Income and education as determinants of hospital utilization but not mortality in heart failure
A Carrete, D Blanco, E Santiago-Vacas, V Peric, M Ruiz, P Codina, A Borrellas, C Badia, M Domingo, B Gonzalez, E Crespo, A Pulido, P Velayos, A Ros, A Bayes-GenisAbstract
Background
Heart failure (HF) is one of the most prevalent diseases and changes in medical therapy have had a great impact in its prognosis, leading to a reduction of mortality in patients referred to a HF clinic. The impact of socioeconomic status on HF prognosis remains unknown.
Purpose
To evaluate socioeconomic status in patients referred to an outpatient clinic over the span of 20 years and to analyse trends in mortality.
Methods
A retrospective analysis of a prospective registry of HF patients in a specialised ambulatory HF clinic was conducted, from August 3rd 2001 ( opening of the HF unit) to December 31st 2023. We analyzed the patients educational background, as well as their income and their marital status at admission. The variables analysed include age, sex, aetiology, HF type (preserved - HFpEF, reduced - HFrEF, mildly-reduced - HFmrEF), NYHA class, left ventricle ejection fraction (LVEF), highest level of education, marital status and renta-per-capita according to zip-code. Mortality and total number of hospital admissions were also included.
Results
A total of 3672 patients were included (mean age 66.8 ± 12,8, 29.9% women). 56.9% were smokers or ex-smokers and 23.3% were alcohol users or had a history of alcohol abuse. 65% had hypertension, 41.9% had diabetes and 54% had dyslipidemia. The average LVEF was 37% ± 14.4. The main aetiology of the referred patients was ischaemic heart disease (44.3%). There was a total of 5463 hospital admissions, but only 44.5% were related to HF. Average renta-per-capita was 31997€ ± 8473.6€. 62% of patients had no education or primary education only. 68% were married or in a relationship. There was a total of 5463 hospital admissions, over 50% not related to HF. Income was classified into three categories (low, medium or high) and bivariate analysis was performed, which showed no significant association between income and mortality (p=0.536). In multivariable logistic regression adjusted for age and sex, income level was not independently associated with mortality. The number of hospital admissions was significantly associated with income (p=0.017). Multivariable Poisson regression analysis adjusted for age, sex, left ventricular ejection fraction (LVEF), aetiology, educational level, and NYHA functional class, income showed a modest and non-linear association with hospital admissions, while higher educational level was independently associated with a lower rate of hospital admissions.
Conclusion
Socioeconomic status was associated with hospital admissions in HF patients, but not with mortality. Educational level and disease severity are independently associated with hospital admissions, which suggest that adverse outcomes in heart failure are primarily driven by clinical complexity, with social factors such as education contributing to differences in healthcare utilization rather than survival.For image description, please refer to the figure legend and surrounding text.