Effects of socioeconomic status on clinical outcomes with ventricular assist devices

Association between psychosocial factors and left ventricular assist device implant outcomes: A systematic review

BACKGROUND

Psychosocial assessment is a core component of the multidisciplinary evaluation for left ventricular assist device (LVAD) implantation. The degree to which psychosocial conditions are considered a contraindication to LVAD implantation continues to be debated. This systematic review examines modifiable psychosocial factors as predictors of outcomes in patients undergoing LVAD implantation.

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The search resulted in 2509 articles. After deduplication, abstract and full-text review, 20 relevant articles were identified.

RESULTS

Included studies evaluated socioeconomic status (n = 6), caregiver characteristics (n = 6), non-adherence (n = 6), substance use (n = 13), and psychiatric disorder (n = 8). The most commonly measured outcomes were all-cause death, readmission rate, and adverse events. Studies varied widely in definition of each psychosocial factor and selected outcomes. No psychosocial factor was consistently associated with a specific outcome in all studies. Socioeconomic status was generally not associated with outcomes. Non-adherence, psychiatric disorder, and substance use were associated with higher risks of mortality, adverse events, and/or readmission. Findings on caregiver characteristics were mixed.

CONCLUSION

Of the psychosocial factors studied, non-adherence, psychiatric disorder, and substance use were the most consistently associated with an increased risk of mortality, readmission, and/or adverse events. Heterogeneity in research methodology and study quality across studies precludes firm conclusions regarding the impact of psychosocial factors on long-term patient outcomes. The results of this review reveal a need for adequately powered studies that use uniform definitions of psychosocial factors to clarify relationships between these factors and outcomes after LVAD implantation.

Socio-economic position, multimorbidity, and health care utilization among Danish left ventricular assist device patients

AIMS

Increasing numbers of patients with advanced heart failure and significant comorbidity and social barriers are considered for left ventricular assist devices (LVADs). We sought to examine health care utilization post-LVAD implantation, including the influence of individual-level socio-economic position and multimorbidity.

METHODS AND RESULTS

We conducted a Danish nationwide cohort study linking individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish national medical and administrative registries. Socio-economic position included cohabitation status, educational level, and employment status. Multimorbidity was defined as two or more chronic conditions from at least two chronic disease groups. Health care utilization (hospital activity, general practice activity, and redeemed medical prescriptions) within 2 years post-discharge after LVAD implantation was evaluated using descriptive statistics at 0.5 year intervals. We identified 119 patients discharged alive with first-time LVAD implanted between 2006 and 2018. The median age of the patients was 56.1 years, and 88.2% were male. Patients were followed until heart transplantation, LVAD explantation, death, 31 December 2018, or for 2 years. The median follow-up was 0.8 years. The highest median use of health care services was observed 0-0.5 years post-LVAD discharge compared with the subsequent follow-up intervals: 0.5-1, 1-1.5, and 1.5-2 years, respectively. The median (interquartile range) number of hospitalizations was 10 (7-14), bed days 14 (9-28), outpatient visits 8 (5-12), telephone contacts with a general practitioner 4 (2-8), and total redeemed medical prescriptions 26 (19-37) within 0-0.5 years post-LVAD discharge compared with the median utilization within the consecutive follow-up periods [e.g. within 0.5-1 year: hospitalizations 5 (3-8), bed days 8 (4-14), outpatient visits 5 (3-8), telephone contacts 2 (0-5), and redeemed medical prescriptions 24 (18-30)]. The median use of health care services was stable from 0.5 years onwards. The median number of hospitalizations and bed days was slightly higher in patients living alone with a low educational level or low employment status within 0-0.5 years post-LVAD implantation. Finally, the median number of in-hospital days and redeemed prescriptions was higher among patients with pre-existing multimorbidity.

CONCLUSIONS

Among patients who underwent LVAD implantation, health care utilization was high in the early post-LVAD discharge phase and was influenced by socio-economic position. Multimorbidity influenced the number of in-hospital days and redeemed prescriptions during the 2 year follow-up.

Intersection of social determinants of health with ventricular assist device therapy: An integrative review

BACKGROUND

Social determinants of health (SDOH) may influence the clinical management of patients with heart failure. Further research is warranted on the relationship between SDOH and Ventricular Assist Device (VAD) therapy for heart failure.

OBJECTIVES

The purpose of this integrative review was to synthesize the state of knowledge on the intersection of SDOH with VAD therapy.

METHODS

Guided by Whittemore and Knafl's methodology, this literature search captured three concepts of interest including VAD therapy, SDOH, and their domains of intersection with patient selection, decision-making, treatment outcome, and resource allocation. CINAHL, Embase, PsycINFO, PubMed, and Web of Science were searched in March 2023. Articles were included if they were peer-reviewed publications in English, published between 2006 and 2023, conducted in the United States, and examined VAD therapy in the context of adult patients (age ≥ 18 years).

RESULTS

22 quantitative studies meeting the inclusion criteria informed the conceptualization of SDOH using the Healthy People 2030 framework. Four themes captured how the identified SDOH intersected with different processes relating to VAD therapy: patient decision-making, healthcare access and resource allocation, patient selection, and treatment outcomes. Most studies addressed the intersection of SDOH with healthcare access and treatment outcomes.

CONCLUSION

This review highlights substantial gaps in understanding how SDOH intersect with patient and patient selection for VAD. More research using mixed methods designs is warranted. On an institutional level, addressing bias and discrimination may have mitigated health disparities with treatment outcomes, but further research is needed for implementing system-wide change. Standardized assessment of SDOH is recommended throughout clinical practice from patient selection to outpatient VAD care.

Left Ventricular Assist Device Use in Minorities: An Analysis of the National Inpatient Sample

Minorities are less likely to receive a left ventricular assist device (LVAD). This, however, is based on total implant data. By examining rates of LVAD implant among patients admitted with heart failure complicated by cardiogenic shock, we sought to further elucidate LVAD utilization rates and racial disparities. Utilizing the National Inpatient Sample from 2013 to 2019, all patients admitted with a primary diagnosis of heart failure complicated by cardiogenic shock were included for analysis. Those who then received an LVAD during that hospitalization defined the LVAD utilization which was examined for any racial disparities. Left ventricular assist device utilization was low across all racial groups with no significant difference noted in univariate analysis. Non-Hispanic Blacks had the highest length of stay (LOS), the highest proportion of discharge to home (71.52%), and the lowest inpatient mortality (6.33%). Multivariable modeling confirmed the relationship between race and LOS; however, no differences were noted in mortality. Non-Hispanic Blacks were found to be less likely to receive an LVAD; however, when controlling for payer, median household income, and comorbidities, this relationship was no longer seen. Left ventricular assist devices remain an underutilized therapy in cardiogenic shock. When using a multivariable model, race does not appear to affect LVAD utilization.

Long-Term Medical Treatment and Adherence in Patients With Left Ventricular Assist Devices: A Danish Nationwide Cohort Study

The use of a left ventricular assist device (LVAD) in treating advanced heart failure has increased. However, data regarding medical treatment and adherence following LVAD implantation is sparse, particularly whether socioeconomic factors (cohabitation status, educational level, employment status, and income) and multimorbidity influence these aspects, which are known to impact adherence in heart failure patients. We performed a nationwide cohort study of 119 patients with LVAD implanted between January 1, 2006, and December 31, 2018, who were discharged alive with LVAD therapy. We linked individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish medical and administrative registers. Medical treatment 90-day pre-LVAD and 720-day post-LVAD were assessed using descriptive statistics in 90-day intervals. Medication adherence (proportion of days covered ≥80%) was assessed 181- to 720-day post-LVAD. The proportions of patients using angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (88.7%), beta-blockers (67.0%), mineralocorticoid receptor antagonists (62.9%), warfarin (87.6%), and aspirin (55.7%) within 90-day post-LVAD were higher than pre-LVAD and were stable during follow-up. Medication adherence ranged from 86.7% (aspirin) to 97.8% (warfarin). Socioeconomic factors and multimorbidity did not influence medical medication use and adherence. Among LVAD patients, medical treatment and adherence are at high levels, regardless of socioeconomic background and multimorbidity.

Influence of Social Determinants of Health on Heart Failure Outcomes: A Systematic Review

Background Prior research suggests an association between clinical outcomes in heart failure (HF) and social determinants of health (SDoH). Because providers should identify and address SDoH in care delivery, we evaluated how SDoH have been defined, measured, and evaluated in studies that examine HF outcomes. Methods and Results Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, databases were searched for observational or interventional studies published between 2009 and 2021 that assessed the influence of SDoH on outcomes. Selected articles were assessed for quality using a validated rating scheme. We identified 1373 unique articles for screening; 104 were selected for full-text review, and 59 met the inclusion criteria, including retrospective and prospective cohort, cross-sectional, and intervention studies. The majority examined readmissions and hospitalizations (k=33), mortality or survival (k=29), and success of medical devices and transplantation (k=8). SDoH examined most commonly included race, ethnicity, age, sex, socioeconomic status, and education or health literacy. Studies used a range of 1 to 9 SDoH as primary independent variables and 0 to 7 SDoH as controls. Multiple data sources were employed and frequently were electronic medical records linked with national surveys and disease registries. The effects of SDoH on HF outcomes were inconsistent because of the heterogeneity of data sources and SDoH constructs. Conclusions Our systematic review reveals shortcomings in measurement and deployment of SDoH variables in HF care. Validated measures need to be prospectively and intentionally collected to facilitate appropriate analysis, reporting, and replication of data across studies and inform the design of appropriate, evidence-based interventions that can ameliorate significant HF morbidity and societal costs.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Socioeconomic Disparities in Referral for Invasive Hemodynamic Evaluation for Advanced Heart Failure: A Nationwide Cohort Study

BACKGROUND

Factors determining referral for advanced heart failure (HF) evaluation are poorly studied. We studied the influence of socioeconomic aspects on the referral process in Denmark, which has a taxpayer-funded national health care system.

METHODS

We identified all patients aged 18 to 75 years with a first diagnosis of HF during 2010 to 2018. Hospitalized patients had to be discharged alive and were then followed for the outcome of undergoing a right heart catheterization (RHC) used as a surrogate marker of advanced HF work-up.

RESULTS

Of 36 637 newly diagnosed patients with HF, 680 (1.9%) underwent RHC during the follow-up period (median time to RHC of 280 days [interquartile range, 73-914]). Factors associated with a higher likelihood of RHC included the highest versus lowest household income quartile (HR, 1.56 [95% CI, 1.19-2.06]; P=0.001), being diagnosed with HF at a tertiary versus nontertiary hospital (HR, 1.68 [95% CI, 1.37-2.05]; P<0.001) and during a hospitalization versus outpatient visit (HR, 1.67 [95% CI, 1.42-1.95]; P<0.001). Level of education, occupational status, and distance to tertiary hospital were not independently associated with RHC. Older age, cancer, and a psychiatric diagnosis were independently associated with a decreased probability of RHC.

CONCLUSIONS

Higher household income, HF diagnosis during hospitalization, and first admission at a tertiary hospital were associated with increased likelihood of subsequent referral for RHC independent of other demographic and clinical variables. Greater attention may be required to ensure timely referral for advanced HF therapies in lower income groups.

A varied approach to left ventricular assist device follow-up improves cost-effectiveness

BACKGROUND

Left ventricular assist device (LVAD) implantation improves outcomes in advanced heart failure, however, the optimal frequency of outpatient assessments to improve cost-effectiveness and potentially avert readmissions is unclear.

METHODS

To test if varying the frequency of follow-up after LVAD implantation reduces readmissions and improves cost-effectiveness, a less intensive follow-up (LIFU) strategy with scheduled visits at 1 month and then every 6 months was compared to an intensive follow-up (IFU) group with scheduled visits at 1, 2, and 4 weeks, and then every 3 months post-implant. We developed a decision-tree model to evaluate the cost-effectiveness of different follow-up schedules at 3, 6, and 12-months. The readmission rates for LIFU and IFU, along with the associated costs, were estimated using data from the IBM MarketScan Commercial Claims Databases (2015-2018). A total of 349 patients were enrolled, with 193 and 156 in the IFU and LIFU groups.

RESULTS

Patients with IFU were found to have a lower risk for readmission at 3 months (HR: 0.69, 95% confidence interval (CI): 0.60-0.79), but this difference diminished overtime at 6 months (HR: 0.84, 95% CI: 0.73-0.96) and 12 months (HR: 0.94, 95% CI: 0.83-1.06). The incremental net benefit of IFU, when compared with LIFU, is greatest in the first 3 months and also diminishes over time (3 months: $19616, 6 months $9257, 12 months $717).

CONCLUSIONS

An initial IFU strategy, followed by a period of de-escalation at the 6-month post-implant mark in lower-risk patients, may be a more cost-effective strategy to provide follow-up care while not predisposing patients to a higher risk of readmission.

The impact of socioeconomic status in patients with left ventricular assist devices (LVADs)

BACKGROUND

Socioeconomic status (SES) can be a powerful predictor of adverse outcomes among heart failure patients but its impact on survival and readmission following left ventricular assist device (LVAD) implantation surgery is poorly understood. We investigated if the LVAD recipients from more deprived neighborhoods experienced higher mortality and readmission rate after device implantation as compared to those from less deprived areas.

METHODS

This is a single center, retrospective analysis evaluating adults who received Heartmate III and Heartware HVAD implants between 2009 and 2018. SES indicators were area of deprivation index (ADI), race and income. Our cohort was grouped by ADI quartiles from least deprived (Q1), Q2, Q3 to the most deprived (Q4). Outcomes included overall mortality and readmission following surgery.

RESULTS

A total of 191 patients were included in the study. Demographics by SES indicators demonstrated that least deprived (Q1) patients were older than the most deprived (65 vs. 57, p < .01), African-American patients originated from more deprived neighborhoods than Caucasians (ADI 87 vs. 62, p < .001), and high-income patients had higher preoperative BUN and creatinine. Outcome differences included a decreased risk of death in most deprived patients (Q4) compared to the least deprived (Q1), however after adjusting for age, LVAD indication, and INTERMACS profile this was no longer significant. No differences in survival or readmission by race or income was observed CONCLUSION: SES does not independently impact survival and readmission after Heartware HVAD and Heartmate III LVAD implantation. More studies are needed to evaluate if other SES factors affect these outcomes.

Impact of Socioeconomic Status on Outcomes After Ventricular Assist Device Implantation Using the Area Deprivation Index

BACKGROUND

This study evaluates the Area Deprivation Index (ADI) as a novel prognostic metric of socioeconomic status for patients with a left ventricular assist device.

METHODS AND RESULTS

A retrospective analysis of patients with a left ventricular assist device at a high-volume institution from 2007 to 2018 was conducted. Socioeconomic status was determined using the ADI, a multifactorial neighborhood-based metric where higher ADI denotes worse socioeconomic status. Patients were stratified into 4 ADI cohorts. Long-term survival was compared with multivariate analysis. Of the 380 patients stratified by ADI, 35 were in the 10th percentile or lower, 218 were in the 11th-50th percentile, 104 were in the 51st-89th percentile, and 23 were in the 90th percentile or higher. Baseline characteristics were comparable. On multivariate analysis, being male (hazard ratio [HR], 0.14; P = .01), bridge-to-transplant (HR, 0.14; P = .03), and not requiring biventricular support (HR, 0.02; P < .01) were protective, whereas chronic kidney disease (HR, 9.07; P < .01) and an elevated total bilirubin (HR, 3.56; P = .02) were harmful. The ADI as a continuous variable did not affect survival; however, categorically, a higher ADI was protective (ADI 90-100: HR, 0.07; P = .04).

CONCLUSIONS

Socioeconomically disadvantaged patients had noninferior outcomes given appropriate pre-implant optimization and workup.

Racial differences in outcomes after receiving advanced heart failure therapies

PURPOSE OF REVIEW

Despite advances in medical and device-based therapies for advanced heart failure as well as public policy, disparities by race/ethnicity persist in heart failure clinical outcomes. The purpose of this review is to describe disparities in outcomes by race--ethnicity in patients after receipt of heart transplantation and left ventricular assist device (LVAD), and the current understanding of factors contributing to these disparities.

RECENT FINDINGS

The proportion of black and Latinx patients receiving advanced heart failure therapies continues to rise, and they have worse hemodynamic profiles at the time of referral for heart transplantation and LVAD. Black patients have lower rates of survival after heart transplantation, in part because of higher rates of cellular and humoral rejection that may be mediated through unique gene pathways, and increased risk for allosensitization and de-novo donor-specific antibodies. Factors that have previously been cited as reasons for worse outcomes in race--ethnic minorities, including psychosocial risk and lower SES, may not be as strongly correlated with outcomes after LVAD.

SUMMARY

Black and Latinx patients are sicker at the time of referral for advanced heart failure therapies. Despite higher psychosocial risk factors among race--ethnic minorities, outcomes after LVAD appear to be similar to white patients. Black patients continue to have lower posttransplant survival, because of a complex interplay of immunologic susceptibility, clinical and socioeconomic factors. No single factor accounts for the disparities in clinical outcomes for race--ethnic minorities, and thus consideration of these components together is critical in management of these patients.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Evaluating the impact of chronic obstructive pulmonary disease on in-hospital outcomes following left ventricular assist device implantation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a cause of ventricular dysfunction. However, in the setting of patients with heart failure undergoing left ventricular assist device (LVAD) implantation, there is a paucity of data on the association between COPD and in-hospital outcomes.

METHODS AND RESULTS

Retrospective cohort study based on the NIS including patients ≥18 years who underwent LVAD implantation from 2011 to 2017. Multivariate regression was used to evaluate the impact of COPD on in-hospital outcomes. A total of 25,503 patients underwent LVAD implantation, of which 13.8% also had COPD. COPD group was older (median 62 vs. 58 years), and more males (82% vs. 76.4%, p < .001 for both). COPD group had more hypertension, diabetes, atrial tachyarrhythmias, dyslipidemia, prior stroke, coronary artery diseases, pulmonary hypertension, and chronic kidney disease (p < .001 for all). No differences in strokes, infections, mechanical circulatory support, and LVAD thrombosis. There was a higher incident of inpatient acute kidney injury, major bleeding, cardiac complications, thromboembolism, and cardiac arrest in patients without COPD (p < .05 for all). Compared with no-COPD group, COPD group had a lower mortality (6.2% vs. 12.4%; odds ratio, 0.59; confidence interval, 0.512-0.685; p < .05).

CONCLUSION

Patients with COPD undergoing LVAD implantation have more comorbidities, without an associated increase mortality.

Defining the relative contribution of health care environmental components to patient outcomes in the model of 30-day readmission after coronary artery bypass graft (CABG)

BACKGROUND

Patient outcomes following health care interventions may be dependent on a variety of factors: patient, surgeon, hospital, information technology, and temporal, cultural, and socioeconomic factors, among others. In this study, we characterize the relative contribution of each of these factors using a model of 30-day readmission following coronary artery bypass graft.

METHODS

The Healthcare Cost and Utilization Project, the American Hospital Association Annual Health Survey Databases, the Healthcare Information and Management Systems Society, and the Distressed Communities Index from 2010 to 2013 were linked for Florida, Iowa, Massachusetts, Maryland, New York, and Washington. Logistic regression, random forest, decision tree, gradient boosting, k-nearest-neighbors classification, and XGBoost tree models were implemented. Modeling results were compared on the basis of predictive accuracy, sensitivity, specificity, and area under the curve. Decision tree performed best and was selected for further analysis. A gradient-boosted model was used to quantify factor contribution.

RESULTS

The model had 45,352 patients, 54,096 admissions, and a 16.2% 30-day readmission rate after coronary artery bypass graft. The top 10 predictors were disposition at discharge, number of chronic conditions, total procedures, median household income, adults without high school diplomas, primary payer method, Agency for Healthcare Research and Quality comorbidity: renal failure, patient location (urban-rural), admission type, and age categories. The top 3 socioeconomic predictors were estimated state median household income, adults without high school diplomas, and patient location (urban versus rural designation). The relative contribution of patient/temporal, socioeconomic, hospital information technology, and hospital factors to readmission is 83.45%, 5.71%, 6.34%, and 4.31%, respectively.

CONCLUSION

In this model, the contribution of socioeconomic factors is substantive but lags significantly behind patient/temporal factors. With ever increasing availability of data, identification of contributors to patient outcomes within the overall health care macroenvironment will allow prioritization of interventions.

The Approach to the Psychosocial Evaluation of Cardiac Transplant and Mechanical Circulatory Support Candidates

PURPOSE OF REVIEW

We update evidence underlying the recommendations of a 2018 multi-society consensus report regarding the psychosocial evaluation of individuals for cardiothoracic transplantation and mechanical circulatory support (MCS). In the present review, we focus on heart transplantation and MCS.

RECENT FINDINGS

Expert opinion and new evidence support the inclusion of ten core content areas in the psychosocial evaluation. Prospective data indicate that psychosocial factors can predict post-transplantation/post-implantation outcomes. Such factors include treatment adherence history, mental health and substance use history, cognitive impairment, knowledge about treatment options, and social factors such as socioeconomic status. For other factors (e.g., coping, social support), new evidence is weaker because it derives largely from cross-sectional studies. Concerning evaluation process issues, expert opinion remains consistent with consensus recommendations, but there is a dearth of empirical evidence. The psychosocial evaluation can identify factors relevant for candidacy for heart transplantation and MCS implantation. It enables the provision of interventions to improve patients' viability as candidates, and facilitates care planning.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Effects of socioeconomic status on clinical outcomes with ventricular assist devices

BACKGROUND

Lower socioeconomic status (SES) is a known risk factor for worse outcomes after major cardiovascular interventions. Furthermore, individuals with lower SES face barriers to evaluation for advanced heart failure therapies, including ventricular assist device (VAD) implantation.

HYPOTHESIS

Examination of the effects of individual determinants of SES on VAD outcomes will show similar survival benefit in patients with lower compared with higher SES.

METHODS

All VAD implants at the University of Florida from January 2008 to December 2015 were reviewed. Patient-level determinants of SES included place of residence, education level, marital status, insurance status, and financial resources stratified by percent federal poverty level. Survival or transplantation at 1 year, 30-day readmission, implant length of stay (LOS), and an aggregate of VAD-related complications were assessed in univariate fashion and multivariable regression modeling.

RESULTS

A total of 111 patients were included (mean age at the time of implant 57.6 years, 82.8% men). More than half received destination therapy. At 1 year, 78.3% were alive on device support or had undergone successful transplantation. There were no differences in survival, 30-day readmission, or aggregate VAD complications by the SES category. Although patients with lower levels of education had longer LOS in univariate analysis, on multivariable ordinal regression modeling, this relationship was no longer seen.

CONCLUSIONS

Patients with lower SES receive the same survival benefit from VAD implantation and are not more likely to have 30-day readmissions, complications of device support, or prolonged implant LOS. Therefore, VAD implantation should not be withheld based on these parameters alone.