HF Care Differs Among Asian Subgroups in the US

Disaggregating patients categorized as “Asian” into individual ethnicity groups reveals some disparities in the quality of inpatient heart failure (HF) care that otherwise wouldn’t be evident, new data show.

Compared with non-Hispanic white patients, for instance, Vietnamese men hospitalized for HF were less likely to receive optimal medical therapy (OMT) at discharge, and along with Filipina women, they also were less likely to have extended lengths of stay.

“It's important that in considering the health of our population at large, that there's also appropriate representation of the Asian American community, which is the fastest growing immigrant population in the US and is projected to be the largest immigrant population in the US in the coming decades,” said senior study author Nilay S. Shah, MD, MPH (Northwestern University Feinberg School of Medicine, Chicago, IL).  ”As this population rapidly grows, understanding their experiences of healthcare and of health and disease will become increasingly important.”

 Within the Asian American population, some CV differences are known, including that Korean and Chinese individuals have a somewhat lower risk of CVD compared with others under that umbrella. But untangling the differences is difficult because many hospitals do not include complete race and ethnicity data in electronic medical records. Shah’s analysis comprised patients in the Get With The Guidelines–Heart Failure registry, but even so, it only included those from the six largest Asian American communities: Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese, with an additional category for all others identifying as Asian.

In an editorial accompanying the new paper, Andy Y. Lee, MD (University of California-Irvine), and colleagues note that efforts to disaggregate Asian American research data are essential not only to understanding differences in treatment, but “to formulate actionable policy and clinical interventions in promoting equity for all.”

Numerous Between-Group Differences Seen

For the study, published this week in JACC, Shah and colleagues led by Xiaoning Huang, PhD (Northwestern University Feinberg School of Medicine), analyzed data from 7,261 Asian patients (mean age 69.9-78.8 years; 41%-51% female) and 768,566 non-Hispanic white patients (mean age 74.6 years; 47% female). All were hospitalized for heart failure at one of 824 hospitals in the United States.

Diabetes at baseline was most prevalent in Asian Indian patients, as was hypertension, while Filipino patients had the highest prevalence of hyperlipidemia. The latter group also had the highest frequency of current or former smoking. Other findings included a differential prevalence of HF with reduced ejection fraction, which was nearly 40% in Korean women, while Asian Indian women had a much lower prevalence that was similar to non-Hispanic white women.

Vietnamese men were 32% less likely than men in other groups to receive OMT. For all men, the OMT rates ranged from 31% in those who were Japanese and Vietnamese to 58% in Asian Indians, compared with 40% in non-Hispanic white patients. For all women, the range was from 30% in those who were Korean to 54% in Asian Indians, compared with 38% in non-Hispanic White patients.

Hospital stays longer than 4 days were 32% less likely in Vietnamese men and 44% less likely in Filipina women compared with non-Hispanic white patients, with considerable variation across individual Asian groups.

Filipina women also were 48% less likely than non-Hispanic white women to experience defect-free care. Defect-free care was defined as all HF care quality measures for which a patient was eligible, including prescription of up to three medication classes, a follow-up visit scheduled within 7 days of discharge, and HF enhanced education in the form of referral to a HF management program, 60 or more minutes of patient education, or receipt of a HF workbook.

No differences were seen in rates of in-hospital mortality for any Asian group compared with non-Hispanic white patients.

Untangling Outcomes Data

Shah said the findings raise numerous questions for which the answers are difficult to extract, including how much of an impact socioeconomic differences, English proficiency, and cultural norms have on the outcomes.

Length of stay, for example, is a challenging metric to understand.

“In itself it is of course a measure of how long somebody was in the hospital, and how long somebody was in the hospital could be related to the fact that they were sicker when they are admitted,” Shah said. “But they also could  have trouble understanding recommendations for health behaviors and that keeps them in the hospital longer. So, there's a little bit of a disconnect between the actual measure itself and the complexity of factors that actually go into determining somebody's length of stay.”

For the Vietnamese men and Filipina women with lower odds of extended stays, they could theoretically be healthier, but they also could have been treated suboptimally and discharged too early.

“That's actually an area that we're seeking to understand better, particularly to understand what the optimal quality improvement interventions might be for those patients,” Shah added.

According to Lee and colleagues, the study highlights why providers should be working at  improving patient education and communication through language aids and culturally concordant education.

Like the investigators, the editorialists also urge placing greater emphasis on “conducting clinical trials inclusive of Asian American participants and industry-wide disaggregation of Asian American data.”

This study could have potentially included a larger cohort of patients, but more than 21,000 Asian patients in the registry were excluded because they didn’t have specific subgroup identification available.

“Distinct Asian group data have been collected by the US Census Bureau since 1997 and have been studied annually by the American Community Survey since 2005,” Lee and colleagues write. “However, there is no standardization of racial data within medical records, and this study can be considered a call to action toward implementing universal standards to reflect disaggregated data being captured at the federal level.”

Shah said doing so is feasible and moves the needle forward toward better personalized care for patients.

“The  process of expanding the ability for patients to self-identify should be done in partnership with communities and should be done respecting the demographics of the population that a health system serves,” he added. “But there are certainly health systems that do it better than others. The only reason why this study was possible was because there are some health systems that do enable people who identify as Asian to identify in disaggregated groups, and then there are others that don't.”