key: cord-0891235-dkkc7fq5
authors: Norris-Grey, Caitlin; Manmathan, Gavin; Pimenta, Dominic
title: Letter by Norris-Grey et al Regarding Article, “Multiple Vulnerabilities to Health Disparities and Incident Heart Failure Hospitalization in the REGARDS Study”
date: 2020-12-11
journal: Circ Cardiovasc Qual Outcomes
DOI: 10.1161/circoutcomes.120.007389
sha: e10668714588d7b7f5ef72e7e0ba249918626bef
doc_id: 891235
cord_uid: dkkc7fq5

nan

We read with interest the article by Pinheiro et al exploring the relationship between socially determined vulnerabilities (SDVs) and heart failure (HF) hospitalization. 1 The article should be applauded for investigating the effects of cumulative SDVs, which are more likely to occur in clusters. This approach gives a better reflection of the real-life effects SDVs have on the risk of HF hospitalization and proposes a simple method of identification of SDVs by health care professionals to identify at-risk patients.

We were interested to see that of the 10 SDVs analyzed using bivariate analysis, only 6 were deemed significant and included in the SDV count used in later Cox regression models. We would like to question the use of bivariate analysis as a method of prefiltering variables before further analysis. Although we recognize this is a common statistical tool often used by data scientists, it comes with the risk of excluding variables that seem nonsignificant on bivariate analysis but may become significant on later analysis because of interaction with other variables. This is especially important as the authors described how SDVs can cluster, indicating the possibility of confounding, which cannot be controlled for on bivariate analysis.

Deek et al 2 have recently shown that health education interventions can reduce mortality of patients with HF in Lebanon. The observed effect remained for a long period of time after the implementation of a single educational intervention. Given this effect, it would be interesting to explore whether health education interventions are a routine part of clinical care in the hospitals included in the study by Pinheiro et al, and whether the number of SDVs has an impact on the delivery or efficacy of such interventions. For example, Deek et al identified family members as an important part of the delivery of education to patients with HF, which may suggest that social isolation impacts the efficacy of educational interventions.

Data from Fu et al 3 looking into the relationship between compliance of quality indicators and health expenses in China revealed a negative correlation at the extreme quantile of expenses. It can be argued that SDVs may reduce compliance to quality indicators as SDVs act as a barrier to adequate quality of care. At extreme hospitals expenses further measures should therefore be taken to improve quality of care and to identify SDVs.

Considering the current climate, it is important to interpret these results going forward into a post-coronavirus disease world. Frankfurter et al observed a decrease in the number of Emergency Department visits and hospitalizations because of acute decompensated HF from March 2020 to April 2020 compared with the same period in 2019. 4 A trend was found toward higher inpatient mortality of these patients. One possible explanation is the potential increase in the numbers of SDVs for individual patients because of the social and economic effects 

Multiple vulnerabilities to health disparities and incident heart failure hospitalization in the REGARDS study

A single educational intervention on heart failure self-care: extended follow-up from a multisite randomized controlled trial

Association between compliance with quality indicators and hospitalisation expenses in patients with heart failure: a retrospective study using quantile regression model in China

Reduced rate of hospital presentations for heart failure during the COVID-19 pandemic in Toronto