Author + information
- Khadijah Breathett, MD, MS∗ ()
- ↵∗Address for correspondence:
Dr. Khadijah Breathett, Division of Cardiology, University of Arizona, 1501 North Campbell Avenue, Tucson, Arizona 85724.
Heart failure health status is poor in women, racial or ethnic minorities, and the socioeconomically disadvantaged (1). In comparison with men, women have a higher prevalence of heart failure, more symptoms, and worse quality of life (1,2). The risks of adverse outcomes caused by heart failure are compounded by the intersectionality of sex, race or ethnicity, and low socioeconomic position (2,3). Furthermore, women and racial or ethnic minorities are often undertreated and understudied in clinical trials (4). As illustrated in the study by Khariton et al. (5), which is reported in this issue of JACC: Heart Failure, the older white male demographic was associated with the best heart failure health status.
In a multicenter registry of patients with heart failure with reduced ejection fraction (CHAMP-HF [Change the Management of Patients with Heart Failure]), Khariton et al. (5) studied cross-sectional associations of sex, race or ethnicity, and household income with heart failure health status. Health status was defined using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), which included patient-reported outcomes such as symptoms, physical and social limitations, and quality of life. The study found female sex, African-American race, Hispanic ethnicity, and low household income to be associated with lower heart failure health status. Adjustments were made for variability in comorbidities, vital signs, prior hospitalizations, and medications using backward selection models. Female sex, Hispanic ethnicity, and income were independently associated with lower heart failure health status after adjustment. This study did not address associations between time-dependent titrations in evidence-based medication and initiation of cardiac rehabilitation. However, it supported data suggesting that patient-reported outcomes are unsatisfactory for women, racial or ethnic minorities, and individuals of lower socioeconomic position (1).
How Do We Make Equity in Heart Failure Health Status a National Priority?
First, the U.S. health care system administrators must understand the value of obtaining health status through patient-reported outcomes. Multiple validated measures of heart failure health status, most notably the KCCQ, demonstrated independent associations with mortality and heart failure hospitalizations (1). Ideal heart failure health status translates into longer quality-adjusted life-years and reduced health care costs (1). Seeking an ideal heart failure health status will align with fundamental goals of the U.S. Institute of Medicine and the World Health Organization (1).
Second, measurement of heart failure health status must be performed uniformly and nationally among all patient demographics. CHAMP-HF has demonstrated feasibility in obtaining the KCCQ at multiple centers across the United States (5). The Centers for Medicare & Medicaid Services Merit-Based Payment System provides benefits for programs that collect patient-reported outcomes; however, the implementation of health status collection has not been generalized nationwide (5).
Third, the measurement of heart failure health status should be mandated at intervals both pre- and post-intervention. This step is imperative in achieving equity in health status among women, racial or ethnic minorities, and patients of lower socioeconomic position. After providing an intervention, improvement in patient-reported outcomes for heart failure may boost adherence and increase the likelihood of achieving target levels of evidence-based treatments as a result of positive reinforcement. The lack of improvement or worsening in patient-reported outcomes could guide individualized treatment. Secondarily, individualized treatment may also reduce bias in clinical decision making (6).
Finally, increased uptake of patient-reported outcomes may require a “carrot and stick” health policy approach. Gleaning from success of the Hospital Readmission Reduction Program and poor uptake of the Centers for Medicare & Medicaid Services Merit-Based Payment System, policymakers should consider developing a mandatory, tiered rewards and penalty program to measure patient-reported outcomes, such as heart failure health status. Centers should be rewarded financially for high levels of adoption and maintenance of heart failure health status measurements. Centers with low baseline heart failure health status should be provided with grant opportunities for the development and implementation of system-wide interventions. The health care systems that demonstrate the greatest improvements in heart failure health status, particularly among groups with lower health status such as women, racial or ethnic minorities, and lower socioeconomic groups, should receive significant financial benefits that may support their resources to maintain success. In addition, a threshold for not achieving adoption and maintenance of health status, or a lack of attempting to improve health status, should result in financial penalties. Appointing the Patient-Centered Outcomes Research Institute with resources to lead these research-focused initiatives may result in a more equitable health care system.
The ideal heart failure health status can be a right for all patients with heart failure, not a privilege. Achieving the ideal heart failure health status will require reliable measurement of heart failure health status, repeat measurement of heart failure health status pre- and post-interventions, and a supportive health care policy that prioritizes heart failure health status. Women, racial or ethnic minorities, and patients of lower socioeconomic position can achieve equity in ideal heart failure status.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Dr. Breathett has received support from the National Institutes of Health (NIH grant L60 MD010857) and from the University of Arizona Health Sciences (Strategic Priorities Faculty Initiative Grant).
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