Disparities by Sex, Race, and Ethnicity in Use of Left Ventricular Assist Devices and Heart Transplants Among Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

The extent to which sex, racial, and ethnic groups receive advanced heart therapies equitably is unclear. We estimated the population rate of left ventricular assist device (LVAD) and heart transplant (HT) use among (non-Hispanic) White, Hispanic, and (non-Hispanic) Black men and women who have heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

We used a retrospective cohort design combining counts of LVAD and HT procedures from 19 state inpatient discharge databases from 2010 to 2018 with counts of adults with HFrEF. Our primary outcome measures were the number of LVAD and HT procedures per 1000 adults with HFrEF. The main exposures were sex, race, ethnicity, and age. We used Poisson regression models to estimate procedure rates adjusted for differences in age, sex, race, and ethnicity. In 2018, the estimated population of adults aged 35 to 84 years with HFrEF was 69 736, of whom 44% were women. Among men, the LVAD rate was 45.6, and the HT rate was 26.9. Relative to men, LVAD and HT rates were 72% and 62% lower among women (P<0.001). Relative to White men, LVAD and HT rates were 25% and 46% lower (P<0.001) among Black men. Among Hispanic men and women and Black women, LVAD and HT rates were similar (P>0.05) or higher (P<0.01) than among their White counterparts.

CONCLUSIONS

Among adults with HFrEF, the use of LVAD and HT is lower among women and Black men. Health systems and policymakers should identify and ameliorate sources of sex and racial inequities.

Medicaid expansion associated with no change in emergency department use across racial and ethnic groups

OBJECTIVE

To estimate changes in the emergency department (ED) visit rate, hospitalization share of ED visits, and ED visit volumes associated with Medicaid expansion among Hispanic, Black, and White adults.

DATA COLLECTION/EXTRACTION METHODS

For the population of adults aged 26-64 with no insurance or Medicaid coverage, we obtained census population and ED visit counts during 2010-2018 in nine expansion and five nonexpansion states.

MAIN OUTCOMES AND MEASURES

The primary outcome was the annual number of ED visits per 100 adults ("ED rate"). The secondary outcomes were the share of ED visits leading to hospitalization, total number ("volumes") of all ED visits, ED visits leading to discharge ("treat-and-release") and ED visits leading to hospitalization ("transfer-to-inpatient"), and the share of the study population with Medicaid ("Medicaid share").

STUDY DESIGN

An event-study difference in differences design that contrasts pre- versus post-expansion changes in outcomes in Medicaid expansion and nonexpansion states.

PRINCIPAL FINDINGS

In 2013, the ED rate was 92.6, 34.4, and 59.2 ED visits among Black, Hispanic, and White adults, respectively. The expansion was associated with no change in ED rate in all three groups in each of the five post-expansion years. We found that expansion was associated with no change in the hospitalization share of ED visits and the volume of all ED visits, treat-and-release ED visits, and transfer-to-inpatient ED visits. The expansion was associated with an 11.7% annual increase (95% CI, 2.7%-21.2%) in the Medicaid share of Hispanic adults, but no significant change among Black adults (3.8%; 95% CI, -0.04% to 7.7%).

CONCLUSION

ACA Medicaid expansion was associated with no changes in the rate of ED visits among Black, Hispanic, and White adults. Expanding Medicaid eligibility may not change ED use, including among Black and Hispanic subgroups.

Disparities in Potentially Preventable Hospitalizations: Near-National Estimates for Hispanics

OBJECTIVE

To obtain near-national rates of potentially preventable hospitalization (PPH)-a marker of barriers to outpatient care access-for Hispanics; to examine their differences from other race-ethnic groups and by Hispanic national origin; and to identify key mediating factors.

DATA SOURCES/STUDY SETTING

Data from all-payer inpatient discharge databases for 15 states accounting for 85 percent of Hispanics nationally.

STUDY DESIGN

Combining counts of inpatient discharges with census population for adults aged 18 and older, we estimated age-sex-adjusted PPH rates. We examined county-level variation in race-ethnic disparities in these rates to identify the mediating role of area-level indicators of chronic condition prevalence, socioeconomic status (SES), health care access, acculturation, and provider availability.

PRINCIPAL FINDINGS

Age-sex-adjusted PPH rates were 13 percent higher among Hispanics (1,375 per 100,000 adults) and 111 percent higher among blacks (2,578) compared to whites (1,221). Among Hispanics, these rates were relatively higher in areas with predominantly Puerto Rican and Cuban Americans than in areas with Hispanics of other nationalities. Small area variation in chronic condition prevalence and SES fully accounted for the higher rates among Hispanics, but only partially among blacks.

CONCLUSIONS

Hispanics and blacks face higher barriers to outpatient care access; the higher barriers among Hispanics (but not blacks) seem mediated by SES, lack of insurance, cost barriers, and limited provider availability.