HF hospitalizations remain more common in men, black patients

Clyde W. Yancy, MD, MSc, MACC, FAHA, MACP, FHFSA

This is quite credible work that brings a number of important concepts to our attention. The burden of HF is important; once the disease is experienced, patients typically have a shorter life expectancy and a lesser quality of life. No matter how good we are — and I’m one of the big proponents and promulgators of evidence-based therapy — we can never restore the ‘pre-[HF] stage.’

It’s an unbelievably important message to say definitively we’ve seen a real reduction in HF hospitalization and, as the authors have suggested, we think this is has been generated by two dynamics. One has been broader use of evidence-based medical and device therapies for HF. We and others have opined that when we do the right thing for the right patient at the right time, we see better outcomes. These data support our long-held assertions.

Even more provocative is the benefit of prevention, ie, better treatment of hypertension and better management of ACS. It is intuitive and now more evidence based that as we successfully treat [ACS] and hypertension, the burden of [HF] attributable to those two circumstances will fall. This would seem as if it’s an all-positive message.

What this dataset also brings is new knowledge at a top-tier level, from a fairly large representative sample of U.S. hospitals, that there has been as much as a 20% reduction in HF hospitalization burden and correspondingly a presumed major reduction in the consumption of health care resources to treat this condition.

What is sobering, however, is that these benefits have not been realized across the board. Not all patient groups have benefitted. Importantly, several higher-risk groups, eg, African American men and women, remain with higher event rates. This disparity is of concern. Some would deem it unacceptable. Given the influence of hypertension in this cohort, the focus should be clear: detect and treat hypertension and treat it according to the most representative targets that have been demonstrated in other datasets, specifically SPRINT, to lower the burden of HF. We have an opportunity to lower the burden of new onset disease. This is a call that we must heed.

For the Hispanic or Latino patient, there at least has been some narrowing of the disparity gap, and outcomes for that cohort have moved in a favorable trend. For the African-American group, at least in this dataset, we don’t see that movement. What are the explanations? Is that a function of access to health care? Is that a function of not correctly identifying the disease? It’s very interesting that some of the information in this dataset is self-reported, and the presumption is that there’s a fairly important percent of self-reporting that is underreported; are the data accurate in African Americans? Is there some bias? Is there some necessity for more intensive patient education?

Obviously, we’re getting right to the heart of the matter in saying there’s an evident health care disparity when we look at HF hospitalizations as a function of race and even as a function of ethnicity.

Eliminating disparities is tough work, but we know that raising awareness and taking a quality improvement initiative are both reasonably successful and have a durable impact. Race- or ethnicity-specific initiatives, ie, black-only or Hispanic-only initiative, are not likely to be successful over the long term. 

These data tell us three things. No. 1, we have made significant improvements in the burden of HF hospitalizations in this country. That’s a good thing. No. 2, the improvements have not been across the board and the data identify evidence that is consistent with a fairly striking health care disparity, one that needs to be addressed through raising awareness, education and redoubling our efforts with quality improvement for all patients with HF. And no. 3 is so incredibly important: These data, though they can’t nearly provide incontrovertible proof, endorse the concept that prevention of HF through better treatment of hypertension and CAD has led to a declining burden of HF. These three points matter.

At a recent HF meeting in Europe, a colleague pointed out how important it is to prevent patients from joining the ‘HF club.’ This is not the club you want to join. Once a patient has had the first episode of HF, their prognosis with regards to longevity is forever different. It’s very clear that if we can prevent entry into the HF club, we can provide such an extraordinary service to our patient population. We’re making headway. Fewer people are joining the club, but by the same token, we have to make even more efforts to prevent patients, regardless of background, race or ethnicity from being members of that club.

There are caveats about this database worth noting. These data are aggregate data. Some of this burden is de novo hospitalization, but some of these data may well be readmissions for HF. I’d like to believe that some of the reduction is in fact attributable to the many, many efforts made by many disease management teams to reduce the likelihood of readmission.

Here’s the takeaway: When we adopt these global comprehensive approaches of prevention, treatment, deployment of best practices, optimizing medical and device therapies, we can make an improvement. I would argue that we still have not fully optimized medical and device therapies, particularly the most newly available medical and device therapies. There’s even more traction to be had. If we’ve made this much headway with what we would now call the legacy treatments, imagine what’s possible as we incorporate the newer treatments. We can start to turn the tide on HF; these data now fuel our momentum.