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

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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.