Congestive heart failure hospitalizations and survival in California: Patterns according to race/ethnicity

doi:10.1016/S0002-8703(99)70417-5

American Heart Journal

Volume 137, Issue 5, May 1999, Pages 919-927

https://doi.org/10.1016/S0002-8703(99)70417-5 Get rights and content

Abstract

Background Congestive heart failure (CHF) disproportionately affects African Americans, but data are limited concerning CHF hospitalization patterns among Hispanic and Asian populations, the 2 fastest growing ethnic groups in the United States, and race/ethnic patterns of rehospitalization and survival among patients with CHF are unknown. We conducted a study to assess rates of CHF hospitalization, readmission, and survival among diverse populations in California. Methods and Results We used 2 study designs. First, we calculated the population-based incidence of CHF hospitalization in California in 1991. Next we conducted a retrospective cohort study that identified patients initially hospitalized for CHF in 1991 or 1992 and followed these patients for 12 months after their index hospitalization to determine their likelihood of rehospitalization or death. Data were analyzed with Cox proportional hazards models. African Americans had the highest rate of CHF hospitalization. Age-adjusted hospitalization rates were comparable among whites, Latinos, and Asian women and all lower than those in African American, whereas Asian men had the lowest rates. On adjusted analyses, African Americans were more likely than whites and Asians to be rehospitalized (relative risk 1.07; 95% confidence interval 1.04 to 1.10). However, they were less likely to die within the 12-month follow-up period (relative risk 0.86; 95% confidence interval 0.82 to 0.90). Whites, conversely, had the highest posthospitalization mortality rates. Conclusions These findings demonstrate important racial-ethnic differences in CHF morbidity and mortality rates. The disparate findings of higher hospitalization and rehospitalization rates and lower mortality rates among African Americans than whites may represent differences in the underlying pathophysiology of CHF in these groups or differences in access to quality care. Further studies are needed to explain these seemingly paradoxical outcomes. (Am Heart J 1999;137:919-27.)

Section snippets

Methods

Our study has 2 major components. The first is an analysis of the population-based incidence of hospitalization for CHF in California in 1991. This analysis compares rates by using episodes of hospitalization as the unit of analysis with rates based on counts of unique individuals hospitalized for CHF within the year. The second component is a retrospective cohort study that identifies patients initially hospitalized for CHF in 1991 or 1992 and follows these patients for 12 months after their

Incidence study

Rates of CHF hospitalization in California in 1991 according to race-ethnicity are shown in Table I.African American men and women had the highest overall age-adjusted rates of hospitalization (62.6 and 45.4 per 10,000, respectively). The rate for African American women was 1.7 times that of white women and the rate for African American men 2.2 times that of white men (Fig 1).

. A, Relative rates of hospitalization for heart failure in women on the basis of race/ethnicity and shown by age group.

Discussion

We found significant racial/ethnic differences in California CHF hospitalization rates and in outcomes after hospitalization for CHF. African Americans were more likely to be hospitalized for CHF than any other race/ethnic group. Among women younger than age 65, the incidence of CHF hospitalization was 2.5 times higher for African Americans than for whites. Among men younger than 65, the CHF hospitalization rate was almost 4 times greater for African Americans than for whites. These findings

Acknowledgements

We thank our colleagues at the UCSF Medical Effectiveness Research Center for Diverse Populations for their helpful comments. Dr Grumbach is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar.

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Advanced heart failure (HF) therapies improve survival in patients with stage D HF. We sought to evaluate differences by race/ethnicity and sex in advanced HF therapy referrals and decision-making across a multicenter survey. We performed a retrospective analysis of patients referred for evaluation for advanced HF therapies at 9 centers (n = 515) across the United States. The median age was 58 years, and 73% were male. White patients comprised 55.7% of referrals, whereas non-White patients comprised 44.3%. Non-ischemic etiology was more common in non-White patients (66.6% vs 47.4% p = 0.0005), and ischemic etiology was more common in men (37.8% vs 20.4% p = 0.0005). The primary reason for referral differed by race/ethnicity but not sex, with ventricular arrhythmias (7.6% vs 3%, p = 0.024) and pulmonary hypertension (3.4% vs 0.4% p = 0.018) being more common in White patients, whereas worsening HF was less common (25.4% vs 35.9%; p = 0.009). White patients were offered left ventricular assist devices (LVADs) (60.3% vs 54.7 p = 0.039) and heart transplants (51.8% vs 33.1% p = 0.0007) more often than non-White patients. The preference not to pursue LVAD therapy was more common in non-White patients (17.6% vs 9.6%; p = 0.049). Men were more often declined for a heart transplant because of psychosocial contraindications (34% vs 15%, p = 0.005). In conclusion, in this multicenter analysis of referrals for advanced HF therapies, we observed significant differences by race, ethnicity, and sex in both referral characteristics and evaluation outcomes. Further investigation is warranted to better understand why rates of LVAD and transplantation may be lower in non-White patients who are referred for advanced therapies.
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^☆: Supported by the Agency for Health Care Policy and Research grant Nos. HS07373 and HS08362, and the National Institute on Aging, the National Institute of Nursing Research, and the Office of Research on Minority Health, National Institutes of Health, Grant No 1 P30 AGI5272.

^☆☆: Reprint requests: Mark Alexander, PhD, Medical Effectiveness Research Center for Diverse Populations, Box 1694, University of California, San Francisco, CA 94143-1694.

^★: 0002-8703/99/$8.00 + 0 4/1/94542

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Congestive heart failure hospitalizations and survival in California: Patterns according to race/ethnicity☆,☆☆,★

Abstract

Section snippets

Methods

Incidence study

Discussion

Acknowledgements

Am Heart J

J Am Coll Cardiol

J Cardiac Failure

Am Heart J

Am Heart J

J Am Coll Cardiol

Heart and stroke facts: 1996 statistical supplement

Survival after the onset of congestive heart failure in Framingham heart study subjects

Circulation

Economic impact of heart failure in the United States: time for a different approach

J Heart Lung Transplant

Heart failure: evaluation and care of patients with left ventricular systolic dysfunction

1993 Summary: national hospital discharge survey. Advance data from vital and health statistics, No. 249

Trends in hospitalization rates for heart failure in the United States

Arch Intern Med

Hospitalization for congestive heart failure: explaining racial differences

JAMA