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.