Impact of Community Wealth on Use of Cardiac-Resynchronization Therapy With Defibrillators for Heart Failure Patients

BACKGROUND: Disparities in cardiovascular disease treatment are a major health policy concern. A complex interplay of patient, provider, and social contextual factors affect inequities in care. METHODS AND RESULTS: We used data regarding 22 205 patient stays in the National Cardiovascular Data Registry to explore the effect of hospital resources on receipt of a heart failure therapy, cardiac-resynchronization therapy with defibrillation (CRT-D). When added to patient-level variables, hospital ownership, cardiac patient volume, cardiac procedure availability, CRT-D, implantable cardioverter-defibrillator implantation volumes, and hospital financial characteristics were individually predictive of CRT-D receipt. In the full hierarchical model, average median household income (P<0.0001) and implantable cardioverter-defibrillator implantation volume (P<0.001) remained significant predictors of CRT-D receipt. Patients treated at hospitals in affluent communities were more likely to receive CRT-D than patients treated in poor communities, despite accounting for other patient and hospital characteristics, including insurance status. CONCLUSIONS: These findings suggest that the likelihood of receiving CRT-D is mediated by community wealth and hospital resources, and that health policy targeting insurance coverage alone may be ineffective in resolving inequities in care.