Abstract 284: Social Determinants of Health and 90 Day Mortality after Hospitalization for Heart Failure in the REasons for Geographic and Racial differences in Stroke (REGARDS) Study

Abstract Background Understanding health care experiences during the COVID-19 pandemic may provide insights into patient needs and inform policy. The objective of this study was to describe health care experiences by race and social determinants of health. Methods We conducted a telephone survey (July 6, 2020-September 4, 2021) among 9492 Black and White participants in the longitudinal REasons for Geographic And Racial Differences in Stroke cohort study, age 58–105 years, from the continental United States. Among participants with symptoms of COVID-19, outcomes were: 1. Sought care or advice for the illness; 2. Received a SARS-CoV-2 test for the illness; and 3. Tested positive. Among participants without symptoms of COVID-19, outcomes were: 1. Wanted a test; 2. Wanted and received a test; 3. Did not want but received a test; and 4. Tested positive. We examined these outcomes overall and in subgroups defined by race, household income, marital status, education, area-level poverty, rural residence, Medicaid expansion, public health infrastructure ranking, and residential segregation. Results The average age of participants was 76.8 years, 36% were Black, and 57% were female. Among participants with COVID-19 symptoms (n = 697), 74% sought care or advice for the illness, 50% received a SARS-CoV-2 test, and 25% had a positive test (50% of those tested). Among participants without potential COVID-19 symptoms (n = 8795), 29% wanted a SARS-CoV-2 test, 22% wanted and received a test, 8% did not want but received a test, and 1% tested positive; a greater percentage of participants who were Black compared to White wanted (38% vs 23%, p < 0.001) and received tests (30% vs 18%, p < 0.001) and tested positive (1.4% vs 0.8%, p = 0.005). Conclusions In this national study of older US adults, many participants with potential COVID-19 symptoms and asymptomatic participants who desired testing did not receive COVID-19 testing.

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Abstract 262: The Impact of Social Determinants of Health on Heart Failure Readmission in a Veteran Population: A Single Center Study

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.262 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Sunita K Mahabir ◽

Neal Olarte ◽

Ana M Palacio

Keyword(s):

Heart Failure ◽

High Risk ◽

Social Determinants Of Health ◽

Social Determinants ◽

Social Factors ◽

Determinants Of Health ◽

Fiscal Year ◽

Readmission Rates ◽

Validated Questionnaire ◽

The Impact

Background: Chronic heart failure (CHF) affects more than 5 million Americans and accounts for approximately 1 million hospitalizations annually. Readmission in CHF patients is associated with higher mortality and consumes a significant portion of hospital resources. Readmission rates may be higher when socioeconomic factors limit medication compliance and follow-up. In light of the high prevalence of CHF and the penalties associated with readmission rates, our study aims to identify factors that place our veterans with CHF at higher risk for readmission and in so doing, develop a profile for patients with a high risk of readmission that will benefit from focused intervention. Our goal is to use the information acquired in this study to reduce CHF readmission in the Miami VAMC by 10% over a 12-month period. Methods: This is an ongoing retrospective study conducted at the Miami VAMC. The Strategic Analysis for Improvement and Learning (SAIL) report was used to identify patients with CHF who were admitted to the Miami VAMC over fiscal year 2019 (FY19), the period from September 2018 to August 2019. Data was collected on various clinical baseline characteristics and social determinants of health from the patients' electronic health records for those admitted as well as for those with recurrent admissions within FY19. Using a previously validated questionnaire, identified patients will undergo further interview, in person or by phone, to identify social factors that may place them at higher risk for readmission. Results/Anticipated Results: A total of 185 patients were admitted during FY19 and of these, 38 had recurrent admissions. The mean time to readmission was 82 days. 76% of the patients readmitted had heart failure with reduced ejection fraction. Multiple co-morbidities were seen in the readmitted group, the commonest being hypertension (82%), diabetes (63%) and chronic kidney disease (39%). Thirty percent of those readmitted had a history of illicit drug use compared to 26% of those who were not readmitted. This population was also found to have multiple psychiatric co-morbidities - depression, anxiety and post-traumatic stress disorder. The odds of having one or more readmission within 12 months was 25% greater in those with psychiatric illness than in those without. Conclusion: Preliminary data analysis shows that psycho-social factors may play a role in recurrent admission in CHF patients. Further data will be collected to determine the impact of factors such as housing, education level and income on readmission risk so that patients at high risk can be identified and targeted with improved care co-ordination services to reduce this risk. As a unified health system, the VAMC is uniquely equipped with resources to address these disparities.

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Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Circulation ◽

10.1161/cir.0000000000000767 ◽

2020 ◽

Vol 141 (22) ◽

Cited By ~ 7

Author(s):

Connie White-Williams ◽

Laura P. Rossi ◽

Vera A. Bittner ◽

Andrea Driscoll ◽

Raegan W. Durant ◽

...

Keyword(s):

Heart Failure ◽

Social Determinants Of Health ◽

Social Determinants ◽

Healthcare Providers ◽

Clinical Syndrome ◽

Assessment Tools ◽

Determinants Of Health ◽

Number Of Patients ◽

Patients With Heart Failure ◽

Scientific Statement

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

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Social Determinants of Health and 30-Day Readmissions Among Adults Hospitalized for Heart Failure in the REGARDS Study

Circulation Heart Failure ◽

10.1161/circheartfailure.121.008409 ◽

2021 ◽

Author(s):

Madeline R. Sterling ◽

Joanna Bryan Ringel ◽

Laura C. Pinheiro ◽

Monika M. Safford ◽

Emily B. Levitan ◽

...

Keyword(s):

Public Health ◽

Heart Failure ◽

Older Adults ◽

Health Professional ◽

Social Determinants Of Health ◽

Social Determinants ◽

Public Health Infrastructure ◽

Health Infrastructure ◽

Regards Study ◽

Health Professional Shortage Area

Background: It is not known which social determinants of health (SDOH) impact 30-day readmission after a heart failure (HF) hospitalization among older adults. We examined the association of 9 individual SDOH with 30-day readmission after an HF hospitalization. Methods and Results: Using the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), we included Medicare beneficiaries who were discharged alive after an HF hospitalization between 2003 and 2014. We assessed 9 SDOH based on the Healthy People 2030 Framework: race, education, income, social isolation, social network, residential poverty, Health Professional Shortage Area, rural residence, and state public health infrastructure. The primary outcome was 30-day all-cause readmission. For each SDOH, we calculated incidence per 1000 person-years and multivariable-adjusted hazard ratios of readmission. Among 690 participants, the median age was 76 years at hospitalization (interquartile range, 71–82), 44.3% were women, 35.5% were Black, 23.5% had low educational attainment, 63.0% had low income, 21.0% had zip code–level poverty, 43.5% resided in Health Professional Shortage Areas, 39.3% lived in states with poor public health infrastructure, 13.1% were socially isolated, 13.3% had poor social networks, and 10.2% lived in rural areas. The 30-day readmission rate was 22.4%. In an unadjusted analysis, only Health Professional Shortage Area was significantly associated with 30-day readmission; in a fully adjusted analysis, none of the 9 SDOH were individually associated with 30-day readmission. Conclusions: In this modestly sized national cohort, although prevalent, none of the SDOH were associated with 30-day readmission after an HF hospitalization. Policies or interventions that only target individual SDOH to reduce readmissions after HF hospitalizations may not be sufficient to prevent readmission among older adults.

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Social determinants of health and cancer mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study

Cancer ◽

10.1002/cncr.33894 ◽

2021 ◽

Author(s):

Laura C. Pinheiro ◽

Evgeniya Reshetnyak ◽

Tomi Akinyemiju ◽

Erica Phillips ◽

Monika M. Safford

Keyword(s):

Cohort Study ◽

Social Determinants Of Health ◽

Racial Differences ◽

Social Determinants ◽

Cancer Mortality ◽

Determinants Of Health

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Number of Social Determinants of Health and Fatal and Nonfatal Incident Coronary Heart Disease in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Circulation ◽

10.1161/circulationaha.120.048026 ◽

2020 ◽

Author(s):

Monika M. Safford ◽

Evgeniya Reshetnyak ◽

Madeline R. Sterling ◽

Joshua S. Richman ◽

Paul M. Muntner ◽

...

Keyword(s):

Coronary Heart Disease ◽

Heart Disease ◽

Social Determinants Of Health ◽

Racial Differences ◽

Social Determinants ◽

Clinical Care ◽

Community Dwelling ◽

Determinants Of Health ◽

Incident Coronary Heart Disease ◽

Prospective Longitudinal

Background: Social determinants of health (SDH) are individually associated with incident coronary heart disease (CHD) events. Indices reflecting social deprivation have been developed for population management, but are difficult to operationalize during clinical care. We examined whether a simple count of SDH is associated with fatal incident CHD and nonfatal myocardial infarction (MI). Methods: We used data from the prospective longitudinal REasons for Geographic And Racial Differences in Stroke cohort study, a national population-based sample of community-dwelling Black and white adults age ≥45 years recruited from 2003-7. Seven SDH from the five Healthy People 2020 domains included social context (Black race, social isolation); education (educational attainment); economic stability (annual household income); neighborhood (living in a zip code with high poverty); and healthcare (lacking health insurance, living in one of the 9 US states with the least public health infrastructure). Outcomes were expert adjudicated fatal incident CHD and nonfatal MI. Results: Of 22,152 participants free of CHD at baseline, 58.8% were women, 42.0% were Blacks, 20.6% had no SDH, 30.6% had 1, 23.0% had 2, and 25.8% had ≥3. There were 463 fatal incident CHD events and 932 nonfatal MIs over median 10.7 years [IQR 6.6-12.7]. Fewer SDH were associated with nonfatal MI than with fatal incident CHD. The age-adjusted incidence per 1000 person-years increased with the number of SDH for both fatal incident CHD (0 SDH 1.30, 1 SDH 1.44, 2 SDH 2.05, ≥3 SDH 2.86) and nonfatal MI (0 SDH 3.91, 1 SDH 4.33, ≥2 SDH 5.44). Compared to those without SDH, crude and fully adjusted hazard ratios (HR) for fatal incident CHD among those with ≥3 SDH were 3.00 (95% CI 2.17, 4.15) and 1.67 (95% CI 1.18, 2.37), respectively; and that for nonfatal MI among those with ≥2 SDH were 1.57 (95% CI 1.30, 1.90) and 1.14 (0.93, 1.41), respectively. Conclusions: A greater burden of SDH was associated with a graded increase in risk of incident CHD, with greater magnitude and independent associations for fatal incident CHD. Counting the number of SDH may be a promising approach that could be incorporated into clinical care to identify individuals at high risk of CHD.

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Abstract 14837: Social Determinants of Health and Outcomes in Patients With Advanced Heart Failure: Findings From PAL-HF

Circulation ◽

10.1161/circ.142.suppl_3.14837 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Vanessa Blumer ◽

Joseph G Rogers ◽

Christopher OConnor ◽

Robert M Clare ◽

Daniel B Mark ◽

...

Keyword(s):

Heart Failure ◽

Palliative Care ◽

Usual Care ◽

Social Determinants Of Health ◽

Clinical Outcomes ◽

Social Determinants ◽

Economic Security ◽

Determinants Of Health ◽

Anxiety And Depression ◽

Anxiety Depression

Background: Social determinants of health (SDH) are associated with cardiovascular disease outcomes, but the overall influence of SDH on end-stage heart failure has not been well-described. Methods: In the Palliative Care in Heart Failure (PAL-HF) study, 150 advanced HF patients were randomized to usual care or usual care plus palliative care intervention. In the present analysis, quality of life (QoL) metrics [Kansas City Cardiomyopathy Questionnaire (KCCQ) and Functional Assessment of Chronic Illness Therapy (FACIT) Palliative care (PAL)], anxiety and depression (Hospital Anxiety and Depression Scale; HADS Depression, HADS Anxiety) and clinical outcomes (mortality, rehospitalization) were examined based on SDH (marital status, employment status, economic security, education level). For statistical analyses, patients were grouped per independent variable of interest in dichotomous categories (partner vs. no partner, employed/retired vs. unemployed, patient-reported economic constraints vs. no constraints, education beyond high school (HS) vs. less than HS). Repeated measures models were used to compare QoL metrics between SDH groups and Cox models for clinical outcomes. Results: At 6-month follow-up, having a partner, being employed, education beyond HS, and having economic security were not associated with better QoL or anxiety/depression metrics in advanced HF patients. Unemployment and education less than HS were associated with increased 6-month rehospitalization (both p=0.03). SDH measures were not associated with mortality (all p>0.05) (Table). Conclusions: In this analysis of PAL-HF patients, SDH were not associated with improved QoL or anxiety/depression metrics over 6 months. However, being employed and education beyond HS were associated with reduced rehospitalization. Further studies accounting for SDH are needed to better determine how these factors should be incorporated into palliative care interventions in advanced HF.

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Abstract P554: Multiple Social Determinants of Health and Incident Stroke in the Reasons for Geographic and Racial Differences in Stroke Study

Circulation ◽

10.1161/circ.141.suppl_1.p554 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Author(s):

Evgeniya Reshetnyak ◽

Laura C. Pinheiro ◽

Monika M. Safford ◽

Mariella Ntamatungiro ◽

April P. Carson ◽

...

Keyword(s):

Social Determinants Of Health ◽

Racial Differences ◽

Social Determinants ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Determinants Of Health ◽

Cox Models ◽

Black And White ◽

Cox Proportional Hazards Models ◽

Stroke Study

Introduction: Although social determinants of health (SDOH) were shown to be individually associated with incident stroke, few studies explored the effect of multiple SDOH within the same individuals on incident stroke. To address this limitation, we operationalized SDOH as a count and examined its association with incident stroke. This approach is practically appealing in clinical settings - it is easy to calculate and interpret. Hypothesis: We hypothesized that a greater number of SDOH within individuals would be significantly associated with a higher risk of incident stroke. Methods: REGARDS is a prospective cohort of 30,239 black and white adults aged > 45 years recruited in 2003-2007. Sociodemographic, medical history, and stroke risk factors were collected at baseline. To define exposure, we followed the Healthy People 2020 framework, and initially used 10 SDOH to represent 5 domains: education, health, social, economic and neighborhood factors. We selected SDOH that were significantly associated with incident stroke: race, education, income, zip code poverty, health insurance, social isolation, and residence in states with poor public health infrastructure. We then created a primary exposure - a count of SDOH for each individual. The outcome was expert adjudicated incident strokes. Cox proportional hazards models examined associations between a count of SDOH (0, 1, 2, 3+) and incident stroke, adjusting for confounders. Results: This study included 27,813 individuals free from stroke at baseline. We observed 1470 incident strokes during the follow-up. A significant interaction between SDOH count and age resulted in stratification at 75 years. In fully adjusted Cox models, among individuals <75 years, risk of stroke amplified with each increase in number of SDOH. This pattern was not observed among those 75+ years (Table 1). Conclusions: Individuals <75 years with a greater number of SDOH had higher risk of stroke. Targeting individuals with multiple SDOH, especially those <75 years, may help reduce risk of stroke.

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