Heart, Thoracic, and Vascular Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., V.M.).
Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center (M.S.V.-S., S.G.).
Circulation. 2022 Jan 11;145(2):110-121. doi: 10.1161/CIRCULATIONAHA.121.057756. Epub 2021 Nov 8.
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.
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.
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.
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.
社会经济劣势是心力衰竭患者不良结局的重要决定因素。然而，社区经济困境对心力衰竭患者不良结局的贡献可能因种族和族裔而异。
从医疗保险 MedPAR 部分 A 100% 文件中确定了 2014 年至 2019 年期间报告为黑种人、白种人和西班牙裔的心力衰竭住院患者。我们使用患者居住的邮政编码，根据困境社区指数（五分位 5：经济困境与五分位 1-4：非困境）量化社区经济困境。连续和分类（困境与非困境）困境社区指数指标与 30 天、6 个月和 1 年风险调整死亡率、再入院负担和家庭时间的相关性，分别按种族和族裔群体进行评估。
研究纳入了 1611586 名白种人（13.2%经济困境）、205840 名黑种人（50.6%经济困境）和 89199 名西班牙裔（27.3%经济困境）患者。在白种人群体中，居住在经济困境（而非非困境）社区与 30 天和 1 年随访时不良结局风险增加显著相关。在黑种人和西班牙裔患者中，与居住在困境社区相比，居住在非困境社区的不良结局风险在 30 天内并无显著差异，但在 1 年随访时变得更为显著。同样，在受限立方样条分析中，白种人社区经济困境指数与不良结局风险之间的相关性更强且呈梯度分布（而非黑种人和西班牙裔患者）。此外，黑种人患者的社区经济困境与不良结局风险之间的关联在农村地区与城市地区有所不同。在农村地区，居住在经济困境社区与 1 年随访时的死亡率升高和家庭时间减少显著相关，但在城市地区则不然。
社区经济困境与不良结局风险之间的关联因种族和族裔群体而异，在短期和长期随访中，白种人患者的相关性更强。在黑种人患者中，社区经济困境与不良结局风险之间的关联在短期内不太明显，而在长期随访和农村地区则更为显著。
