Mortality From Heart Failure Increases 3-Fold From Having Just 1 SDOH

There is a 15% to 20% greater chance of death in the 90 days following a hospitalization for heart failure (HF) among patients with Medicare compared with the general population, making the condition the top cause of hospitalization in these patients. Social determinants of health (SDOH) are factors that influence this rate.

Research published online last week in the Journal of the American Heart Association show how having just 1 SDOH markedly increased 90-day mortality among Medicare beneficiaries, while no such link was found if a patient had more than 1 SDOH. This despite the results showing patients with more than 1 SDOH were more likely to live in high-poverty areas and had more comorbidities.

The study population comprised 690 patients from 440 US hospitals. Their median (interquartile range [IQR]) age was 76 (71-82) years at the first hospitalization for HF between 2003 and 2014, and they had to have Medicare Part A coverage from 6 months before that hospitalization through the following 90 days. The authors consulted Healthy People 2020 to design their study criteria.

Using data from the national prospective observational Reasons for Geographic and Racial Differences in Stroke study, the authors investigated the influence of 9 SDOH on mortality: black race, social isolation (a max of 1 monthly visit), social network (the patient has a caregiver when necessary), low educational level (not a high school graduate), low annual household income (<$35,000), lives in a rural area (based on Rural Urban Commuting area codes), lives in a zip code with high poverty (>25% of residents live below the federal poverty line), lives in an area with few health professionals, and public health infrastructure. These fit in to 5 categories: social and community, education, economic stability, neighborhood and built environment, and health and healthcare.

“I think the powerful influence of these social determinants of health is incredible and underappreciated,” said Madeline R. Sterling, MD, MPH, MS, lead author of the study and assistant professor of medicine in the Division of General Internal Medicine at Weill Cornell Medicine in New York.

Overall, 71% of the study population had at least 1 SDOH (39% had 1; 32% had at least 2), while 28% had none. The SDOH with the most influence were the following:

• Black race (hazard ratio [HR], 1.55; 95% Cl, 0.99-2.43)
• Living in an area with few health professionals (HR, 1.56; 95% CI, 1.00-2.42)
• Not having a caretaker when necessary (HR, 1.60; 95% CI, 0.92-2.79)
• Rural location (HR, 1.60; 95% CI, 0.84-3.04; P <.20)

In addition, 90-day mortality was more than 3 times likely among patients with just 1 SDOH as it was among those with at least 2 or none, per 1000 person-years:

• 1 SDOH: 1.85
• At least 2 SDOH: 1.77
• No SDOH: 0.54

“The results of this study suggest that having any of an individual’s SDOH assessed herein nearly tripled the risk of 90-day mortality after a hospitalization for HF, independent of a host of covariates,” the authors concluded. “Assessing SDOH may serve as a new marker for identifying and intervening upon the most vulnerable HF patients in the post-discharge period.”

To make progress against the influence of SDOH, the study team hopes their results will aid in the design of population-based interventions against 90-day mortality for patients with HF, even by including just 1 SDOH in their risk predictions. The authors also note that their results add to evidence from previous studies showing that SDOH must be considered leading factors in the health of patients post discharge.

References

Sterling MR, Ringel JB, Pinheiro LC, et al. Social determinants of health and 90-day mortality after hospitalization for heart failure in the REGARDS study [published online April 22, 2020]. J Am Heart Assoc. doi: 10.1161/JAHA.119.014836.