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. 2020 Dec;13(12):e007947.
doi: 10.1161/CIRCHEARTFAILURE.120.007947. Epub 2020 Nov 9.

Excess 30-Day Heart Failure Readmissions and Mortality in Black Patients Increases With Neighborhood Deprivation

Shivani A Patel  1 , Maya Krasnow  2 , Kaitlyn Long  1 , Theresa Shirey  3 , Neal Dickert  4 , Alanna A Morris  4
Affiliations

Excess 30-Day Heart Failure Readmissions and Mortality in Black Patients Increases With Neighborhood Deprivation

Shivani A Patel et al. Circ Heart Fail. 2020 Dec.

Abstract

Background: Longstanding racial disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. We examined whether neighborhood environment modifies the disparity in 30-day HF readmissions and mortality between Black and White patients in the Southeastern United States.

Methods: We created a geocoded retrospective cohort of patients hospitalized for acute HF within Emory Healthcare from 2010 to 2018. Quartiles of the Social Deprivation Index characterized neighborhood deprivation at the census tract level. We estimated the relative risk of 30-day readmission and 30-day mortality following an index hospitalization for acute HF. Excess readmissions and mortality were estimated as the absolute risk difference between Black and White patients within each Social Deprivation Index quartile, adjusted for geographic clustering, demographic, clinical, and hospital characteristics.

Results: The cohort included 30 630 patients, mean age 66 years, 48% female, 53% Black. Compared with White patients, Black patients were more likely to reside in deprived census tracts and have higher comorbidity scores. From 2010 to 2018, 29.4% of Black and 23.0% of White patients experienced either a 30-day HF readmission or 30-day death (P<0.001). Excess in composite 30-day HF readmissions and mortality for Black patients ranged from 3.9% (95% CI, 1.5%-6.3%; P=0.0002) to 6.8% (95% CI, 4.1%-9.5%; P<0.0001) across Social Deprivation Index quartiles. Accounting for traditional risk factors did not eliminate the Black excess in combined 30-day HF readmissions or mortality in any of the neighborhood quartiles.

Conclusions: Excess 30-day HF readmissions and mortality are present among Black patients in every neighborhood strata and increase with progressive neighborhood socioeconomic deprivation.

Keywords: heart failure; hospitalization; patients; residential characteristics; social determinants of health.

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Conflict of interest statement

Disclosures: None of the authors have any conflicts of interest to report related to this research.

Figures

Figure 1.
Figure 1.. Absolute risk of 30-d HF readmissions, 30-d mortality, and composite endpoint in White patients and Black patients stratified by age and type of HF.
The unadjusted risk of 30-d readmissions and the composite endpoint was higher in Black compared with White patients whether stratified by age or type of HF. The unadjusted risk of 30-d mortality was higher in Black compared with White patients older than age 65 years , and higher in Black compared with White patients. *p<0.05, **p<0.01, ***p<0.001.
Figure 1.
Figure 1.. Absolute risk of 30-d HF readmissions, 30-d mortality, and composite endpoint in White patients and Black patients stratified by age and type of HF.
The unadjusted risk of 30-d readmissions and the composite endpoint was higher in Black compared with White patients whether stratified by age or type of HF. The unadjusted risk of 30-d mortality was higher in Black compared with White patients older than age 65 years , and higher in Black compared with White patients. *p<0.05, **p<0.01, ***p<0.001.
Figure 1.
Figure 1.. Absolute risk of 30-d HF readmissions, 30-d mortality, and composite endpoint in White patients and Black patients stratified by age and type of HF.
The unadjusted risk of 30-d readmissions and the composite endpoint was higher in Black compared with White patients whether stratified by age or type of HF. The unadjusted risk of 30-d mortality was higher in Black compared with White patients older than age 65 years , and higher in Black compared with White patients. *p<0.05, **p<0.01, ***p<0.001.
Figure 1.
Figure 1.. Absolute risk of 30-d HF readmissions, 30-d mortality, and composite endpoint in White patients and Black patients stratified by age and type of HF.
The unadjusted risk of 30-d readmissions and the composite endpoint was higher in Black compared with White patients whether stratified by age or type of HF. The unadjusted risk of 30-d mortality was higher in Black compared with White patients older than age 65 years , and higher in Black compared with White patients. *p<0.05, **p<0.01, ***p<0.001.
Figure 1.
Figure 1.. Absolute risk of 30-d HF readmissions, 30-d mortality, and composite endpoint in White patients and Black patients stratified by age and type of HF.
The unadjusted risk of 30-d readmissions and the composite endpoint was higher in Black compared with White patients whether stratified by age or type of HF. The unadjusted risk of 30-d mortality was higher in Black compared with White patients older than age 65 years , and higher in Black compared with White patients. *p<0.05, **p<0.01, ***p<0.001.
Figure 1.
Figure 1.. Absolute risk of 30-d HF readmissions, 30-d mortality, and composite endpoint in White patients and Black patients stratified by age and type of HF.
The unadjusted risk of 30-d readmissions and the composite endpoint was higher in Black compared with White patients whether stratified by age or type of HF. The unadjusted risk of 30-d mortality was higher in Black compared with White patients older than age 65 years , and higher in Black compared with White patients. *p<0.05, **p<0.01, ***p<0.001.
Figure 2.
Figure 2.. Percentage of patients residing in each quartile of the social deprivation index according to racial group.
The figure shows the distribution of Black and White patients within each unit of the SDI. For example, <1% of Black patients resided in census tracts with SDI score 0–3 while 3.5% of White patients resided in census tracts with an SDI score of 0–2. Because the residential distribution of Black patients is overlaid on the distribution of White patients, the mauve color represents the percentage of black patients in census tracts in which there is a larger percentage of White patients. SDI, Social Deprivation Index
Figure 3.
Figure 3.. Excess risk of 30-d HF readmission (A), 30-d mortality (B), and composite endpoint (C) in Black compared with White patients hospitalized for acute heart failure.
The figure shows absolute risk differences between blacks and whites (reference) in each outcome by quartile of the Social Deprivation Index. The demographics adjusted risk difference accounts for age, sex, insurance, hospital location and year of index hospitalization; the fully adjusted risk difference further accounts for HF type, hypertension, diabetes, coronary artery disease, chronic kidney disease, atrial fibrillation, chronic pulmonary disease, peripheral vascular disease, systolic blood pressure, heart rate, respiration, estimated glomerular filtration rate, blood urea nitrogen, hemoglobin, and sodium, and discharging specialty. HF, Heart Failure; Q2, Quartile 2; Q3, Quartile 3
Figure 3.
Figure 3.. Excess risk of 30-d HF readmission (A), 30-d mortality (B), and composite endpoint (C) in Black compared with White patients hospitalized for acute heart failure.
The figure shows absolute risk differences between blacks and whites (reference) in each outcome by quartile of the Social Deprivation Index. The demographics adjusted risk difference accounts for age, sex, insurance, hospital location and year of index hospitalization; the fully adjusted risk difference further accounts for HF type, hypertension, diabetes, coronary artery disease, chronic kidney disease, atrial fibrillation, chronic pulmonary disease, peripheral vascular disease, systolic blood pressure, heart rate, respiration, estimated glomerular filtration rate, blood urea nitrogen, hemoglobin, and sodium, and discharging specialty. HF, Heart Failure; Q2, Quartile 2; Q3, Quartile 3
Figure 3.
Figure 3.. Excess risk of 30-d HF readmission (A), 30-d mortality (B), and composite endpoint (C) in Black compared with White patients hospitalized for acute heart failure.
The figure shows absolute risk differences between blacks and whites (reference) in each outcome by quartile of the Social Deprivation Index. The demographics adjusted risk difference accounts for age, sex, insurance, hospital location and year of index hospitalization; the fully adjusted risk difference further accounts for HF type, hypertension, diabetes, coronary artery disease, chronic kidney disease, atrial fibrillation, chronic pulmonary disease, peripheral vascular disease, systolic blood pressure, heart rate, respiration, estimated glomerular filtration rate, blood urea nitrogen, hemoglobin, and sodium, and discharging specialty. HF, Heart Failure; Q2, Quartile 2; Q3, Quartile 3
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