Health Disparities in Patients with Congestive Heart Failure Exacerbations in Los Angeles County
Vinh Q. Lam1,2, Shahrzad Bazargan-Hejazi1, 2, Deyu Pan1, Stacey A. Teruya1,2
1College of
Medicine, Charles R. Drew University of Medicine and Science, Los Angeles,
California, USA
2David Geffen School of Medicine, University of California, Los Angeles, USA
*Corresponding author: Shahrzad Bazargan-Hejazi, Charles R. Drew University of Medicine and Science, 1731 East 120th Street, Los Angeles, CA 90059, USA. Tel: +13233573464; Email: shahrzadbazargan@cdrewu.edu
Received Date: 29 May, 2018; Accepted Date: 12 June,
2018; Published Date: 20 June, 2018
Citation: Lam VQ, Bazargan-Hejazi S, Pan D, Teruya SA (2018) Health Disparities in Patients with Congestive Heart Failure Exacerbations in Los Angeles County. Emerg Med Inves: 176. DOI: 10.29011/2475-5605.000076
1. Abstract
1.1. Background: Congestive Heart Failure (CHF) is a
leading cause of death in the
1.2. Methods:
This is a retrospective
analysis using the Office of Statewide Health Planning and Development (OSHPD)
Emergency Department, and
1.3. Results: SPA 6 had higher hospitalization rates
across all races and ethnicities, compared to
1.4. Conclusions: CHF continues to disproportionately affect Black
individuals in
2. Keywords: Congestive Heart Failure; CHF Exacerbation; Emergency Department; Hospitalization; Race; Health Disparities.
1. Abbreviations
CHF : Congestive
Heart Failure
OSHPD : Office
of Statewide Health Planning and Development
ED : Emergency
Department
SPA : Service Planning Area
2. Introduction
Affecting more
than six million people a year, heart failure extracts a heavy toll in
morbidity, mortality, and health care costs in the
There are eight
Service Planning areas (SPAs) in
CHF is a leading
cause of hospital admissions, particularly in underserved populations [7]. Research suggests that hospitalization rates may
be reduced through access to quality care [8]. A
preliminary search of the literature, however, revealed little additional
findings on racial, ethnic and demographic factors and rates of CHF
exacerbations, specifically among patients presenting to emergency departments
in SPA 6 and in
2.1. Specific Aims and Goals
We first assessed
five-year trends of CHF exacerbations in Emergency Departments (EDs) in
Our study goal was
to provide insight into the CHF exacerbation population seen in the emergency
department in
3. Materials and Methods
This is a
retrospective analysis of Emergency Department and
·
Age.
·
Gender.
·
Race/ethnicity
as White, Black, Hispanic, and Asian/Other.
·
Disposition
as discharged home, hospitalized, transferred, left against medical advice, or expired.
·
Insurance
type, or method of payment.
· Principal diagnosis.
Subject records
with missing or masked demographics were excluded, as were patients younger
than 18, and those who resided outside of
4. Results
We identified
13,766 patients with congestive heart failure exacerbation who presented to the
emergency department in
We also noted that
SPA 6 represents only 10.2% of the total
SPA 6 also had the
highest prevalence of CHF exacerbation from 2005 to 2009, compared to the other
service planning areas (Table 3). During this
period, the mean CHF exacerbation rate was highest for Blacks, at 136.8 per
100,000 per year. For Whites, Hispanics, and Asians/Other, the rate was 47.3,
20.3, and 14.9 per 100,000, respectively. There was a decrease in CHF
exacerbation across all races and ethnicities from 2005 - 2009 (p < 0.001). However, prevalence
during this time period was the highest for the Black population, relative to
all other races and ethnicities (p
< 0.001).
In
5. Discussion
Heart disease
remains a serious medical condition in the
CHF is labeled an “Ambulatory Care Sensitive Condition” (ACSC) by the Agency for Healthcare Research and Quality (AHRQ) [9]. This indicates that the condition and its adverse effects could be avoided or minimized through timely and appropriate health intervention and services [10]. Our findings and other research suggest that, despite available preventive clinical guidelines to reduce CHF-related hospitalizations [11], many patients are not benefiting from screening, diagnosis and treatment recommendations [5].
Socioeconomic
factors may explain this disparity, at least in part.
Economic factors may
also explain the high prevalence of CHF exacerbation rates among Blacks in SPA
6, who represent almost a third of its population. This service planning area
had a higher percent of self-pay (16.7%) and Medicaid (18.5%) patients, compared
to all of
Our results also
show that the majority (56.3%) of CHF exacerbation patients in SPA 6 were 35 to
64 years old. In
In comparison to
all of
6. Limitations
This is a retrospective, observational study. We were limited to records in the OSHPD Emergency Department database, from 2005 to 2009. Patients may have visited the emergency department for multiple CHF exacerbation events. However, the dataset does not distinguish between separate visits, or events involving the same individual. As a result, one person may have had multiple exacerbations, which are reported separately in OSHPD.
We did not have access to information about patients’ comorbidities, CHF severity, medication adherence patterns, or number of visits per year to his or her primary care physician. This may have been helpful in identifying other factors, such as compliance and pre-existing conditions, associated with CHF exacerbations treated in the emergency department.
7. Conclusions
Our findings indicate that: 1) SPA 6 suffered the highest burden of CHF exacerbations, compared to all other SPAs; 2) Blacks are consistently and disproportionately affected with CHF exacerbations compared to other races and ethnicities, every year from 2005 to 2009; 3) a younger population in SPA 6 was affected by CHF exacerbations, compared to the rest of L.A. County; and 4) all races and ethnicities living in SPA 6 were more likely to be hospitalized for a CHF exacerbation, compared to L.A. County as a whole.
Improving these health outcomes appears to depend on overcoming barriers in access to regular and quality healthcare, and through patient education and outreach. Clearly, enabling better routine and preventative primary care and other provider visits, and access to free or affordable prescriptions is warranted. This is especially true for the Black population, which appears to suffer disproportionately from CHF, as well as other negative health outcomes. Future research on the association of CHF exacerbation with different sociodemographic measures among minority, underserved and disadvantaged patients is needed. These can identify and help mitigate inequities and weaknesses in our health care system, which are manifest through stark health disparities among different racial, ethnic and socioeconomic groups.
8. Acknowledgements:
Research
for this article was supported in part by NIH Accelerated Excellence in
Translational Sciences (AXIS) grant number 2U54MD007598-07; the
Race/Ethnicity |
Total no. of CHF cases |
% of CHF Cases in L. A. County |
% of L.A. County Population |
White |
5644 |
41.07% |
30.10% |
Black |
4397 |
31.99% |
9.10% |
Hispanic |
2869 |
20.87% |
47.30% |
Asian/Other |
834 |
6.07% |
13.50% |
Age Range |
|
|
|
Under 1 year |
NA |
NA |
NA |
1-17 years |
NA |
NA |
NA |
18-34 years |
302 |
2.20% |
NA |
35-64 years |
5439 |
39.57% |
NA |
65 years or greater |
8003 |
58.23% |
NA |
Gender |
|
|
|
Male |
6689 |
48.67% |
49.50% |
Female |
7055 |
51.33% |
50.50% |
Service Planning Area (SPA) |
|
|
|
SPA 1 |
448 |
3.27% |
3.42% |
SPA 2 |
2388 |
17.45% |
21.10% |
SPA 3 |
1904 |
13.92% |
18.36% |
SPA 4 |
1256 |
9.18% |
12.39% |
SPA 5 |
585 |
4.28% |
6.25% |
SPA 6 |
3042 |
22.23% |
10.24% |
SPA 7 |
1560 |
11.40% |
13.56% |
SPA 8 |
2500 |
18.27% |
15.78% |
NA = Not Available |
Table 1: Congestive heart failure exacerbation cases seen in the Emergency Department in Los Angeles County (2005-2009).
Race/Ethnicity |
Total CHF cases seen in ED |
% of CHF Cases in ED Encounters |
White |
95 |
3.12% |
Black |
2562 |
84.22% |
Hispanic |
323 |
10.62% |
Asian/Other |
62 |
2.04% |
Age Range |
|
|
Under 1 year |
NA |
NA |
1-17 years |
NA |
NA |
18-34 years |
95 |
3.12% |
35-64 years |
1714 |
56.34% |
65 years or greater |
1233 |
40.53% |
Gender |
|
|
Male |
1470 |
48.32% |
Female |
1572 |
51.68% |
Table 2: Congestive heart failure exacerbation cases seen in SPA 6 emergency departments (2005-2009).
|
2005-2009 (Mean) |
2005 |
2006 |
2007 |
2008 |
2009 |
White |
|
|
|
|
|
|
N |
1129 |
1336 |
1217 |
1137 |
1017 |
937 |
Population |
2388231 |
2427135 |
2404210 |
2384459 |
2376037 |
2349313 |
Ratio* |
47.27 |
55.04 |
50.62 |
47.68 |
42.80 |
39.88 |
Black |
|
|
|
|
|
|
N |
879 |
951 |
983 |
1020 |
706 |
737 |
Population |
642772 |
646414 |
643563 |
641222 |
641034 |
641626 |
Ratio* |
136.7514879 |
147.12 |
152.74 |
159.07 |
110.13 |
114.86 |
Hispanic |
|
|
|
|
|
|
N |
573 |
599 |
623 |
580 |
556 |
511 |
Population |
3072510 |
2955497 |
2991504 |
3031737 |
3184452 |
3199360 |
Ratio* |
18.64924768 |
20.27 |
20.83 |
19.13 |
17.46 |
15.97 |
Asian/Other |
|
|
|
|
|
|
N |
167 |
156 |
156 |
170 |
188 |
164 |
Population |
1076288 |
1049363 |
1060326 |
1073100 |
1089820 |
1108831 |
Ratio* |
15.51629304 |
14.87 |
14.71 |
15.84 |
17.25 |
14.79 |
*per 100,000 |
Table 3: Congestive heart failure exacerbation cases in L.A. County (N) from 2005 to 2009 by race and ethnicity.
L. A. County |
Discharged Home |
Hospitalized |
Transferred |
Left Against Medical Advice |
Expired |
White |
4030 (71.4%) |
855(15.2%) |
360(6.4%) |
261(4.6%) |
47(0.8%) |
Black |
3195 (72.7%) |
710(16.2%) |
182(4.1%) |
278(6.3%) |
12(0.3%) |
Hispanic |
2228 (77.7%) |
343(12%) |
136(4.7%) |
119(4.2%) |
12(0.4%) |
Asian/Other |
590(70.7%) |
132(15.8%) |
56(6.7%) |
40(-4.8%) |
7(0.8%) |
SPA 6 |
|
|
|
|
|
White |
56(59.0%) |
27(28.4%) |
9(9.5%) |
3(3.2%) |
0 |
Black |
1797 (70.1%) |
476(18.6%) |
113(4.4%) |
162(6.3%) |
6(0.2%) |
Hispanic |
224(69.4%) |
58(18.0%) |
13(4.0%) |
20(6.2%) |
1(0.3%) |
Asian/Other |
37(59.7%) |
16(25.8%) |
5(8.1%) |
2(3.2%) |
1(1.6%) |
Table 4: L. A. County and SPA 6 discharge outcomes for CHF patients seen in the ED.
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