Quality of Care for Black Patients with Heart Failure Improving at US Hospitals

Gregg Fonarow, MD
Credit: UCLA Newsroom

New research from the Get With The Guidelines-HF (GWTG-HF) program is highlighting the strides made toward equitable heart failure care at US-based hospitals for minority patient populations.

Although the study also highlights room for improvement in certain areas, results of the study indicate the quality of heart failure care was equitable for 11 of 14 evidence-based clinical care measures and no in-hospital disparities were observed for Black patients compared to their White counterparts among hospitals enrolled in the GWTG-HF program.¹

“These findings suggest Get With The Guidelines can help hospitals achieve equitable care for patients hospitalized with heart failure, an important American Heart Association aim,” said study investigator Gregg Fonarow, MD, interim chief of the division of cardiology, director of the Ahmanson-UCLA Cardiomyopathy Center, co-director of the Preventative Cardiology Program, and the Eliot Corday Chair in Cardiovascular Medicine and Science at the University of California, Los Angeles.² “While there remain critical population-level disparities in access to care, social determinants of health and care quality in other settings, the Get With The Guidelines – HF program is having an important impact.”

Dating back to 1999, more than 2600 US hospitals can claim to be a participant in a Get With The Guidelines program, which includes programs in atrial fibrillation, stroke, coronary artery disease, and more. According to the AHA, nearly 80% of the US population has access to hospitals participating in the program and participation in a Get With The Guidelines program is associated with a reduction in 30-day readmission rates relative to non-participating hospitals.³

Launched in 2005, the GWTG-HF registry is an in-hospital program for improving care by promoting adherence to treatment guidelines.³ From the registry, investigators obtained information related to a cohort of 422,483 individuals from 480 participating hospitals for potential inclusion in their analyses. For the purpose of analysis, investigators noted cohort of 96 hospitals classified as having a high portion of Black patients, with Black patients making up 58.3% of hospitalizations at these sites relative to 13.3% at the other 384 hospitals.¹

The overall study cohort of 422,483 individuals had a mean age of 73 years, was 53.1% male, and 67.4% were White. Compared to those at other hospitals, patients at hospitals with a high proportion of Black patients were younger (mean age, 66 years vs 75 years), and more likely to be women (46.1% vs 47.1%) Black adults (58.3% vs 13.3%), insured by Medicaid (29.9%vs 14.4%), and have a reduced ejection fraction of less than 40% (54% vs 42.5%).¹

Quality of heart failure care was based on 14 evidence-based measures, overall defect-free heart failure care, and 30-day readmissions and mortality in Medicare patients. The 14 measures included use of ACE/ARBs or ARNI at discharge, evidence-based β-blocker use, smoking cessation counseling, aldosterone antagonist at discharge, ARNI use at discharge, anticoagulation for atrial fibrillation or atrial flutter, appropriate use of hydralazine/nitrates at discharge, venous thromboembolism prophylaxis in hospital, cardiac resynchronization-defibrillator therapy or pacing therapy placement or prescription at discharge, ICD counseling or placement at discharge, influenza vaccination during flu season, pneumococcal vaccination prior to discharge, postdischarge follow-up appointment, and follow-up appointment scheduled within 7 days after discharge.¹

Upon analysis, results indicated quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of the 14 quality of care measures. The 11 measures with equitable performance for hospitals with a high proportion of Black patients highlighted by investigators were use of ACE/ARBs or ARNIs for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91 [95% confidence interval [CI], 0.65-1.27]), evidence-based β-blocker use (94.7% vs 93.7%; OR, 1.02 [95% CI, 0.82-1.28]), ARNI use at discharge (14.3% vs 16.8%; OR, 0.74; [95% CI, 0.54-1.02]), anticoagulation for atrial fibrillation or flutter (88.8% vs 87.5%; OR, 1.05 [95% CI, 0.76-1.45]), and ICD counseling, placement, or prescription at discharge (70.9% vs 71.0%; OR, 0.75 [95% CI, 0.50-1.13]).¹

In regard to the other 3 measures, results indicated patients at hospitals with a high proportion of Black patients were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; [95% CI, 0.53-0.86]), receive cardiac resynchronization device placement or prescription (50.6% vs 53.8%; OR, 0.63; [95% CI, 0.42-0.95]), or receive an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; [95% CI, 0.50-0.97]).¹

Further analysis suggested the rate of defect-free heart failure care was similar between hospitals (82.6% vs 83.4%; OR, 0.89 [955 CI, 0.67-1.19]) and there were no significant within-hospital differences observed for quality for Black patients compared to White patients. In subgroup analyses among Medicare beneficiaries, results suggested patients at hospitals with a high proportion of Black patients had an increased risk of 30-day readmissions (Hazard ratio [HR], 1.14 [95% CI, 1.02-1.26]) but similar risk of 30-day mortality (HR, 0.92 [95% CI, 0.84-1.02]) in adjusted models.¹

“For more than 20 years, Get With The Guidelines has made strides toward equitable, evidence-based care for all,” said Michelle Albert, MD, MPH, FACC, FAHA, volunteer president of the American Heart Association and the Walter A. Haas-Lucie Stern Endowed chair in cardiology and professor in medicine at the University of California at San Francisco.² “This study shows the great strides we have made in heart failure care, as well as opportunities for even more improvement.”

References:

1. Diamond J, Ayodele I, Fonarow GC, et al. Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. Published online April 19, 2023. doi:10.1001/jamacardio.2023.0695
2. Study finds equitable heart failure care, but challenges remain. American Heart Association. https://newsroom.heart.org/news/study-finds-equitable-heart-failure-care-but-challenges-remain. Published April 19, 2023. Accessed April 20, 2023.
3. Get with the Guidelines®. www.heart.org. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines. Accessed April 20, 2023.