JACC. Heart failure · 2026
Hospital Referral Region Dissimilarity and Black-White Differences in Heart Failure Outcomes Among Medicare Beneficiaries.
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Bolakale-Rufai Ikeoluwapo Kendra, Knapp Shannon M, Wadhera Rishi K, Breathett Khadijah
Аннотация
BACKGROUND: It is unknown whether racial disparities in heart failure (HF) outcomes are driven by geographic segregation of care, wherein Black patients receive treatment in different hospital referral regions (HRRs) than White patients.
OBJECTIVES: The authors examined whether HRR segregation is associated with mortality and rehospitalization for Black vs White patients with HF.
METHODS: Using U.S. Medicare data (100% files), the authors identified hospitalizations among Black and White patients with HF, who were discharged between 2017 and 2018 and followed up to March 2020. HRR segregation was measured using the dissimilarity index (DI) and categorized into tertiles (with higher DI indicating greater segregation of care). Mixed-effects Cox models were used to analyze survival from hospital admission and time from discharge to heart failure hospitalization, with mortality as a competing event, adjusting for demographics and comorbidities.
RESULTS: This analytic cohort included 513,846 patients (86.2% White; 13.8% Black) from 201 HRRs (mean age: 81.4 years [White], 76.2 years [Black]), of which 498,697 survived to discharge and were included in the rehospitalization analysis. The adjusted hazard of mortality was lower for Black patients than for White patients across all HRR segregation levels (low: HR: 0.91 [95% CI: 0.89-0.93]; medium: HR: 0.90 [95% CI: 0.88-0.92]; or high: HR: 0.90 [95% CI: 0.88-0.91]). The adjusted heart failure hospitalization hazard was 21% higher for Black patients than for White patients in the highest DI HRRs, with a significant gradient across tertiles (low: HR: 1.03 [95% CI: 0.97-1.09]; medium: HR: 1.14 [95% CI: 1.08-1.20]; or high: HR: 1.21 [95% CI: 1.16-1.26]).
CONCLUSIONS: In this nationally representative HF cohort, Black patients had a lower hazard of mortality across all HRRs compared to White patients. However, rehospitalization risk was significantly higher for Black patients than for White patients who received care in more highly segregated regions.
OBJECTIVES: The authors examined whether HRR segregation is associated with mortality and rehospitalization for Black vs White patients with HF.
METHODS: Using U.S. Medicare data (100% files), the authors identified hospitalizations among Black and White patients with HF, who were discharged between 2017 and 2018 and followed up to March 2020. HRR segregation was measured using the dissimilarity index (DI) and categorized into tertiles (with higher DI indicating greater segregation of care). Mixed-effects Cox models were used to analyze survival from hospital admission and time from discharge to heart failure hospitalization, with mortality as a competing event, adjusting for demographics and comorbidities.
RESULTS: This analytic cohort included 513,846 patients (86.2% White; 13.8% Black) from 201 HRRs (mean age: 81.4 years [White], 76.2 years [Black]), of which 498,697 survived to discharge and were included in the rehospitalization analysis. The adjusted hazard of mortality was lower for Black patients than for White patients across all HRR segregation levels (low: HR: 0.91 [95% CI: 0.89-0.93]; medium: HR: 0.90 [95% CI: 0.88-0.92]; or high: HR: 0.90 [95% CI: 0.88-0.91]). The adjusted heart failure hospitalization hazard was 21% higher for Black patients than for White patients in the highest DI HRRs, with a significant gradient across tertiles (low: HR: 1.03 [95% CI: 0.97-1.09]; medium: HR: 1.14 [95% CI: 1.08-1.20]; or high: HR: 1.21 [95% CI: 1.16-1.26]).
CONCLUSIONS: In this nationally representative HF cohort, Black patients had a lower hazard of mortality across all HRRs compared to White patients. However, rehospitalization risk was significantly higher for Black patients than for White patients who received care in more highly segregated regions.