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Ward-Caviness CK, Danesh Yazdi M, Moyer J, et al. Long-term exposure to air pollution from particles is associated with 30-day re-instructions and hospital visits in patients with heart failure.J am Heart Assoc. 2021;10(10):e019430.
Draft
Researchers conducted an observational study using quasi-Poisson regression models to associate annual average levels of particulate matter at the time of heart failure (HF) diagnosis with the number of hospital visits and 30-day readmissions.
Study population
The population data analyzed in this study comes from the research resource of the Environmental Protection Agency (EPA) Clinical and Archived Records Research for Environmental Studies (EPA Cares). This resource consists of electronic patient files that are merged with environmental load data to facilitate environmental health studies. The researchers analyzed data from a total of 20,920 patients with heart failure (10,998 women, 9,922 men). The average age was 68.8 years. There were 13,875 white participants, 5,564 black participants and 1,481 listed participants listed as "other".
pollution
Investigators geocoded primary patient addresses at street level and estimated daily particulate matter exposure2.5(Particulate matter with diameters of 2.5 microns or smaller) using a validated model.1Each patient was linked to a 1 × 1 km grid cell based on their address, and the researchers used this grid cell to calculate average annual air pollution exposure. They determined initial heart failure diagnosis and hospital admissions through electronic medical records.
Target parameters
The researchers used quasi-poisson models that were adapted to the age of fine dust With the number of hospital visits and 30-day re-occupations.
Important knowledge
A total of 442,244 hospital visits were recorded for this patient cohort over an average follow-up of 2.79 years.
A 1-µg/m3An increase in fine dust pollution was associated with an increase of 9.31 % (95 % AI, 7.85 % –10.8 %) of the hospital visits as a whole; an increase of 4.35 % (95 % AI, 1.12 % –7.68 %) in inpatient recordings; And an increase of 14.2 % (95 % AI, 8.41 % –20.2 %) in the 30-day re-resolutions. These associations were robust compared to various modeling approaches.
The authors conclude: "An increased exposure to air pollution in patients with heart failure increases 30-day resumption, outpatient visits and inpatient recordings, which indicates a general increase in morbidity with increasing exposure."
Practice implications
The prevalence of heart failure is increasing in the United States. By 2030, an estimated 8 million people will have heart failure, a 46% increase from 2012. In 2012, the total cost of heart failure in the United States was estimated at $30.7 billion, with approximately 68% of these costs attributable to direct healthcare costs such as hospital visits and inpatient stays. By 2030, the cost of heart failure is estimated to be $69.8 billion, an increase of 127%.2
These filters are inexpensive and designed to be exchanged at regular intervals, but only a few people are aware of it, they still know that these filters are available as a HEPA filter that were specially developed for removing fine dust.
Although our attention in clinical practice is addressed to every single patient, these larger trends are worth mentioning because they indicate who and what we will see in the examination room.
Thanks to the Affordable Care Act, which imposes fines on hospitals for poor performance, hospital readmission rates are now a key metric in evaluating hospital performance. Under the Hospital Readmissions Reduction Program, increased 30-day readmission rates resulted in 3% of Medicare and Medicaid fee-for-service payments being withheld for heart failure and 5 other conditions. While 3% may not sound like much, it amounted to hundreds of millions of dollars in 2020. Although corporate financial concerns are not at the top of our list of concerns, this study provides a valuable calculation for assessing difficult environmental pollution risks.
It is well known that long-term exposure to air pollution increases the risk of hospitalization. A 2019 study by Danesh Yazdi reported long-term exposure to particulate matter2.5was associated with an increased probability of inpatient admission in the Medicare population, even in areas where PM2.5The concentrations were under the current annual national ambient Air Quality standard of 12 µg/m3.3
The biological mechanisms explaining these associations have been well explained and include systemic inflammation, increased activation of the autonomic nervous system, and oxidative stress induced by PM infiltration2.5Particles in the airways.4-6
The current Ward Caviness study only considered the subgroup of patients with existing heart failure. To summarize the results, a 1-µg/m3The increase in fine dust pollution was connected by 14.2 % with an increase in the entire hospital visits by 9.31 %, an increase in inpatient recordings by 4.35 % and an increase in 30-day reproductions (see section "Key results" for confidence intervals). In this data, black patients with heart failure had the highest associations between the hospital visits as a whole and the long -term exposure to air pollution; The associated risk was 40 % higher in black patients than in white patients. These racial differences were even greater in 30-day returns. Since minorities are often exposed to above-average air pollution, it is possible that some of the health differences observed in heart failure patients are caused by exposure to air pollution.7
A similar explanation may contribute to the racial disparities in breast cancer rates among black women, who are more likely to have aggressive subtypes of breast cancer. High PM2.5Exposure was associated with a higher risk of more aggressive forms of breast cancer.8
Data such as those presented in this and other recent studies suggest that certain subgroups of patients—in this case, those with congestive heart failure—may benefit from reducing their PM exposure2.5. Even if we believe that this is a problem that should be addressed at local, state or national level, our patients who suffer from an illness should not be asked to wait until the political leadership or even basic organizations cause changes. Rather, they should be encouraged to take proactive measures to reduce their own exposure.
Exposure can be reduced by modern ventilation and filter systems in residential and business buildings. Modern cars are equipped with air filters in the interior. These filters are inexpensive and designed to be exchanged at regular intervals, but only a few people are aware of it, they still know that these filters are available as a HEPA filter that were specially developed for removing fine dust.
Health practitioners should use this new data in terms of congestive heart failure and PM2.5To specifically encourage patients with cardiovascular diseases to actively reduce their exposure. A clinical study by Maestas et al. (N=40) in 2018, conducted in Detroit, Michigan, reported that portable household air filters reduce particulate matter2.5Exposure by more than 50 %.9
According to the World Bank database, average PM exposure2.5has fallen from 9.741 µg/m in the United States3in 2011 to 7.41 µg/m3in 2017.10The EPA offers current information on the degree of pollution according to the postcode www.airnow.gov.11If the results of Maestas are correct and home filter are reduced by half - let's say another 3.5 µg/m3(3.5 x 9.3 = 32.55%) – such an intervention could reduce hospital visits for heart failure patients by a third. For us and our patients, it's not about reducing healthcare costs, it's about reducing suffering, and these numbers suggest that efforts to reduce exposure to air pollutants could make a significant difference and be worthwhile.