Neighborhood Deprivation and Racial Disparities in Heart Failure Outcomes: A Counterfactual Approach

Wenxi Huang; Yuru Zhu; Stephen E Kimmel; Mustafa M Ahmed; Steven M Smith; Yao An Lee; Carl Yang; Jiang Bian; Yong Chen; Jingchuan Guo

doi:10.1016/j.jacadv.2025.101808

Neighborhood Deprivation and Racial Disparities in Heart Failure Outcomes: A Counterfactual Approach

JACC Adv. 2025 Jun;4(6 Pt 2):101808. doi: 10.1016/j.jacadv.2025.101808.

Authors

Wenxi Huang¹, Yuru Zhu², Stephen E Kimmel³, Mustafa M Ahmed⁴, Steven M Smith⁵, Yao An Lee¹, Carl Yang⁶, Jiang Bian⁷, Yong Chen⁸, Jingchuan Guo⁹

Affiliations

¹ Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.
² Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
³ Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida, USA.
⁴ Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA.
⁵ Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA; Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA.
⁶ Department of Computer Science, Emory College of Arts and Sciences, Emory University, Atlanta, Georgia, USA.
⁷ Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University Health, Indianapolis, Indiana, USA.
⁸ Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address: ychen123@upenn.edu.
⁹ Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA. Electronic address: guoj1@ufl.edu.

PMID: 40579056
DOI: 10.1016/j.jacadv.2025.101808

Abstract

Background: Heart failure (HF) is a major contributor to hospitalizations and mortality in the United States, with significant racial disparities in care access and clinical outcomes. Social determinants of health (SDoH) play a critical role in shaping these disparities.

Objectives: This study aimed to assess the impact of neighborhood deprivation on racial disparities in HF outcomes and quantify the changes in adverse outcomes if non-Hispanic Black (NHB) patients resided in neighborhoods with SDoH level equal to those of non-Hispanic White (NHW) patients.

Methods: We conducted a retrospective cohort study using electronic health records from the University of Florida, including adults hospitalized for HF between 2016 and 2021. SDoH level was measured using the Area Deprivation Index (ADI). The primary outcome was a composite measure of 1-year readmission and all-cause mortality. A counterfactual framework was applied to estimate how NHB patient outcomes might change if they lived in neighborhoods with ADI distributions equivalent to NHW patients.

Results: Among 42,279 patients (mean age 65 ± 14.3 years; 48% women), NHB patients had more 1-year composite outcomes (32.92%) compared to NHW patients (27.69%). Adjusted analyses showed NHB patients had a higher risk of readmission or mortality (aOR: 1.101; 95% CI: 1.063-1.139). Counterfactual modeling showed that if NHB patients resided in neighborhoods with ADI distributions same as NHW patients, their outcome rate would decrease by 1.31% (95% CI: 1.309%-1.311%).

Conclusions: This study highlights racial disparities in HF outcomes attributed to neighborhood deprivation. Improving socioeconomic conditions in deprived neighborhoods could mitigate disparities in HF.

Keywords: Area Deprivation Index; heart failure; hospital readmission; neighborhood deprivation; racial disparities.