Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Abstract

Background: The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced mortality and readmission rates. However, not all patients see a cardiologist when hospitalized for HF. Since reasons remain unclear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement. Methods: We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF from 2009-2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH: Black race, social isolation, social network, educational attainment, annual household income, living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area, and residing in a state with poor public health infrastructure. The primary outcome was cardiologist involvement. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with significant associations were retained for multivariable analysis. Covariates included age, race, sex, HF characteristics, comorbidities, and hospital characteristics. Results: We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years, 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH significantly associated with cardiologist involvement. After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]). Conclusions: Adults with low household income were 11% less likely to have a cardiologist involved in their care during a hospitalization for HF. This suggests that socioeconomic status may implicitly bias their care.

Competing Interest Statement

Dr. Goyal is supported by American Heart Association grant 20CDA35310455, National Institute on Aging grant K76AG064428, and Loan Repayment Program award L30AG060521; Dr. Goyal receives personal fees for medicolegal consulting related to heart failure; receives consulting fees from Sensorum Health; and has received honoraria from Akcea Therapeutics, Inc.

Funding Statement

This research project is supported by cooperative agreement U01 NS041588 co-funded by the National Institute of Neurological Disorders and Stroke (NINDS) and the National Institute on Aging (NIA), National Institutes of Health, Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINDS or the NIA. Representatives of the NINDS were involved in the review of the manuscript but were not directly involved in the collection, management, analysis, or interpretation of the data. Additional funding was provided by National Heart, Lung, and Blood Institute (NHLBI) grant R01HL080477 (Dr. Safford) and NIA grant R03AG056446 (Dr. Goyal). Dr. Sterling is supported by the NHLBI (K23HL150160). The views expressed here do not reflect those of the NHLBI.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study protocol was reviewed and approved by Weill Cornell Medicine's and the University of Alabama at Birmingham's Institutional Review Boards. All participants provided written informed consent.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

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I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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Data Availability

The authors thank the other investigators, the staff, and the participants of the REGARDS study (REasons for Geographic And Racial Differences in Stroke) for their valuable contributions. A full list of participating REGARDS investigators and institutions can be found at http://www.regardsstudy.org.

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