Community-level Economic Distress, Race, and Risk of Adverse Outcomes Following Heart Failure Hospitalization among Medicare Beneficiaries.

Background: Socioeconomic disadvantage is a strong determinant of adverse outcomes in patients with heart failure (HF). However, the contribution of community-level economic distress to adverse outcomes in HF may differ across races. Methods: Patients of self-reported Black, White, and Hispanic race/ethnicity hospitalized with HF between 2014 and 2019 were identified from the 100% CMS MedPAR database. We used patient-level residential zip code to quantify community-level economic distress based on the distressed community index (DCI, Quintile 5: economically distressed vs. Quintiles 1-4: non-distressed). The association of continuous and categorical measures (distressed vs. non-distressed) of DCI with 30-day, 6-month, and 1-year risk-adjusted mortality, readmission burden, and home time were assessed separately by race/ethnicity groups. Results: The study included 1,611,586 White (13.2% economically distressed), and 205,840 Black (50.6% economically distressed) and 89,199 Hispanic (27.3% economically distressed) patients. Among White patients, living in economically distressed (vs. non-distressed) communities was significantly associated with a higher risk of adverse outcomes at 30-days and 1-year follow-up. Among Black and Hispanic patients, the risk of adverse outcomes associated with living in distressed vs. non-distressed communities was not meaningfully different at 30-days and became more prominent by 1-year follow-up. Similarly, in the restricted cubic spline analysis, a stronger and more graded association was observed between DCI score and risk of adverse outcomes in White patients (vs. Black and Hispanic patients). Furthermore, the association between community-level economic distress and risk of adverse outcomes for Black patients differed in rural vs. urban areas. Living in economically distressed communities was significantly associated with a higher risk of mortality and lower home time at 1-year follow-up in rural areas but not urban areas. Conclusions: The association between community-level economic distress and risk of adverse outcomes differs across race-ethnic groups, with a stronger association noted in White patients at short- and long-term follow-up. Among Black patients, the association of community-level economic distress with a higher risk of adverse outcomes is less evident in the short term and is more robust and significant in the long-term follow-up and rural areas.