Impact of Socioeconomic Status on Emergency Department Visits in Patients With Atrial Fibrillation: A Nationwide Population-Based Cohort Study

Association between neighborhood household income and inpatient atrial fibrillation outcomes

BACKGROUND

The impact of socioeconomic status on the clinical outcomes of patients admitted to the hospital for atrial fibrillation (AF) is not well described.

OBJECTIVE

The purpose of this study was to determine the association between median neighborhood household income (mNHI) and clinical outcomes among patients admitted to the hospital for AF.

METHODS

We retrospectively analyzed primary AF hospitalizations from the United States National Inpatient Sample between 2016 and 2020. The analyzed sample was divided into quartiles based on the mNHI in the zip code of the patient's residence. The lowest quartile was used as the reference category. Study outcomes included inpatient procedure utilization (ablation, cardioversion, percutaneous left atrial appendage closure), length of stay, cost, mortality, and disposition. Weighted multivariable logistic and linear regression, adjusting for multiple patient and hospital-level characteristics, was performed.

RESULTS

Patients in the highest mNHI quartile had lower comorbidity burden, lower in-hospital mortality (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.7-0.87; P <.001), lower discharges to care facility (OR 0.86; 95% CI 0.83-0.9; P <.001), shorter length of stay (adjusted mean difference -0.26; 95% CI -0.30 to -0.22; P <.001), higher procedure utilization, and higher health care costs ($12,124 vs $10,018) compared to the lowest mNHI quartile patients.

CONCLUSION

We identified significantly higher in-hospital mortality and lower procedural/resource utilization in patients living in lower-income neighborhoods compared to higher-income neighborhoods. Further research is needed to better understand the drivers of these disparities and the strategies to improve health care disparities between socioeconomic groups.

Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

Social determinants of health and clinical outcomes among patients with atrial fibrillation: evidence from a global federated health research network

BACKGROUND

Few studies have investigated the role of social determinants of health (SDoH) in patients with atrial fibrillation (AF).

AIM

To investigate the relationship between SDoH and adverse events in a large multinational AF cohort.

DESIGN

Retrospective study utilizing a global federated health research network (TriNetX).

METHODS

Patients with AF were categorized as socially deprived defined according to ICD codes based on three SDoHs: (i) extreme poverty; (ii) unemployment; and/or (iii) problems related with living alone. The outcomes were the 5-year risk of a composite outcomes of all-cause death, hospitalization, ischemic heart disease (IHD), stroke, heart failure (HF) or severe ventricular arrhythmias. Cox regression was used to compute hazard rate ratios (HRs) and 95% confidence intervals (CIs) following 1:1 propensity score matching (PSM).

RESULTS

The study included 24 631 socially deprived (68.8 ± 16.0 years; females 51.8%) and 2 462 092 non-deprived AF patients (75.5 ± 13.1 years; females 43.8%). Before PSM, socially deprived patients had a higher risk of the composite outcome (HR 1.9, 95% CI 1.87-1.93), all-cause death (HR 1.34, 95% CI 1.28-1.39), hospitalization (HR 2.01, 95% CI 1.98-2.04), IHD (HR 1.67, 95% CI 1.64-1.70), stroke (HR 2.60, 95% CI 2.51-2.64), HF (HR 1.91, 95% CI 1.86-1.96) and severe ventricular arrhythmias (HR 1.83, 95% CI 1.76-1.90) compared to non-deprived AF patients. The PSM-based hazard ratios for the primary composite outcome were 1.54 (95% CI 1.49-1.60) for the unemployed AF patients; 1.39 (95% CI 1.31-1.47) for patients with extreme poverty or with low income; and 1.42 (95% CI 1.37-1.47) for those with problems related with living alone.

CONCLUSIONS

In patients with AF, social deprivation is associated with an increased risk of death and adverse cardiac events. The presence of possible unmeasured bias associated with the retrospective design requires confirmation in future prospective studies.

Adherence to the atrial fibrillation better care pathway and its associated factors among rural patients with atrial fibrillation in China: A cross-sectional study

BACKGROUND

The atrial fibrillation better care (ABC) pathway is an effective strategy for the integrated management of atrial fibrillation (AF). Current data on adherence to the ABC pathway among rural patients with AF in China are limited.

OBJECTIVES

To investigated adherence to the ABC pathway and its associated factors among rural patients with AF in China.

METHODS

In the cross-sectional study, we recruited 870 rural patients with AF from July 2022 to July 2023 in China. AF-related sociodemographic and clinical data was collected.

RESULTS

Among the 870 rural patients with AF, 437 (50.23 %) were male, 714 (82.07 %) were ≥65 years old. The level of adherence to ABC pathway was extremely low (5.75 %), and its associated factors included patients ≥75 years (compared with those <65 years, OR=0.165, 95 %CI: 0.065-0.417, P < 0.001), junior middle school and senior middle school education or above (compared with primary school education or below, OR=3.441, 95 %CI: 1.144-10.351, P = 0.028; OR=11.438, 95 %CI: 3.758-34.814, P < 0.001), average monthly household income per capita 1000-3000 RMB and >3000 RMB (compared with <1000 RMB, OR=3.993, 95 %CI: 1.343-11.877, P = 0.013; OR=4.474, 95 %CI: 1.478-13.541, P = 0.008), persistent AF (compared with paroxysmal AF, OR=0.062, 95 %CI: 0.008-0.466, P = 0.007) and multimorbidity (OR=0.356, 95 %CI: 0.163-0.781, P = 0.010).

CONCLUSIONS

There is an urgent need to develop targeted interventions and national policies to improve the adherence to the ABC pathway of rural AF patients in China.

When the economy falters, hearts suffer: Economic recessions as a social determinant of health in cardiovascular emergencies

INTRODUCTION

While the relationships between cardiovascular disease (CVD), stress, and financial strain are well studied, the association between recessionary periods and macroeconomic conditions on incidence of disease-specific CVD emergency department (ED) visits is not well established.

OBJECTIVES

This retrospective observational study aimed to assess the relationship between macroeconomic trends and CVD ED visits.

METHODS

This study uses data from the National Hospital Ambulatory Care Survey (NHAMCS), Federal Reserve Economic Database (FRED), National Bureau of Economic Research (NBER), and CVD groupings from National Vital Statistics (NVS) and Center for Medicare and Medicaid Services (CMS) from 1999 to 2020 to analyze ED visits in relation to macroeconomic indicators and NBER defined recessions and expansions.

RESULTS

CVD ED visits grew by 79.7% from 1999 to 2020, significantly more than total ED visits (27.8%, p < 0.001). A national estimate of 213.2 million CVD ED visits, with 22.9 million visits in economic recessions were analyzed. A secondary group including a 6-month period before and after each recession (defined as a "broadened recession") was also analyzed to account for potential leading and lagging effects of the recession, with a total of 50.0 million visits. A significantly higher proportion of CVD ED visits related to heart failure (HF) and other acute ischemic heart diseases (IHD) was observed during recessionary time periods both directly and with a 6-month lead and lag (p < 0.05). The proportion of aortic aneurysm and dissection (AAA) and atherosclerosis (ASVD) ED visits was significantly higher (p = 0.024) in the recession period with a 6-month lead and lag. When controlled for common demographic factors, economic approximations of recession such as the CPI, federal funds rate, and real disposable income were significantly associated with increased CVD ED visits.

CONCLUSION

Macroeconomic trends have a significant relationship with the overall mix of CVD ED visits and represent an understudied social determinant of health.