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Is Heart Failure Care Affected by Socioeconomic Status? Danish Study Indicates Yes


To reduce poor outcomes from heart failure care disparities, Danish researchers probed the link between individual socioeconomic factors and care quality for patients with reduced ejection fraction.

To reduce poor outcomes from unequal care for heart failure under a universal health care system, Danish researchers investigated the link between individual socioeconomic factors and quality of care for patients with heart failure with reduced ejection fraction (HFrEF). The results were published recently in ESC Heart Failure.

“Socioeconomic disparities in HF care may potentially contribute to the observed differences in mortality and readmission risk according to socioeconomic status,” the authors noted. “However, data on the relationship between socioeconomic status and HF care are sparse among patients with HF.”

The Danish Heart Failure Registry, Danish National Patient Registry, Danish Civil Registration System, National Prescription Registry, and Statistics Denmark provided data on 15,290 patients who received an initial diagnosis of primary heart failure (left ventricular ejection fraction <40%), according to International Classification of Diseases, 10th Edition, criteria between January 2008 and October 2015.

At the heart of this investigation was the possible link between 3 individual socioeconomic factors—cohabitation status, education level, and income—and receipt of quality heart failure care, which the team defined according to the following 6 measures:

  • Disease classified according to New York Heart Association (NYHA) criteria
  • Treatment with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs)
  • Treatment with beta-blockers
  • Treatment with mineralocorticoid receptor antagonists
  • Referred to an exercise regimen
  • Received patient education

Results show that for individuals with HFrEF, living alone (as a cohabitation status), having a low level of education, and having income in the lowest tertile meant the following outcomes were less likely to happen:

1. Living alone:

  • Have NYHA-classified disease (adjusted OR [aOR], 0.81; 95% CI, 0.72-0.90)
  • Prescribed ACE inhibitors/ARBs (aOR, 0.76; 95% CI, 0.68-0.88)
  • Prescribed beta-blockers (aOR, 0.84; 95% CI, 0.76-0.93)
  • Be referred for exercise (aOR, 0.75; 95% CI, 0.69-0.81)
  • Receive patient education (aOR, 0. 73; 95% CI, 0.67-0.80)

2. Low education:

  • Have NYHA-classified disease (aOR, 0.81; 95% CI, 0.79-1.11)
  • Prescribed ACE inhibitors/ARBs (aOR, 0.99; 95% CI, 0.81-1.20)
  • Prescribed beta-blockers (aOR, 0.93; 95% CI, 0.79-1.09)
  • Be referred for exercise (aOR, 0.73; 95% CI, 0.65-0.82)
  • Receive patient education (aOR, 0.86; 95% CI, 0.75-0.98)

3. Low income:

  • Have NYHA-classified disease (aOR, 0.67; 95% CI, 0.58-0.79)
  • Prescribed ACE inhibitors/ARBs (aOR, 0.80, 95% CI, 0.67-0.95)
  • Prescribed beta-blockers (aOR, 0.88, 95% CI, 0.86-1.01)
  • Be referred for exercise (aOR, 0.59, 95% CI, 0.53,0.64)
  • Receive patient education (aOR, 0.66; 95% CI, 0.59-0.74)

Differences were not seen after adjusting for sex, age, inpatient vs outpatient status, and 2008-2010 compared with 2011-2015.

According to the authors, “Inequity in HF care place socially deprived patients with HFrEF at double risk. Our analyses revealed a gap in the quality of HF care provided by the Danish healthcare system regardless of the causal mechanisms.”

Living alone and lack of social support have a negative impact on follow-up care, in that patients are less likely to adhere to their clinician recommendations, they note, or be able to access cardiac rehabilitation services.

To improve care for these patients of low socioeconomic status, clinicians need to be educated themselves on the barriers patients face. Health care systems also should target these barriers at the organization, provider, and patient levels when developing policies that affect health care strategies meant to reduce care disparities, the authors said.


Schjødt I, Johnsen SP, Strömberg A, Valentin JB, Løgstrup BB. Inequalities in heart failure care in a tax-financed universal healthcare system: a nationwide population-based cohort study. ESC Heart Fail. Published online August 7, 2020. doi:10.1002/ehf2.12938

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