Assess, address social determinants of health to close ‘widening gap’ in cardiology care
When it comes to CV health and outcomes, data show that a person’s ZIP code is often more predictive than a diagnostic code, correlating with everything from access to care and medications to mortality after hospital admission.
WHO defines social determinants of health as the circumstances into which people are born, grow, live, work and age and the wider set of forces and systems shaping the conditions of daily life. Those social factors — coupled with structural racism and biases affecting historically marginalized populations — have a profound impact on CVD risk and outcomes. Clinical care and treatment for CVD accounts for just 10% to 20% of the modifiable contributors to healthy outcomes, with the other 80% to 90% attributed to social determinants of health, according to a scientific statement from the American Heart Association, published in January in Circulation.
“It is imperative for us, as cardiologists, to look at the big picture: to achieve CV health equity for all, we must incorporate addressing social determinants of health into our day-to-day practice,” Modele O. Ogunniyi, MD, MPH, FACC, FACP, FAHA, associate professor of medicine with the division of cardiology at Emory University School of Medicine and associate medical director of Grady Memorial Hospital’s comprehensive heart failure management program, told Cardiology Today. “Social determinants of health — access to and quality of health care and education, housing, social and community support and economic stability, in addition to systemic factors such as racism and discrimination — drive the widening gap in disparities we see in CVD.”
Concurrent interventions to address directly social determinants of health, such as approaches to improve food insecurity, as well as addressing root causes through policy changes, are critical, according to the authors of the recent AHA statement. But experts agree that cardiologists, too, can play a unique role in addressing social determinants of health and have a direct impact on their patients’ outcomes and quality of life.
“Politicians and pundits often say our health care is disadvantaged because, despite spending more per capita than other Westernized societies, life expectancy in the U.S. is only 16th among other advanced countries,” Cardiology Today Editorial Board Member Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA, professor of medicine in the John W. Deming department of medicine at Tulane University School of Medicine, said in an interview. “However, this statement is misleading. If you examine people who have means, adequate insurance, live in a safe environment, have access to healthy foods and sources of care, they live as long and as fruitful a life as people living in Japan or western Europe. The disparity in life expectancy is because of the impact of disparities related to social determinants of health.”
Environment and disease burden
The burden of CVD risk factors is disproportionately borne by women and men of ethnic and racial minorities, who are more likely to live in disadvantaged areas due to a history of racial residential segregation.
Today, Black women have the highest rates of obesity of any racial group in the U.S., according to CDC data, and have a higher incidence of MI or fatal CHD compared with white women or men in all age groups. Similarly, Black men have the lowest levels of CV health based on the AHA’s Life’s Simple 7 metrics — physical activity, diet, cholesterol, BP, BMI, smoking and glycemic control — in addition to higher rates of obesity, lower rates of physical activity and a higher rate of smoking when compared with men from other race groups, according to Joshua J. Joseph, MD, MPH, FAHA, assistant professor of medicine in the division of endocrinology, diabetes and metabolism at The Ohio State University College of Medicine in Columbus.
“The question becomes: Why?” Joseph told Cardiology Today. “It is a hard question to answer. We think it is partially due to mistrust of the health care system. It is partially due to the social determinants of health — socioeconomic status and how that influences health over time. Racism, especially structural racism, is a persistent source of stress, drives mistrust and social determinants of health and is associated with lower Life’s Simple 7.”
CVD rates are particularly high in younger American Indian and Alaska Native individuals; more than one-third of CVD deaths in this population occur before age 65 years, and most are secondary to CHD.
In an analysis of National Health and Nutrition Examination Survey data published in October in JAMA, Black adults had higher age- and sex-adjusted BMI, systolic BP and HbA1c compared with white adults from 1999 to 2018. Additionally, the mean 10-year atherosclerotic CVD risk adjusted for age and sex was higher for Black vs. white participants, but this was mediated by social determinants of health, such as education, income, housing, employment, health insurance and access to health care.
In addition, the maldistribution of doctors and nurses and the lack of adequate health care facilities in rural communities is a well-known factor in health risk, accentuated by continued economic decline in those regions.
Asking the right questions
The American Academy of Family Physicians provides a social needs screening guide for patients, including an adaptable short- and long-form screening tool that assesses needs related to housing, food, transportation, utilities and personal safety.
Experts agree social determinants of health screenings should be integrated into clinical care delivery, encouraging clinicians to tailor care to the social needs of their patients. However, there are other questions cardiologists should be asking beyond a questionnaire to better assess patient needs, Ferdinand said.
“One of the first questions I ask a person is: ‘Who came with you today?’” Ferdinand said. “Many times, that support person can partner with us as specialists to help them understand the risk involved in their condition and the need to access medications or undergo certain procedures.”
Recent data published in JAMA Network Open also show Black women who reported having a negative net worth were 2.5 times more likely to have sustained hypertension compared with Black women reporting positive net worth, independent of education level and income, suggesting limited assets or a lack of economic reserve may be associated with poor CVD outcomes in this at-risk group. Yet, survey questions to determine socioeconomic status are often ineffective measures of net worth for underrepresented or marginalized populations.
“We have published research on financial strain and ideal CV health, showing they are related,” Michelle A. Albert, MD, MPH, FACC, FAHA, president of the Association of Black Cardiologists, president-elect of the AHA and professor of medicine at the University of California, San Francisco, told Cardiology Today. “The one question that is very strongly correlated is: ‘Are you able to meet your expenses at the end of the month?’ That is a sensitive question around financial strain. We know, for example, that African American adults who earn the same income as white adults may still live paycheck to paycheck because of a lack of intergenerational wealth, especially if they do not own a home.”
Getting to know the patient should be a routine part of any appointment, as should checking in at follow-up visits to see how social factors impact their ability to receive care, according to Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, associate professor of medicine in the division of cardiology, advanced HF/transplant specialist and leader of health equity research at Indiana University School of Medicine and Indiana University Health and Cardiology Today Editorial Board Member.
“To assume [a patient’s situation] is the same when you meet that person each time over the trajectory of your relationship with them would be wrong,” Breathett told Cardiology Today. “Things happen to people over time, like job loss or illness of a family member. We need more time to meet with these patients to truly assess these things. For every individual, it is different. You won’t know unless you ask.”
Listening is equally important, Albert said.
“Many of my patients who happen to be of same racial background as me will come and have a conversation and say, ‘This is the first time I feel a doctor has sat and listened to me,’” Albert said. “At a very basic level, it is important to get at why they are coming to see you. I always start with, ‘How can I help you today?’ Your agenda might not be their agenda. Oftentimes, it is not. Create a situation where they feel more comfortable to ask more consequential questions.”
Role of interventions
It is well established that incorporating social determinants of health screening and interventions into chronic disease clinical care improves patient outcomes. However, current guidelines largely exclude social determinants of health-informed approaches, according to a review on social determinants of CVD published in Circulation Research. The AHA has suggested expanding social determinants of health education for cardiologists at all levels.
The review also called for improvements in clinical education to better inform health care providers about how to identify and address their patients’ social needs.
“When I am on clinical service, I infuse the social factors into my teaching of fellows and junior faculty,” Albert said.
At Grady Memorial Hospital, the Grady Heart Failure Program, launched in 2011, is designed to address barriers to health equity at the patient level, especially among patients of low socioeconomic status, Ogunniyi said. The Grady Implementation Guide was developed based on the program’s evaluation by the CDC’s Division for Heart Disease and Stroke Prevention.
“We identified the top barriers to care and developed patient-centered programs to address these barriers,” Ogunniyi said. “Those were lack of transportation, finances and medication and lack of connection to resources. As a group, we addressed these issues. Patients admitted with HF receive a 30-day supply of HF medications at hospital discharge. We now have a full-time nurse care coordinator who ensures patients have a follow-up clinic appointment scheduled before discharge in our HF clinic within 48 to 72 hours.”
Transportation to or from clinic appointments is provided for patients who need it through a partnership with rideshare support services, Ogunniyi said.
“Some may assume that patients from underrepresented groups are not invested in their health care,” Ogunniyi said. “They are. You just have to empower them with the resources and provide equitable and accessible health care.”
Develop ‘cultural humility’
Data suggest that social determinants of health do not fully account for racial and ethnic disparities in care; racial discordance between patients and physicians also predicts worse quality of care compared with racial concordance. However, barriers remain to increasing the Black, Hispanic and Indigenous cardiologist workforce. According to the American College of Cardiology’s Professional Life Survey, although African Americans make up 13% of the U.S. population, fewer than 3% of cardiologists identified as Black as of 2015.
“The data change, but approximately 15% of cardiologists are women and 3% are Black,” Breathett said. “Given how many patients with CVD are Black, or Black women, the odds are they are not going to see a Black woman cardiologist. There simply are not enough of us.”
Concordance between the provider and their patient has been shown to increase medication adherence and may improve outcomes, Ferdinand said. However, implicit bias or cultural competency training alone will not solve the often-reported problem of poor physician-patient communication.
“What I suggest is we as clinicians embrace the concept of cultural humility,” Ferdinand said. “Cultural humility goes beyond cultural competency. Cultural competency is a body of knowledge of how patients think or act. Cultural humility involves us overcoming our own biases. That means self-reflection, learning from our patients and being respectful of some of the mistrust patients may have, and taking the extra step. Try and develop a positive relationship with our patients to improve access and adherence.”
Breathett said patients should feel like they have a “level of trust” with their health care provider. If a patient feels uncomfortable with a provider, for any reason, they should seek care elsewhere, she said.
“We know that many health care professionals have an inherent lack of trust of patients of color, with translates to inequitable care,” Breathett said. “It’s not right and we must figure out how we are going to do things differently. Many try to say they do not see color or how can a clinician not want the best for all patients? Those are naive statements. It is abundantly clear that we do not live in a fair and equitable society. Yet, there are still populations who feel this is not a priority. We must push forward in recognizing how we contribute to the problems as clinicians and as scientists. Then, we must act, changing our systems and our day-to-day operations.”
- References:
- Breathett K, et al. J Am Heart Assoc. 2019;doi:10.1161/JAHA.119.013592.
- Grady Implementation Guide. Available at: www.cdc.gov/dhdsp/evaluation_resources/guides/grady.htm. Accessed March 11, 2022.
- Johnson AE, et al. Circulation. 2021;doi:10.1161/CIRCULATIONAHA.121.053566.
- Joseph JJ, et al. Circulation. 2022;doi:10.1161/CIR.0000000000001040.
- Lindley KJ, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.09.011.
- Ogunniyi MO, et al. J Am Coll Cardiol. 2021;doi:10.1016/j/jacc.2021.06.017.
- Powell-Wiley TM, et al. Circ Res. 2022;doi:10.1161/CIRCRESAHA.121.319811.
- Social determinants of health guide to social needs screening. Available at: www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-guide-sdoh.pdf. Accessed March 11, 2022.
- Spikes T, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.0331.
- Weinhold I, et al. Health Pol. 2014;doi:10.1016/j.healthpol.2014.07.018.
- For more information:
- Michelle A. Albert, MD, MPH, FACC, FAHA, can be reached at michelle.albert@ucsf.edu.
- Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, can be reached at kbreath@iu.edu; Twitter: @kbreathettmd.
- Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA, can be reached at kferdina@tulane.edu; Twitter: @kcferdmd.
- Joshua J. Joseph, MD, MPH, FAHA, can be reached at joshua.joseph@osumc.edu; Twitter: @joshuajosephmd.
- Modele O. Ogunniyi, MD, MPH, FACC, FACP, FAHA, can be reached at modele.ogunniyi@emory.edu; Twitter: @modeldoc.
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