The Impact of Health Care Disparities on Patients With Heart Failure

Abstract

Heart failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from stage A to stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known health care disparities that exist in the care of patients with HF and to provide a context for how clinicians and researchers should assess both biological and social determinants of HF risk in vulnerable populations. Furthermore, this document provides a framework for future steps that can be used to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help decrease disparities within HF care.

Keywords: Heart failure; health care disparities; outcomes; race–ethnicity.

Fig. 1.

Elements contributing to inequities in heart failure (HF) care and outcomes among racial and ethnic minority groups. The higher risk for HF, and inequities in HF care for racial–ethnic minority individuals, is related to the higher prevalence of traditional risk factors, structural factors that influence socioeconomic status and other social determinants of health, as well as community and health system factors that adversely impact health care quality.

Fig. 2.

Disparities in heart failure (HF) hospitalization rates for racial and ethnic minority patients compared with White patients. Compared with White men and women, national age-standardized HF hospitalization rates are higher for Black men and women, with no change from 2002 to 2013. Solid bars indicate HF hospitalization rates in 2002, dashed bars indicate HF hospitalization in 2013. Although Hispanic men and women had higher HF hospitalization rates than White men and women in 2002, the relative difference narrowed greatly by 2013. Asian and Pacific Islander (API) men and women had lower HF hospitalization rates than White men and women in 2002, with even greater reductions demonstrated in 2013. Adapted from Ziaeian et al.API, Asian and Pacific Islander.

Fig. 3.

Solutions to eliminate health care disparities for patients with heart failure. CV, cardiovascular; DEI, diversity, equity, and inclusion; GDMT, guideline-directed medical therapy; PI, principal investigator.

Fig. 4.

Excess risk of 30-d heart failure (HF) readmission in Black compared with White patients hospitalized for acute HF according to quartiles of neighborhood deprivation. The figure plots the absolute risk differences between Black and White individuals (reference) in 30-day HF readmission by quartile of the Social Deprivation Index, and demonstrates a higher risk of readmission for Black patients with HF at every level of socioeconomic deprivation. Q2 indicates quartile 2; and Q3, quartile 3. From Patel et al.

Fig. 5.

Lack of resources for heart failure care in community settings compared with advanced heart failure centers. Structural racism and residential segregation have resulted in severe economic disinvestment in neighborhoods with greater proportions of minority residents. Residential segregation has also resulted in a deeply segregated health care system that perpetuates health care disparities. Black and Hispanic patients are more likely to receive care in local community settings and safety net hospitals. Because the most specialized and comprehensive care for heart failure is often only available in advanced heart failure centers, improving access to specialty care by ensuring equity in referrals to CV specialists is critical to decreasing disparities. CMR, cardiac magnetic resonance; CV, cardiovascular; GDMT, guideline-directed medical therapy; IV, intravenous; LVAD, left ventricular assist device; PYP, pyrophosphate.