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Racial disparities in emergent HF care, outcomes identified
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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.
Perspective
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Alanna Morris, MD, MSc, FHFSA, FACC
One of the things noted by the researchers was if the black and Hispanic patients are less likely to be seen in outpatient care by a cardiologist, then they will be less likely to be admitted to a cardiology service when they get admitted to the hospital.
They also brought up a couple of other points related to implicit bias, which are incredibly important. Oftentimes, what we as providers consider to be the trigger for admission is dietary noncompliance, medical noncompliance or other factors that we put on the patient. In other words, we “blame” the patient for their readmission.
Most patients, regardless of race/ethnicity, would admit to at least some degree of noncompliance with medications, dietary restrictions or other things. The data related to implicit bias clearly shows that providers are much more likely to view black and other minority patients as being noncompliant. In an ED setting, if a minority patient comes in with their second, third or fourth admission for HF, there may be a bias to assume that the patient is the reason why they keep getting readmitted as opposed to the provider being part of the problem.
I like this paper because the researchers tried to analyze some of the additional drivers of readmission, related to not only socioeconomic differences like the area deprivation index and comorbidity indices, but also, factors within the health care system that can push patients in one direction or the other.
This is part of the data that we need to see to understand the incredibly disparate rates of HF hospitalization for African Americans in particular. Because our hospital systems are now being penalized for excess readmissions, we have to understand not only patient-related factors but also system-related factors that keep patients coming back to the hospital.
Within our systems, if we are delivering care differently to patients based on their race or ethnicity, we have to address it. This study gives us the data that we need to see that we are managing and treating patients differently based on race and ethnicity. That observation is incredibly important, because if we are not allowing the sickest patients to see the CV specialists, it’s no surprise that they are more likely to be readmitted with HF.
Since our hospital systems are being penalized by CMS for excess readmissions, as the researchers pointed out in this study, many hospital systems need to be doing more research in implementation science to try to understand what the barriers are for hospital medicine teams to consult cardiology. Are they getting pushed back from cardiology providers such that those patients are not being seen? Are there provider alerts that need to go be initiated in the ED, such that if a patient has been admitted three or four times, a trigger goes up to alert the ED physician to admit directly to a cardiology service rather than a hospitalist service because they are more high risk.
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