determine the associations between cardiology involvement in clinical care during admission and (1) patient race and (2) GDMT prescription, adjusting for age and comorbidities. RESULTS Among 668 patients (32.6% Black, 67.4% White, 93.3% commercially insured), there was no significant difference in the odds of cardiology involvement in clinical care by race (aOR: 1.41; 95%CI: 0.87-2.33, P=0.17). Inpatient cardiology care was associated with 2.75 times increased odds of having a prescription claim for GDMT (BB) for White patients (aOR: 2.75; 95%CI 1.50-5.06, P=0.001), and the estimated effect size was similar but not statistically significant for Black patients (aOR: 2.20, 95% CI, 0.84-5.71, P=0.11). The interaction between race and cardiology involvement in clinical care was not statistically significant for the receipt of BB prescription. Among 274 non-pregnant patients with PPCM (37.2% Black, 62.8% White), 5.8% received triple GDMT. Of these, none of the Black patients lacking cardiology care had triple GDMT. However, cardiology involvement in care was not significantly associated with triple GDMT for either race. CONCLUSIONS Among a commercially insured population within PPCM, race was not associated with cardiology involvement in clinical care during hospitalization. However, cardiology involvement in care was associated with significantly higher odds of prescription claims for BB for only White patients. Additional strategies are needed to support equitable GDMT prescription.
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Affiliation(s)
- Ikeoluwapo Kendra Bolakale-Rufai
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, 1800 North Capitol Avenue, Indianapolis, IN, 46202, USA
| | - Shannon M Knapp
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, 1800 North Capitol Avenue, Indianapolis, IN, 46202, USA
| | - Amber E Johnson
- Division of Cardiology, University of Chicago, Chicago, IL, USA
| | | | - Selma Mohammed
- Division of Cardiology, Creighton University, Omaha, USA
| | - Daniel Addison
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, USA
| | | | - Khadijah Breathett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, 1800 North Capitol Avenue, Indianapolis, IN, 46202, USA.
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Zhang DT, Onyebeke C, Nahid M, Balkan L, Musse M, Pinheiro LC, Sterling MR, Durant RW, Brown TM, Levitan EB, Safford MM, Goyal P. Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.23.23287671. [PMID: 36993687 PMCID: PMC10055565 DOI: 10.1101/2023.03.23.23287671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Introduction The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Since reasons for this are not entirely clear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. We hypothesized that SDOH would be inversely associated with cardiologist involvement in the care of adults hospitalized for HF. Methods We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF between 2009 and 2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH, which align with the Healthy People 2030 conceptual model: Black race, social isolation (0-1 visits from a family or friend in the past month), social network/caregiver availability (having someone to care for them if ill), educational attainment < high school, annual household income < $35,000, living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area, and residing in a state with poor public health infrastructure. The primary outcome was cardiologist involvement, a binary variable which was defined as involvement of a cardiologist as the primary responsible clinician or as a consultant, collected via chart review. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with statistically significant associations (p<0.10) were retained for multivariable analysis. Potential confounders/covariates for the multivariable analysis included age, race, sex, HF characteristics, comorbidities, and hospital characteristics. Results We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years (IQR 71.0-83.7), 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH that had a statistically significant association with cardiologist involvement in a bivariate analysis (RR: 0.88 [95% CI: 0.82-0.95]). After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]). Conclusions Adults with low household income were 11% less likely to have a cardiologist involved in their care during a hospitalization for HF. This suggests that socioeconomic status may implicitly bias the care provided to patients hospitalized for HF.
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Affiliation(s)
- David T. Zhang
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Musarrat Nahid
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Lauren Balkan
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Laura C. Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Madeline R. Sterling
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Raegan W. Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd M. Brown
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Parag Goyal
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
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Falsetti L, Viticchi G, Zaccone V, Guerrieri E, Diblasi I, Giuliani L, Giovenali L, Gialluca Palma LE, Marconi L, Mariottini M, Fioranelli A, Moroncini G, Pansoni A, Burattini M, Tarquinio N. Clusters of Comorbidities in the Short-Term Prognosis of Acute Heart Failure among Elderly Patients: A Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1394. [PMID: 36295555 PMCID: PMC9610682 DOI: 10.3390/medicina58101394] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Elderly patients affected by acute heart failure (AHF) often show different patterns of comorbidities. In this paper, we aimed to evaluate how chronic comorbidities cluster and which pattern of comorbidities is more strongly related to in-hospital death in AHF. Materials and Methods: All patients admitted for AHF to an Internal Medicine Department (01/2015−01/2019) were retrospectively evaluated; the main outcome of this study was in-hospital death during an admission for AHF; age, sex, the Charlson comorbidity index (CCI), and 17 different chronic pathologies were investigated; the association between the comorbidities was studied with Pearson’s bivariate test, considering a level of p ≤ 0.10 significant, and considering p < 0.05 strongly significant. Thus, we identified the clusters of comorbidities associated with the main outcome and tested the CCI and each cluster against in-hospital death with logistic regression analysis, assessing the accuracy of the prediction with ROC curve analysis. Results: A total of 459 consecutive patients (age: 83.9 ± 8.02 years; males: 56.6%). A total of 55 (12%) subjects reached the main outcome; the CCI and 16 clusters of comorbidities emerged as being associated with in-hospital death from AHF. Of these, CCI and six clusters showed an accurate prediction of in-hospital death. Conclusions: Both the CCI and specific clusters of comorbidities are associated with in-hospital death from AHF among elderly patients. Specific phenotypes show a greater association with a worse short-term prognosis than a more generic scale, such as the CCI.
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Affiliation(s)
- Lorenzo Falsetti
- Department of Emergency Medicine, Internal and Sub-Intensive Medicine, Azienda Ospedaliero-Universitaria “Ospedali Riuniti”, 60100 Ancona, Italy
| | - Giovanna Viticchi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Azienda Ospedaliero-Universitaria “Ospedali Riuniti”, 60100 Ancona, Italy
| | - Vincenzo Zaccone
- Department of Emergency Medicine, Internal and Sub-Intensive Medicine, Azienda Ospedaliero-Universitaria “Ospedali Riuniti”, 60100 Ancona, Italy
| | - Emanuele Guerrieri
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy
| | - Ilaria Diblasi
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy
| | - Luca Giuliani
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy
| | - Laura Giovenali
- Emergency Medicine Residency Program, Marche Polytechnic University, 60100 Ancona, Italy
| | | | - Lucia Marconi
- Internal Medicine Department, Istituto Nazionale di Ricerca e Cura Anziani, INRCA-IRCCS, 60027 Ancona, Italy
| | - Margherita Mariottini
- Internal Medicine Department, Istituto Nazionale di Ricerca e Cura Anziani, INRCA-IRCCS, 60027 Ancona, Italy
| | - Agnese Fioranelli
- Internal Medicine Department, Istituto Nazionale di Ricerca e Cura Anziani, INRCA-IRCCS, 60027 Ancona, Italy
| | - Gianluca Moroncini
- Department of Experimental and Clinical Medicine, Clinica Medica, Azienda Ospedaliero-Universitaria “Ospedali Riuniti”, 60100 Ancona, Italy
| | - Adolfo Pansoni
- Emergency Medicine Department, Istituto Nazionale di Ricerca e Cura Anziani, INRCA-IRCCS, 60027 Ancona, Italy
| | - Maurizio Burattini
- Internal Medicine Department, Istituto Nazionale di Ricerca e Cura Anziani, INRCA-IRCCS, 60027 Ancona, Italy
| | - Nicola Tarquinio
- Internal Medicine Department, Istituto Nazionale di Ricerca e Cura Anziani, INRCA-IRCCS, 60027 Ancona, Italy
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Schikowski EM, Swabe G, Chan SY, Magnani JW. Association between income and likelihood of right heart catheterization in individuals with pulmonary hypertension: A US claims database analysis. Pulm Circ 2022; 12:e12132. [PMID: 36176897 PMCID: PMC9476889 DOI: 10.1002/pul2.12132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/22/2022] Open
Abstract
We used a US-based administrative claims database to determine associations between annual household income and the likelihood of right heart catheterization (RHC) among individuals with pulmonary hypertension. Those with annual household income < $40,000 were 19% less likely to receive RHC compared to individuals with annual household income ≥ $100,000 (p < 0.0001).
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Affiliation(s)
- Erin M. Schikowski
- Department of MedicineUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Gretchen Swabe
- Department of Medicine, Center for Research on Health CareUniversity of Pittsburgh School of MedicinePittsburghUSA
| | - Stephen Y. Chan
- Department of MedicineUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine InstituteUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Jared W. Magnani
- Department of MedicineUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
- Department of Medicine, Center for Research on Health CareUniversity of Pittsburgh School of MedicinePittsburghUSA
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Takahashi S, Tanno K, Yonekura Y, Ohsawa M, Kuribayashi T, Ishibashi Y, Omama S, Tanaka F, Onoda T, Sakata K, Koshiyama M, Itai K, Okayama A. Low educational level increases functional disability risk subsequent to heart failure in Japan: On behalf of the Iwate KENCO study group. PLoS One 2021; 16:e0253017. [PMID: 34101763 PMCID: PMC8186788 DOI: 10.1371/journal.pone.0253017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/27/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives The risk factors that contribute to future functional disability after heart failure (HF) are poorly understood. The aim of this study was to determine potential risk factors to future functional disability after HF in the general older adult population in Japan. Methods The subjects who were community-dwelling older adults aged 65 or older without a history of cardiovascular diseases and functional disability were followed in this prospective study for 11 years. Two case groups were determined from the 4,644 subjects: no long-term care insurance (LTCI) after HF (n = 52) and LTCI after HF (n = 44). We selected the controls by randomly matching each case of HF with three of the remaining 4,548 subjects who were event-free during the period: those with no LTCI and no HF with age +/-1 years and of the same sex, control for the no LTCI after HF group (n = 156), and control for the LTCI after HF group (n = 132). HF was diagnosed according to the Framingham diagnostic criteria. Individuals with a functional disability were those who had been newly certified by the LTCI during the observation period. Objective data including blood samples and several socioeconomic items in the baseline survey were assessed using a self-reported questionnaire. Results Significantly associated risk factors were lower educational levels (odds ratio (OR) [95% confidence interval (CI)]: 3.72 [1.63–8.48]) in the LTCI after HF group and hypertension (2.20 [1.10–4.43]) in no LTCI after HF group. Regular alcohol consumption and unmarried status were marginally significantly associated with LTCI after HF (OR [95% CI]; drinker = 2.69 [0.95–7.66]; P = 0.063; unmarried status = 2.54 [0.91–7.15]; P = 0.076). Conclusion Preventive measures must be taken to protect older adults with unfavorable social factors from disability after HF via a multidisciplinary approach.
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Affiliation(s)
- Shuko Takahashi
- Division of Medical Education, Iwate Medical University, Shiwa-gun, Iwate, Japan
- Takemi Program in International Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Department of Health and Welfare, Iwate Prefectural Government, Morioka, Iwate, Japan
- * E-mail:
| | - Kozo Tanno
- Department of Hygiene and Preventive Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Iwate, Japan
| | | | - Masaki Ohsawa
- Morioka Tsunagi Onsen Hospital, Morioka, Iwate, Japan
| | - Toru Kuribayashi
- Faculty of Humanities and Social Sciences, Iwate University, Morioka, Japan
| | - Yasuhiro Ishibashi
- Department of Neurology and Gerontology, Iwate Medical University, Shiwa-gun, Iwate, Japan
| | - Shinichi Omama
- Department of Neurosurgery, Iwate Medical University, Shiwa-gun, Iwate, Japan
| | - Fumitaka Tanaka
- Division of Nephrology and Hypertension, School of Medicine, Iwate Medical University, Shiwa-gun, Iwate, Japan
| | | | - Kiyomi Sakata
- Department of Hygiene and Preventive Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Iwate, Japan
| | | | - Kazuyoshi Itai
- Department of Nutritional Sciences, Morioka University, Takizawa, Japan
| | - Akira Okayama
- Research Institute of Strategy for Prevention, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW This review discusses the current state of racial and ethnic inequities in heart failure burden, outcomes, and management. This review also frames considerations for bridging disparities to optimize quality heart failure care across diverse communities. RECENT FINDINGS Treatment options for heart failure have diversified and overall heart failure survival has improved with the advent of effective pharmacologic and nonpharmacologic therapies. With increased recognition, some racial/ethnic disparity gaps have narrowed whereas others in heart failure outcomes, utilization of therapies, and advanced therapy access persist or worsen. SUMMARY Racial and ethnic minorities have the highest incidence, prevalence, and hospitalization rates from heart failure. In spite of improved therapies and overall survival, the mortality disparity gap in African American patients has widened over time. Racial/ethnic inequities in access to cardiovascular care, utilization of efficacious guideline-directed heart failure therapies, and allocation of advanced therapies may contribute to disparate outcomes. Strategic and earnest interventions considering social and structural determinants of health are critically needed to bridge racial/ethnic disparities, increase dissemination, and implementation of preventive and therapeutic measures, and collectively improve the health and longevity of patients with heart failure.
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Affiliation(s)
- Sabra C. Lewsey
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ
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8
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de Carvalho Dutra A, Silva LL, Pedroso RB, Tchuisseu YP, da Silva MT, Bergamini M, Scheidt JFHC, Iora PH, do Lago Franco R, Staton CA, Vissoci JRN, Nihei OK, de Andrade L. The Impact of Socioeconomic Factors, Coverage and Access to Health on Heart Ischemic Disease Mortality in a Brazilian Southern State: A Geospatial Analysis. Glob Heart 2021; 16:5. [PMID: 33598385 PMCID: PMC7824986 DOI: 10.5334/gh.770] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
Background No other disease has killed more than ischemic heart disease (IHD) for the past few years globally. Despite the advances in cardiology, the response time for starting treatment still leads patients to death because of the lack of healthcare coverage and access to referral centers. Objectives To analyze the spatial disparities related to IHD mortality in the Parana state, Brazil. Methods An ecological study using secondary data from Brazilian Health Informatics Department between 2013-2017 was performed to verify the IHD mortality. An spatial analysis was performed using the Global Moran and Local Indicators of Spatial Association (LISA) to verify the spatial dependency of IHD mortality. Lastly, multivariate spatial regression models were also developed using Ordinary Least Squares and Geographically Weighted Regression (GWR) to identify socioeconomic indicators (aging, income, and illiteracy rates), exam coverage (catheterization, angioplasty, and revascularization rates), and access to health (access index to cardiologists and chemical reperfusion centers) significantly correlated with IHD mortality. The chosen model was based on p < 0.05, highest adjusted R2 and lowest Akaike Information Criterion. Results A total of 22,920 individuals died from IHD between 2013-2017. The spatial analysis confirmed a positive spatial autocorrelation global between IDH mortality rates (Moran's I: 0.633, p < 0.01). The LISA analysis identified six high-high pattern clusters composed by 66 municipalities (16.5%). GWR presented the best model (Adjusted R2: 0.72) showing that accessibility to cardiologists and chemical reperfusion centers, and revascularization and angioplasty rates differentially affect the IHD mortality rates geographically. Aging and illiteracy rate presented positive correlation with IHD mortality rate, while income ratio presented negative correlation (p < 0.05). Conclusion Regions of vulnerability were unveiled by the spatial analysis where sociodemographic, exam coverage and accessibility to health variables impacted differently the IHD mortality rates in Paraná state, Brazil. Highlights The increase in ischemic heart disease mortality rates is related to geographical disparities.The IHD mortality is differentially associated to socioeconomic factors, exam coverage, and access to health.Higher accessibility to chemical reperfusion centers did not necessarily improve patient outcomes in some regions of the state.Clusters of high mortality rate are placed in regions with low amount of cardiologists, income and schooling.
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Affiliation(s)
- Amanda de Carvalho Dutra
- Post-Graduation Program in Health Sciences, State University of Maringá, Maringá, Paraná, BR
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
| | - Lincoln Luís Silva
- Post-Graduation Program in Biosciences and Physiopathology, State University of Maringá, Maringá, Paraná, BR
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
| | - Raíssa Bocchi Pedroso
- Post-Graduation Program in Health Sciences, State University of Maringá, Maringá, Paraná, BR
| | - Yolande Pokam Tchuisseu
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, US
| | - Mariana Teixeira da Silva
- Post-Graduation Program in Health Sciences, State University of Maringá, Maringá, Paraná, BR
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
| | - Marcela Bergamini
- Post-Graduation Program in Health Sciences, State University of Maringá, Maringá, Paraná, BR
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
| | - João Felipe Hermann Costa Scheidt
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
- Department of Medicine, State University of Maringá, Maringá, Paraná, BR
| | - Pedro Henrique Iora
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
- Department of Medicine, State University of Maringá, Maringá, Paraná, BR
| | - Rogério do Lago Franco
- Post-Graduation Program in Health Sciences, State University of Maringá, Maringá, Paraná, BR
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
| | - Catherine Ann Staton
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, US
- Duke Global Health Institute, Duke University, Durham, North Carolina, US
| | - João Ricardo Nickenig Vissoci
- Post-Graduation Program in Health Sciences, State University of Maringá, Maringá, Paraná, BR
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
- Duke Global Health Institute, Duke University, Durham, North Carolina, US
| | - Oscar Kenji Nihei
- Education, Letters and Health Center, State University of the West of Paraná, Foz do Iguaçu, Paraná, BR
| | - Luciano de Andrade
- Post-Graduation Program in Health Sciences, State University of Maringá, Maringá, Paraná, BR
- Study Group on Digital Technologies and Geoprocessing in Health (GETS), State University of Maringá Maringá, Paraná, BR
- Department of Medicine, State University of Maringá, Maringá, Paraná, BR
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9
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Piña IL. If It Is Not Health Care Access or Insurance Coverage, Then Why Do Racial Disparities Persist? JACC-HEART FAILURE 2019; 6:421-423. [PMID: 29724364 DOI: 10.1016/j.jchf.2018.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 03/27/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Ileana L Piña
- Division of Cardiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.
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Lo AX, Donnelly JP, Durant RW, Collins SP, Levitan EB, Storrow AB, Bittner V. A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure. Am J Prev Med 2018; 55:S31-S39. [PMID: 30670199 PMCID: PMC11328969 DOI: 10.1016/j.amepre.2018.05.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/11/2018] [Accepted: 05/16/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure. METHODS National Hospital Ambulatory Medicare Care Survey data on 2001-2010 emergency department visits were analyzed in 2015-2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models. RESULTS More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037). CONCLUSIONS These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding. SUPPLEMENT INFORMATION This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.
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Affiliation(s)
- Alexander X Lo
- Department of Emergency Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois.
| | - John P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Raegan W Durant
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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11
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Breathett K, Liu WG, Allen LA, Daugherty SL, Blair IV, Jones J, Grunwald GK, Moss M, Kiser TH, Burnham E, Vandivier RW, Clark BJ, Lewis EF, Mazimba S, Battaglia C, Ho PM, Peterson PN. African Americans Are Less Likely to Receive Care by a Cardiologist During an Intensive Care Unit Admission for Heart Failure. JACC. HEART FAILURE 2018; 6:413-420. [PMID: 29724363 PMCID: PMC5940011 DOI: 10.1016/j.jchf.2018.02.015] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/22/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to determine whether the likelihood of receiving primary intensive care unit (ICU) care by a cardiologist versus a noncardiologist was greater for Caucasians than for African Americans admitted to an ICU for heart failure (HF). The authors further evaluated whether primary ICU care by a cardiologist is associated with higher in-hospital survival, irrespective of race. BACKGROUND Increasing data demonstrate an association between better HF outcomes and care by a cardiologist. It is unclear if previously noted racial differences in cardiology care persist in an ICU setting. METHODS Using the Premier database, adult patients admitted to an ICU with a primary discharge diagnosis of HF from 2010 to 2014 were included. Hierarchical logistic regression models were used to determine the association between race and primary ICU care by a cardiologist, adjusting for patient and hospital variables. Cox regression with inverse probability weighting was used to assess the association between cardiology care and in-hospital mortality. RESULTS Among 104,835 patients (80.3% Caucasians, 19.7% African Americans), Caucasians had higher odds of care by a cardiologist than African Americans (adjusted odds ratio: 1.42; 95% confidence interval: 1.34 to 1.51). Compared with a noncardiologist, primary ICU care by a cardiologist was associated with higher in-hospital survival (adjusted hazard ratio: 1.20, 95% confidence interval: 1.11 to 1.28). The higher likelihood of survival did not differ by patient race (interaction p = 0.32). CONCLUSIONS Among patients admitted to an ICU for HF, African Americans were less likely than Caucasians to receive primary care by a cardiologist. Primary care by a cardiologist was associated with higher survival for both Caucasians and African Americans.
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Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona.
| | - Wenhui G Liu
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Larry A Allen
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stacie L Daugherty
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado
| | | | - Gary K Grunwald
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado; Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Tyree H Kiser
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado; Department of Clinical Pharmacy, University of Colorado, Aurora, Colorado
| | - Ellen Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Eldrin F Lewis
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sula Mazimba
- Division of Cardiology, University of Virginia Health System, Charlottesville, Virginia
| | - Catherine Battaglia
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado; University of Colorado School of Public Health, Denver, Colorado
| | - P Michael Ho
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Division of Cardiology, Denver Health Medical Center, Denver, Colorado
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12
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Lam VQ, Bazargan-Hejazi S, Pan D, Teruya SA. Health Disparities in Patients with Congestive Heart Failure Exacerbations in Los Angeles County. ACTA ACUST UNITED AC 2018; 6. [PMID: 31058254 DOI: 10.29011/2475-5605.000076] [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: 11/19/2022]
Abstract
Background 1.1.Congestive Heart Failure (CHF) is a leading cause of death in the USA, with over 500,000 new cases diagnosed each year. While rates of CHF exacerbation across all races and ethnicities decreased from 2005 to 2009, the number of Black patients with CHF exacerbation who present in Los Angeles (L. A.) County Emergency Departments (ED) remained the highest. We examine disparities in CHF exacerbation rates in L. A. County, and in Los Angeles Service Planning Area (SPA) 6, and compare CHF-related outcomes, and the disposition of these patients post-ED visit. Methods 1.2.This is a retrospective analysis using the Office of Statewide Health Planning and Development (OSHPD) Emergency Department, and Ambulatory Surgery Center database from 2005 to 2009. We used the following variables: congestive heart failure, ICD-9 code 428.0, age, gender, race/ethnicity, insurance status, and disposition. Univariate and descriptive statistics identified distributions of the study variables. There were a total of 13,766 in the study population. Results 1.3.SPA 6 had higher hospitalization rates across all races and ethnicities, compared to L.A. County as a whole. Blacks constitute 9.1% of the County population, but represented 32% of patients diagnosed with CHF in the ED. Only about 10% of L. A. County's population resides in SPA 6, yet over 22% of the entire County's CHF patients reside there. Conclusions 1.4.CHF continues to disproportionately affect Black individuals in L.A. County, and younger adults in SPA 6. Our results indicate that residing in this service planning area, in addition to race, can predict greater likelihood of presenting with CHF exacerbation in the ED, and greater likelihood of hospitalization. Future research on the association of CHF exacerbation with different sociodemographic measures among minority, underserved and disadvantaged patients is needed. These can identify and help mitigate inequities and weaknesses in our health care system, which are manifest through stark health disparities among different racial, ethnic and socioeconomic groups.
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Affiliation(s)
- Vinh Q Lam
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Shahrzad Bazargan-Hejazi
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Deyu Pan
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Stacey A Teruya
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, USA
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13
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Lambrinou E, Kalogirou F, Lamnisos D, Papathanassoglou E, Protopapas A, Sourtzi P, Barberis VI, Lemonidou C, Antoniades LC, Middleton N. The Greek version of the 9-item European Heart Failure Self-care Behaviour Scale: a multidimensional or a uni-dimensional scale? Heart Lung 2014; 43:494-9. [PMID: 25109661 DOI: 10.1016/j.hrtlng.2014.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 07/10/2014] [Accepted: 07/14/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the dimensionality of the Greek version of the European Heart Failure Self-care Behaviour Scale (Gr9-EHFScBS) in a Greek-Cypriot population. BACKGROUND EHFScBS is a valid and reliable scale which is widely used for assessing heart failure (HF) patients' self-care behaviors. METHODS EHFScBS was translated into Greek and was administered to 128 Greek-Cypriot HF patients. The internal consistency, construct validity and discriminant validity of the scale were assessed. RESULTS Confirmatory factor analysis failed to capture the proposed theoretical structure. Further exploratory factor analysis provided a three-factor solution accounting for 53.35% of the variance, though the scale is better used as a whole. Cronbach's alpha was moderate 0.66, but deletion of any item decreased the alpha coefficient. Discriminant validity was supported by the poor correlation between EHFScBS and Minnesota Living with Heart Failure Questionnaire scores. CONCLUSION Even though results do not conform to the multidimensionality of the scale, assessment of the tool provided acceptable validity and reliability measures to support its usage among Greek speaking populations.
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Affiliation(s)
- Ekaterini Lambrinou
- Nursing Department, School of Health Sciences, Cyprus University of Technology, 15 Vragadinou Str., 3041 Limassol, Cyprus.
| | - Fotini Kalogirou
- Nursing Department, School of Health Sciences, Cyprus University of Technology, 15 Vragadinou Str., 3041 Limassol, Cyprus
| | - Demetris Lamnisos
- Department of Health Science, School of Sciences, European University Cyprus, 6, Diogenes Str., Engomi, P.O. Box 22006, 1516 Nicosia, Cyprus
| | - Elizabeth Papathanassoglou
- Nursing Department, School of Health Sciences, Cyprus University of Technology, 15 Vragadinou Str., 3041 Limassol, Cyprus
| | - Andreas Protopapas
- Nursing Department, School of Health Sciences, Cyprus University of Technology, 15 Vragadinou Str., 3041 Limassol, Cyprus
| | - Panayota Sourtzi
- Faculty of Nursing, University of Athens, 123 Papadiamantopoulou Str., Goudi, Athens 11527, Greece
| | - Vassilis I Barberis
- Cardiology Department, American Medical Center/American Heart Institute, Cyprus
| | - Chrysoula Lemonidou
- Faculty of Nursing, University of Athens, 123 Papadiamantopoulou Str., Goudi, Athens 11527, Greece
| | - Loizos C Antoniades
- Cardiology Department, Larnaca General Hospital, 1 Pandoras, Larnaca, Cyprus
| | - Nicos Middleton
- Nursing Department, School of Health Sciences, Cyprus University of Technology, 15 Vragadinou Str., 3041 Limassol, Cyprus
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14
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Lambrinou E, Protopapas A, Kalogirou F. Educational Challenges to the Health Care Professional in Heart Failure Care. Curr Heart Fail Rep 2014; 11:299-306. [DOI: 10.1007/s11897-014-0203-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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15
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Cuyjet AB, Akinboboye O. Acute heart failure in the African American patient. J Card Fail 2014; 20:533-40. [PMID: 24814871 DOI: 10.1016/j.cardfail.2014.04.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/07/2014] [Accepted: 04/28/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND African Americans (AAs) are disproportionately affected by acute heart failure (AHF) compared with other racial/ethnic groups. Disparities in AHF risk factors among AAs are attributed to higher rates of hypertension and diabetes mellitus, lower socioeconomic status, higher dietary caloric and salt intake, and biologic/genetic differences. However, AAs are frequently underrepresented in AHF clinical trials, and race-related differences in risks and clinical outcomes are not well understood. OBJECTIVE The aim of this work was to review published data on AHF in the AA population, including management strategies that may differ based on race and common barriers to optimal care. METHODS Publications were identified in Pubmed (through June 10, 2013) with the use of the search strategy terms (acute heart failure) AND (black OR African American OR racial). RESULTS Racial disparities in the quality of AHF care are relatively uncommon; however, racial differences in pathophysiology have resulted in differing pharmacologic recommendations (eg, isosorbide dinitrate plus hydralazine is indicated only in AAs). Various socioeconomic factors influence disease progression, treatment compliance, and hospitalization/rehospitalization rates. CONCLUSIONS Further research would enhance understanding of pathophysiologic heart failure differences between racial groups. Programs are needed that incorporate known clinical and cultural differences to improve quality of care and reduce the disease burden of AHF for all patients.
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Affiliation(s)
| | - Ola Akinboboye
- Association of Black Cardiologists, Washington DC Heart House, Washington, DC; Weill Medical College of Cornell University, New York, New York; Laurelton Heart Specialists P.C., Rosedale, New York
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16
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Hawkins NM, Jhund PS, McMurray JJV, Capewell S. Heart failure and socioeconomic status: accumulating evidence of inequality. Eur J Heart Fail 2012; 14:138-46. [PMID: 22253454 DOI: 10.1093/eurjhf/hfr168] [Citation(s) in RCA: 196] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Socioeconomic status (SES) is a powerful predictor of incident coronary disease and adverse cardiovascular outcomes. Understanding the impact of SES on heart failure (HF) development and subsequent outcomes may help to develop effective and equitable prevention, detection, and treatment strategies METHODS AND RESULTS A systematic literature review of electronic databases including PubMed, EMBASE, CINAHL, and the Cochrane Library, restricted to human subjects, was carried out. The principal outcomes were incidence, prevalence, hospitalizations, mortality, and treatment of HF. Socioeconomic measures included education, occupation, employment relations, social class, income, housing characteristics, and composite and area level indicators. Additional studies were identified from bibliographies of relevant articles and reviews. Twenty-eight studies were identified. Lower SES was associated with increased incidence of HF, either in the community or presenting to hospital. The adjusted risk of developing HF was increased by ∼30-50% in most reports. Readmission rates following hospitalization were likewise greater in more deprived patients. Although fewer studies examined mortality, lower SES was associated with poorer survival. Evidence defining the equity of medical treatment of patients with HF was scarce and conflicting. CONCLUSIONS Socioeconomic deprivation is a powerful independent predictor of HF development and adverse outcomes. However, the precise mechanisms accounting for this risk remain elusive. Heart failure represents the endpoint of numerous different pathophysiological processes and 'chains of events', each modifiable throughout the disease trajectories. The interaction between SES and HF is accordingly complex. Disentangling the many and varied life course processes is challenging. A better understanding of these issues may help attenuate the health inequalities so clearly evident among patients with HF.
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Affiliation(s)
- Nathaniel M Hawkins
- Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK.
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17
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Despair over disparities: challenges and pathways to "affordable care". J Am Coll Cardiol 2011; 58:1472-3. [PMID: 21939831 DOI: 10.1016/j.jacc.2011.06.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Accepted: 06/28/2011] [Indexed: 11/21/2022]
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18
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Barbareschi G, Sanderman R, Leegte IL, van Veldhuisen DJ, Jaarsma T. Educational Level and the Quality of Life of Heart Failure Patients: A Longitudinal Study. J Card Fail 2011; 17:47-53. [DOI: 10.1016/j.cardfail.2010.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 08/09/2010] [Accepted: 08/11/2010] [Indexed: 11/16/2022]
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19
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Hasan O, Orav EJ, Hicks LS. Insurance status and hospital care for myocardial infarction, stroke, and pneumonia. J Hosp Med 2010; 5:452-9. [PMID: 20540165 DOI: 10.1002/jhm.687] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite widely documented variations in health care outcomes by insurance status, few nationally representative studies have examined such disparities in the inpatient setting. OBJECTIVE To determine whether there are insurance-related differences in hospital care for 3 common medical conditions. DESIGN AND SUBJECTS Retrospective database analysis of 154,381 adult discharges (age 18-64 years) with a principal diagnosis of acute myocardial infarction (AMI), stroke, or pneumonia from the 2005 Nationwide Inpatient Sample (NIS). MEASUREMENTS For each diagnosis, we compared in-hospital mortality, length of stay (LOS), and cost per hospitalization for Medicaid and uninsured patients with the privately insured. RESULTS Compared with the privately insured, in-hospital mortality among AMI and stroke patients was significantly higher for the uninsured (adjusted odds ratio [OR] 1.52, 95% confidence interval [CI] [1.24-1.85] for AMI and 1.49 [1.29-1.72] for stroke) and among pneumonia patients was significantly higher for Medicaid recipients (1.21 [1.01-1.45]). Excluding patients who died during hospitalization, LOS was consistently longer for Medicaid recipients for all 3 conditions (adjusted ratio 1.07, 95% CI [1.05-1.09] for AMI, 1.17 [1.14-1.20] for stroke, and 1.04 [1.03-1.06] for pneumonia), although costs were significantly higher for Medicaid recipients for only 2 of the 3 conditions (adjusted ratio 1.06, 95% CI [1.04-1.09] for stroke and 1.05 [1.04-1.07] for pneumonia). CONCLUSIONS In this nationally representative study of working-age Americans hospitalized for 3 common medical conditions, significantly lower in-hospital mortality was noted for privately insured patients compared with the uninsured or Medicaid recipients. Interventions to reduce insurance-related gaps in inpatient quality of care should be investigated.
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Affiliation(s)
- Omar Hasan
- Department of Medicine, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02120-1613, USA
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20
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Abstract
Practitioners in critical care have made a significant progress in caring for dying patients in critical care by taking advantage of the suggestions from their professional groups. Progress has been made in responding to and controlling patients' pain. Major initiatives from the Joint Commission and the American Pain Society have helped direct this improvement. Palliative care consultations as well as ethics consultations have improved symptom control in the critically ill. Issues of consent have been problematic for dying patients in critical care especially in the area of discontinuing therapies. But, better policies related to advance directives have been developed to ensure good care. Spiritual care has received more attention, and now chaplains are recognized by the Society for Critical Care Medicine as integral to the critical care team. The American Association of Critical-Care Nurses has been a leader in improving end-of-life issues and continues to spearhead many projects to improve end-of-life care.
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Affiliation(s)
- Barbara B Ott
- College of Nursing, Villanova University, Villanova, Pennsylvania 19085, USA.
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21
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Avery CL, Mills KT, Chambless LE, Chang PP, Folsom AR, Mosley TH, Ni H, Rosamond WD, Wagenknecht L, Wood J, Heiss G. Long-term association between self-reported signs and symptoms and heart failure hospitalizations: the Atherosclerosis Risk In Communities (ARIC) Study. Eur J Heart Fail 2010; 12:232-8. [PMID: 20097681 DOI: 10.1093/eurjhf/hfp203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Christy L Avery
- Department of Epidemiology, University of North Carolina at Chapel Hill, Bank of America Center, 137 E. Franklin St, Suite 306, Chapel Hill, NC 27514, USA.
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22
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Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJV. Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. Eur J Heart Fail 2009; 11:130-9. [PMID: 19168510 PMCID: PMC2639415 DOI: 10.1093/eurjhf/hfn013] [Citation(s) in RCA: 378] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 08/31/2008] [Accepted: 11/03/2008] [Indexed: 11/12/2022] Open
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are global epidemics incurring significant morbidity and mortality. The combination presents many diagnostic challenges. Clinical symptoms and signs frequently overlap. Evaluation of cardiac and pulmonary function is often problematic and occasionally misleading. Echocardiography and pulmonary function tests should be performed in every patient. Careful interpretation is required to avoid misdiagnosis and inappropriate treatment. Airflow obstruction, in particular, must be demonstrated when clinically euvolaemic. Very high and very low concentrations of natriuretic peptides have high positive and negative predictive values for diagnosing HF in those with both conditions. Intermediate values are less informative. Both conditions are systemic disorders with overlapping pathophysiological processes. In patients with HF, COPD is consistently an independent predictor of death and hospitalization. However, the impact on ischaemic and arrhythmic events is unknown. Greater collaboration is required between cardiologists and pulmonologists to better identify and manage concurrent HF and COPD. The resulting symptomatic and prognostic benefits outweigh those attainable by treating either condition alone.
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Affiliation(s)
- Nathaniel Mark Hawkins
- Aintree Cardiac Centre, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK.
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23
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Rodriguez KL, Appelt CJ, Switzer GE, Sonel AF, Arnold RM. Veterans' decision-making preferences and perceived involvement in care for chronic heart failure. Heart Lung 2008; 37:440-8. [PMID: 18992627 DOI: 10.1016/j.hrtlng.2008.02.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 01/17/2008] [Accepted: 02/08/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with heart failure require a great deal of information about their disease, but it is also important to know about their preferences for involvement in medical decision making and about factors that may influence their preferences so that patients' needs, values, and preferences can be met by clinicians. OBJECTIVES We assessed patients' preferred role and perceived level of involvement in medical decision making and tested the effects of patients' age and role preference on perceived involvement in medical decision making. METHODS We conducted a telephone survey of 90 adults being treated for heart failure by a Veterans Affairs primary care provider or cardiologist. Patients' preferred role in treatment decisions was assessed using the Control Preferences Scale. Perceptions about their involvement in decision making during the most recent clinic visit was measured using a subscale of the Perceived Involvement in Care Scale. Descriptive, correlational, and generalized linear regression analyses were conducted. RESULTS Most patients were elderly (mean = 70.1 years), male (94.4%), and white (85.6%), and had New York Heart Association class II disease (55.6%). Forty-three patients (47.8%) preferred a passive role in decision making, 19 patients (21.1%) preferred an active role, and 28 patients (31.1%) preferred a collaborative role. Most patients believed that their decision-making involvement was relatively passive, as indicated by a mean score of .96 (range, 0-4) on the Perceived Involvement in Care Scale decision-making subscale. Older age was associated with passive role preference (r = .263; P < .05) and less perceived involvement in decision making (r = -.279; P < .01). In addition, less perceived involvement in decision making during the last clinic visit was associated with a preference for a more passive decision-making role (r = rho.355; P < .01). Generalized linear regression analysis indicated that when patients' perceived decision-making involvement was regressed on age and patients' role preferences, age was no longer significantly associated with involvement (beta = -.196; P = .061), but that control preferences continued to exhibit an independent effect on perceived involvement in medical decision making (beta = -.341; P = .003). CONCLUSION The results suggest that the preferences of patients with heart failure for a more passive role in decision making may be a stronger independent predictor of patients' perceived involvement in decision making than patients' age.
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Affiliation(s)
- Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15206, USA
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Fang J, Mensah GA, Croft JB, Keenan NL. Heart failure-related hospitalization in the U.S., 1979 to 2004. J Am Coll Cardiol 2008; 52:428-34. [PMID: 18672162 DOI: 10.1016/j.jacc.2008.03.061] [Citation(s) in RCA: 435] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 03/05/2008] [Accepted: 03/18/2008] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Jing Fang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341-3714, USA.
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Sui X, Gheorghiade M, Zannad F, Young JB, Ahmed A. A propensity matched study of the association of education and outcomes in chronic heart failure. Int J Cardiol 2007; 129:93-9. [PMID: 17643517 PMCID: PMC2657036 DOI: 10.1016/j.ijcard.2007.05.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Revised: 04/30/2007] [Accepted: 05/19/2007] [Indexed: 11/15/2022]
Abstract
BACKGROUND Heart failure (HF) patients' knowledge about their disease may improve short-term outcomes and may be related to their level of education. However, the effects of patients and spousal education on long-term outcomes in ambulatory chronic HF are unknown. METHODS Of the 571 patients enrolled in the quality of life sub-study of the Digitalis Investigation Group trial, 159 patients or their spouses reported having higher (>12 years) education. Propensity score for higher education, calculated for each patient using a logistic regression model, was used to match 112 (70% of 159) higher education patients with 215 patients with high school (<or=12 years) education. Matched Cox regression analyses were used to estimate associations of high school education with mortality and hospitalizations. RESULTS All-cause hospitalizations occurred in 56% (rate, 3233/10,000 person-years) of higher education and 65% (rate, 4558/10,000 person-years) of high school education patients (hazard ratio {HR} for high school, compared with higher education=1.52; 95% confidence interval {CI}=1.06-2.16; p=0.022). Hospitalizations due to cardiovascular causes occurred in 42% (rate, 2067/10,000 person-years) of higher education and 50% (rate, 4558/10,000 person-years) of high school education patients (HR=1.55; 95% CI, 1.05-2.30; p=0.029). All-cause mortality occurred in 20% (rate, 746/10,000 person-years) of higher education and 30% (rate, 1204/10,000 person-years) of high school education patients (HR=1.52; 95% CI=0.89-2.58; p=0.124). CONCLUSIONS Compared with >12 years of education, lower education was associated with increased hospitalizations among ambulatory chronic HF patients. Patient and spousal education levels may be used to risk stratify HF patients at high risk for hospitalizations.
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Affiliation(s)
- Xuemei Sui
- University of South Carolina, Columbia, SC, USA
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- University of Alabama at Birmingham, Birmingham, AL, USA
- VA Medical Center, Birmingham, AL, USA
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Rathore SS, Masoudi FA, Wang Y, Curtis JP, Foody JM, Havranek EP, Krumholz HM. Socioeconomic status, treatment, and outcomes among elderly patients hospitalized with heart failure: findings from the National Heart Failure Project. Am Heart J 2006; 152:371-8. [PMID: 16875925 PMCID: PMC2790269 DOI: 10.1016/j.ahj.2005.12.002] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Accepted: 12/06/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prior studies have reported conflicting findings concerning the association of socioeconomic status (SES), treatment, and outcomes in patients hospitalized with heart failure (HF). METHODS We conducted a retrospective analysis of medical record data from a national sample of Medicare beneficiaries hospitalized with HF between March 1998 and April 1999 (n = 25,086) to assess the association of patient SES, treatment, and outcomes. Patients' SES was designated as lower, lower-middle, higher-middle, and higher using residential ZIP code characteristics. Patients were evaluated for left ventricular systolic function assessment, prescription of angiotensin-converting enzyme inhibitors at discharge, readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission. Hierarchical logistic regression models were used to assess the association of SES, quality of care, and outcomes adjusting for patient, physician, and hospital characteristics. RESULTS Lower SES patients (relative risk [RR] 0.92, 95% CI 0.87-0.96) were modestly less likely to have had a left ventricular systolic function assessment, but had a similar adjusted likelihood of being prescribed angiotensin-converting enzyme inhibitors (RR 1.03, 95% CI 0.93-1.11) compared with higher SES patients after multivariable adjustment. Socioeconomic status was not associated with 30-day mortality after multivariable adjustment, but lower SES patients had a higher risk of 1-year mortality (RR 1.10, 95% CI 1.02-1.19) and readmission within 1 year of discharge (RR 1.08, 95% CI 1.03-1.12) compared with higher SES patients. CONCLUSIONS Socioeconomic status in patients hospitalized with HF was not strongly associated with quality of care or 30-day mortality. However, the increased risk of 1-year mortality and readmission among patients of lower SES suggest SES may influence outcomes after hospitalization for HF.
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Affiliation(s)
- Saif S Rathore
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8088, USA.
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Abstract
Heart failure is a clinical syndrome that results in diminished tissue perfusion and volume overload. Because of increasing population age and improved survival after myocardial infarction, the prevalence of heart failure is likely to increase dramatically. Primary care physicians are in an ideal position to care for patients throughout the spectrum of heart failure, from identifying patients at increased risk to managing the final stages of the disease. New understandings of heart failure pathophysiology have led to more effective treatments aimed at blocking neurohormonal pathways. There is still much to be learned about the pathophysiology and treatment of diastolic heart failure, and rapidly expanding knowledge of heart failure is likely to lead to better treatment in the coming years.
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Affiliation(s)
- Jason Wilbur
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
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Atienza F, Anguita M, Martinez-Alzamora N, Osca J, Ojeda S, Almenar L, Ridocci F, Vallés F, de Velasco JA. Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program. Eur J Heart Fail 2004; 6:643-52. [PMID: 15302014 DOI: 10.1016/j.ejheart.2003.11.023] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Accepted: 11/07/2003] [Indexed: 11/19/2022] Open
Abstract
AIMS Disease management programs can reduce hospitalizations in high-risk heart failure (HF) patients, but generalizability to the population hospitalized for HF remains to be proven. We aimed to assess the effectiveness of a discharge and outpatient management program in a non-selected cohort of patients hospitalized for HF. METHODS AND RESULTS Patients admitted with decompensated HF were randomized to receive usual care (n=174) or an intervention (n=164) consisting of a comprehensive hospital discharge planning and close follow-up at a HF clinic. After a median of 509 days, there were fewer events (readmission or death) in the intervention as compared with the control group (156 vs. 250), which represents 47% (95%CI: 29-65; P<0.001) event reduction per observation year. At 1-year, time to first event, time to first all-cause and HF readmission, and time to death were increased in the intervention group (P<0.001). All-cause and HF readmission rates per observation year were significantly lower, quality of life improved and overall cost of care was reduced in the intervention group. CONCLUSIONS This comprehensive hospital discharge and outpatient management program prolonged time to first event, reduced hospital readmissions, improved survival and quality of life of patients hospitalized for HF, while reducing cost of management.
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Affiliation(s)
- Felipe Atienza
- Department of Cardiology, Hospital General Universitario de Valencia, Valencia, Spain.
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Foody JM, Rathore SS, Wang Y, Herrin J, Masoudi FA, Havranek EP, Radford MJ, Krumholz HM. Predictors of cardiologist care for older patients hospitalized for heart failure. Am Heart J 2004; 147:66-73. [PMID: 14691421 DOI: 10.1016/j.ahj.2003.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies have suggested that cardiologists may provide higher quality heart failure care than generalists. However, national rates of specialty care during hospitalization for heart failure and factors associated with care by a cardiologist are unknown. METHODS We assessed specialty care in a sample of Medicare patients hospitalized nationwide with heart failure between 1998 and 1999 (n = 25,869). Multivariable hierarchical logistic regression models were used to identify factors independently associated with treatment by a cardiologist. RESULTS One-quarter (25.5%) of patients had a cardiologist as their attending physician, 31.3% of patients received a cardiology consult, and 43.2% of patients were not treated by a cardiologist during hospitalization. Older patients (age <75 years: referent; age 75-84 years: risk ratio [RR], 0.92; 95% CI, 0.86-0.98; age > or =85 years: RR, 0.81; 95% CI, 0.74-0.88) and women (RR, 0.87; 95% CI, 0.83-0.93) were less likely to have an attending cardiologist. Patients with a history of heart failure (RR, 1.13; 95% CI, 1.06-1.20), coronary disease (RR, 1.23; 95% CI, 1.14-1.32), coronary artery bypass grafting (RR, 1.42; 95% CI, 1.32-1.42), or percutaneous transluminal coronary angioplasty (RR, 1.30; 95% CI, 1.19-1.42) were more likely to be treated by a cardiologist, whereas patients with chronic obstructive pulmonary disease (RR, 0.74; 95% CI, 0.70-0.79) and dementia (RR, 0.61; 95% CI, 0.54-0.70) were less likely to be treated by a cardiologist. Patient race was not associated with treatment by a cardiologist. The strongest predictors of attending cardiology care were hospital factors, including large volume (>300 beds; RR, 1.45; 95% CI, 1.32-1.42) and geographic location (RR, 1.00 Northeast (referent) vs RR, 0.55; 95% CI 0.46-0.65 Midwest). CONCLUSIONS Slightly more than half of older patients with heart failure received care from a cardiologist. Several patient characteristics, including age and sex, were associated with the use of specialty care, suggesting that factors other than clinical presentation may independently influence the use of specialty care.
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Affiliation(s)
- JoAnne Micale Foody
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn 06520-8025, USA
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LaVeist TA, Arthur M, Morgan A, Rubinstein M, Kinder J, Kinney LM, Plantholt S. The cardiac access longitudinal study. A study of access to invasive cardiology among African American and white patients. J Am Coll Cardiol 2003; 41:1159-66. [PMID: 12679217 DOI: 10.1016/s0735-1097(03)00042-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES We sought to identify factors contributing to racial disparity in the receipt of coronary angiography (CA). BACKGROUND Numerous studies have demonstrated that African American patients are less likely to receive needed diagnostic and therapeutic coronary procedures than white patients. This report summarizes the methods and findings of a study linking medical records with patient and physician interviews to address racial disparities in the utilization of CA. METHODS This is a retrospective, cross-sectional study conducted in three urban hospitals in Maryland. A total of 9,275 medical records were reviewed, representing all 7,058 cardiac patients admitted in a two-year period. We identified 2,623 patients who, according to American College of Cardiology guidelines, were candidates for receiving CA. A total of 1,669 patients (721 African Americans and 948 whites) and 74% of their physicians were successfully interviewed. Multivariate and hierarchical multivariate logistic regression were used to construct a model of receipt of CA within one year of the hospitalization. RESULTS The unadjusted odds of white patients receiving CA was three times greater than the odds for African American patients (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.4 to 3.7). Adjusting for patients' clinical and social characteristics resulted in a 13% reduction in the OR for race. Adjusting for physician and health care system characteristics reduced the OR by 43%, to 1.7 (95% CI 1.3 to 2.4). CONCLUSIONS Racial disparity in the utilization of CA is a function of differences in the health care system "context" in which African American and white patients obtain care, combined with differences in the specific clinical characteristics of patients.
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Affiliation(s)
- Thomas A LaVeist
- Center for Health Disparities Solutions, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland 21205, USA.
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Ahmed A, Sims RV, Allman RM, DeLong JF, Aronow WS. Racial variations in cardiology care among hospitalized older heart failure patients. HEART DISEASE (HAGERSTOWN, MD.) 2003; 5:8-14. [PMID: 12549984 DOI: 10.1097/01.hdx.0000050408.07809.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this retrospective follow-up study, the authors examined the association between race and the receipt of cardiology care in 1062 Medicare beneficiaries 65 years of age and older who were hospitalized with heart failure. The primary outcome measure was receipt of care from a cardiologist (via admission or consultation). Using logistic regression analyses, crude and adjusted odds ratios (OR) and 95% confidence intervals (95%CI) of receipt of cardiology care were estimated for nonwhite versus white patients. Two hundred (19%) patients were nonwhites and 483 (46%) patients received care from cardiologists. Proportion of patients receiving cardiology care was lower among nonwhite patients (35% versus 48% among whites; P = 0.001), and nonwhite race was associated with a lower odds of receiving cardiology care (crude OR = 0.57; 95%CI = 0.42-0.79). After adjustment for various patient characteristics and process-of-care variables, the magnitude and precision of the association between nonwhite race and a lower odds of receiving care from a cardiologist remained unchanged (adjusted OR = 0.43; 95% CI = 0.30-0.62). These findings suggest that nonwhite elderly hospitalized heart failure patients are less likely to be cared for by cardiologists.
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Affiliation(s)
- Ali Ahmed
- Department of Medicine, University of Alabama at Birmingham (UAB), AL 35294-2041, USA.
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Abstract
PURPOSE The volume of research on end-of-life care, death, and dying has exploded during the past decade. This article reviews the conceptual and methodological adequacy of end-of-life research to date, focusing on limitations of research to date and ways of improving future research. DESIGN AND METHODS A systematic search was conducted to identify the base of end-of-life research. Approximately 400 empirical articles were identified and are the basis of this review. RESULTS Although much has been learned from research to date, limitations in the knowledge base are substantial. The most fundamental problems identified are conceptual and include failure to define dying; neglect of the distinctions among quality of life, quality of death, and quality of end-of-life care. Methodologically, the single greatest problem is the lack of longitudinal studies that cover more than the time period immediately before death. IMPLICATIONS Gaps in the research base include insufficient attention to psychological and spiritual issues, the prevalence of psychiatric disorder and the effectiveness of the treatment of such disorders among dying persons, provider and health system variables, social and cultural diversity, and the effects of comorbidity on trajectories of dying.
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Affiliation(s)
- Linda K George
- Department of Sociology, Institute for Care at the End of Life, Duke University, Durham, NC 27708, USA.
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