Addressing Disparities in Heart Failure Care without Borders

'It is a capital mistake to theorize before one has data.' A. Conan Doyle1 Over the last several decades, we have witnessed great strides forward in heart-failure therapeutics. While the usual challenges and targets for new interventions persist—improving quality of life, decreasing admissions, and reducing mortality—we have also turned our attention to critical assessments of heart failure care delivery in real world, non-study populations. Disparities in health-care outcomes have become a focus for researchers and policy makers, and with good reason. In the setting of rising costs and increasing prevalence of chronic heart failure, there is heightened urgency for rigorous research and evaluation to ensure that the benefits of treatment reach as many patients with heart failure as possible. Unfortunately, in many countries, minority populations, especially those in lower socioeconomic strata, may be particularly vulnerable to both the development of and adverse outcomes with heart failure. Among various ethnic, racial and religious groups, differences may exist in genetics, risk factor prevalence, lifestyle and adherence patterns, and access to care. Minority populations may be particularly susceptible to low health literacy and numeracy, language and cultural barriers, the presence of food deserts, frequent economic and physical displacement, and more. All of these factors have the potential to negatively impact outcomes. In the USA, the focus has been based largely on race (African Americans and to a lesser extent Latinos). Although the data are generally reassuring with regard to hospital care delivered to minority patients admitted with acutely decompensated heart failure,2-5 both adherence to heart failure medication and health literacy are lower in the African American group.6, 7 Further, non-physiological variables, many based on sociodemographics, are important in predicting readmission following heart failure admission.8, 9 Kind et al.10 using an 'area deprivation index', which is based on multiple US census indicators for poverty, education, housing, and employment, demonstrated that patients in the bottom 15% had higher readmission rates. Specifically, relative to the top 85%, the three lowest 5% groups had adjusted risk ratios for readmission following an admission for heart failure of 1.06, 1.06, and 1.08, respectively (all highly significant P-values). It is in this context that Gotsman and colleagues11 examined risk factors, treatment, and outcomes in two populations in Jerusalem: Israeli Arabs and Jews. Taking advantage of a rich database from the Clalit Health Service, the largest health maintenance organization in Israel, they demonstrate similar prevalence of heart failure and use of standard of care medications in a cohort of nearly 7000 patients. Heart failure has an earlier age of onset in Israeli Arabs, possibly owing to a greater prevalence of diabetes, obesity, and smoking. Outcome data provide a mixed picture: while a combined end-point of cardiac-related hospitalizations and death demonstrated a trend toward a higher event rate in Arab men compared with Jewish men, multivariate Cox regression analysis adjusted for age showed no difference in mortality. Given the contemporary health status of Arab men in several nearby countries, with many facing existential physical threats and mental stress, the data generated by Gotsman et al.11 are more than reassuring. However, as with all such research based on large databases, the current analysis raises new questions, for example: Are there differences in resource utilization? Is access to advanced therapies such as ventricular assist devices and transplant comparable? To what degree might genomics provide a more comprehensive understanding of potential differences in response to beta blockade or renin–angiotensin–aldosterone system (RAAS) blockade, if any? Despite these uncertainties and the always present need for more granularity in health services research, it should be noted at the very least that we can feel confident there is no signal of systemic bias at play: in this instance, disparity appears to be centred on risk factors, a problem that requires a public health approach but not necessarily a systematic overhaul of the national health-care system. The literature outside the USA is quite limited in this area. We know that there are differences by country, for example in the use of implantable cardioverter defibrillators.12 Age has also been studied.13 However, there are few, if any, studies that address differences by patient ethnicity, race or religion, which makes the paper by Gotsman and colleagues11 even more significant. Heart failure is truly a syndrome with manifold contributors—some physiological and many not. Objectively seeking an understanding of the influences on outcomes is an important task. As such, Gotsman and colleagues11 are to be congratulated for collecting and presenting their data. Now the 'heavy lifting' begins, expanding the research and devising well-constructed interventions to modify risk factors and to improve outcomes for all Jerusalemites. For all of us, as heart failure physicians, as researchers and as policy makers, it is an equally important undertaking in our respective national homes. No funding was received for this article. Conflict of interest: none declared.