Trends in Heart Failure Mortality Disparities Before and After the Implementation of The Affordable Care Act: The Chicago Experience

Abstract

Background Heart failure remains a leading cause of morbidity and mortality in the United States affecting 6.2 million Americans, with a projected prevalence of > 8 million affected by 2030. The impact of heart failure is not shared equitably, the overall age-adjusted death rate for heart failure is 89.7 per 100,000. African American males (118.2) and females (86.0) have a higher death rate compared to white men (111.3) and women (80.4). Studies have also shown that economic burden has been associated with increased heart failure mortality. Access to care has been associated with poor outcomes in HF. The Patient protection and Affordable Care Act (ACA) was signed into law March 10th, 2010 and led to increased health insurance coverage and increased healthcare access. In this study we describe the secular trends on HF mortality in the city of Chicago. Methods This was a retrospective analysis of the City of Chicago Department of Public Health's Epidemiology & Public Health Informatics Data portal from 1999-2017. City level heart failure mortality rates were collected in rates per 100,000 and assessed for change prior to implementation of the ACA and late implementation of the ACA. Mortality rates were categorized by race, gender, and economic hardship. Economic hardship was defined by the 6 variable economic hardship index and was subcategorized as high, medium, and low hardship. Results Overall age-adjusted heart failure mortality rates decreased annually by -1.9% by the end of the pre-ACA period (p= 0.001). By the late ACA period there was a +1.8% annual increase in overall heart failure mortality (p = 0.001). African Americans had a -2.4% reduction and Whites had a -1.14% reduction prior to ACA. Post ACA African Americans had a +2.9% annual increase in HF mortality, and Whites had a -1.14% reduction (p = 0.001). In women HF mortality decreased annually by -2.9% pre-ACA (0.001) and continued to decline by -1.1% (p = .001) by late ACA. HF Mortality in men decreased by -1.1% (p = .004) annually pre-ACA, and increased by +3.1% (p = .001) annually by late ACA. Medium economic burden was associated with a +5.7% (p = .009) annual increase in HF mortality by late ACA. No difference was observed in those with high or low economic burden. Conclusions Following implementation of the ACA, the city of Chicago experienced an increase in the rate of HF mortality. The post ACA period was also notable for widening of racial, gender, and economic disparities in HF mortality. Further investigation into contributing factors is warranted.