Comparing Two Methods of Caring for Black and Hispanic Adults with Heart Failure after They Leave the Hospital [Internet]

Background: In the United States, Black and Hispanic populations experience a high prevalence of heart failure (HF). To address this disparity, we sought to compare health care utilization and quality of life (QOL) for Black and Hispanic patients admitted to a “safety net” hospital for HF. Patients were randomly assigned to receive a telehealth self-monitoring (TSM) intervention or comprehensive outpatient management (COM).

Objectives:

1. Aim 1: To assess usability and adapt TSM to facilitate acceptability and feasibility in a population of underserved Black and Hispanic patients.

2. Aim 2: To compare inpatient and emergency department (ED) utilization and QOL of underserved patients with HF randomized at discharge to TSM or COM.

Methods: We used a mixed-methods approach, including a randomized controlled trial (RCT), to assess TSM usability and effectiveness. Medical history, hospital utilization, demographics, depression, anxiety, and QOL were recorded at days 1 and 90. TSM patients transmitted their vital signs daily and attended a weekly video visit. We analyzed binary outcomes for ED visits and hospitalizations using the standard chi-square or Fisher exact test. We also used Poisson or negative binomial regression, repeated-measures analysis of variance, or generalized estimating equations (GEEs) as appropriate. We based the choice of Poisson, overdispersed Poisson, or negative binomial on standard goodness-of-fit statistics (the deviance statistic). We computed associated 95% CIs for these proportions and their differences using exact methods.

Results:

1. Aim 1: We used the ADAPT-ITT framework (Assessment, Decisions, Administration, Production, Topical experts, Integration, Training staff, and Testing) to tailor the TSM intervention. The adaptation, based on data from 3 focus groups, theater testing, and a small pilot study, resulted in an acceptable and feasible intervention for the target patient population.

2. Aim 2: Of the 104 patients randomized, 31% were Hispanic, 69% Black, and 41% female. Overall, 72% of patients reported incomes of <$10 000/year. Intention-to-treat (ITT) analyses revealed no significant utilization differences between TSM and COM groups for (1 or more) all-cause ED visits (relative risk [RR], 1.37; 95% CI, 0.83-2.27) or hospitalizations (RR, 0.92; 95% CI, 0.57-1.48) and mean length of stay (TSM: 5.2 vs COM: 3.6 days) within 90 days of discharge. The average number of all-cause hospitalizations greater than 90 days was significantly lower for COM patients (TSM = 0.78 vs COM = 0.55; P = .03). Finally, while QOL improved for both groups over time (TSM baseline = 62.7; 90-day = 36.3; COM baseline = 59.2; 90-day = 27.8; P = .5), COM patients reported a greater reduction of anxiety (TSM baseline = 50%; 90-day = 28%; COM baseline = 57%; 90-day = 13%; P = .05). TSM adherence was low: 50% of participants provided <10 transmittals of vital signs during the 90-day period.

Conclusions: While the ADAPT-ITT framework was successfully utilized to tailor a TSM intervention for patients with HF from Black and Hispanic low-income communities, TSM was not associated with reduced all-cause 90-day ED and inpatient utilization. The mean number of all-cause hospitalizations was significantly lower for the COM group. QOL and depression did not differ between the 2 groups, while COM patients reported a greater reduction of anxiety over time.

Limitations and Subpopulation Considerations: This single-center study may not be generalizable to other underserved patients with HF. Future studies should address methods to improve compliance to improve TSM treatment effect size on all-cause– and HF-related utilization outcomes.