Impact of Community Wealth on Use of Cardiac-Resynchronization Therapy With Defibrillators for Heart Failure Patients

Abstract

Background— Disparities in cardiovascular disease treatment are a major health policy concern. A complex interplay of patient, provider, and social contextual factors affect inequities in care. Methods and Results— We used data regarding 22 205 patient stays in the National Cardiovascular Data Registry to explore the effect of hospital resources on receipt of a heart failure therapy, cardiac-resynchronization therapy with defibrillation (CRT-D). When added to patient-level variables, hospital ownership, cardiac patient volume, cardiac procedure availability, CRT-D, implantable cardioverter-defibrillator implantation volumes, and hospital financial characteristics were individually predictive of CRT-D receipt. In the full hierarchical model, average median household income ( P <0.0001) and implantable cardioverter-defibrillator implantation volume ( P <0.001) remained significant predictors of CRT-D receipt. Patients treated at hospitals in affluent communities were more likely to receive CRT-D than patients treated in poor communities, despite accounting for other patient and hospital characteristics, including insurance status. Conclusions— These findings suggest that the likelihood of receiving CRT-D is mediated by community wealth and hospital resources, and that health policy targeting insurance coverage alone may be ineffective in resolving inequities in care.