Socioeconomic status could be an important factor of social determinants of health (SDOH) in affecting bias among health care physicians for patients who were hospitalized with heart failure (HF), according to results of a study published in JAMA Network Open. Although involvement of a cardiologist for HF has been associated with reduced rates of in-hospital mortality and hospital readmission, not all patients see a cardiologist when hospitalized for HF, the study authors said.

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Investigators aimed to analyze 9 different factors of SDOH and the association of cardiologists’ involvement in care for those with HF. They used the Reasons for Geographic and Racial Differences in Stroke cohort, including 1000 individuals from 549 hospitals in the United States.

Approximately 75.1% received cardiology services when hospitalized, and the average age was 77.8 years, 47.9% were female, and 41.4% were Black, according to the results. Data were included from 2009 to 2017, and individuals were included if they were 45 years or older. They were contacted by mail and then by telephone and were from 48 states and the Districts of Columbia. Alaska and Hawaii were not included. Data included medical history, health behaviors, and risk factors, which were followed up by an in-home visit for baseline vials, bloodwork, medication reconciliation, and other tests to determine health.

Investigators contacted the individuals by phone every 6 months to ask about health status and hospitalizations. If an individual was hospitalized for a possible cardiovascular-associated cause, the investigators received their medical records and reviewed the data. The SDOH measures included economic stability, education access and quality, social and community context, health care access and quality, and neighborhood and built environment, according to the study authors.

The 9 measures of SDOH included were Black race; social isolation, which investigators defined as 0 to 1 visits from family or a friend within the past month; social network and/or caregiver availability; low educational attainment, defined as less than high school education; annual household income below $35,000; living in rural areas; living in a zip code with high poverty; living in a Health Professional Shortage Area; and living in a state with poor public health infrastructure.

The study authors reported that low income was the only factor of SDOH that was significantly associated with cardiologist involvement. Out of 876 individuals who had baseline income data, approximately 56.2% had a low income. These individuals were also more likely to be Black, female, and to have diabetes, according to the results. Those with low incomes were also more likely to have HF with preserved ejection fraction and less likely to have a history of arrhythmia.

Furthermore, of 831 individuals, approximately 94.9% had insurance, with investigators finding that the prevalence of insurance was comparable for individuals who did or did not have a cardiologist’s involvement with care. Investigators also did not find significant results for the interaction with those aged 65 years or older.

The study authors stated that social factors, like low income, could bias health care physicians, especially for those with HF, and they call for more attention to this disparity in care.


Zhang DT, Onyebeke C, Nahid M, et al. Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure. JAMA Netw Open. 2023;6(11):e2344070. doi:10.1001/jamanetworkopen.2023.44070