Examining Impact of Social Determinants on Mortality After Heart Failure

Madeline Sterling, MD, MPH

New research from an analysis of the REGARDS Study is shedding new light on social factors impacting the health and 90-day mortality outcomes in patients hospitalized for heart failure (HF).

Investigators found presence of 1 of the 9 social determinants of health examined in the study, which included race, education, and income, was linked to a risk of death nearly 3 times greater than those without any of the 9 determinants.

“I think the powerful influence of these social determinants of health is incredible and underappreciated,” said lead investigator Madeline Sterling, MD, MPH, assistant professor of medicine at Weill Cornell Medicine and an internist at New York-Presbyterian/Weill Cornell Medical Center, in a statement. “Our findings add to a growing body of research that suggests social determinants matter.”

In an effort to identify underserved populations and improve outcomes for patients hospitalized with HF, Sterling and a team of colleagues from Weill Cornell Medicine designed their study to evaluate the burden of social determinants of health using patient data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Included in their analysis were Medicare beneficiaries 65 years of age or older discharged alive after HF hospitalization.

Investigators used the Healthy People 2020 conceptual framework to guide their analysis. From this, they developed 9 social determinants of health, including black race, social isolation (defined as having 0—1 visits from a family or friend in the past month), reporting not having someone to care for them if ill (social network), not graduating high school (low educational attainment), low annual household income (less than $35,000), living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area (HPSA), and poor public health infrastructure. The primary outcome of the analysis was all-cause 90-day mortality after discharge.

Of the 30,239 REGARDS participants, only 690 were included in the investigators’ analysis. Of the 690, 598 had total on all social determinants of health—170 participants had 0 social determinants of health, 236 had 1, and 192 had 2 or more.

Compared to patients with 0 and 1 social determinant of health, those with 2 or more were younger at the time of hospitalization, more likely to be when, more likely to have less education, and have less income. Additionally, those with more than 2 social determinants of health were less likely to undergo coronary revascularization during hospitalization and had longer lengths of stays.

In the 690 participants included, 79 died within 90 days of discharge date. Of note, 28% had 0 social determinants of health, 39% had 1 and 32% had 2 or more. In comparison to those with 0, the age-adjusted hazard ratio for those with 1 social determinant was 2.89 (95% CI, 1.46—5.72) and increased to 3.06 (95% CI, 1.51-6.19). Investigators also noted adjusted the hazard ratio was 2.78 (95% CI, 1.37–5.62) and 2.57 (95% CI, 1.19–5.54) for participants with 1 and 2 or more social determinants of health, respectively.

Investigators noted multiple limitations within their study. Limitations included only assessing for social determinants at baseline, having a modest sample size, and being unable to assess for other social determinants of health such as availability of food and housing.

This study, “Social Determinants of Health and 90-Day Mortality After Hospitalization for Heart Failure in the REGARDS Study,” is published in the Journal of the American Heart Association.