Unfavorable social determinants of health are associated with higher burden of financial toxicity among patients with atherosclerotic cardiovascular disease in the US: findings from the National Health Interview Survey

Javier Valero-Elizondo, Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA. zjaved@houstonmethodist.org.
Zulqarnain Javed, Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
Rohan Khera, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
Mauricio E. Tano, Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
Ramzi Dudum, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA.
Isaac Acquah, Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
Adnan A. Hyder, Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
Julia Andrieni, Population Health and Primary Care, Houston Methodist Hospital, Houston, TX, USA.
Garima Sharma, Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Michael J. Blaha, Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Salim S. Virani, Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
Ron Blankstein, Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.
Miguel Cainzos-Achirica, Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
Khurram Nasir, Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA.

Document Type

Journal Article

Publication Date

12-6-2022

Journal

Archives of public health = Archives belges de sante publique

Volume

80

Issue

1

DOI

10.1186/s13690-022-00987-z

Keywords

Cardiovascular disease; Disparities; Equity; Financial toxicity; Social determinants of health

Abstract

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood. METHODS: Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence. RESULTS: Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features. CONCLUSIONS: An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.

Department

Global Health

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