American Heart Association

ournal of the American Heart Association
J Am Heart Assoc. 2020;9:e014836. DOI: 10.1161/JAHA.119.014836 1
ORIGINAL RESEARCH
Social Determinants of Health and 90-Day
Mortality After Hospitalization for Heart
Failure in the REGARDS Study
Madeline R. Sterling , MD, MPH, MS; Joanna Bryan Ringel, MPH; Laura C. Pinheiro, PhD, MPH;
Monika M. Safford, MD; Emily B. Levitan, ScD; Erica Phillips, MD, MS; Todd M. Brown, MD, MSPH;
Parag Goyal, MD, MS
BACKGROUND: Outcomes following heart failure (HF) hospitalizations are poor, with 90-day mortality rates of 15% to 20%.
Although prior studies found associations between individual social determinants of health (SDOH) and post-discharge mortality, less is known about how an individuals’ total burden of SDOH affects 90-day mortality.
METHODS AND RESULTS: We included participants of the REGARDS (Reasons for Geographic and Racial Differences in Stroke)
Study who were Medicare beneficiaries aged ≥65 years discharged alive after an adjudicated HF hospitalization. Guided by
the Healthy People 2020 Framework, we examined 9 SDOH. First, we examined age-adjusted associations between each
SDOH and 90-day mortality; those associated with 90-day mortality were used to create an SDOH count. Next, we determined the hazard of 90-day mortality by the SDOH count, adjusting for confounders. Over 10 years, 690 participants were
hospitalized for HF at 440 unique hospitals in the United States; there were a total of 79 deaths within 90 days. Overall, 28% of
participants had 0 SDOH, 39% had 1, and 32% had ≥2. Compared with those with 0, the age-adjusted hazard ratio for 90-day
mortality among those with 1 SDOH was 2.89 (95% CI, 1.46–5.72) and was 3.06 (1.51–6.19) among those with ≥2 SDOH. The
adjusted hazard ratio was 2.78 (1.37–5.62) and 2.57 (1.19–5.54) for participants with 1 SDOH and ≥2, respectively.
CONCLUSIONS: While having any of the SDOH studied here markedly increased risk of 90-day mortality after an HF hospitalization, a greater burden of SDOH was not associated with significantly greater risk in our population.
Key Words: cohort study ■ heart failure ■ mortality ■ social determinants of health
Heart failure (HF) is the most common cause of
hospitalization among Medicare beneficiaries, resulting in 1 million hospitalizations per year.1 While
health system-, hospital-, and patient-based interventions have been implemented to improve posthospitalization outcomes, mortality rates remain high
and have worsened in recent years.2,3 This is especially
true for Medicare beneficiaries, where 15% to 20% of
individuals discharged alive following an HF hospitalization die within 90 days of discharge.4–7 Although
severity of HF and comorbidity burden are likely to drive
some of this risk of mortality,8,9 an improved understanding of additional factors that contribute to 90-day
mortality following an HF hospitalization is necessary to
develop interventions to target patients at highest risk.
Studies have sought to understand the effect of social determinants of health (SDOH) on mortality after an
HF hospitalization.10,11 SDOH, which are defined as the
conditions in which people are born, grow, work, live,
age, and the wider set of forces and systems shaping
Correspondence to: Madeline R. Sterling, MD, MPH, MS, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th
Street, Box 331, New York, NY 10021. E-mail: mrs9012@med.cornell.edu
Supplementary material for this article is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.119.014836
This study was presented at the American Heart Association Quality of Care and Outcomes Research Scientific Sessions Conference, April 5–6, 2019, in
Arlington, VA. This study was also presented as a poster at the American Heart Association Scientific Sessions, November 17, 2019, in Philadelphia, PA.
For Sources of Funding and Disclosures, see page 10.
© 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative
Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and
is not used for commercial purposes.
JAHA is available at: www.ahajournals.org/journal/jah