Impact of social determinants of health on post-hospitalization outcomes and goal-concordant care in patients with advanced heart failure - 1 Background: Social determinants of health (SDoH) and healthcare inequities influence the advanced illness 2 experience of patients with heart failure (HF). HF is a serious, chronic, and progressive clinical syndrome 3 affecting over 6 million (and rising) adults in the U.S. HF hospitalizations are reported in patients with late-stage, 4 advanced disease and these patients often experience repeat hospitalizations, nearly one-third die within one 5 year following a hospital admission for HF, and almost none survive past two years. Outcomes differ in racial 6 groups, with rates of hospitalizations for HF almost 2.5 times higher in Black patients than white. These health 7 disparities are further exacerbated as HF progresses to an advanced stage, where the general patient preference 8 is to remain at home after being discharged from the hospital after an acute HF incident. While generally 9 accepted that SDoH can be broadly used to identify patients at high risk for worse HF outcomes, what is not yet 10 known is whether any individual SDoH or groups of SDoH are key contributors, or drivers, of adverse health 11 outcomes or readmission after hospital discharge for an acute HF incident, particularly in diverse racial groups 12 with advanced HF. Therefore, we hypothesize that, by applying a combination of SDoH- and health-equity- 13 focused lenses of analysis to a highly diverse cohort of patients with advanced HF, we will be able to reveal the 14 individual, systematic, organizational, structural and/or community factors that drive post-hospitalization 15 outcomes, and, ultimately, lead to hospital readmission. Aim 1 Determine the associations between SDoH and 16 the 30- and 90-day post-hospitalization outcomes among racially diverse patients with advanced (Stage C/D) 17 HF. Aim 2 Identify HF patient perceptions and associated contextual factors of SDoH that influence the 18 achievement of goal-concordant care outcomes among patients with advanced HF living in the community. 19 Methods: We will conduct a prospective, concurrent mixed-methods triangulation study with quantitative and 20 qualitative (quant+QUAL) methodologies to contextualize the experiences of patients with advanced HF post- 21 hospitalization. Inclusion criteria: >18 years-old, hospitalized at the study site, diagnosed with advanced 22 (ACCF/AHA Stage C or D) HF, Meta-Analysis Global Group in Chronic Heart Failure Integer risk score >18 23 (range 0–52). Exclusion criteria: current enrollment in hospice, having a plan for cardiac procedures/surgical 24 therapy within six months, or having a documented non-cardiac terminal illness. Analysis: For binary readmission 25 outcomes, we will use multivariable logistic analysis to evaluate whether SDoH variables associated with 26 readmissions at 30 and/or 90 days. Qualitative analysis will be conducted on patient interviews with vanManen’s 27 phenomenological approach. Findings: Findings from this study will further health equity science by providing 28 the empirical and contextual evidence needed to fill gaps in our understanding about putative SDoH-related 29 individual, systematic, and community-based drivers of post-hospitalization patient-centered HF outcomes in 30 diverse populations with advanced HF.
