Disparities in ED Triage of HF Patients Common, Costly

Patrice Wendling

November 04, 2019

Two years ago, Brigham and Woman's Hospital formed a multidisciplinary committee to root out and address health equity concerns at the Boston academic medical center. Results from one of its first projects, a 9-year analysis of heart failure admissions, suggest the added attention was long overdue.

It found that black and Latinx patients with heart failure were less likely to be admitted to the cardiology service than whites, even after adjustment for demographic and clinical factors. Instead, black and Latinx patients, as well as females and those older than 75 years, were more likely to be sent to the general medicine service (GMS).

Further, admission to GMS was independently associated with higher rates of readmission within 30 days.

"Taken together, our findings suggest that racial inequities in admission patterns may contribute, in part, to the well-documented racial inequities in HF readmissions in the United States," the authors write in the study, published online October 29 in Circulation: Heart Failure.

"This is not unique to a single center or single system, it's everywhere," Eldrin Lewis, MD, MPH, one of the senior authors told theheart.org | Medscape Cardiology. "If you have patients from different groups, there's a possibility that structural inequities can exist."

At first glance, the study makes a statement that is "potentially damning," but "I think we have to be absolutely certain there are not any other unaccounted for explanations for this," said Clyde Yancy, MD, vice dean for diversity and inclusion and chief of cardiology at Northwestern University Feinberg School of Medicine, Chicago, who was not involved in the study.

"The implications of overtly, even subconsciously, directing care to places where it can't be delivered in an ideal manner for people who have clear symptoms and have a known history of less than good outcomes is something about which we should all be concerned," he told theheart.org | Medscape Cardiology.

"I don't know that it is necessary for us to impugn any medical center or to begin offering statements of a radical call for change. But I do think we need to use this information as an impetus to sit down and be more deliberate in the way we study this, such as looking at it prospectively," Yancy said.

Several studies have shown unequal access to specialty care, including one Lewis coauthored last year that reported that black patients admitted to the ICU for heart failure are less likely to receive care by a cardiologist than white patients.

"The downside of the data that we've seen so far is that it's at a 30,000-foot view and uses administrative databases," said Lewis, a cardiovascular medicine and heart transplantation specialist at the Brigham. "Here we coupled the administrative base in our hospital with detailed chart reviews for each patient, so we can actually look at patient-level data and that's something that hasn't been well characterized."

The chart reviews also allowed for propensity-score-matching to adjust for patient characteristics other than ethnicity that might explain the differences, but "the propensity-matched cohort had no difference, at all, in terms of the findings," he said.

Data Source

The retrospective study involved patients who self-referred to the Brigham's emergency department and were admitted with a primary diagnosis of heart failure to the GMS (n = 1147) or cardiology service (n  =2117) from September 2008 to November 2017. In all, 872 patients identified as black, 340 as Latinx, and 1921 as white.

White patients were older, more likely to be male, and to have been seen in a cardiology clinic in the previous year. Black and Latinx patients were more likely to live in the Boston metro area, to be Medicaid beneficiaries, and to have been seen by a Brigham and Women's primary care provider in the previous year.

During their first admission, 67% of white patients were admitted to cardiology, compared with 53% of black and 53% of Latinx patients (< .0001).

After adjustment for neighborhood disadvantage, comorbidities, year of admission, and other confounders, the likelihood of admission to the cardiology service remained significantly lower for patients who were black, Latinx, or female.

Likelihood of Admission to Cardiology Service
Comparison Adjusted Rate Ratio 95% CI
Black vs white 0.91 0.84–0.98
Latinx vs white 0.83 0.72–0.97
Female vs male 0.91 0.86–0.97

Notably, patients older than 75 years were also less apt to get on the cardiology service than younger patients (rate ratio [RR], 0.85; 95% CI, 0.77 - 0.95).

"That part we can't explain," Lewis said. "The downside of observational data is you don't have causality; you can just show the strength of the association. Certainly one possibility is ageism. It could be that they have more comorbid conditions or less advocacy for getting them to cardiology."

Chronic pulmonary disease, end-stage renal disease, and being seen by a primary care provider at the institution in the previous year were independently associated with admission to GMS, whereas cardiac valvular disease, arrhythmia, and being seen in an institutional cardiology clinic in the previous year were independently associated with admission to the cardiology service.

Although having seen an outpatient cardiologist at the institution was the strongest predictor of admission to the cardiology service, Lewis observed that a motivation for the study was seeing patients he'd followed for years go through the emergency department only to be admitted to the GMS.

"This was a common thing, to the point I would tell my patients to have them page me before they make a decision," he said, adding that one patient, when told Lewis couldn't be reached, went so far as to page him directly and hand the call to the emergency staff.

Admission to the cardiology service was independently associated with a 16% lower risk for 30-day readmission (hazard ratio [HR], 0.84; 95% CI, 0.72 - 0.97).

Black race was independently associated with a lower 30-day mortality risk (HR, 0.52; 95% CI, 0.39 - 0.91), a finding that has been seen in other studies. The reasons are unclear, but there may be a lower threshold for admitted blacks or, once admitted, patients are more likely to receive guideline-directed medical therapy, Lewis suggested.

One-fourth of patients initially admitted to GMS received follow-up at a cardiology clinic within 30 days, compared with 46% of those initially admitted to the cardiology service (< .0001).

After their first admission, 38% of white patients received cardiology follow-up, compared with 38% of black patients and 45% of Latinx patients (P = .04).

Integrating Health Equity

"I think health equity should be integrated into the fabric of healthcare operations, such that data can be collected just as we collect other data in administrative databases," Lewis said. "If we don't look for it, we aren't going to find it."

The authors note they were unable to evaluate for differential cardiology consultation in the medical service on the basis of race, which is known to play an important role in the intensive care setting. Other limitations include the potential for unmeasured confounders, an inability to account for heart failure severity, that readmission rates reflect only those to Brigham and Women's, and data were unavailable on overall rates of postdischarge follow-up.

Lewis described the project as looking through a structural racism lens, noting that they used the Public Health Critical Race Praxis for antiracism research, but walked back from a statement in the report that "our analysis demonstrates the presence of structural racism in admission service for heart failure patients, as well as important inequities, based on sex and age."

"I would emphasize that we didn't say it represents racism," he said. "We were very careful to say it suggests that racial inequities in admission patterns may exist, and I use the word 'may' continually because we don't know for sure. Basically, you need to do a randomized trial to say definitively this is racism."

There are any number of reasonable explanations for why patients may be triaged or admitted to certain areas of the hospital, such as time of day, time of week, concomitant comorbidities, or distribution of available hospital beds, Yancy observed.

"I applaud the investigators for bringing up the question, but although they have made the question legitimate, I don't think we yet have the question answered," he told theheart.org | Medscape Cardiology. "I don't embrace entirely that this is evidence of disparate care."

Lewis said he is proud of Brigham and Women's commitment to improving health inequities but that the work isn't over. As a result of the findings, two new grants have been funded. The first grant will use real-time surveys of physicians involved in the admission process, as well as patients being admitted, to better understand what drives the admission-decision process. The survey results will be used to create standardized admission service guidelines for patients with heart failure.

The second grant is aimed at creating a standardized approach for managing patients admitted to the general medical service, including very clear guidelines for when a cardiologist should be consulted, when a patient should be transferred from GMS to cardiology, and discharging patients from the area with a cardiologist in the Brigham system, he said. This project is underway and metrics are already being collected.

"Anytime you talk about race, it's automatically a sensitive topic because no one wants to say they treat people differently," Lewis observed. "But in essence, if we don't look for it, we won't find it. As Martin Luther King [Jr.] said, racism that exists in healthcare is probably one of the worse forms of racism, because you have a patient who is vulnerable and they are trusting that they are getting the best care possible."

The study was supported by Brigham and Women's Hospital. The authors report no relevant financial conflicts of interest. Yancy reports serving on the board of directors for the American Heart Association and consulting/related activities for the European Association for Cardio-Thoracic Surgery and JAMA.

Circ Heart Fail. Published online October 29, 2019. Full text

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