Unveiling the link: social determinants of health, quality of life, and burden of treatment in heart failure patients.

Objectives: Black and Hispanic American patients have seen an increase in heart failure (HF) rates, with higher rates of hospitalizations and age-adjusted mortality. Our study aims to examine the associations between Social Determinants of Health (SDoH), difficulties associated with the workload assigned to the patients by healthcare providers/healthcare system measured as Burden of Treatment (BoT), and Quality of Life (QoL) in a predominantly minority, low income population of patients with heart failure in the South Bronx.

Methods: We included 265 patients hospitalized for HF decompensation. They were administered questionnaires to evaluate SDoH, QoL (EQ-5D), and BoT (Patient Experience with Treatment and Self-management-PETS questionnaire) at baseline. We fitted 10 zero-inflated negative binomial models to determine associations between total SDOH and total QoL with each BoT domain. We modelled the likelihood that a patient reports no burden on a given domain as well as the severity of the burden among patients who report burden.

Results: The mean age of our cohort was 63.7 years, with 66% male, 50% Hispanic ethnicity and 48% Black. Spanish was the predominant primary language of communication. Their mean Charlson Comorbidity Index was 5.32 (SD = 2.6). Heart failure with reduced ejection fraction (HFrEF) was present in 72% of our participating patients. The mean composite SDoH score was 3.4 (SD = 1.9), with 31% of the cohort reporting problems paying their bills, 28% with food insecurity, and 35% requiring public assistance. Among the 5 domains measured by EQ-5D for evaluating QoL, moderate to severe difficulty was experienced by 88% of our cohort in at least one of the five domains, and severe difficulty in at least one of the five domains was reported in 23% of our patients. Of the ten domains evaluated for Burden of Treatment (BoT), the highest median scores obtained from our cohort were for difficulty with medical expenses, role and social activity limitations, difficulty with accessing healthcare services, difficulty with medical information, and physical and mental exhaustion due to self-care. Zero-inflated models identified a significant association between higher SDoH scores and having some burden of treatment in 6 of the 10 domains, particularly in the domains of difficulty with healthcare expenses and difficulty with self-care interfering with social/daily activities. Additionally, high SDoH scores were also associated with greater severity of burden in 7 of the 10 domains, particularly relating to understanding medical information and difficulty with healthcare expenses. Poor QoL was associated with increased BoT in 6 of the 10 domains. QoL was strongly associated with the burdens of physical and mental exhaustion and difficulty with medical appointments.

Conclusions: Our findings highlight the interplay of SDoH, QoL and BoT in driving health disparities in heart failure patients. The positive correlation between SDoH and BoT demonstrates the impact that SDoH has on the treatment experiences of HF patients and their ability to manage their illness. Difficulty with healthcare expenses, understanding medical information, keeping track of medical appointments, self-care responsibilities affecting work, family and daily activities, and increased physical and mental fatigue due to self-care were the predominant domains affecting our study population. These findings signal the need for healthcare systems to identify at-risk individuals and implement individualized strategies to reduce the burden that treatment places on patients. Minimally Disruptive Medicine, which emphasizes understanding the patient's perspectives and tailoring treatment to the patient's daily life, may be an important tool in providing equitable care to these at-risk populations.