The Association of Insurance Status and Neighborhood Deprivation with Mortality in Hospitalized Adults with Comorbid Heart Failure and Diabetes Open Access

Abstract

Background: Heart failure and diabetes are significant public health issues, individually and simultaneously. Social determinants play a major role in the incidence of both conditions, access to health care and services, and poor health outcomes. The impact of race, individual socioeconomic position, and geography on diabetes incidence have been thoroughly studied. Few studies examine the joint role of healthcare access and neighborhood characteristics with health outcomes in patients hospitalized with heart failure and co-morbid diabetes.

Objective: The purpose of this study was to evaluate the relationship of insurance status and neighborhood deprivation with mortality among hospitalized patients with comorbid acute heart failure (HF) and diabetes mellitus (DM).

Methods: A retrospective cohort of Black and White patients with acute HF and DM with a recorded hospitalization between 2010-2018 within a single healthcare system was created. Among 10,598 patients (mean age 72 years, 47.4% female, 55.0% Black), we used log binomial regression to evaluate the association of individual insurance status and quartiles of a neighborhood social deprivation index (SDI; measured at the zip code level, where quartile 1 indicated lowest deprivation) with death, stratifying by race and sex.

Results: From 2010 to 2018, the absolute risk of all-cause mortality was 20.8%. In Black women, those with Medicaid insurance were less likely to die than those with private insurance (RR=0.63; 95% CI 0.40-0.98). In White women, those living in SDI quartile 2 were less likely to die than those living in SDI quartile 1 (RR-0.72; 95% CI 0.52-0.98). There were no other significant differences in mortality between insurance status or SDI quartiles across race and sex stratifications.

Conclusions and Recommendations: Among hospitalized patients with a history of HF and DM, insurance status and neighborhood deprivation were not significantly associated with all- cause mortality in most demographic groups. Access to quality healthcare may even out racial disparities in mortality outcomes in patients with comorbid HF and DM. Further research should examine a composite of death and hospital readmission and employ time-to-event methods.

Table of Contents

CHAPTER 1: Introduction……………………………………………………………………………………………………………1

CHAPTER 2: Literature Review……………………………………………………………………………………………………..3

Heart Failure and Diabetes…………………………………………………………………………………………………………..3

Disparities in Diabetes Burden and Complications……………………………………………………………………..........4

Diabetes Management and Treatment……………………………………………………………………………………….......6

The Role of Social Determinants in Diabetes Outcomes……………………………………………………………............9

Summary of Problem and Study Relevance………………………………………………………………………………........11

CHAPTER 3: Methods…………………………………………………………………………………………………………….….12

Data Source………………………………………………………………………………………………………………………….....12

Study Population……………………………………………………………………………………………………………………...12

Outcome……………………………………………………………………………………………………………………………..….13

Social Deprivation Index…………………………………………………………………………………………………………....13

Covariates…………………………………………………………………………………………………………………………..…..14

Statistical Analysis……………………………………………………………………………………………………………………14

CHAPTER 4: Results………………………………………………………………………………………………………………….16

Insurance Status………………………………………………………………………………………………………………………16

Neighborhood Deprivation………………………………………………………………………………………………………...17

CHAPTER 5: Discussion and Recommendations……………………………………………………………………….........19

Public Health Recommendations…………………………………………………………………………………………….......21

References………………………………………………………………………………………………………………………………23

Tables and Figures…………………………………………………………………………………………………………………....33

Table 1. Baseline patient characteristics at time of index hospitalization. ………………………………..................33

Table 2. Mortality in patients by race and sex. ……………………………………………………………………….............36

Table 3. Risk ratio of mortality associated with insurance status and social deprivation. ………........................37

Table 4. Baseline patient characteristics who were included and excluded in the analysis. ……........................39

Figure 1. Flow diagram for study participants. ………………………………………………………………………............41

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Keyword	heart failure hospitalization diabetes neighborhood insurance social deprivation index
Committee Chair / Thesis Advisor	Patel, Shivani, Emory University
Committee Members	Morris, Alanna, Emory University

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