Editorial

Epidemiology of heart failure in the United States

Approximately three million U.S. adult women have heart failure (HF), increasing their risk of adverse perioperative outcomes. While gender and racial differences are reported in surgical outcomes, less is known about 30-day perioperative outcomes in HF patients.

To characterize and compare gender and racial differences in 30-day perioperative outcomes in adults with new or acute/worsening HF.

The 2012–2013 American College of Surgeons National Surgical Quality Improvement Program database of surgical patients (n = 9458) with HF was analyzed. Logistic regression was used to adjust for gender and racial differences in baseline covariates.

No gender difference in mortality (odds ratio = 0.922, 95% confidence interval = 0.0792–1.073, p = 0.294) was noted. Whites were more likely than Blacks to die 30 days after surgery (14% vs 9%, p < 0.001); after adjustment, Blacks were more likely to experience complications and be readmitted compared to Whites.

There was no gender difference in mortality. White patients with HF were more likely to die after surgery than Black patients.

The aim of this work was to estimate agreement of self-reported heart failure (HF) with physician-diagnosed HF and compare the prevalence of HF according to method of ascertainment.

ARIC cohort members (60–83 years of age) were asked annually whether a physician indicated that they have HF. For those self-reporting HF, physicians were asked to confirm their patients' HF status. Physician-diagnosed HF included surveillance of hospitalized HF and hospitalized and outpatient HF identified in administrative claims databases. We estimated sensitivity, specificity, positive predicted value, kappa, prevalence and bias–adjusted kappa (PABAK), and prevalence. Compared with physician-diagnosed HF, sensitivity of self-report was low (28%–38%) and specificity was high (96%–97%). Agreement was poor (kappa 0.32–0.39) and increased when adjusted for prevalence and bias (PABAK 0.73–0.83). Prevalence of HF measured by self-report (9.0%), ARIC-classified hospitalizations (11.2%), and administrative hospitalization claims (12.7%) were similar. When outpatient HF claims were included, prevalence of HF increased to 18.6%.

For accurate estimates HF burden, self-reports of HF are best confirmed by means of appropriate diagnostic tests or medical records. Our results highlight the need for improved awareness and understanding of HF by patients, because accurate patient awareness of the diagnosis may enhance management of this common condition.

This study sought to determine whether racial and ethnic differences exist among patients with similar access to care. We examined outcomes after heart failure hospitalization within a large municipal health system.

Racial and ethnic disparities in heart failure outcomes are present in administrative data, and one explanation is differential access to care.

We performed a retrospective cohort study of 8,532 hospitalizations of adults with heart failure at 11 hospitals in New York City from 2007 to 2010. Primary exposure was ethnicity and race, and outcomes were 30- and 90-day readmission and 30-day and 1-year mortality rates. Generalized estimating equations were used to test for associations between ethnicity and race and outcomes with covariate adjustment.

Of the number of hospitalizations included, 4,305 (51%) were for blacks, 2,449 (29%) were for Hispanics, 1,494 (18%) were for whites, and 284 (3%) were for Asians. Compared to whites, blacks and Asians had lower 1-year mortality, with adjusted odds ratios (aORs) of 0.75 (95% confidence interval [CI]: 0.59 to 0.94) and 0.57 (95% CI: 0.38 to 0.85), respectively, and rates for Hispanics were not significantly different (aOR: 0.81; 95% CI: 0.64 to 1.03). Hispanics had higher odds of readmission than whites (aOR: 1.27; 95% CI: 1.03 to 1.57) at 30 (aOR: 1.40; 95% CI: 1.15 to 1.70) and 90 days. Blacks had higher odds of readmission than whites at 90 days (aOR:1.21; 95% CI: 1.01 to 1.47).

Racial and ethnic differences in outcomes after heart failure hospitalization were present within a large municipal health system. Access to a municipal health system may not be sufficient to eliminate disparities in heart failure outcomes.

The impact of a healthy lifestyle on risk of heart failure (HF) is not well known.

The objectives of this study were to evaluate the effect of a combination of lifestyle factors on incident HF and to further investigate whether weighting each lifestyle factor has additional impact.

Participants were 84,537 post-menopausal women from the WHI (Women’s Health Initiative) observational study, free of self-reported HF at baseline. A healthy lifestyle score (HL score) was created wherein women received 1 point for each healthy criterion met: high-scoring Alternative Healthy Eating Index, physically active, healthy body mass index, and currently not smoking. A weighted score (wHL score) was also created in which each lifestyle factor was weighted according to its independent magnitude of effect on HF. The incidence of hospitalized HF was determined by trained adjudicators using standardized methodology.

There were 1,826 HF cases over a mean follow-up of 11 years. HL score was strongly associated with risk of HF (multivariable-adjusted hazard ratio [HR] [95% confidence interval (CI)] 0.49 [95% CI: 0.38 to 0.62], 0.36 [95% CI: 0.28 to 0.46], 0.24 [95% CI: 0.19 to 0.31], and 0.23 [95% CI: 0.17 to 0.30] for HL score of 1, 2, 3, and 4 vs. 0, respectively). The HL score and wHL score were similarly associated with HF risk (HR: 0.46 [95% CI: 0.41 to 0.52] for HL score; HR: 0.48 [95% CI: 0.42 to 0.55] for wHL score, comparing the highest tertile to the lowest). The HL score was also strongly associated with HF risk among women without antecedent coronary heart disease, diabetes, or hypertension.

An increasingly healthy lifestyle was associated with decreasing HF risk among post-menopausal women, even in the absence of antecedent coronary heart disease, hypertension, and diabetes. Weighting the lifestyle factors had minimal impact.

Few data exist on prevalence, morbidity, and mortality of pediatric heart failure hospitalizations. We tested the hypotheses that pediatric heart failure–related hospitalizations increased over time but that mortality decreased. Factors associated with mortality and length of stay were also assessed.

A retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed for pediatric (age ≤18 years) heart failure–related hospitalizations for the years 1997, 2000, 2003, and 2006. Hospitalizations did not significantly increase over time, ranging from 11,153 (95% confidence interval [CI] 8,898–13,409) in 2003 to 13,892 (95% CI 11,528–16,256) in 2006. Hospital length of stay increased from 1997 (mean 13.8 days, 95% CI 12.5–15.2) to 2006 (mean 19.4 days, 95% CI 18.2 to 20.6). Hospital mortality was 7.3% (95% CI 6.9–8.0) and did not vary significantly between years; however, risk-adjusted mortality was less in 2006 (odds ratio 0.70, 95% CI 0.61 to 0.80). The greatest risk of mortality occurred with extracorporeal membrane oxygenation, acute renal failure, and sepsis.

Heart failure–related hospitalizations occur in 11,000–14,000 children annually in the United States, with an overall mortality of 7%. Many comorbid conditions influenced hospital mortality.

Although differences in heart failure (HF) hospitalization rates by race and sex are well documented, little is known about geographic variations in hospitalizations for HF, the most common discharge diagnosis for Medicare beneficiaries.

Using exploratory spatial data analysis techniques, the authors examined hospitalization rates for HF as the first-listed discharge diagnosis among Medicare beneficiaries in a 10-state Tennessee catchment area, based on the resident states reported by Tennessee hospitals from 2000 to 2004.

The age-adjusted HF hospitalization rate (per 1000) among Medicare beneficiaries was 23.3 [95% confidence interval (CI), 23.3–23.4] for the Tennessee catchment area, 21.4 (95% CI, 21.4–21.5) outside the catchment area and 21.9 (95% CI, 21.9–22.0) for the overall United States. The age-adjusted HF hospitalization rates were also significantly higher in the catchment area than outside the catchment area and overall, among men, women and whites, whereas rates among the blacks were higher outside the catchment area. Beneficiaries in the catchment area also had higher age-specific HF hospitalization rates. Among states in the catchment area, the highest mean county-level rates were in Mississippi (30.6 ± 7.6) and Kentucky (29.2 ± 11.5), and the lowest were in North Carolina (21.7 ± 5.7) and Virginia (21.8 ± 6.6).

Knowledge of these geographic differences in HF hospitalization rates can be useful in identifying needs of healthcare providers, allocating resources, developing comprehensive HF outreach programs and formulating policies to reduce these differences.