Readmission and Mortality following Heart Failure Hospitalization: the Role of Neighborhood Pharmacy Availability and Accessibility Restricted; Files Only

Abstract

Background: People with heart failure (HF) in the United States are at high risk for readmission following hospitalization for their condition. Neighborhood-level access to medication post-discharge may be a contributing factor to readmissions. We examined measures of pharmacy accessibility in the state of Georgia and associated readmission and mortality following hospitalization for HF.

 

Methods: We collected pharmacy data from three corporate, local, and federal government sources to assess the distribution of pharmacies in Georgia between 2010-2017. Pharmacy density per 10,000 residents was derived at the census tract level based on each of the three data sources. These census tract measures were merged with patient data from a single healthcare system in the US south. We estimated the association of pharmacy density measures with 30-day and 90-day HF readmission, death, and a composite of HF readmission or death following an index hospitalization for acute HF. Adjusted models accounted for patient demographics, clinical characteristics, and neighborhood-level social factors. We also examined effect modification by race and neighborhood-level vehicle ownership (NVO).

 

Results: There was a small but robust protective association between pharmacy density per 10,000 people and 30- and 90-day HF outcomes. Based on pharmacy measures from the National Neighborhood Data Archive (NaNDA) in 2017, we observed a lower relative risk of 30-day HF outcomes (RR= 0.99, 95% CI: 0.98 – 0.99) for every unit of pharmacy density. In addition, there was a lower relative risk of 90-day HF readmission (RR= 0.99, 95% CI: 0.98 – 1.00), 90-day death (RR= 0.99, 95% CI: 0.98 – 0.99), and 90-day composite measure (RR= 0.99, 95% CI: 0.99 – 1.00) for every unit of pharmacy density. In stratified analysis by race, we observed statistically significant associations only in Black HF patients. In stratified analysis by NVO, no statistically significant associations were observed. Across data sources, little variation was observed in the magnitudes of the associations.

 

Conclusions: Neighborhood-level pharmacy density was associated with lower risk of HF readmissions in patients. Findings warrant further exploration regarding whether increasing pharmacy accessibility—and improving access to medications—could be a target for interventions aimed at reducing HF readmissions.

Table of Contents

1. Introduction....................................................................................................... 1

2. Extended Lit Review............................................................................................ 3

Heart Failure Definition, Types, Causes, and Stages................................................ 3

Heart Failure Readmissions/Mortality and Medication Adherence........................... 7

Access to Medications and its Unstudied Effects in HF Readmissions and Mortality... 8

3. Methods............................................................................................................. 13

Data Sources....................................................................................................... 13

Setting................................................................................................................ 15

Pharmacy measures.............................................................................................. 15

Patient Population.............................................................................................. 15

Patient Readmissions and Mortality Following Hospitalization............................... 16

Patient Neighborhood Social Covariates................................................................ 16

Patient Clinical Covariates................................................................................... 16

Statistical Analyses.............................................................................................. 17

4. Results................................................................................................................ 20

5. Discussion.......................................................................................................... 46

Public Health Implications................................................................................... 50

Strengths and Limitations.................................................................................... 51

6. Conclusion.......................................................................................................... 52

References.............................................................................................................. 53

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health Health Sciences, Pharmacy
Palavra-chave	Pharmacy Accessibility 30-day HF readmissions Neighborhood-Level Disparities Heart Failure 90-day HF readmissions Pharmacy Measures
Committee Chair / Thesis Advisor	Shivani A. Patel, Emory University
Committee Members	Nicole Fields, Emory University

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