Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

Abstract

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84–0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72–0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

Racial/Ethnic and Socioeconomic Disparities in Management of Incident Paroxysmal Atrial Fibrillation

“…Reduced access to specialty care, including cardiovascular care, has been demonstrated among Black patients. 19 , 20 , 21 Although we adjusted for the number of outpatient cardiology visits per 12 months, these treatment differences may reflect barriers in accessing specialty cardiology care, particularly referral to a cardiac electrophysiologist for the management of paroxysmal AF, among Black patients. Black patients may receive more paroxysmal AF care from general medicine and cardiology practitioners, who may be comfortable prescribing commonly used rate control agents but may be less comfortable prescribing AADs because of their adverse and toxic effects.…”

The organizational growth mindset: Animating improvement and innovation in medical education

“…Currently, leaders across the world advocate for changes to the content, stance, structures and practices of medical education 11‐15 . Hospital departments, 16 medical schools 13,15 and entire national health systems 12,17 have heeded the call, embracing challenge, nourishing creativity and demonstrating openness to large‐scale change. Others have been more reticent, exposing an organizational fixed/performance approach that may arise from exaggerating internal and external risk and perceived threats to the departmental or institutional status.…”

Heart Failure Admission Service Triage (H-FAST) Study: Racialized Differences in Perceived Patient Self-Advocacy as a Driver of Admission Inequities

“…Studies utilizing the Public Health Critical Race praxis operationalize Critical Race Theory to elucidate mechanisms through which structural racism creates these inequities and to build action plans accordingly [ 4 - 6 ]. At our large, urban, academic medical center, racial inequities in the admission of HF patients were identified retrospectively, demonstrating that Black and Latinx patients were disproportionately admitted to a general medicine service (GMS) rather than cardiology; the strongest predictor of admission to cardiology was having an established relationship with an in-network cardiologist [ 7 ]. Subsequently, a multidisciplinary working group hypothesized nine potential drivers of this manifestation of structural racism, including admission guidelines; hospital bed availability; cardiology service census; prior service to which the patient was admitted; having an in-network cardiologist; patient self-advocacy; outpatient provider advocacy; clinical uncertainty, including other active co-morbid conditions as well as complex social needs, concomitant psychiatric and/or substance use disorders at the time of admission; and clinician implicit bias.…”