Racial disparities in emergent HF care, outcomes identified
Black and Hispanic patients admitted with HF are less likely to be treated in cardiac units than white patients and have a higher rate for readmission within 30 days of discharge, according to a study published in Circulation: Heart Failure.
Researchers observed that black (adjusted rate ratio [aRR] = 0.91; 95% CI, 0.84-0.98) and Hispanic patients with HF (aRR = 0.83; 95% CI, 0.72-0.97) had a lower rate for admission to the cardiology service compared with white patients.
In addition, 26% of white patients were readmitted within 30 days after discharge compared with 29% of black patients and 29% of Hispanic patients (P = .0043).
Moreover, admission to cardiac units was independently associated with readmission within 30 days (HR = 0.84; 95% CI, 0.72-0.97), whereas race was not (black vs. white, HR = 1.09; 95% CI, 0.92-1.29; Hispanic vs. white, HR = 1.14; 95% CI, 0.91-1.42).
“These findings also highlight other structural inequities that exist, such as barriers to accessing outpatient cardiology care for our black and Latinx patients, leading to decreased admission to cardiology service and subsequent worse HF outcomes. We urge health care policy makers to recognize how our current health care systems promote the interests of dominant group members and recommend that care delivery be designed to prioritize the care of our most marginalized patients,” Michelle E. Morse, MD, MPH, hospitalist at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School, told Healio. “We believe there are a multitude of interrelated structural drivers that are pervasive across our health care system and consequently in our institution. Black and Latinx patients likely have barriers to accessing outpatient cardiology care as they were less likely to have an outpatient cardiologist at our institution, which was the strongest predictor of admission to the inpatient cardiology service.”
In other findings, black patients discharged after admission to general medical services rather than a cardiac unit had higher risk for death within 30 days (3% vs. < 1%, P = .01), but there were no differences for white patients (4% vs. 4%, P = .82) or Hispanic patients (3% vs. 3%, P = .85). In addition, of white patients admitted during the study period, 38% were seen in follow-up visits to a cardiology clinic within 30 days vs. 34% of black patients and 45% of Hispanic patients (P = .04).
“Levels of perceived discrimination and mistrust in the health care system may also lead to differential self-advocacy for admission to a specialized service by patients from different backgrounds,” Morse told Healio. “While structural drivers are likely the prevailing forces, implicit bias is ubiquitous and probably contributes as well. It is plausible that patients with less financial resources and lower health literacy are in some cases seen as “too psychosocially complex” to be admitted to a cardiology service. Additionally, our institution frequently operates at near-maximal census, pressuring the admission service decision, as well as likely exacerbating both structural drivers and implicit biases.”
In this retrospective cohort study of 1,967 unique patients (67% white; 24% black; 10% Hispanic) admitted between September 2008 and November 2017 at a single large urban large urban academic referral center, researchers examined the relationship between race and admission service, and its effect on 30-day readmission and mortality. According to the study, patients were self-referred to the ED and admitted to either the cardiology or general medicine service with a principal diagnosis of HF.
“Identifying inequities is the first step in a process. With significant institutional support and leadership commitment, we have begun the work to address these demonstrated inequities through two pilot projects,” Morse told Healio. “In one project, we are conducting real-time surveys of the physicians involved in the admissions process, as well as the patients being admitted, to better understand what drives the decision regarding which service a patient is admitted to. The results of these surveys will inform the creation of objective admission service guidelines for patients with HF.” – by Scott Buzby
Disclosures: The authors report no relevant financial disclosures.