Are Social Determinants Of Health Related To Physical Frailty In Heart Failure?

Abstract

Introduction

Physical frailty affects a significant number of adults with heart failure (HF), conferring worse clinical and patient-reported outcomes. While the biological (including sex) and physiological factors contributing to physical frailty in HF are beginning to be understood, the contributing role of social determinants of health have not been studied.

Purpose

To identify associations between social determinants of health (SDOH) and physical frailty among adults with HF.

Methods

We performed a secondary analysis of combined data from two studies of adults with New York Heart Association (NYHA) functional class I-IV HF. Physical frailty was measured with the Frailty Phenotype Criteria: unintentional weight loss, weakness, slowness, physical exhaustion, and low physical activity. We examined the following SDOH factors: race/ethnicity (Non-Hispanic White vs. all other races/ethnicities), level of education (bachelor's degree or higher vs. some college vs. high school or less), financial status (have enough or more than enough to make ends meet vs. do not have enough to make ends meet), employment status (employed vs. retired/unemployed), marital status (married/living with domestic partner vs. single/divorced/widowed), and having someone to confide in (yes vs. no). Logistic regression (odds ratios (OR) with 95% confidence intervals (CI)), adjusted for the known contributors (age, sex, NYHA class, and comorbidity index), was used to identify SDOH predictors of physical frailty. We also explored the influence of sex on associations between each SDOH factor and physical frailty using interaction testing.

Results

The sample (n = 160) was 61.7±14.6 years, 44% female, and 62% were NYHA class III/IV. Physical frailty was identified in 44% of the sample. Significant predictors of physical frailty were female sex (OR 3.67, 95% CI [1.62, 8.33]) and being retired/unemployed (OR 3.86, 95% CI [1.38, 10.80]). A nested logistic regression model demonstrated that the block of SDOH factors significantly predicted physical frailty above and beyond age, sex, NYHA class, and comorbidity index (Wald chi² = 14.09, p < 0.05; Δ pseudo R² = 8%). Finally, lower education was a stronger predictor of physical frailty for women than for men (interaction p < 0.05).

Conclusions

SDOH, individually and in combination, are potential significant contributors to physical frailty in HF. Retirement or unemployment was a notable predictor of frailty, indicating that it warrants further research and clinical evaluation as a potential sentinel event for adults with HF. Additionally, female sex continues to be strongly associated with and influences predictors of physical frailty in HF.