Disparities in Diagnostic Utilization Patterns Between Heart Failure With Preserved Ejection Fraction (HFpEF) and Heart Failure With Reduced Ejection Fraction (HFrEF): A Nationwide Analysis

Background Heart failure (HF) is a leading cause of morbidity and hospitalization, encompassing distinct phenotypes: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). Disparities in diagnostic imaging may contribute to underdiagnosis and unequal care. This study evaluates differences in combined diagnostic imaging utilization between HFpEF and HFrEF, focusing on social determinants of health (SDoH) and hospital region. Methods We conducted a retrospective cross-sectional study using the 2020 National Inpatient Sample (NIS). Adults (≥18 years) hospitalized with HF were identified using International Classification of Diseases, 10th revision (ICD-10) codes. The primary outcome was receipt of any diagnostic imaging (composite of echocardiography, cardiac magnetic resonance imaging (MRI), and cardiac catheterization). We examined associations between imaging and patient-level (race, income, education, insurance, employment) and hospital-level (region) factors using separate multivariable logistic regression models for HFpEF and HFrEF groups. Results Among 6.47 million weighted HF admissions, 6.95% were HFpEF and 6.55% were HFrEF. Combined diagnostic imaging utilization was low overall (1.72%). After adjustment, Black patients had lower odds of HFpEF diagnosis (adjusted odds ratio (aOR) 0.83, 95% confidence interval (CI): 0.83-0.84) but higher odds for HFrEF (aOR 1.24, 95% CI: 1.23-1.25) than White patients. Cardiac catheterization was strongly associated with both phenotypes (HFpEF, aOR 3.68, 95% CI: 3.62-3.73; HFrEF, aOR 6.23; 95% CI: 6.14-6.32; all p<0.001). Income, education, employment, and hospital region were all significant predictors of imaging disparities. Conclusion Marked disparities in diagnostic imaging exist for both HF phenotypes, driven by race, socioeconomic status, and geography. Despite the clinical importance of imaging, underutilization persists, particularly among minoritized and disadvantaged populations, exacerbated by structural barriers. Implementing targeted interventions to address diagnostic access is essential for equitable HF care.