Heart failure (HF) hospitalization has increased among young adults in the U.S. since 2013, and almost half of these patients are Black and from homes in the lowest quartile of national household income, according to a new 15-year analysis.
The analysis also showed declining hospital mortality in this “medically distinct” population of patients, but with a higher cost of care and bigger comorbidity burden.
The longitudinal findings were reported in a manuscript published Monday online by lead author Vardhman Jain, MD, Cleveland Clinic Foundation, and colleagues, ahead of the May issue of JACC: Heart Failure.
HF is one of the biggest hospitalization and healthcare resource drains in the U.S., affecting more than 6.5 million – mostly older – adults. “It carries a significant health care cost burden that is estimated to rise from about $30 billion in 2012 to about $70 billion by 2030,” said the researchers.
The condition has also affected an increasing proportion of younger patients in recent years, said the researchers, adding that the lifetime risk for those who develop the condition at 40 years of age is estimated to be 20%. “These adverse patterns may be a reflection of the rising burden of noncardiovascular comorbidities, including diabetes, obesity, chronic kidney disease, and substance use in the United States and worldwide.”
Younger HF patients are more likely to have nonischemic etiology, worse medical and dietary adherence and higher readmission rates compared with older counterparts, as well as distinct clinical and biomarker profiles at presentation, “which may render their management challenging,” the researchers added.
Yet, data on the clinical characteristics and outcomes of young adults hospitalized for HF are limited, with the large majority of published data from routine U.S. clinical practice stemming from middle-aged or older HF adults, such as those insured under Medicare.
The current study, therefore, set out to analyze clinical characteristics, comorbidity burden, resource utilization and healthcare costs in 767,180 adults aged 18 to 45 years who were hospitalized with HF as a primary diagnosis from January 2004 to December 2018 (accounting for 4.78% out of a total adult population of 16,049,424 HF patients) in the all-payer U.S. National Inpatient Sample database.
At baseline, in 5-year intervals – 2004 to 2008 (261,906 patients), 2009 to 2013 (229,164 patients) and 2014 to 2018 (276,180 patients) – the mean age remained similar, at around the 38 years mark, and sex-weighting remained stable (37.39%, 36.81% and 37.02% female, respectively).
The total number of young adults with HF was equivalent to 4.32 per 10,000 person-years (95% confidence interval [CI]: 4.31-4.33).
Overall, HF hospitalizations per 10,000 in the U.S. young adult population dropped from 2.43 in 2004 to 1.82 in 2012 (95% CI: 2.42-2.44), but rose from 1.83 in 2013 (95% CI: 1.82-1.84) to 2.51 in 2018 (95% CI: 2.50-2.53, P for trend <0.001 for both).
Young Black adults with low income the majority
Throughout the entire study period, Black adults (50.1%) made up for a significantly higher proportion of HF hospitalizations compared with white (31.9%) and Hispanic (12.2%) adults.
Black men constituted the largest demographic group throughout the study, accounting for 30.4%.
In the 5-year interval groups, the number of Black patients remained similar at 50.87%, 51.48% and 48.32%, respectively, as did the proportion of white (31.92%, 31.23% and 32.38%), Hispanic (12.2%, 11.28% and 12.88) and “other” (5%, 6.01% and 6.42%) patients.
Black adults also had a higher burden of comorbidities including hypertension, obesity and renal failure. They were also more likely to live in zip codes within the lowest quartile of income.
Nearly half (45.8%) of all patients of any race lived in zip codes in the lowest quartile of national household income, increasing slightly throughout the study (from 45.3% in 2004-2008 to 46.9% in 2014-2018; P < 0.001).
The majority of hospitalizations were among Medicare or Medicaid beneficiaries (57.9%), rising over time from 54.1% in 2004-2008 to 62.9% in 2014-2018. This is compared with private insurance patients, who made up 22.5% of hospitalizations overall.
Hospitalizations were most common in the South (47.5%), hospitals with large bed sizes (62.5%) and urban teaching hospitals (60.2%), but were lowest in rural hospitals (8.3%).
Meanwhile, the cost of care was also lower for Black adults ($13,333) compared to white adults ($17,586) over the study period.
Inflation-adjusted cost for the entire population grew from a mean $12,449 in 2004 to $16,786 in 2018.
The cost of care was also higher for men, increasing from $12,764 in 2004 to $15,953 in 2018 versus $11,939 to $14,127 during the same period for women.
Hypertension (49.1%) was the most prevalent risk factor, although it was more common in the distant past (52.81% of patients in 2004-2008) compared to more contemporary populations (39.24% in 2014-2018).
Obesity was the next most common (34.4%), though unlike hypertension, obesity increased over time, from 24.6% in 2004-2008 to 42.97% in 2014-2018.
Smoking was a risk factor in 34.2% overall (again increasing from 24.1% in 2004-2008 to 45.35% in 2014-2018), while diabetes was present in 32.5% (rising from 29.56% in 2004-2008 to 34.78% in 2014-2018).
Between the 2004-2008 and 2014-2018 periods, other comorbidities that grew included drug abuse (13.97% to 15.42%), chronic renal failure (25.15% to 36.94%), deficiency anemias (18.82% to 29.52%), hypothyroidism (4.83% to 7.2%), prior myocardial infarction rates (6.03% to 7.99%) and neurologic disorders (3.62% to 4.82%).
Despite rising hospitalization rates and a stable length of stay (5.2 days) over time, in-hospital mortality (overall 1.3%) decreased over time. This trend was consistent by sex and race.
In-hospital mortality was similar in men and women, but lower in Black patients than in white patients (1.05% vs. 1.58%; adjusted odds ratio [OR]: 0.59; 95% CI: 0.53-0.66; P< 0.01).
In-hospital mortality was higher for HF with reduced ejection fraction compared with HF with preserved ejection fraction (1.35% vs 0.65%; adjusted OR: 2.02; 95% CI: 1.66-2.45; P < 0.01), though both crude and adjusted in-hospital mortality decreased in both HF phenotypes over the study period.
“Multivariate logistic regression showed that peripheral vascular disease, renal failure, valvular heart disease, hypothyroidism, liver disease, and neurologic disorders were associated with a higher likelihood of inpatient mortality.”
Multidimensional approach needed
The researchers stressed that rising HF hospitalizations among young adults “constitute an important cause of loss of productive work years and health care resource utilization.”
“Understanding the trends in their comorbidity burden, hospitalization rates, in-hospital complications, and mortality is important for physicians and health policy makers,” they added.
The researchers concluded by calling for a “multidimensional approach” encompassing physicians, health policymakers, stakeholders and payers to address the rising burden, “with a focus on the economically productive young middle age demographic.”
Jain V, Minhas AMK, Khan SU, et al. Trends in HF Hospitalizations Among Young Adults in the United States From 2004 to 2018. JACC Heart Fail 2022;10:350-362.
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