Social adversity is associated with higher mortality in PH

BOSTON—Social adversity is associated with worse survival among patients with pulmonary hypertension (PH), according to a new retrospective study of a New York City population. Among patients with HIV and heart failure, PH was associated with approximately a threefold increase in all-cause mortality, but this risk increased to approximately sevenfold when social disadvantage identified by a licensed social worker was also present.

A sub-analysis of both HIV and non-HIV patients showed worse mortality rates due to social disadvantage in both groups.

“Almost the majority of the patients we treat are either socially disadvantaged, uninsured or undocumented, so we, as a group of residents, decided to study the impact of these factors on their health and the care that can be provided. We started using two cohorts and now continue to do so with each new resident,” said Luca Biawati, MD, who presented the study at the 2024 American College of Chest Physicians (CHEST) Annual Meeting.

“The presence of any form of socioeconomic disadvantage negatively impacts health care, and for a large portion of the population, there are some factors that could likely be addressed through institutional or hospital policies,” said Biawati, an internal medicine resident at the hospital. Jacobi Medical Center, Bronx, New York.

Other factors are more difficult to eliminate, such as lack of education. “(Some patients) do not realize the seriousness of their problem and medical condition until it is too late, and then they become insufficiently suitable for treatment or simply because of the social situation they cannot qualify for advanced treatments,” said Biawati.

The researchers formed two groups: one consisting of patients with HIV and heart failure who may or may not have had PH, and another consisting of patients with PH with or without HIV and heart failure. In the HIV/heart failure group, PH without social adverse effects was associated with a nearly threefold increase in all-cause mortality (hazard ratio (HR) 2.83; P = 0.004), while PH combined with social disadvantage was associated with a more than sevenfold increase in all-cause mortality (HR, 7.14; P <0.001). Social adversity without PA was associated with a more than fourfold increase (HR, 4.47; P <0.001).

In the PH cohort, social adversity was associated with lower survival (P <0.001). When the researchers broke down the results by type of social adversity, they found a statistically significant association between increased mortality risk and economic instability among the HIV-positive population (HR, 2.59; P = 0.040), problems with transport among the HIV population (HR, 12.8; P <0.001), as well as lack of social or family support as in the case of HIV- (HR, 5.49; P <0.001) and HIV+ population (RR, 2.03; P = 0.028).

The study inspired interventions that are now being studied at the institution, Biawati said. “We have a policy of dispensing sachets of medicines when a socially disadvantaged patient is discharged. We literally go to the pharmacy, bring a bag of medications and (put it in) their hands before they leave the hospital. They get a 1 or 3 month supply, depending on the medication, and then we usually discharge them with a clinical appointment already scheduled with a pulmonologist or primary care physician, and we usually call them before each appointment to confirm that they are coming . This increases the chances of some success, but there is still a very long way to go,” Biawati said.

Biawati did not know the results of the intervention, so he could not report whether it worked. “But I can tell you that I have had busier clinics, so hopefully that means there are more of them,” he said.

According to Sandeep Jain, MD, who moderated the session, the problem is complex. “Social difficulties mean lack of education. Lack of education means non-compliance. Non-compliance means what can you do if people don’t take their medications? So everything came together. This is all a lack of education and lack of money, lack of family support. And they have to take these medications every single day. It’s not that simple. It is very easy for us to say that I was on antiretroviral treatment for 6 months. It is almost impossible to continue regular treatment for such a long time (for a socially disadvantaged patient). You can’t blame them if they don’t get treatment. It is very difficult for them,” Jain said.

This highlights the need for interventions that can meet the needs of socially disadvantaged patients. “We must (practice) medicine taking into account the social status of the patient, and not just the medicine we study in books. This is what we face every day. We have treatments and then life happens. These patients are much more difficult to care for,” Biawati said.

Biawati and Jain reported no relevant financial relationships.

Jim Kling is a writer based in Bellingham, Washington.