Division of General Internal Medicine (L.C.P., E.R., M.R.S., M.M.S., P.G.), Department of Medicine, Weill Cornell Medicine, New York, NY.
Department of Epidemiology, University of Alabama at Birmingham (E.B.L.).
Circ Cardiovasc Qual Outcomes. 2020 Aug;13(8):e006438. doi: 10.1161/CIRCOUTCOMES.119.006438. Epub 2020 Jul 24.
Socially determined vulnerabilities (SDVs) to health disparities often cluster within the same individual. SDVs are separately associated with increased risk of heart failure (HF). The objective of this study was to determine the cumulative effect of SDVs to health disparities on incident HF hospitalization.
Using the REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort study, we studied 25 790 participants without known HF and followed them for 10+ years. Our primary outcome was an incident HF hospitalization through December 31, 2016. Guided by the Healthy People 2020 framework for social determinants of health, we examined 10 potential SDVs. We retained SDVs associated with incident HF hospitalization (<0.10) and created an SDV count (0, 1, 2, 3+). Using the count, we estimated Cox proportional hazard models to examine associations with incident HF hospitalization, adjusting for potential confounders. Models were stratified by age (45-64, 65-74, and 75+ years) because past reports suggest greater disparities in HF incidence at younger ages. Participants were followed for a median of 10.1 years (interquartile range, 6.5-11.9). Black race, low educational attainment, low annual household income, zip code poverty, poor public health infrastructure, and lack of health insurance were associated with incident HF hospitalization. In adjusted models, among those 45 to 64 years, compared with having no SDV, having 1 SDV (hazard ratio, 1.85 [95% CI, 1.12-3.05]), 2 SDVs (hazard ratio, 2.12 [95% CI, 1.28-3.50]), and 3+ SDVs (hazard ratio, 2.45 [95% CI, 1.48-4.04]) were significantly associated with incident HF hospitalization ( for trend, 0.001). We observed no significant associations for older individuals.
A greater number of SDVs significantly increased risk of incident HF hospitalization among adults <65 years, which persisted after adjustment for cardiovascular risk factors. Using a simple SDV count that could be obtained from a social history during clinical assessment may identify younger individuals at increased risk.
社会决定的健康差异脆弱性（SDV）通常在同一个体中聚集。SDV 分别与心力衰竭（HF）风险增加相关。本研究的目的是确定 SDV 对健康差异的累积效应与 HF 住院事件的关系。
利用 REGARDS（地理和种族差异中风原因）队列研究，我们研究了 25790 名无已知 HF 的参与者，并对他们进行了 10 年以上的随访。我们的主要结局是通过 2016 年 12 月 31 日的 HF 住院事件。根据《健康人民 2020 框架》中社会决定因素的健康，我们检查了 10 种潜在的 SDV。我们保留了与 HF 住院事件相关的 SDV（<0.10），并创建了 SDV 计数（0、1、2、3+）。使用该计数，我们估计了 Cox 比例风险模型，以检验与 HF 住院事件的关联，调整了潜在的混杂因素。模型按年龄（45-64、65-74 和 75+岁）分层，因为过去的报告表明，HF 发病率在年轻人群中差异更大。参与者的中位随访时间为 10.1 年（四分位间距，6.5-11.9）。黑人种族、教育程度低、家庭年收入低、邮政编码贫困、公共卫生基础设施差和缺乏医疗保险与 HF 住院事件相关。在调整后的模型中，在 45 至 64 岁的人群中，与没有 SDV 相比，有 1 个 SDV（风险比，1.85[95%CI，1.12-3.05]）、2 个 SDV（风险比，2.12[95%CI，1.28-3.50]）和 3 个或更多 SDV（风险比，2.45[95%CI，1.48-4.04]）与 HF 住院事件显著相关（趋势检验，0.001）。我们没有观察到年龄较大的个体有显著关联。
在<65 岁的成年人中，SDV 的数量增加与 HF 住院事件的风险显著增加有关，在调整心血管风险因素后仍然存在。使用简单的 SDV 计数，可以从临床评估中的社会史中获得，这可能可以识别出风险较高的年轻个体。
