Impact of Social Determinants on Outcomes in Patients with Left Ventricular Assist Devices
Aurora L, Ahluwalia G, Mahan M, and Williams CT. Impact of Social Determinants on Outcomes in Patients with Left Ventricular Assist Devices. J Card Fail 2019; 25(8):S127.
J Card Fail
Background: Durable, continuous flow Left Ventricular Assist Devices (LVAD) used as a bridge to transplantation and destination therapy continue to have improved survival. Despite ongoing advances in technology, LVADs continue to be associated with significant adverse events. Socioeconomic determinants are known to be associated with worse outcomes in patients with chronic heart failure. We sought to examine the association of social determinants with outcomes after LVAD implantation. Methods: Using electronic medical records, we conducted a retrospective chart review of 358 patients undergoing LVAD (HeartMate II, HeartMate III, HeartWare) implantation from January 2006 to October 2018 at a tertiary care center. We collected data including median household income, comorbid conditions, self-identified substance use, and cognitive assessment determined by the Montreal Cognitive Assessment tool. We examined the association between 30-day readmission rate, right ventricular failure (RVF), need for hemodialysis (HD), and occurrence of driveline infection post LVAD implantation with the pre-specified covariates. Univariate two-group comparisons using analysis of variance (ANOVA) for continuous variables or chi-square or Fisher's exact tests for categorical variables was used. Results: The study population was comprised of 74.9% males, with a mean age of 55 ± 12, 52% Caucasians, and 39.1% African Americans. The mean household income was $53,298. There was no significant difference between substance use (p=0.684), median household income (p=0.696), co-morbid conditions and occurrence of RVF after LVAD implantation. Similar comparison showed no significant differences between substance use (p=0.522), median household income (p=0.534), and occurrence of HD after LVAD placement. History of chronic kidney disease (CKD) was found predominantly in patients who ended up on dialysis compared to those with no past medical history of CKD (p=0.044). There were no significant differences between substance use (p=0.323), median household income (p=0.564), co-morbidities and occurrence of driveline infection after LVAD implantation. There was also no significant difference noted between the presence of RVF after LVAD implantation, the need for HD or the occurrence of a driveline infection and the clinical status (defined as ongoing LVAD support, transplant, or death). There was a significant difference between 30-day readmission rate and clinical status (p=0.001) such that increased mortality was associated in patients with ongoing LVAD support and patients who received a transplant if they had a hospital readmission. Conclusion: Management of heart failure is not only dependent on disease process but also upon access to health care, education, and resources. This study demonstrated that social determinants did not impact outcomes related to LVAD support. Due to complexity of LVAD patients, health care providers need to carefully take into consideration the complex interaction of health and social factors which directly affect patient care.