Essien, Utibe R.

Importance Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia’s often paroxysmal nature and individuals’ disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF. Observations The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF. Conclusions and Relevance Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.

Background: Outcomes in heart failure with reduced ejection fraction (HFrEF) are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics Data Mart, patients with HFrEF and ≥6 months of enrollment for follow-up (2016–2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as proportion of days covered ≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322 007 individuals with incident HFrEF, 135 282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40 000) were significantly less likely (odds ratio, 0.83 [95% CI, 0.76–0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100 000). Annual income <$40 000 was associated with lower odds of proportion of days covered ≥80% compared with income ≥$100 000 (odds ratio, 0.70 [95% CI, 0.59–0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.

Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline directed medical therapy. Objective: To study the association between median annual household income and: (1) odds of receiving sacubitril/valsartan, a novel angiotensin receptor/neprilysin inhibitor (ARNI) therapy among insured patients with heart failure with reduced ejection fraction (HFrEF) and (2) medication adherence (measured as the proportion of days covered (PDC)). Hypothesis: lower income is associated with lower odds of receiving and adhering to ARNI among patients with HFrEF. Methods: Using Optum’s deidentified Clinformatics® Data Mart, patients with ≥ 2 diagnoses of HFrEF and ≥ 6 months of enrollment for follow up (2016-2020) were included. Covariates included age, race, ethnicity, sex, educational attainment, household net worth, geographical region and Elixhauser comorbidity index. Prescription for ARNI was defined by presence of a claim within 180 days. Adherence was defined as PDC ≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. We also assessed for race-income interaction. Results: Among 322007 individuals with HFrEF diagnosis, 136,613 had ≥6 months of complete data. Of the patients eligible for ARNI, only 5.4% (7409/136613) received a claim within 180 days of HFrEF diagnosis. After adjusting for social and clinical factors, the odds were elevated for ARNI claim within 180 days of HFrEF diagnosis (OR=1.38, 95% CI: 1.27, 1.49) for the highest income category (>$100K) compared with the lowest (<$40K). After adjustment, income <$40k) was associated with a 47% higher odds of PDC<80% compared with income >$100K. Conclusions: Higher patient income is associated with increased likelihood of an ARNI claim within 180 days of HFrEF diagnosis, even after adjusting for socioeconomic and clinical factors. Future analyses are needed to determine other social factors associated with delay in ARNI initiation and long-term adherence.