Socioeconomic status, Medicaid coverage, clinical comorbidity, and rehospitalization or death after an incident heart failure hospitalization: Atherosclerosis Risk in Communities cohort (1987 to 2004)

Abstract

Background: Among patients with heart failure (HF), early readmission or death and repeat hospitalizations may be indicators of poor disease management or more severe disease.

Methods and results: We assessed the association of neighborhood median household income (nINC) and Medicaid status with rehospitalization or death in the Atherosclerosis Risk in Communities cohort study (1987 to 2004) after an incident HF hospitalization in the context of individual socioeconomic status and evaluated the relationship for modification by demographic and comorbidity factors. We used generalized linear Poisson mixed models to estimate rehospitalization rate ratios and 95% CIs and Cox regression to estimate hazard ratios (HRs) and 95% CIs of rehospitalization or death. In models controlling for race and study community, sex, age at HF diagnosis, body mass index, hypertension, educational attainment, alcohol use, and smoking, patients with a high burden of comorbidity who were living in low-nINC areas at baseline had an elevated hazard of all-cause rehospitalization (HR, 1.40; 95% CI, 1.10 to 1.77), death (HR, 1.36; 95% CI, 1.02 to 1.80), and rehospitalization or death (HR, 1.36; 95% CI, 1.08 to 1.70) as well as increased rates of hospitalization compared to those with a high burden of comorbidity living in high-nINC areas. Medicaid recipients with a low level of comorbidity had an increased hazard of all-cause rehospitalization (HR, 1.19; 95% CI, 1.05 to 1.36) and rehospitalization or death (HR, 1.21; 95% CI, 1.07 to 1.37) and a higher rate of repeat hospitalizations compared to non-Medicaid recipients.

Conclusions: Comorbidity burden appears to influence the association among nINC, Medicaid status, and rehospitalization and death in patients with HF.

Figure 1

Cumulative proportion of participants with an incident heart failure hospitalization experiencing rehospitalization, death and rehospitalization or death, The ARIC study (1987–2004)

Figure 2

Survival after the Incident HF Hospitalization: Time to Rehospitalization by Comorbidity Burden and nINC: The ARIC study (1987–2004).

Figure 2

Survival after the Incident HF Hospitalization: Time to Rehospitalization by Comorbidity Burden and nINC: The ARIC study (1987–2004).

Figure 3

Rate Ratios (and 95% CI) for All-cause, CVD- and HF-related Rehospitalizations among Participants with Incident Hospitalized HF: The ARIC study (1987–2004). *nINC and Medicaid status plus race/study community, gender and age at index event †Model 1 plus hypertension, body mass index, current smoker, current drinker and educational attainment

Figure 3

Rate Ratios (and 95% CI) for All-cause, CVD- and HF-related Rehospitalizations among Participants with Incident Hospitalized HF: The ARIC study (1987–2004). *nINC and Medicaid status plus race/study community, gender and age at index event †Model 1 plus hypertension, body mass index, current smoker, current drinker and educational attainment