Understanding and addressing risks of low socioeconomic status and diabetes for heart failure

摘要 心力衰竭(HF)与高发病率、死亡率和成本有关，精炼是人们非常感兴趣的 降低心力衰竭风险的策略。糖尿病(DM)和低社会经济地位(SES)都是独立的风险 影响高频的因素，这两个因素共同与入射高频有协同作用。一个主要职能部门 这些关联的后果是心肺功能受损，并对预后和 生活质量。此外，低社会经济地位和糖尿病在种族和少数民族中的比例过高， 因此，造成高频差异的原因之一。应对与联合应用相关的高心力衰竭风险的策略 低SES和DM将需要关注健康的社会决定因素。问题解决培训和社区 卫生工作者(CHW)的支持有效地克服了护理障碍，改善了生活方式，DM自我 管理、保健系统参与和风险因素控制，但尚未应用于 应对心力衰竭风险。通过了解心力衰竭的地理差异，将进一步了解预防工作 风险和阐明可能作为干预目标的临床危险因素。因此，我们建议一项 在350名患有低SES、糖尿病、肥胖和早期心功能障碍的人中进行的随机试验，测试 问题解决培训、社区妇女支持和与社区伙伴关系的多层次干预效果 在健身、风险因素控制、心脏损伤/纤维化标志物和质量方面支持生活方式改变的设施 生活的一部分。我们建议：目标1：使用电子病历数据a)比较 在城市、农村和郊区，糖尿病患者中发生心力衰竭的社区自发性硬化， 以及b)确定与糖尿病相关的心衰的可改变的临床危险因素，这些因素在 SES低的人群。目标2：采用循证、务实的干预措施来改进 低SES、糖尿病、肥胖和心脏早期患者的功能状态及危险因素控制 功能障碍，使用基于社区的参与性研究(CBPR)和以患者为中心的结果 研究(PCOR)原则。目标3：在随机对照试验中测试一年多水平 问题解决培训的干预，CHW用于增强社会支持和卫生系统 参与和使用社区设施来支持生活方式的改变改善心肺功能 低SES、糖尿病、肥胖和早期心脏功能障碍者的健康状况和相关结果更多 而不是加强教育和与社区卫生项目的联系。这项工作将阐明 应对与低SES和DM相关的心力衰竭风险的策略，这是造成心力衰竭差异的关键因素。

Summary Heart failure (HF) is associated with high morbidity, mortality and costs, and there is great interest in refining strategies to reduce HF risk. Diabetes (DM) and low socioeconomic status (SES) are each independent risk factors for HF, and both factors together have a synergistic association with incident HF. A major functional consequence of these associations is impaired cardiorespiratory fitness, with implications for prognosis and quality of life. Additionally, low SES and DM are over-represented among racial and ethnic minorities and therefore a cause of HF disparities. Strategies to address the high HF risk associated with the combination of low SES and DM will require a focus on social determinants of health. Problem-solving training and community health worker (CHW) support are effective in overcoming barriers to care, and improving lifestyle, DM self- management, health system engagement and risk factor control, but they have not yet been applied to addressing HF risk. Prevention efforts would be further informed by understanding geographic disparities in HF risk and elucidating clinical risk factors that might serve as targets for intervention. We therefore propose a randomized trial among 350 persons with low SES, DM, obesity and early cardiac dysfunction, testing the effects of a multi-level intervention of problem-solving training, CHW support and partnership with community facilities to support lifestyle change on fitness, risk factor control, markers of cardiac injury/fibrosis and quality of life. We propose: Aim 1: To use electronic medical record data to a) compare the association of neighborhood SES with incident HF in patients with DM, across urban, rural and suburban settings, and b) to identify modifiable clinical risk factors for HF associated with DM that are more prevalent in persons with low SES. Aim 2: To adapt an evidence-based, pragmatic intervention to improve functional status and risk factor control in persons with low SES, DM, obesity and early cardiac dysfunction, using community-based participatory research (CBPR) and patient-centered outcomes research (PCOR) principles. Aim 3: To test, in a randomized controlled trial, if a 1-year multilevel intervention of problem-solving training, CHW use to enhance social support and health system engagement, and use of community facilities to support lifestyle change improves cardiorespiratory fitness and related outcomes in those with low SES, DM, obesity and early cardiac dysfunction, more than enhanced education and connection with community health programs. This work will elucidate strategies to address HF risk related to low SES and DM, which are key contributors to HF disparities.