140 Exploring Heart Failure-Related Emergency Department Visits and Hospitalizations From the Patient Perspective

Abstract

Low-income African-Americans with heart failure represent a vulnerable population that has poor clinical outcomes despite high rates of emergency department (ED) visits and hospitalizations. The patient-level factors that contribute to these high rates of health service utilization have not been clearly defined. The purpose of this study is to identify, among low-income African-Americans, patient-perceived medical and social challenges that contribute to poor heart failure-related clinical outcomes, avoidable ED visits, and avoidable hospitalizations. Semi-structured interviews were conducted with a convenience sample of African-American patients who presented to a high volume, inner-city, county-owned, teaching ED in Los Angeles. Patients were eligible for the study if they were being admitted to the hospital for a chronic heart failure exacerbation. The patients were interviewed in the ED or inpatient medicine ward. The interview incorporated questions to examine patients' experiences and beliefs regarding heart failure-related quality of life, general heart failure knowledge, patient-provider interactions, medication adherence, self-management skills, and health system navigation. Two follow-up interviews were performed by telephone with each study participant at 7 days and 30 days following discharge. The follow-up interviews included additional questions regarding patient satisfaction, the quality and comprehension of hospital discharge instructions, ease of new medication regimen, and outpatient follow-up care. Audio files of the interviews were transcribed and organized using Atlas.ti software. Themes were coded using grounded theory methods. Theme saturation was pre-defined as the identification of recurrent themes in greater than 70% of the interviews. Preliminary interviews were conducted with 7 African-American patients with a hospital admission diagnosis of chronic heart failure. The patients consisted of 5 men and 2 women, whose age ranged from 47 to 65 years old. One patient had Medicare insurance and the remaining patients were uninsured. All of the patients had a New York Heart Association classification of 3. Five salient themes were consistently identified that were believed by the patients to contribute to poor health and increased use of hospital-based care: 1) Competing demands due to economic or social stressors which results in medication noncompliance, 2) Dietary challenges and lack of nutrition education, 3) Poor patient-provider communication and/or interactions, 4) Unwarranted judgment by health providers and/or family, and 5) Lack of social support to make and maintain healthy lifestyle changes. All of the patients stated that they had adequate access to health care providers and heart failure related information. African-Americans with heart failure represent a vulnerable population that is subject to poor health outcomes despite costly health service utilization. However, lack of access to medical care is not a patient-perceived contributor to poor health. This qualitative study suggests that social and community factors may have a greater than expected impact on health behaviors and outcomes. The results from this study will be used to develop a community-based intervention to decrease avoidable ED visits and hospitalizations among low-income African-Americans with heart failure.