Heart failure hits the poor extra hard

Poor women are more likely to end up in the hospital with heart failure, even when taking other measures of health and well-being into consideration. That's according to a new study that also showed women who didn't finish high school were at higher risk than those who received more education.

"It's kind of a double insult," said Dr Harlan Krumholz, a cardiologist at Yale School of Medicine in New Haven. "They have to deal with social circumstances, and then when people get sick in that situation, it gets a whole lot worse. We need to try to intervene early to prevent these things from happening," he said.

The research involved about 26,000 healthy, post-menopausal women who were part of the US. National Institutes of Health (NIH)-funded Women's Health Initiative. At the beginning of the study, women were surveyed on health and lifestyle habits, as well as their household income and how far they had gone in school.

Every six months for the next eight years, a team led by Dr Rashmee Shah from Cedars-Sinai Medical Center in Los Angeles checked women's medical records to determine which of them were hospitalised for heart failure – when the heart becomes far less efficient.

In total, there were 663 cases of heart failure, the researchers reported in the Journal of the American College of Cardiology. Each year, an average of 57 out of every 10,000 women with a household income of less than $20,000 per year were hospitalised with heart failure. That compared to only about 17 out of 10,000 women whose families made more than R380 000

When the researchers accounted for race, underlying health factors and whether women smoked and drank, those in the lowest income bracket still had a 56% higher risk of heart failure than the wealthiest women. In addition, women that didn't finish high school were 21% more likely to be hospitalised for the condition than college grads.

What is responsible?

The researchers said that two key drivers of heart risks in poor women may be less access to preventive care and less communication with doctors and understanding of health risks.

Shah said that women's neighbourhoods may play a role in their heart risks as well – for example, whether or not it's safe to walk outside and if there are grocery stores nearby. With poor, older women, she said, "The big message here is that we are identifying an at-risk group that is growing."

Krumholz, who was not involved in the research, said the findings are a "challenge" to doctors to do a better job of treating underlying diseases such as high blood pressure in their poorer patients, and to stop heart disease before it happens.

"The risk factors for heart disease, in particular heart failure, are concentrated in certain groups in society, particularly those with low income," he said. "When early problems arise that could be intervened on, those aren't addressed adequately."

Privately insured did better

Another study published this week in the same journal found that people with government-funded health insurance (Medicare or Medicaid) and those without insurance were less likely to get proven, potentially life-saving treatment for heart failure than those with private insurance.

That included drugs like beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), as well as implantable devices that monitor heart rhythms and can deliver electric shocks when the heart is in trouble.

Researchers led by Dr John Kapoor of the University of Chicago Pritzker School of Medicine also reported that of almost 100,000 older adults with heart failure, those on Medicaid were 22% more likely to die in the hospital than the privately-insured.

Kapoor and his colleagues said they couldn't be sure whether the differences were due to doctors' treatment choices, or if some patients turned down tre atment they couldn't afford.

Dr Marvin Konstam from Tufts Medical Center in Boston said that doctors may take into account how much a patient's insurance will reimburse them for treatment – or whether they'll get paid at all.

For example, in Massachusetts, "Depending on what problem the patient has... on average, hospitals are losing money every time they admit a Medicaid patient," Konstam, who wrote a commentary on the study, said. "That's bound to have an impact on what types of treatments are delivered."

A whole-patient focus to both disease prevention and treatment could start to address gaps between the poor and wealthy and those with and without private insurance, researchers said. "Sometimes it's easy for us to forget that investment in prevention can pay dividends," Krumholz concluded.

(Reuters Health, Genevra Pittman, September 2011)

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