Zhang David T, Onyebeke Chukwuma, Nahid Musarrat, Balkan Lauren, Musse Mahad, Pinheiro Laura C, Sterling Madeline R, Durant Raegan W, Brown Todd M, Levitan Emily B, Safford Monika M, Goyal Parag
Department of Medicine, Weill Cornell Medicine, New York, NY.
Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY.
medRxiv. 2023 Mar 24:2023.03.23.23287671. doi: 10.1101/2023.03.23.23287671.
The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Since reasons for this are not entirely clear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. We hypothesized that SDOH would be inversely associated with cardiologist involvement in the care of adults hospitalized for HF.
We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF between 2009 and 2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH, which align with the Healthy People 2030 conceptual model: Black race, social isolation (0-1 visits from a family or friend in the past month), social network/caregiver availability (having someone to care for them if ill), educational attainment < high school, annual household income < $35,000, 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, a binary variable which was defined as involvement of a cardiologist as the primary responsible clinician or as a consultant, collected via chart review. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with statistically significant associations (p<0.10) were retained for multivariable analysis. Potential confounders/covariates for the multivariable analysis included age, race, sex, HF characteristics, comorbidities, and hospital characteristics.
We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years (IQR 71.0-83.7), 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH that had a statistically significant association with cardiologist involvement in a bivariate analysis (RR: 0.88 [95% CI: 0.82-0.95]). After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]).
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 the care provided to patients hospitalized for HF.
在因心力衰竭（HF）住院期间，心脏病专家参与成人患者的护理与降低院内死亡率和再住院率相关。然而，并非所有因HF住院的患者都会见到心脏病专家。由于原因尚不完全清楚，我们试图确定健康的社会决定因素（SDOH）是否与心脏病专家参与HF住院成人的管理有关。我们假设SDOH与心脏病专家参与HF住院成人的护理呈负相关。
我们纳入了来自全国性的中风地理和种族差异原因（REGARDS）队列的成年参与者，他们在2009年至2017年期间因HF经历了经裁定的住院治疗。我们排除了在缺乏心脏病学服务的机构住院的参与者（n = 246）。我们检查了九个候选SDOH，这些与《健康人民2030》概念模型一致：黑人种族、社会隔离（过去一个月家人或朋友来访0 - 1次）、社会网络/照顾者可用性（生病时有照顾他们的人）、教育程度低于高中、家庭年收入低于35,000美元、居住在农村地区、居住在贫困率高的邮政编码地区、居住在卫生专业人员短缺地区以及居住在公共卫生基础设施差的州。主要结局是心脏病专家的参与，这是一个二元变量，定义为心脏病专家作为主要负责临床医生或顾问的参与，通过病历审查收集。我们使用具有稳健标准误差的泊松回归检查每个SDOH与心脏病专家参与之间的关联。具有统计学显著关联（p < 0.10）的候选SDOH被保留用于多变量分析。多变量分析中的潜在混杂因素/协变量包括年龄、种族、性别、HF特征、合并症和医院特征。
我们检查了在美国549家独特医院住院的876名参与者。中位年龄为77.5岁（IQR 71.0 - 83.7），45.9%为女性，41.4%为黑人，56.2%收入低。低家庭收入（每年< 35,000美元）是在二元分析中与心脏病专家参与具有统计学显著关联的唯一SDOH（RR：0.88 [95% CI：0.82 - 0.95]）。在调整潜在混杂因素后，低收入仍然呈负相关（RR：0.89 [95% CI：0.82 - 0.97]）。
家庭收入低的成年人在因HF住院期间，心脏病专家参与其护理的可能性低11%。这表明社会经济地位可能会隐含地影响为因HF住院的患者提供的护理。
