Abstract 12790: The Role of Social Determinants of Health in Rural Hf Outcomes

Abstract

Background: Over 6.5 million Americans suffer from heart failure (HF) and 20% of these, 1.5 million Americans, live in rural areas. Compared to urban patients with HF, rural patients have higher rates of hospitalization and higher mortality. The reasons for these disparities are not well understood. In this study, we aimed to determine how much of the variation in urban/rural 30-day mortality could be explained by: 1) comorbidities; 2) guideline directed medical therapy (GDMT) use and 3) social determinants of health (SDOH). Methods: Using 100% Medicare Parts A and B and a random 40% sample of Part D, a cohort of 356,194 fee-for-service beneficiaries with ≥1 hospitalization for HFrEF between 2008 and 2016 was created. Rurality was determined using the beneficiaries’ ZIP code of residence and the Rural/Urban Commuting Areas (RUCA) classification. Hierarchical, logistic regression modeling, we then examined the association between 1) comorbidities; 2) GDMT use; and 3) the area deprivation index (ADI), a summary variable capturing multiple SDOH, and 30-day death after hospital discharge among HF patients in urban vs. rural areas. Results: When adjusting only for age, sex and race, rural patients have 15% higher odds of death (95% CI 12%, 19%, p<0.001) in the 30 days after discharge for HFrEF. When comorbidities are added, the odd increase to 18% - an unexpected finding since comorbidity burdens are higher in rural areas. When GDMT use is added, the odds increase to 20%, also unexpected since prior work has shown GDMT is higher in rural areas. When ADI is added, the odds decrease to 14% (95% CI 10%, 18%, p<0.001), suggesting that unlike comorbidities and GDMT use, ADI explains much of variation in urban/rural 30-day death rates. Conclusion: Living in a rural area is associated with a higher risk of 30-day death following a HFrEF hospitalization. Unlike comorbidities and GDMT use, SDOH appear to explain much of this difference in 30-day death rates.