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A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure

      Introduction

      Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure.

      Methods

      National Hospital Ambulatory Medicare Care Survey data on 2001–2010 emergency department visits were analyzed in 2015–2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models.

      Results

      More than 12 million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65 years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65 years, there was a significant interaction between clinical acuity X race with regard to hospitalization (p=0.037).

      Conclusions

      These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding.

      Supplement information

      This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

      INTRODUCTION

      H eart failure (HF) is the leading cause of hospitalization in adults aged 65 years and older,
      • Harinstein ME
      • Flaherty JD
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      • et al.
      Clinical assessment of acute heart failure syndromes: emergency department through the early post-discharge period.
      • Joynt KE
      • Orav EJ
      • Jha AK
      Thirty-day readmission rates for Medicare beneficiaries by race and site of care.
      with 44% having more than one hospitalization annually.
      • Will JC
      • Valderrama AL
      • Yoon PW
      Preventable hospitalizations for congestive heart failure: establishing a baseline to monitor trends and disparities.
      The burden is disproportionately borne by blacks aged 65 years and older, with higher rates of preventable hospitalization,
      • Will JC
      • Valderrama AL
      • Yoon PW
      Preventable hospitalizations for congestive heart failure: establishing a baseline to monitor trends and disparities.
      30-day rehospitalization,
      • Joynt KE
      • Orav EJ
      • Jha AK
      Thirty-day readmission rates for Medicare beneficiaries by race and site of care.
      and 1-year rehospitalization
      • Rathore SS
      • Foody JM
      • Wang Y
      • et al.
      Race, quality of care, and outcomes of elderly patients hospitalized with heart failure.
      than whites. These disparities in healthcare utilization further strain a healthcare system struggling with one million HF hospitalizations and more than $50 billion in total related costs annually.
      • Harinstein ME
      • Flaherty JD
      • Fonarow GC
      • et al.
      Clinical assessment of acute heart failure syndromes: emergency department through the early post-discharge period.
      • Roger VL
      Epidemiology of heart failure.
      Emergency departments (EDs) play important roles in HF hospitalization, with nearly one million visits annually and more than 80% of visits resulting in hospitalizations.
      • Storrow AB
      • Jenkins CA
      • Self WH
      • et al.
      The burden of acute heart failure on U.S. emergency departments.
      Conversely, 80% of all HF hospitalizations originate in the ED.
      • Weintraub NL
      • Collins SP
      • Pang PS
      • et al.
      Acute heart failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims: a scientific statement from the American Heart Association.
      HF hospitalizations have been described as a “sentinel event” that begins the spiral of hospital readmissions and ultimate death.
      • Collins SP
      • Pang PS
      • Fonarow GC
      • Yancy CW
      • Bonow RO
      • Gheorghiade M
      Is hospital admission for heart failure really necessary? The role of the emergency department and observation unit in preventing hospitalization and rehospitalization.
      • Desai AS
      • Stevenson LW
      There must be a better way: piloting alternate routes around heart failure hospitalizations.
      • Bello NA
      • Claggett B
      • Desai AS
      • et al.
      Influence of previous heart failure hospitalization on cardiovascular events in patients with reduced and preserved ejection fraction.
      Hospitalization decisions in the ED therefore greatly impact patient outcomes, healthcare costs, and resource utilization. However, data on ED hospitalization decisions are lacking. Disparities in access to outpatient care across age
      • Feldman DE
      • Huynh T
      • Lauriers JD
      • et al.
      Access to heart failure care post emergency department visit: do we meet established benchmarks and does it matter.
      and race
      • Auerbach AD
      • Hamel MB
      • Califf RM
      • et al.
      Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure.
      • Cook NL
      • Ayanian JZ
      • Orav EJ
      • Hicks LS
      Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care.
      can contribute to avoidable hospitalizations.
      • Hasegawa K
      • Tsugawa Y
      • Camargo Jr, CA
      Brown DF. Frequent utilization of the emergency department for acute heart failure syndrome: a population-based study.
      • Bindman AB
      • Grumbach K
      • Osmond D
      • et al.
      Preventable hospitalizations and access to health care.
      Racial disparities involving HF hospitalizations
      • Will JC
      • Valderrama AL
      • Yoon PW
      Preventable hospitalizations for congestive heart failure: establishing a baseline to monitor trends and disparities.
      • O'Neil SS
      • Lake T
      • Merrill A
      • Wilson A
      • Mann DA
      • Bartnyska LM
      Racial disparities in hospitalizations for ambulatory care-sensitive conditions.
      and ED care
      • Johnston V
      • Bao Y
      Race/ethnicity-related and payer-related disparities in the timeliness of emergency care in U.S. emergency departments.
      • Sonnenfeld N
      • Pitts SR
      • Schappert SM
      • Decker SL
      Emergency department volume and racial and ethnic differences in waiting times in the United States.
      exist, but may vary by age.
      • Clay OJ
      • Roth DL
      • Safford MM
      • Sawyer PL
      • Allman RM
      Predictors of overnight hospital admission in older African American and Caucasian Medicare beneficiaries.
      Improved understanding of ED hospitalization practices for HF may help reduce potentially avoidable hospitalization and improve patient outcomes. To address the study hypothesis of an excess of hospitalizations for HF patients from the ED, which may differ across age and race, this study examines race- and age-related disparities in hospitalization patterns involving ED visits for HF.

      METHODS

      Study Population

      This study utilized 2001–2010 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). The University of Alabama at Birmingham IRB granted an exemption for this analysis of publicly available data. NHAMCS methods have been published elsewhere.
      • McCaig LF
      • Burt CW
      Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers.
      • Hugli O
      • Braun JE
      • Kim S
      • Pelletier AJ
      • Camargo Jr, CA
      United States emergency department visits for acute decompensated heart failure, 1992 to 2001.
      • Caterino JM
      • Ting SA
      • Sisbarro SG
      • Espinola JA
      • Camargo Jr, CA
      Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001–2008.
      • Valderrama AL
      • Fang J
      • Merritt RK
      • Hong Y
      Cardiac arrest patients in the emergency department—National Hospital Ambulatory Medical Care Survey, 2001–2007.

      Yusuf HR, Atrash HK, Grosse SD, Parker CS, Grant AM. Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999–2007. Am J Prev Med. 2010;38(4)(suppl): S536-S541 https://doi.org/10.1016/j.amepre.2010.01.001

      • Blecker S
      • Ladapo JA
      • Doran KM
      • Goldfeld KS
      • Katz S
      Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.
      Briefly, NHAMCS is an annual national probability sample survey of ED visits at U.S. hospitals by the National Center for Health Statistics.
      • McCaig LF
      • Burt CW
      Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers.
      ED visits for HF were identified using ICD-9 diagnosis codes for HF (402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, and 428.0–428.9) and for acute edema of the lung, unspecified (518.4), based on diagnosis codes used by the Center for Medicare and Medicaid Services for assessment of HF readmission and previous studies.
      • Storrow AB
      • Jenkins CA
      • Self WH
      • et al.
      The burden of acute heart failure on U.S. emergency departments.
      • Hugli O
      • Braun JE
      • Kim S
      • Pelletier AJ
      • Camargo Jr, CA
      United States emergency department visits for acute decompensated heart failure, 1992 to 2001.
      ,
      • Blecker S
      • Ladapo JA
      • Doran KM
      • Goldfeld KS
      • Katz S
      Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.
      One primary diagnosis and two secondary diagnoses were listed for each ED visit. Following previous studies, all visits with these ICD-9 codes in any of the three diagnosis entries were included.
      • Hugli O
      • Braun JE
      • Kim S
      • Pelletier AJ
      • Camargo Jr, CA
      United States emergency department visits for acute decompensated heart failure, 1992 to 2001.
      • Caterino JM
      • Ting SA
      • Sisbarro SG
      • Espinola JA
      • Camargo Jr, CA
      Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001–2008.
      ,
      • Blecker S
      • Ladapo JA
      • Doran KM
      • Goldfeld KS
      • Katz S
      Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.
      The 2001–2010 data set included 3,623 unweighted ED encounters representing 12.2 million survey-weighted ED visits for HF.

      Measures

      Sociodemographic characteristics included age, sex, race, and insurance type (Medicare, Medicaid, private insurance, or a combination of self-pay, other, or unknown). Clinical characteristics included reasons for visit; ED triage clinical acuity level; vital signs; HF treatment medications; length of ED visit (in minutes); disposition (admission or discharge); and any previous ED visit in the last 72 hours. Hospital characteristics included population setting and geographic region based on Metropolitan Statistical Areas and U.S. Census geographic regions (Northeast, Midwest, West, and South), respectively.
      • Valderrama AL
      • Fang J
      • Merritt RK
      • Hong Y
      Cardiac arrest patients in the emergency department—National Hospital Ambulatory Medical Care Survey, 2001–2007.
      • Chamberlain JM
      • Teach SJ
      • Hayes KL
      • Badolato G
      • Goyal MK
      Practice pattern variation in the care of children with acute asthma.
      Triage clinical acuity (“clinical acuity”) is defined as the level of urgency of care assigned to each patient at the time of ED triage, based on the urgency and amount of resources anticipated for the provision of care to that patient.
      • Tanabe P
      • Gimbel R
      • Yarnold PR
      • Adams JG
      The Emergency Severity Index (version 3) 5-level triage system scores predict ED resource consumption.
      • Tanabe P
      • Gimbel R
      • Yarnold PR
      • Kyriacou DN
      • Adams JG
      Reliability and validity of scores on The Emergency Severity Index version 3.
      From 2001 to 2004, these categories were as follows: unknown or no triage, <15 minutes, 15–60 minutes, more than 1–2 hours, and more than 2–24 hours. From 2005 to 2010, these categories were revised as follows: immediate, 1–14 minutes, 15–60 minutes, more than 1–2 hours, more than 2–24 hours, no triage, and unknown. Overall, 12.8% of all cases were recorded as no triage or unknown, but their respective proportions did not vary by race or hospitalization. These visits were excluded from further analyses. Clinical acuity was categorized in dichotomous fashion to establish a uniform definition across all years, as previously described
      • Green SM
      Emergency department patient acuity varies by age.
      • Lo AX
      • Flood KL
      • Biese K
      • Platts-Mills TF
      • Donnelly JP
      • Carpenter CR
      Factors associated with hospital admission for older adults receiving care in U.S. emergency departments.
      : <15 minutes (this comprised <15 minutes for 2001–2004 and immediate, 1–14 minutes for 2005–2010) and ≥15 minutes for all other categories. The primary outcome was hospital admission. To examine nonclinical influences that may potentially contribute to racial disparities in hospitalizations, the analyses were restricted to floor unit admissions, excluding intensive care unit (ICU) admissions, on the premise that ICU admissions represented valid indications for hospitalization and were less likely than floor admissions to be influenced by less objective provider decisions, whether reflecting potentially avoidable admissions or “social admissions” for nonclinical reasons.
      • Lo AX
      • Flood KL
      • Biese K
      • Platts-Mills TF
      • Donnelly JP
      • Carpenter CR
      Factors associated with hospital admission for older adults receiving care in U.S. emergency departments.

      Statistical Analysis

      The number of visits were reported as average annualized estimates, as recommended by the National Center for Health Statistics.
      • McCaig LF
      • Burt CW
      Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers.
      The frequency of the top five reasons for ED visits for HF were compared across age and race. The prevalence of visit characteristics were compared across race, using means and percentages for continuous and categorical variables, respectively. P-values were calculated from adjusted F-tests of equal means and Rao–Scott corrected chi-square tests of association. The association between clinical acuity and hospitalization was examined separately by race, and stratified by age (18–64 vs ≥65 years), using multivariable modified Poisson regression models and reported as prevalence ratios.
      • Zou G
      A modified Poisson regression approach to prospective studies with binary data.
      The statistical interaction between clinical acuity X race, relating to the prediction of hospitalization within each age strata, was examined using multivariable modified Poisson models. Validation analysis to assess for possible differential misclassification of clinical acuity across race was achieved by comparing the prevalence of key HF management variables across clinical acuity levels in whites and blacks. These included systolic blood pressure >160 mmHg or <100 mmHg, respiratory rate >24 breaths per minute, oxygen saturation <90% on room air, and vasodilator agent use. The prevalence of endotracheal intubation and vasopressor agent use had insufficient numbers of cases to allow statistically meaningful comparisons across clinical acuity levels.
      NHAMCS data were analyzed using National Center for Health Statistics–defined sampling weight provided to yield unbiased national estimates of ED visit characteristics.
      • McCaig LF
      • Burt CW
      Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers.
      Statistical analyses were performed in 2015–2017 using Stata, version 12.

      RESULTS

      From 2001 to 2010, there were 3,623 unweighted ED encounters representing 12,249,822 survey-weighted U.S. ED visits for HF. Among these, 74.5% involved whites and 23% blacks; 2.5% involved other race and were excluded from further analyses. The final sample comprised 3,534 unweighted or 11,947,582 survey-weighted ED visits involving blacks and whites, with complete data.
      The most common reason for ED visits was shortness of breath, accounting for more than one third of all visits. The distribution of the reasons for visits did not differ across race (Table 1).
      Table 1Reasons for ED Visits for Heart Failure 2001–2010
      Reason for visit
      NHAMCS records “shortness of breath” and “dyspnea” as separate reason for visit categories in their data.
      AllWhitesBlacks18–64 years65–79 years≥80 years
      Total number of visits per year
      Figures represent the average number of ED visits per year (in thousands).
      1,225
      Includes patients classified as “other” race.
      925269366427432
      Shortness of breath, %37.837.539.335.243.134.8
      Chest pain, %12.812.213.816.111.910.9
      Dyspnea, %10.711.110.210.711.010.4
      Other heart disease (not ischemic), %3.13.03.64.02.53.0
      General weakness3.03.60.90.93.14.7
      Other32.632.632.233.228.536.2
      p
      Includes patients classified as “other” race.
      =0.079
      p
      p-value represented statistical significance of comparison of proportions, of all reasons for visits, between race groups using Rao-Scott corrected chi-square tests of association.ED, emergency department; NHAMCS, National Hospital Ambulatory Medical Care Survey.
      <0.001
      a NHAMCS records “shortness of breath” and “dyspnea” as separate reason for visit categories in their data.
      b Figures represent the average number of ED visits per year (in thousands).
      c Includes patients classified as “other” race.
      d p-value represented statistical significance of comparison of proportions, of all reasons for visits, between race groups using Rao-Scott corrected chi-square tests of association. ED, emergency department; NHAMCS, National Hospital Ambulatory Medical Care Survey.
      An estimated 52.6% of visits were by women, 70.2% by adults aged ≥65 years, and 70.9% hospitalized, with 14.0% admitted to ICU (Table 2). Observation unit admissions comprised 3.5% of admissions and did not differ by race or age. The highest proportion of visits occurred in the South region. Blacks were younger by 10 years on average, more likely to report Medicaid coverage, represented a higher proportion of South region visits and had longer lengths of stay for their visit. There were no significant differences between blacks and whites with regards to triage clinical acuity.
      Table 2Emergency Department Visit Characteristics for All Adults With Heart Failure 2001–2010
      CharacteristicsBlacks and whitesWhitesBlacksp-value
      Number of visits (per 1,000 per year)
      Figures represent the average number of emergency department visits per 1,000 per year.
      1,195925269
      Age, years, M (95% CI)71.9 (71.0, 72.7)74.1 (73.4, 74.9)64.1 (62.2, 66.0)<0.001
       18–39, n (%)32 (2.7)13 (1.4)19 (7.1)<0.001
       40–64, n (%)324 (27.1)206 (22.2)118 (43.8)
       65–79, n (%)415 (34.7)335 (36.2)80 (29.5)
       ≥80, n (%)424 (35.5)371 (40.1)53 (19.5)
      Female, n (%)629 (52.6)492 (53.1)137 (50.8)0.36
      Insurance, n (%)<0.001
       Medicare821 (68.7)670 (72.4)150 (55.9)
       Medicaid104 (8.7)62 (6.7)43 (15.8)
       Private159 (13.4)125 (13.5)34 (12.7)
       Self pay/other/unknown110 (9.2)68 (7.4)42 (15.6)
      Region, n (%)<0.001
       Northeast246 (20.6)209 (22.6)37 (13.8)
       Midwest312 (26.1)238 (25.7)74 (27.6)
       South445 (37.3)309 (33.4)136 (50.6)
       West191 (16.0)170 (18.3)22 (8.0)
      Metropolitan statistical area, n (%)0.044
       Yes979 (82.0)738 (79.7)242 (89.7)
       No215 (18.0)187 (20.3)28 (10.3)
      Triage clinical acuity, n (%)0.48
       Higher (<15 minutes)465 (44.3)365 (44.8)100 (42.7)
       Lower (≥15 minutes)584 (55.7)450 (55.2)134 (57.3)
      Treatment, n (%)
       Diuretics731 (61.2)571 (61.7)160 (59.2)0.32
       Vasodilators262 (21.9)191 (20.7)70 (26.1)0.010
       Vasopressors16 (1.4)13 (1.4)3 (1.2)0.78
      Visit length, hours, M (95% CI)5.1 (4.8, 5.3)4.8 (4.6, 5.1)5.9 (5.4, 6.5)<0.001
      Disposition, n (%)
       Discharged348 (29.1)260 (28.1)88 (32.5)ref
       Floor680 (56.9)533 (57.6)147 (54.6)0.070
       Intensive care unit168 (14.0)133 (14.3)35 (12.9)0.12
       Admitted (All)847 (70.9)665 (71.9)182 (67.5)0.050
      Seen last 72 hours, n (%)39 (3.7)33 (3.9)7 (3.0)0.33
      Note: Boldface indicates statistical significance (p<0.05). The p-values above represented statistical significance of the comparison of proportions of each of the above visit characteristics, between blacks and whites, using adjusted F tests of equal means and Rao-Scott corrected chi-square tests of association.
      a Figures represent the average number of emergency department visits per 1,000 per year.
      Among all non-ICU admissions, blacks were less likely to be hospitalized than whites (67.5% vs 71.9%, p=0.05; Table 2). This racial disparity was observed among higher acuity patients aged ≥65 years (61.0% vs 71.1%, PR=0.80, 95% CI=0.65, 0.99; Table 3). A similar black–white hospitalization pattern was observed among higher acuity patients aged 18–64 years although the difference was not statistically significant. Among lower acuity patients, blacks and whites did not have significantly different hospitalization rates (Table 3). Among all patients aged ≥65 years, a statistically significant interaction effect (p=0.037) was observed between clinical acuity X race; however, no significant interaction was observed in the younger strata (Table 3). Among whites overall, patients with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (70.9% vs 62.7%, p=0.005), although this pattern was statistically significant only in the older strata, where there were more than three times as many hospitalizations as in the younger strata. Among blacks, the expected pattern of higher hospitalization with higher acuity was not observed in either age strata. The above patterns of racial disparity with regard to hospitalization rates by level of clinical acuity was not observed with ICU admissions.
      Table 3Proportion of Emergency Department Visits for HF Resulting in Hospitalization, Stratified by Age and Race
      Clinical acuityWhiteBlackBlack vs white,

      Prevalence ratio (95% CI)
      All prevalence ratios were derived from multivariable modified Poisson regression models that adjusted for age, sex, vasodilator use, length of visit, metropolitan statistical area, and geographic region.
      Number admitted (per 1,000 per year)Admitted

      % (95% CI)
      Number admitted (per 1,000 per year)Admitted

      % (95% CI)
      Patients aged 18–64 years
      Statistical interaction between clinical acuity and race, p=0.250.
       Higher4670.6 (57.6, 80.9)2460.6 (50.2, 70.1)0.83 (0.63, 1.10)
       Lower5457.7 (48.7, 66.2)4159.2 (49.8, 68.0)1.03 (0.83, 1.27)
       Higher vs lower prevalence ratio  (95% CI)
      All prevalence ratios were derived from multivariable modified Poisson regression models that adjusted for age, sex, vasodilator use, length of visit, metropolitan statistical area, and geographic region.
      1.19 (0.94, 1.52)0.99 (0.76, 1.29)
      Patients aged ≥65 years
      Statistical interaction between clinical acuity and race, p=0.037.HF, heart failure.
       Higher17074.5 (69.8, 78.7)2561.0 (49.6, 71.3)0.80 (0.65, 0.99)
       Lower19463.5 (59.4, 67.3)3871.1 (62.7, 78.3)1.06 (0.92, 1.22)
       Higher vs lower prevalence ratio  (95% CI)
      All prevalence ratios were derived from multivariable modified Poisson regression models that adjusted for age, sex, vasodilator use, length of visit, metropolitan statistical area, and geographic region.
      1.15 (1.04, 1.27)0.86 (0.66, 1.12)
      a All prevalence ratios were derived from multivariable modified Poisson regression models that adjusted for age, sex, vasodilator use, length of visit, metropolitan statistical area, and geographic region.
      b Statistical interaction between clinical acuity and race, p=0.250.
      c Statistical interaction between clinical acuity and race, p=0.037. HF, heart failure.
      In the validation analysis, the prevalence of abnormal vital signs (systolic blood pressure >160 mmHg or <100 mmHg, respiratory rate >24 breaths per minute, or oxygen saturation <90%) and vasodilator agent usage was overall higher among HF patients with higher than lower clinical acuity (Table 4). This pattern was observed among blacks and whites, with the exception that whites with higher clinical acuity had a higher prevalence of respiratory rate >24 breaths per minute than did those with lower clinical acuity (27.2% vs 15.2%) but blacks had nearly equal prevalence (20.1% vs 19.8%) of respiratory rate >24 breaths per minute across clinical acuity levels. There were no significant differences in the respective prevalence of vasodilator use within either race (Table 4).
      Table 4Prevalence (%) of Clinical Characteristics Across Emergency Department Visits, by Race and Clinical Acuity
      Visit characteristicBlackWhitep-value
      p-value represents the statistical significance for comparison of differences across race.
      Higher acuityLower acuityHigher acuityLower acuity
      Number of visits
      Figures represent the average number of emergency department visits per 1,000 per year.O2, oxygen saturation (on room air); RR, respiratory rate (in breaths per minute); SBP, systolic blood pressure (in mmHg).
      4154229306
      SBP<100 (%)7.94.26.34.90.56
      SBP>160 (%)30.424.627.923.30.35
      RR>24 (%)20.119.827.215.20.077
      O2<90% (%)16.89.924.911.20.006
      Vasodilator use (%)21.822.119.717.00.47
      a p-value represents the statistical significance for comparison of differences across race.
      b Figures represent the average number of emergency department visits per 1,000 per year. O2, oxygen saturation (on room air); RR, respiratory rate (in breaths per minute); SBP, systolic blood pressure (in mmHg).

      DISCUSSION

      The results of this study suggest age-related racial disparities in the risk of non-ICU hospitalization among older adults with HF who present to the ED. White ED patients were overall more likely to be hospitalized than blacks. This racial disparity was particularly prominent among the higher acuity patients, and was not influenced by age, given the similar patterns observed in both younger and older age categories. The relationship between race and hospitalization was more complex among lower acuity patients and varied by age. The observation that lower acuity black patients aged 65 years and older demonstrated a higher hospitalization rate than either higher acuity black patients or lower acuity white patients in the same age group was unexpected. These findings contradict the expected norm of a larger proportion of higher acuity patients being hospitalized than lower acuity patents, and may suggest an excess of hospitalizations involving black ED patients aged 65 years and older with HF and lower clinical acuity. To the authors’ knowledge, this is the first study to characterize age-related racial disparities in HF hospitalization from the ED using a nationally representative sample. The lower hospitalization proportion among blacks than whites overall has been previously reported within the NHAMCS cohort for all ED patients and those with HF.
      • Blecker S
      • Ladapo JA
      • Doran KM
      • Goldfeld KS
      • Katz S
      Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.
      • Lo AX
      • Flood KL
      • Biese K
      • Platts-Mills TF
      • Donnelly JP
      • Carpenter CR
      Factors associated with hospital admission for older adults receiving care in U.S. emergency departments.
      However, the overall evidence on comparative hospitalization rates between blacks and whites is contradictory, as other studies have also reported an excess of HF hospitalizations among blacks and blacks aged 65 years and older in particular.
      • Will JC
      • Valderrama AL
      • Yoon PW
      Preventable hospitalizations for congestive heart failure: establishing a baseline to monitor trends and disparities.
      • O'Neil SS
      • Lake T
      • Merrill A
      • Wilson A
      • Mann DA
      • Bartnyska LM
      Racial disparities in hospitalizations for ambulatory care-sensitive conditions.
      ,
      • Zhang W
      • Watanabe-Galloway S
      Ten-year secular trends for congestive heart failure hospitalizations: an analysis of regional differences in the United States.
      This study adds to those reports by characterizing hospitalization patterns resulting from ED visits and raises compelling questions. Particularly, whether the validity of clinical acuity scores vary by race, and what race-dependent factors influence hospitalization among ED patients with HF. Hospitalization of HF patients using NHAMCS data was previously described
      • Blecker S
      • Ladapo JA
      • Doran KM
      • Goldfeld KS
      • Katz S
      Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.
      ; however, unlike this study, that study examined ED disposition, included ICU admissions, and did not focus on age or racial differences.
      Racial disparities in ED triage clinical acuity scoring were reported in Veteran's Affairs EDs, although that study examined all patients and without examining individual diagnoses.
      • Vigil JM
      • Alcock J
      • Coulombe P
      • et al.
      Ethnic disparities in Emergency Severity Index Scores among U.S. Veteran's Affairs emergency department patients.
      This study examined whether the observed hospitalization pattern differences were influenced by differential misclassification of clinical acuity across race. The validation analysis examined the respective prevalence of vital signs and vasodilator use across clinical acuity and race. Although no significant differences with regard to the comparison of abnormal systolic blood pressures and vasodilator use were observed, the absence of a substantially higher prevalence of these abnormalities in the lower acuity groups, and the observed expected higher prevalence of abnormal respiratory rate and oxygen saturation in the higher acuity groups, are reassuring and argue against substantial misclassification of clinical acuity among blacks in this study. Nonetheless, the possibility that the high hospitalization rate in blacks with lower acuity visits were due to differential misclassification (by race) of clinical acuity cannot be excluded and warrants further study.
      Two major clinical implications are underscored by these findings: First, because each HF hospitalization contributes to the vicious cycle of rehospitalization and mortality risk,
      • Collins SP
      • Pang PS
      • Fonarow GC
      • Yancy CW
      • Bonow RO
      • Gheorghiade M
      Is hospital admission for heart failure really necessary? The role of the emergency department and observation unit in preventing hospitalization and rehospitalization.
      • Desai AS
      • Stevenson LW
      There must be a better way: piloting alternate routes around heart failure hospitalizations.
      • Bello NA
      • Claggett B
      • Desai AS
      • et al.
      Influence of previous heart failure hospitalization on cardiovascular events in patients with reduced and preserved ejection fraction.
      the ED offers an opportunity to ameliorate over-hospitalization by shifting the management of unmet care needs to appropriate outpatient settings through improvements in care transitions.
      • Lo AX
      • Biese K
      • Carpenter CR
      Defining quality and outcome in geriatric emergency care.
      Second, because hospitalizations of older adults associated with a decline in cognition, mobility, and function after discharge,
      • Creditor MC
      Hazards of hospitalization of the elderly.
      • Covinsky KE
      • Palmer RM
      • Fortinsky RH
      • et al.
      Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age.
      • Brown CJ
      • Roth DL
      • Allman RM
      • Sawyer P
      • Ritchie CS
      • Roseman JM
      Trajectories of life-space mobility after hospitalization.
      ED-based efforts addressing HF hospitalizations may contribute substantially to the reduction of disability and loss of independence among older adults.
      The reasons for these disparities in care are unclear. Age and race are both prominently used in HF hospitalization risk prediction models.
      • Ross JS
      • Mulvey GK
      • Stauffer B
      • et al.
      Statistical models and patient predictors of readmission for heart failure: a systematic review.
      Age is independently associated with hospitalization among all ED patients
      • Aminzadeh F
      • Dalziel WB
      Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions.
      • Pines JM
      • Mullins PM
      • Cooper JK
      • Feng LB
      • Roth KE
      National trends in emergency department use, care patterns, and quality of care of older adults in the United States.
      and older age is associated with higher rehospitalization in HF across different populations and racial/ethnic groups.
      • Hugli O
      • Braun JE
      • Kim S
      • Pelletier AJ
      • Camargo Jr, CA
      United States emergency department visits for acute decompensated heart failure, 1992 to 2001.
      • Giamouzis G
      • Kalogeropoulos A
      • Georgiopoulou V
      • et al.
      Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions.
      The association between race and HF hospitalization is less clear as studies have produced different findings,
      • Giamouzis G
      • Kalogeropoulos A
      • Georgiopoulou V
      • et al.
      Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions.
      where higher hospitalization rates for whites
      • Hugli O
      • Braun JE
      • Kim S
      • Pelletier AJ
      • Camargo Jr, CA
      United States emergency department visits for acute decompensated heart failure, 1992 to 2001.
      • Shen JJ
      • Washington EL
      • Chung K
      • Bell R
      Factors underlying racial disparities in hospital care of congestive heart failure.
      and blacks
      • Rathore SS
      • Foody JM
      • Wang Y
      • et al.
      Race, quality of care, and outcomes of elderly patients hospitalized with heart failure.
      • Mentz RJ
      • Bittner V
      • Schulte PJ
      • et al.
      Race, exercise training, and outcomes in chronic heart failure: findings from Heart Failure—A Controlled Trial Investigating Outcomes in exercise traiNing (HF-ACTION).
      have been reported. Although variations in outpatient follow-up was proposed as an explanation for the higher hospitalization in blacks in one study,
      • Mentz RJ
      • Bittner V
      • Schulte PJ
      • et al.
      Race, exercise training, and outcomes in chronic heart failure: findings from Heart Failure—A Controlled Trial Investigating Outcomes in exercise traiNing (HF-ACTION).
      the reasons in the other studies were unclear.
      The increased hospitalization among older black HF patients with lower clinical acuity may reflect a greater difficulty for emergency physicians to discharge them home, perhaps from difficulty ensuring a reliable transition of care to the outpatient setting.
      • Lo AX
      • Biese K
      • Carpenter CR
      Defining quality and outcome in geriatric emergency care.
      Older blacks were twice as likely to seek access to routine healthcare in the ED despite having community primary care providers.
      • Hunold KM
      • Richmond NL
      • Waller AE
      • Cutchin MP
      • Voss PR
      • Platts-Mills TF
      Primary care availability and emergency department use by older adults: a population-based analysis.
      Older blacks with HF were less likely to follow up with a specialist after discharge
      • Cook NL
      • Ayanian JZ
      • Orav EJ
      • Hicks LS
      Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care.
      although for unclear reasons. Poor access to care may also contribute to a higher burden of symptoms or with more complex circumstances as suggested by greater lengths of ED stay for blacks than whites,
      • Karaca Z
      • Wong HS
      Racial disparity in duration of patient visits to the emergency department: teaching versus non-teaching hospitals.
      and particularly longer if the patient was hospitalized.
      • Pines JM
      • Russell Localio A
      • Hollander JE
      Racial disparities in emergency department length of stay for admitted patients in the United States.
      • Carrier E
      • Khaldun J
      • Hsia RY
      Association between emergency department length of stay and rates of admission to inpatient and observation services.
      In such situations, the decision to hospitalize these individuals may reflect an inability to safely transition care to outpatient providers. The increased length of stay in the ED may also challenge institutional ED performance metrics involving length of stay benchmarks to the point where hospitalization became the preferred disposition.
      • Lo AX
      • Biese K
      Disseminating and sustaining emergency department innovations for older adults: good ideas deserve better policies.
      Perhaps the apparent excess in lower clinical acuity hospitalization in the age strata 65 years and older was influenced by concomitant complex geriatric conditions among older patients, such as poor function, impaired mobility, cognitive decline, social isolation, and psychosocial conditions.
      • Lo AX
      • Flood KL
      • Biese K
      • Platts-Mills TF
      • Donnelly JP
      • Carpenter CR
      Factors associated with hospital admission for older adults receiving care in U.S. emergency departments.
      Although those ED visits may be categorized as an ED visit for “heart failure,” the patients more likely sought care for unmet geriatric care needs than a true acute HF decompensation.
      • Lo AX
      • Biese K
      Disseminating and sustaining emergency department innovations for older adults: good ideas deserve better policies.
      These complex issues can be neither efficiently managed in the ED nor consistently transitioned to an optimal outpatient care program, therefore often resulting in a “social admission” to the hospital.
      • Lo AX
      • Flood KL
      • Biese K
      • Platts-Mills TF
      • Donnelly JP
      • Carpenter CR
      Factors associated with hospital admission for older adults receiving care in U.S. emergency departments.
      • Lo AX
      • Biese K
      • Carpenter CR
      Defining quality and outcome in geriatric emergency care.
      Nonetheless, the current findings signal an opportunity for interventions to improve alternative dispositions for HF patients, such as outpatient or community patient-centered programs to reduce both the ED visits and the subsequent hospitalizations. Programs that emphasize social support and self-care can improve the outpatient management of HF and may potentially offer an alternative to hospitalization after an episode of ED care.
      • Durant RW
      • Brown QL
      • Cherrington AL
      • Andreae LJ
      • Hardy CM
      • Scarinci IC
      Social support among African Americans with heart failure: is there a role for community health advisors?.
      • Woda A
      • Belknap RA
      • Haglund K
      • Sebern M
      • Lawrence A
      Factors influencing self-care behaviors of African Americans with heart failure: a photovoice project.
      • Cene CW
      • Haymore LB
      • Dolan-Soto D
      • et al.
      Self-care confidence mediates the relationship between perceived social support and self-care maintenance in adults with heart failure.
      However, it is challenging to determine how often the hospitalization decision is driven by the actual determination of an individual patient not having access to outpatient healthcare or social support networks, or perhaps a biased (and false) perception on the part of the clinician that the patient has none. Impairments in mobility and social participation are also associated with increased hospitalization, ED use, and mortality in HF.
      • Chaudhry SI
      • McAvay G
      • Chen S
      • et al.
      Risk factors for hospital admission among older persons with newly diagnosed heart failure: findings from the Cardiovascular Health Study.
      • Lo AX
      • Donnelly JP
      • Jr McGwinG
      • Bittner V
      • Ahmed A
      • Brown CJ
      Impact of gait speed and instrumental activities of daily living on all-cause mortality in adults >/=65 years with heart failure.
      • Lo AX
      • Flood KL
      • Kennedy RE
      • et al.
      The association between life-space and health care utilization in older adults with heart failure.
      These clinical characteristics may often be subtle and not captured by existing national ED patient encounter databases.
      • Lo AX
      • Flood KL
      • Biese K
      • Platts-Mills TF
      • Donnelly JP
      • Carpenter CR
      Factors associated with hospital admission for older adults receiving care in U.S. emergency departments.
      • Owens PL
      • Barrett ML
      • Gibson TB
      • Andrews RM
      • Weinick RM
      • Mutter RL
      Emergency department care in the United States: a profile of national data sources.
      Any hospitalization in older adults is independently associated with declines in function and mobility after discharge that may be irreversible,
      • Covinsky KE
      • Palmer RM
      • Fortinsky RH
      • et al.
      Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age.
      • Brown CJ
      • Roth DL
      • Allman RM
      • Sawyer P
      • Ritchie CS
      • Roseman JM
      Trajectories of life-space mobility after hospitalization.
      and which in turn may increase the risk of future admissions and further functional decline.

      Limitations

      This study required the combination of 10 years of NHAMCS data to attain the sample of 3,623 unweighted ED visits to gain sufficient statistical power to test the research questions. These nationally representative data of ED visits has limited sociodemographic data and lacks the granularity to determine whether hospitalizations were more likely due to social than clinical reasons, such as socioeconomic deprivation, poor social support, or impairments in either mobility or function. Although the clinical acuity provides an indication of the clinical severity at ED presentation, these data did not include each individual's baseline HF severity, such as the New York Heart Association class, or data regarding prior hospitalizations that may provide a clearer indication of each individual's baseline healthcare utilization pattern. The NHAMCS data set also limits the final ED diagnoses to the top three clinical conditions deemed most relevant to the visit and therefore precludes a more detailed analysis of the impact of comorbid conditions, which are more abundant in individuals with HF who are aged 65 years or older.
      • Kitzman DW
      • Rich MW
      Age disparities in heart failure research.
      The case ascertainment scheme followed prior NHAMCS studies using ICD-9 diagnosis codes
      • Hugli O
      • Braun JE
      • Kim S
      • Pelletier AJ
      • Camargo Jr, CA
      United States emergency department visits for acute decompensated heart failure, 1992 to 2001.
      • Caterino JM
      • Ting SA
      • Sisbarro SG
      • Espinola JA
      • Camargo Jr, CA
      Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001–2008.
      ,
      • Blecker S
      • Ladapo JA
      • Doran KM
      • Goldfeld KS
      • Katz S
      Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.
      ; however, missed cases from errors in data collection remain a possibility. The order of the three NHAMCS diagnoses were not designed to reflect a ranking of the clinical impression relating to the final diagnosis for each visit.
      • McCaig LF
      • Burt CW
      Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers.
      Consequently, previous studies using NHAMCS data have considered a diagnosis in any of the three diagnostic fields to reflect a diagnosis related to that individual ED visit without regard for whether it reflects a primary or secondary or tertiary diagnosis.
      • Hugli O
      • Braun JE
      • Kim S
      • Pelletier AJ
      • Camargo Jr, CA
      United States emergency department visits for acute decompensated heart failure, 1992 to 2001.
      • Caterino JM
      • Ting SA
      • Sisbarro SG
      • Espinola JA
      • Camargo Jr, CA
      Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001–2008.
      ,
      • Blecker S
      • Ladapo JA
      • Doran KM
      • Goldfeld KS
      • Katz S
      Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.
      • Lo AX
      • Flood KL
      • Biese K
      • Platts-Mills TF
      • Donnelly JP
      • Carpenter CR
      Factors associated with hospital admission for older adults receiving care in U.S. emergency departments.
      It was therefore not possible to examine differences in admission between primary HF hospitalizations versus secondary HF hospitalizations, as done in prior studies using other administrative data sources that specifically allow for this distinction.
      • Blecker S
      • Paul M
      • Taksler G
      • Ogedegbe G
      • Katz S
      Heart failure-associated hospitalizations in the United States.

      CONCLUSIONS

      Although the underlying reasons for the excess admissions observed in this study are likely multifactorial, these findings suggest that interventions aimed at reducing potentially preventable HF hospitalization might prioritize older blacks with HF in the ED, and focus on the ED as the primary target for hospitalization reduction initiatives. The optimal intervention should be person centered and account for the particular care needs of the individual. For those patients with poor medical and social support, more intensive case management may be beneficial. For others, the aggregation of these unmet geriatric care needs may benefit from an interdisciplinary and comprehensive approach, such as a palliative care model for HF.
      • Goodlin SJ
      Palliative care in congestive heart failure.
      • Jaarsma T
      • Beattie JM
      • Ryder M
      • et al.
      Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology.
      • Dionne-Odom JN
      • Kono A
      • Frost J
      • et al.
      Translating and testing the ENABLE: CHF-PC concurrent palliative care model for older adults with heart failure and their family caregivers.
      It would be impactful to investigate whether improved management of symptom burden in HF may be useful in reducing preventable hospitalizations.

      ACKNOWLEDGMENTS

      Publication of this article was supported by a grant from the National Institute on Minority Health and Health Disparities, National Institutes of Health [grant number U54MD008620]. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the National Institute on Minority Health and Health Disparities or the National Institutes of Health.
      Dr. Lo and Dr. Donnelly take responsibility for the integrity of the data and the accuracy of the data analysis. Lo and Donnelly contributed to the study concept and design and data analysis. All authors contributed to data interpretation and drafting of the mansucript.
      Contents of this article were previously presented at the University of Alabama at Birmingham Health Disparities Research Symposium on April 21, 2016.
      Dr. Collins reports research grant funding from NIH, the Agency for Healthcare Research and Quality, the American Heart Association, the Patient-Centered Outcomes Research Institute and Ortho Clinical, as well as receiving consulting fees from Medtronic and Novartis. Dr. Levitan reports research grant funding from Amgen, serving on the Amgen advisory board and receiving consulting fees from Novartis. Dr. Bittner serves as Senior Guest Editor for Circulation and on the Sanofi advisory board, and reports financial support from the following sources: (1) Contract between University of Alabama at Birmingham (UAB) and Astra Zeneca, Esperion, DalCor for services as National Coordinator for the STRENGTH, CLEAR, and DalGene clinical trials; (2) contract between UAB and Sanofi for service on the ODYSSEY Outcomes Steering Committee; (3) contract between UAB and Astra Zeneca as Site Principal Investigator for ARTEMIS; (4) contract between UAB and Bayer Healthcare as Site Principal Investigator for COMPASS; and (5) contract between UAB School of Public Health and Amgen as Co-Investigator for Pharmacovigilance analyses. No other financial disclosures were reported by the authors of this paper.

      SupPLEMENT NOTE

      This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

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