Title

Association between Social Determinants of Health and Completion of Coronary Artery Disease Testing among Patients with New Onset Heart Failure with Reduced Ejection Fraction

Authors

Samhitha Peddada MD, AnMarie Nguyen PhD, Janet S. Lee MS, Bing Han PhD, Cynthia H. Ho MD, Ming-Sum Lee MD, PhD, Cheng-Wei Huang MD

Introduction

Coronary artery disease (CAD) testing is recommended in patients with heart failure with reduced ejection fraction (HFrEF) to identify etiology and guide management. In our previous study, we noted that 25% of patients ordered for CAD testing within 90 days of hospital discharge for new-onset HFrEF did not complete their evaluation. Social determinants of health (SDoH) have been shown to affect cardiovascular health outcomes. We sought to identify whether SDoH are associated with incomplete testing.

Methods

A retrospective cohort study of patients with new-onset HFrEF with a CAD testing order within 90 days of discharge from 15 Kaiser Permanente Southern California Medical Centers between January 2016 through December 2021 was performed. Patients were excluded if they had a history of heart transplant, hospice enrollment, or expired within 90 days of discharge. The study was approved by the KPSC Institutional Review Board and informed consent was waived. SDoH included type insurance coverage (commercial/private, Medicaid/dual, Medicare) and neighborhood deprivation index (NDI). NDI is an index measuring 13 factors of socioeconomic status (SES) including income, education, occupation, and housing conditions. In our cohort, ?2 and ANOVA testing suggested a correlation between race/ethnicity and SDoH (p<0.001). Therefore, following bivariate analysis, two multivariable logistic regressions were performed with model 1 including age, sex, race/ethnicity and Model 2 (race-agnostic) including age, sex, insurance, and NDI. We also performed an additional sensitivity analysis including all variables (age, sex, race/ethnicity, insurance, NDI). All analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC).

Results

A total of 688 patients with new-onset HFrEF with a CAD testing order within 90 days from hospital discharge were identified. The median (interquartile range) was 65 (56-75) years, 37% were female, and 38% were of White race. The median EF was 27 (20-32)%. In bivariate analysis, factors associated with incomplete testing included patients of Black race (0.55 [95% confidence interval: 0.34-0.87]), NDI Q4 (most deprived, 0.52 [0.31-0.86]), and Medicaid/dual (0.47 [0.25-0.85]), while patient of Hispanic race was borderline associated (0.64 [0.41-1.00]). In model 1, patients of Black (0.55 [0.35-0.88]) and Hispanic (0.63 [0.41-0.99]) race were associated with incomplete testing. In the race-agnostic model, patients with NDI Q4 (0.57 [0.34-0.96]) and Medicaid/dual (0.51[0.27-0.97]) were associated with incomplete testing. In sensitivity analysis including both race/ethnicity and SDoH, only Medicaid/dual insurance coverage (0.51 [0.26-0.93]) was significantly associated with incomplete testing. The race-agnostic model had a similar c-statistics of 0.62 to the more comprehensive sensitivity analysis model while having a lower Akaike information criterion (AIC) at 756.1 than both Model 1 (758.9) and the sensitivity analysis (758.7).

Conclusion

Factors associated with incomplete CAD testing include Black race, lower SES based on NDI, and Medicaid/dual insurance. However, the strongest contributors to testing likelihood were SDoH ( insurance and NDI), as race did not improve model performance. Our study highlights the possibility of substituting race with SDoH to guide decision-making on whether patients should receive CAD testing during hospitalization to minimize incomplete testing.

References

Brandt, E. J. (2023). Social determinants of racial health inequities. The Lancet Public Health, 8(6). https://doi.org/10.1016/s2468-2667(23)00100-7 Yancy, C. W., & Khan, S. S. (2022). Replacing race with social determinants of health in risk prediction—getting it right. JAMA Cardiology, 7(8), 856. https://doi.org/10.1001/jamacardio.2022.1909 Javed, Z., Haisum Maqsood, M., Yahya, T., Amin, Z., Acquah, I., Valero-Elizondo, J., Andrieni, J., Dubey, P., Jackson, R. K., Daffin, M. A., Cainzos-Achirica, M., Hyder, A. A., & Nasir, K. (2022). Race, racism, and Cardiovascular Health: Applying a social determinants of health framework to racial/ethnic disparities in cardiovascular disease. Circulation: Cardiovascular Quality and Outcomes, 15(1). https://doi.org/10.1161/circoutcomes.121.007917