title: 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.
  
  
  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.
authors.affiliation: Center for Cardiovascular Innovation, Northwestern University School of Medicine, Chicago, IL 60611, USA. sfarmer@nmff.org
authors.forename: Steven A
authors.initials: SA
authors.lastname: Farmer
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Tuohy
authors.forename: Dylan S
authors.initials: DS
authors.lastname: Small
authors.forename: Yongfei
authors.initials: Y
authors.lastname: Wang
authors.forename: Peter W
authors.initials: PW
authors.lastname: Groeneveld
mesh_terms: D000368:Aged; D058406:Cardiac Resynchronization Therapy / Q000191:economics*; D058409:Cardiac Resynchronization Therapy Devices / Q000191:economics*; D016009:Chi-Square Distribution; D003153:Community Health Services / Q000191:economics*; D017147:Defibrillators, Implantable / Q000191:economics*; D004469:Economics, Hospital; D004554:Electric Countershock / Q000191:economics* / Q000295:instrumentation; D005260:Female; D017048:Health Care Costs; D006297:Health Services Accessibility / Q000191:economics*; D054625:Healthcare Disparities / Q000191:economics*; D006333:Heart Failure / Q000191:economics / Q000628:therapy*; D006801:Humans; D007182:Income; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012042:Registries; D012111:Residence Characteristics; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States