Social Vulnerability and Location of Death in Heart Failure in the United States

Majority of patients with heart failure (HF) die in either nursing homes or inpatient facilities. Social vulnerability captures multiple domains of socioeconomic position and has been linked with higher HF mortality. We sought to investigate the trends in location of death in patients with HF and its association with social vulnerability. We utilized the multiple cause of death files from the United States (1999-2021) to identify decedents with HF as the underlying cause of death and linked them with county-level social vulnerability index (SVI) available from CDC/ATSDR database. Approximately 1.7 million HF deaths were examined across 3003 United States counties. Most patients (63%) died in a nursing home or inpatient facility, followed by home (28%), and only 4% died in hospice. Death at home had a positive correlation with higher SVI with Pearson's r = 0.26 (P < 0.001) as well as deaths in an inpatient facility r = 0.33 (P < 0.001). Death in a nursing home correlated negatively with SVI with r = -0.46 (P < 0.001). There was no association between hospice utilization and SVI. Locations of death were varied by geographic residence. More patients died at home during the COVID-19 pandemic (OR 1.39, P < 0.001). Social vulnerability was associated with location of death in patients with HF in the US. These associations varied by geographic location. Future studies should focus on social determinants of health and end-of-life care in HF.