Health Status Equity: A Right Not A Privilege

Heart failure health status is poor in women, racial/ethnic minorities, and the socioeconomically disadvantaged.(1) In comparison to 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/ethnicity, and low socioeconomic position.(2, 3) Furthermore, women and racial/ethnic minorities are often undertreated and understudied in clinical trials.(4) As illustrated in the study by Khariton, the older white male demographic was associated with the best heart failure health status.(5)

Among a multi-center registry of patients with heart failure with reduced ejection fraction, (Change the Management of Patients with Heart Failure, CHAMP-HF), Khariton et al. studied cross-sectional associations of gender, race/ethnicity, and household income with heart failure health status.(5) 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 backwards selection models. Female sex, Hispanic ethnicity, and income were independently associated with a lower heart failure health status after adjustment. This study did not address associations between time-dependent titrations in evidence-based medication or initiation of cardiac rehabilitation. However, it supported data that suggest patient reported outcomes are unsatisfactory for women, racial/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. healthcare system administrators must understand the value of obtaining health status through patient reported outcomes. Multiple validated measures of heart failure health status, most notably, 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 healthcare 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 KCCQ at multiple centers across the U.S.(5) The Centers for Medicare & Medicaid Services (CMS) 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/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 due to 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)

Lastly, 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 CMS 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 healthcare systems that demonstrate the greatest improvements in heart failure health status, particularly among groups with lower health status such as women, racial/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 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 healthcare system.

In summary, 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 healthcare policy that prioritizes heart failure health status. Women, racial/ethnic minorities, and patients of lower socioeconomic position can achieve equity in ideal heart failure status.