• heart failure
• systolic

What does poor even mean? Poor means lacking sufficient financial resources, as in ‘the poor people from our community’. Poor also means low quality, as in ‘received poor medical treatment’. Finally, poor means deserving of pity: ‘conditions are shocking, poor patients!’.

Poverty is dreadful. Economically disadvantaged individuals have less quality of life, access to healthcare and generally fewer opportunities in their life. Unsurprisingly, then, income level predicts the outcome of patients with heart failure,1 just like age and left ventricular ejection fraction. But unlike several heart failure predictors of risk, the causal link between poverty and worse prognosis in heart failure patients is not straightforward. Although poverty could be—and is—a marker of limited access to healthcare and lower education, in a disease with rising costs, this explanation seems incomplete. There is a complex and intricate interplay between individual and family income, education and literacy, healthcare structure and access to care, adherence to interventions and clinical outcomes (figure 1). Expensive therapies have been proven to benefit patients with heart failure in a range of clinical scenarios. Devices such as cardiac resynchronisation therapy, implantable cardioverter defibrillator and left ventricular assist device, and medications such as dapagliflozin and sacubitril/valsartan, have entered the clinical armamentarium and improve relevant endpoints. In this circumstance, in a disease with many new, exciting and expensive treatments, the high cost of new therapies could widen the disparity and prognostic gap between rich and poor patients with heart failure. Importantly, simple and cost-saving pharmacological and multidisciplinary strategies have also been shown to improve hard outcomes in heart failure. If access to therapies—costly or inexpensive—leads to better outcomes, we can reasonably infer that poverty is not only associated with but causes worse health outcomes.

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Figure 1

Conceptual framework of the complex and intricate interplay between different components linking poverty and clinical outcomes in heart failure patients.

In this edition of Heart, Hung and colleagues2 ambitiously investigated how income inequalities relate to health outcomes in over 600 000 Taiwanese patients hospitalised with heart failure. Using a national insurance database with >99.9% coverage, they compared baseline characteristics and clinical outcomes between low-income, middle-income and high-income patients. Their findings were predictably concerning. On average, low-income patients had a higher comorbidity burden and were less likely to be treated with ideal heart failure drugs. Low-income patients were also twice as likely to die during the index hospitalisation, less likely to be discharged with guideline-directed therapy and more likely to be readmitted and to die following discharge. These disparities were attenuated, but not eliminated, after adjusting for baseline variables and with propensity matching. Remarkably, differences in health outcomes between income groups were mitigated over time, which the authors attribute to a nationwide healthcare insurance programme that began in 1995, 1 year before the observation period of this study.

These findings endorse the idea that prognosis is worse for low-income heart failure patients, but the explanation for such remains unclear. We highlight three possibilities. First, poverty may simply be an indicator of bad prognosis. Low-income patients often live in rural areas, where access to healthcare is limited. They frequently belong to ethnic minority groups, more subject to prejudice. They have lower education status, which may translate into low health literacy and non-compliance,3 and they have higher levels of unemployment and chronic stress, all of which take a toll in the cardiovascular system. Second, poverty may cause worse outcomes, indirectly. As mentioned above, low-income patients may lack access to expensive, disease-modifying therapies, which limits therapeutic options. They lack access to exercise programmes and facilities, resulting in sedentarism, and to adequate nutrition and healthy meals, resulting in weight gain. Finally, there are also reasons to believe poverty directly leads to poor health outcomes. Scarcity—of food, sleep or money—might reshape thinking and induce excessive focus towards the current necessity at the cost of being incapable to think about long-term consequences.4 In a medical setting, financial toxicity describes the burdens imposed by the astronomical costs of healthcare and is being increasingly studied in cancer as well as cardiovascular diseases.5

Although we describe several reasons why low income could be associated with poor health outcomes—as a marker, an indirect cause or a causative factor—the likely explanation is a combination of all. It is hard to establish definitive causality in an observational setting, especially when compared populations are different. The results of this paper should be interpreted cautiously. Low-income patients were substantially distinct from their high-income counterparts: they were older, more frequently women and had higher prevalence of clinical comorbidities. Unadjusted in-hospital mortality was roughly doubled for low-income versus high-income patients. Thus, both unadjusted baseline characteristics and follow-up results suggest low-income patients were more severe. While the authors correctly controlled for known confounders, we should note this approach is always incomplete. When one adjusts for the presence of hypertension, for instance, this fails to account for differences in disease severity or onset, which may lead to major residual confounding. Furthermore, due to retrospective data collection and missing data, it is not always possible to adjust for other known but important confounders; an example would be the important yet unavailable differentiation between heart failure with reduced or preserved left ventricular ejection fraction. Finally, unknown confounders may also explain part of the result, and these remain uncontrolled in propensity scores. Thus, it is hard to objectively quantify the impact of low income, and one should value the general trend over the specific point estimate.

The paper closes with two main conclusions: first, the prognosis for poor patients with heart failure is worse; second, this health inequality is improving in Taiwan. In this editorial, we explored explanations for the former, but the lesson is in the latter. Time alone does not change health-related outcomes; people might—but how? Physicians might change things simply by acknowledging that low income is another major determinant of health that affects heart failure patients and that inequalities regarding access to therapies may be curbed with innovative but comprehensive strategies. Healthcare professionals should understand how poverty is an indicator and a cause of poor healthcare and strive to explore alternatives to patients. In this scenario, telemedicine is emerging as a potentially groundbreaking option. Policy decision-makers might change things by advancing access to healthcare for their citizens, irrespective of income strata. In Taiwan, the national insurance programme may be a major determinant of the improvement described in this paper, although no direct causal link can be ascertained because of the retrospective, non-controlled and observational nature of the study. Evidently, decreasing economic disparities would also be a direct way to equalise the effectiveness of different healthcare systems. In addition, both physicians and policymakers should realise that the allegedly complex heart failure treatment is paved through simple, inexpensive and often cost-saving therapies.6 In limited-resource scenarios, prioritising such initiatives would be a particularly helpful initial step to improve clinical outcomes. Finally, the role of patients as active counterparts in this setting should not be undermined. Several barriers for implementing heart failure management strategies, not directly related to income, must be adequately addressed in an individual basis. Empowering people living with heart failure is essential to engage disease management programmes and requires education, understanding the needs of patients and restructuring the care delivery systems currently offered.

‘The poor people from our community received poor medical treatment: poor patients!’. As researchers like Hung and colleagues shed light on this overlooked subject, we hope sentences as the above become nothing more than a literary illustration in a world full of exciting novel therapies for heart failure but also confronted by considerable and unwanted deprivations.