Community-Level Economic Distress, Race, and Risk of Adverse Outcomes After Heart Failure Hospitalization Among Medicare Beneficiaries

• Type of Material: Article
• Authors: Amgad Mentias, Cleveland Clinic Foundation; Milind Y Desai, Cleveland Clinic Foundation; Mary S Vaughan-Sarrazin, University of Iowa; Shreya Rao, UT Southwestern Medical Center; Alanna Morris, Emory University; Jennifer L Hall, American Heart Association; Venu Menon, Cleveland Clinic Foundation; Jason Hockenberry, Emory University; Mario Sims, University of Mississippi; Gregg C Fonarow, Ronald Reagan Univ Calif Los Angeles; Saket Girotra, University of Iowa; Ambarish Pandey, UT Southwestern Medical Center
• Language: English
• Date: 2022-01-11
• Publisher: LIPPINCOTT WILLIAMS & WILKINS
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2022 Elsevier B.V. All rights reserved.
• Final Published Version (URL): http://dx.doi.org/10.1161/CIRCULATIONAHA.121.057756
• Title of Journal or Parent Work: CIRCULATION
• Volume: 145
• Issue: 2
• Start Page: 110
• End Page: 121
• Grant/Funding Information: The current research was partly funded by philanthropic gifts by the Haslam Family, Bailey Family and Khouri family to the Cleveland Clinic (PI: Dr. Desai). Dr. Pandey has received research support from the Texas Health Resources Clinical Scholarship, the Gilead Sciences Research Scholar Program, the National Institute on Aging GEMSSTAR Grant (1R03AG067960–01), and Applied Therapeutics.
• Keywords: AFRICAN-AMERICANS; readmission; Peripheral Vascular Disease; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Cardiovascular System & Cardiology; Science & Technology; mortality; HEALTH; heart failure; racial disparity; QUALITY-OF-CARE

Abstract

Background: Socioeconomic disadvantage is a strong determinant of adverse outcomes in patients with heart failure. However, the contribution of community-level economic distress to adverse outcomes in heart failure may differ across races and ethnicities. Methods: Patients of self-reported Black, White, and Hispanic race and ethnicity hospitalized with heart failure between 2014 and 2019 were identified from the Medicare MedPAR Part A 100% Files. We used patient-level residential ZIP code to quantify community-level economic distress on the basis of the Distressed Community Index (quintile 5: economically distressed versus quintiles 1-4: nondistressed). The association of continuous and categorical measures (distressed versus nondistressed) of Distressed Community Index with 30-day, 6-month, and 1-year risk-adjusted mortality, readmission burden, and home time were assessed separately by race and ethnicity groups. Results: The study included 1 611 586 White (13.2% economically distressed), 205 840 Black (50.6% economically distressed), and 89 199 Hispanic (27.3% economically distressed) patients. Among White patients, living in economically distressed (versus nondistressed) communities was significantly associated with a higher risk of adverse outcomes at 30-day and 1-year follow-up. Among Black and Hispanic patients, the risk of adverse outcomes associated with living in distressed versus nondistressed communities was not meaningfully different at 30 days and became more prominent by 1-year follow-up. Similarly, in the restricted cubic spline analysis, a stronger and more graded association was observed between Distressed Community Index score and risk of adverse outcomes in White patients (versus Black and Hispanic patients). Furthermore, the association between community-level economic distress and risk of adverse outcomes for Black patients differed in rural versus urban areas. Living in economically distressed communities was significantly associated with a higher risk of mortality and lower home time at 1-year follow-up in rural areas but not urban areas. Conclusions: The association between community-level economic distress and risk of adverse outcomes differs across race and ethnic groups, with a stronger association noted in White patients at short- and long-term follow-up. Among Black patients, the association of community-level economic distress with a higher risk of adverse outcomes is less evident in the short term and is more robust and significant in the long-term follow-up and rural areas.