Disparities in the Delivery of Heart Failure Care | CardioSource WorldNews Interventions

JACC in a Flash | Heart failure (HF) patients have enjoyed major improvements in survival and quality of life thanks to new treatments like cardiac resynchronization defibrillator (CRT-D) and implantable cardioverter-defibrillator (ICD) therapy, but certain segments of this population have not benefited from these therapies. While the most recent clinical guidelines have endorsed CRT and ICD for the prevention of sudden cardiac death and HF events in patients with heart failure with reduced ejection fraction (HFrEF), regardless of race, there are significant gaps in the quality of care among racial/ethnic minorities and white patients.

In a recent JACC paper, Boback Ziaeian, MD, and colleagues analyzed data from the IMPROVE HF (Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting) study to determine if minority outpatients with HF derive the same benefit from device therapy as their white counterparts in real-world clinical practice.

More than 15,000 patients from 167 US outpatient cardiology practices were included in the IMPROVE HF longitudinal cohort; of the ICD/CRT-D eligible patients (n = 7,748):

  • 44% (3,391) were non-Hispanic white
  • 9% (719) were non-Hispanic black
  • 47% (3,638) were other race, Hispanic ethnicity, or race/ethnicity undocumented

Of the latter category:

  • 93% (3,387) were "race/ethnicity undocumented"
  • 3.9% (142) were Hispanic
  • 1.3% (48) were "other race/ethnicity"
  • 1.1% (39) were non-Hispanic Asian
  • 0.4% (13) were non-Hispanic American Indian/Native American
  • 0.3% (9) were Native Hawaiian/Other Pacific Islander

Notably, non-Hispanic black patients were much younger and more likely to be female compared with the white and "other/undocumented race" patient groups; rates of hypertension and diabetes were also higher in black patients.

At 24 months, patients who had CRT or ICD therapy at study enrollment experienced a 36% reduction in mortality (adjusted OR = 0.64; 95% CI 0.52-0.79; p = 0.002); this association was of a similar magnitude in white, black, and other minority subgroups. The same associations were true when Ziaeian et al. ran separate analyses for CRT-only and ICD-only cohorts: patients with therapies at baseline were less likely to die at 2 years than those without, and the device by race/ethnicity interaction was not significant.

"Our data support the need for race- and ethnicity-specific outcome reporting and refute any meaningful differences in clinical effectiveness as a function of race/ethnicity for either ICD or CRT-D therapy," Dr. Ziaeian and authors concluded, noting that the findings are not entirely generalizable.

"No single factor can account for the variances in care," Sean P. Pinney, MD, wrote in an accompanying editorial. This list includes patient-specific factors like poor health literacy or barriers preventing access to care, as well as minorities' under-representation in clinical trials.

However, despite this under-representation, he noted that the analyis by Ziaeian et al. demonstrates equal benefit among all racial/ethnic groups, so the goal now is to eliminate disparities in the delivery of care. Dr. Pinney suggests several possible solutions to this dilemma:

  • integrating performance improvement programs into clinical practice,
  • leveraging information technologies to provide clinical decision support tools, and
  • broadening insurance coverage to all Americans to improve access to care.

"Whether motivated by pay for performance, public outcomes reporting, or a sense of social justice, providers should now focus on improving care delivery models to eliminate performance gaps and ensure equal care for all Americans," he concluded.

Pinney SP. J Am Coll Cardiol. 2014;64:808-10.
Ziaeian B, Zhang Y, Albert NM, et al. J Am Coll Cardiol. 2014;64:797-807.

Keywords: CardioSource WorldNews Interventions

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