Methods

This study involved a population-based sample of patients with HF who were admitted to hospitals in 44 states from 2001 to 2011. The 2001 to 2011 NIS is a set of hospital inpatient databases collected by the Healthcare Cost and Utilization Project. The NIS is the largest publicly available all-payer inpatient care database, with discharge data from 1,045 hospitals, a stratified sample of 20% of all US hospital discharges. These data include primary and second admission diagnoses; primary and secondary procedures; admission and discharge status; demographic information such as sex, age, race and ethnicity, zip-code derived median income, and length of stay; and hospital region, teaching status, ownership type, and bed size.

Diagnoses and procedures were identified from the International Classification of Diseases, Ninth Edition, Clinical Modification ( ICD-9 CM ) diagnostic codes. Our sample included subjects who were admitted with a principal diagnosis of systolic, diastolic, or systolic and diastolic HF. We identified these patients using ICD-9 codes that encompassed acute and chronic, systolic and diastolic HF, and HF not otherwise specified (428.0-0.1, 428.20-0.23, 428.30-0.33, 428.40-0.43, 428.9). AF was defined using ICD-9 code 427.31.

Our purpose was to determine racial differences in the prevalence of AF in patients with HF and to evaluate inhospital mortality. The study population with a principle diagnosis of HF was divided into 2 groups: (1) HF cases with AF and (2) HF cases without AF. Within this population, we identified 11,485,673 admissions for HF for a period of 11 years. We also examined procedure utilization with the following procedures: (1) cardioversion (99.61, 99.62, 99.69) and (2) catheter ablation (37.34). Finally, we examined these relations by year of admission to assess any trends over time.

Baseline co-morbidities were identified using methods described by Elixhauser et al. The Elixhauser method has been shown to be the co-morbidity measurement method of choice for administrative data. Furthermore, these methods were validated within a subset of the NIS, were determined to be predictive of mortality within this database, and are recommended for adjustment for severity in the NIS database by the Agency for Healthcare Quality Research.

We used SAS software, version 9.1, for all analyses (SAS Institute Inc., Cary, North Carolina). Univariate and distributional analyses included measures of central tendency, kurtosis, and skew. Bivariate comparisons, such as those comparing the patient characteristics and inhospital mortality, were made using Pearson chi-square tests for dichotomous outcomes and with t tests or 1-way analysis of variance for continuous outcomes. Multivariable logistic regression models were used to assess the association of HF and AF with each outcome (prevalence and inhospital mortality) with covariates including age, gender, income, Elixhauser co-morbidities, and hospital length of stay. Co-morbidities included in the regression models were hypertension, coronary artery disease, chronic lung disease, diabetes mellitus, cardiomyopathy, obesity, myocardial infarction, hyperthyroidism, and hypothyroidism. All analyses were weighted using NIS-provided weights to create national estimates for all analyses.

Results

Of the 11,485,673 patients hospitalized with HF in our study, 3,939,129 (34%) had AF ( Table 1 ). Patients with HF and AF had greater inhospital mortality compared with those with HF without AF (4.6% vs 3.3%, respectively, p <0.0001). Although gender distribution between the 2 groups were similar, patients with HF and AF tended to be significantly older than those with HF without AF. The difference in age was more significant in women compared with men ( Table 1 ).

Table 1 illustrates the difference in the co-morbidity rates between patients with HF with and without AF and the racial breakdown of co-morbidities. In regard to prevalence of AF in HF, whites constituted the greatest portion of patients with HF and AF compared with other racial groups ( Table 1 ). After adjustment for demographics and co-morbidities, we found blacks, Hispanics, Asians, and “other race” patients with HF were 47%, 36%, 19%, and 28% less likely, respectively, to have AF than white patients with HF ( Table 2 ).

Table 3 lists, after adjustment for demographics and co-morbidities, patients with HF and AF had a 13% higher inhospital mortality than if they did not have AF. Furthermore, there was a significant difference in mortality among racial groups. Black patients with HF and AF had a 24% higher mortality than if they did not have AF, whereas Hispanic, Asian, and white patients with HF had a 17%, 13%, and 6% higher mortality than if they did not have AF, respectively.

Table 4 demonstrates the inhospital use of cardioversion in patients with HF suffering from AF. It can be seen that, compared with white patients with HF, there was an underutilization of these 2 procedures among minority racial groups. Specifically, black patients with HF and AF were 38% less likely to undergo cardioversion compared with white patients with HF and AF. Similarly, Hispanic and Asian patients with HF and AF were 39% and 33% less likely to undergo cardioversion, respectively. Table 5 illustrates the inhospital use of catheter ablation in patients with HF and AF. black, Hispanic, and Asian patients with HF and AF were 17%, 22%, and 62% less likely, respectively, to undergo catheter ablation compared with white patients with HF and AF.

Table 4

In-hospital use of cardioversion in AF with HF study participants

Race	Odds Ratio (95% CI)	p Value
White	Reference
Black	0.62 (0.61-0.64)	<.0001
Hispanic	0.61 (0.59-0.64)	<.0001
Asian	0.67 (0.63-0.72)	<.0001
Others	0.81 (0.77-0.85)	<.0001

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