Veterans with CVD from historically redlined neighborhoods have elevated risk for events
Click Here to Manage Email Alerts
Key takeaways:
- Among veterans with cardiovascular disease, those from historically redlined neighborhoods were more likely have a CV event or die.
- Policies to undo the health effects of redlining are needed.
Among veterans with atherosclerotic CVD, those from historically redlined neighborhoods had greater risk for CV events compared with those from the lowest-risk neighborhoods, researchers reported.
“The Home Owners’ Loan Corporation (HOLC), created in the 1930s to increase homeownership for working-class U.S. individuals under the New Deal, established a color-coded grading system for neighborhoods in more than 200 U.S. cities according to foreclosure risk,” Salil V. Deo, MD, from the surgical services department at Louis Stokes Veterans Affairs Hospital in Cleveland, and colleagues wrote. “The ratings of these areas were largely based on racial and ethnic compositions and would inform lending risk. Neighborhoods were rated and thus color-coded as A (best [green]), B (still desirable [blue]), C (definitely declining [yellow]), and D (hazardous [red]). This practice, later termed neighborhood redlining, led to decades of disinvestments in redlined neighborhoods and exacerbated residential segregation. This designation ultimately resulted in profound consequences as a direct sequalae of racist policies, culminating in worse neighborhood-level health risk factors, access to care, and adverse environmental exposures in redlined areas.
“Color coding was discontinued in the 1940s. However, it is still unclear whether living in these neighborhoods continues to have a negative association with cardiovascular outcomes,” the researchers wrote.
Deo and colleagues conducted a longitudinal cohort study consisting of 79,997 veterans who received care for established atherosclerotic disease, defined as CAD, peripheral vascular disease or stroke (mean age, 74 years; 2.9% women; 37.3% Black). Patients were stratified by HOLC grade and followed for a median of 4 years.
CV effects of redlining
Compared with those living in HOLC grade A neighborhoods, those living in HOLC grade D (redlined) neighborhoods were more likely to be Black or Hispanic and more likely to have diabetes, HF and chronic kidney disease (CKD), Deo and colleagues found.
In unadjusted models, there was no relationship between HOLC grade and major adverse CV events. However, after adjustment for demographic factors, the grade D group had elevated risk for major adverse CV events (adjusted HR = 1.139; 95% CI, 1.083-1.198; P < .001), all-cause mortality (aHR = 1.129; 95% CI, 1.072-1.19; P < .001) and MI (aHR = 1.148; 95% CI, 1.011-1.303; P < .001) compared with the grade A group, according to the researchers.
There was no relationship between HOLC grade and stroke (HR = 0.889; 95% CI, 0.584-1.353; P = .58).
The effect size was smaller but remained significant after further adjustment for risk factors and social vulnerability, the researchers wrote.
“This study has implications for clinical practice and public health policy,” Deo and colleagues wrote. “First, this study builds on earlier work and suggests that historic sequelae of structural racism may be consistent factors in cardiovascular outcomes. Second, it highlights the need to consider neighborhood characteristics when assessing cardiovascular risk both for individuals and populations. Innovative strategies to improve cardiovascular health in redlined neighborhoods are urgently needed. These may include improving neighborhood designs by increasing greenspace, reducing access to tobacco via increasing taxes and elevating the legal age for purchasing, increasing access to healthy food and implementing novel health care delivery models (eg, mobile health units) to improve cardiovascular outcomes.”
‘Opportunities to dive deeper’
In a related editorial, Colleen A. Burke, PT, DPT, and Hayden B. Bosworth, PhD, both from the department of population health sciences at Duke University School of Medicine, wrote that the study “presents researchers with opportunities to dive deeper to explore the root causes of cardiovascular disease that could in turn point to improved treatment. Furthermore, these findings present clinicians and health care systems with an opportunity to screen patients who may be at higher risk for major adverse CV events so that they can triage and target treatments appropriately. Ultimately, these findings present policymakers with evidence of the persistent harmful outcomes associated with redlining neighborhoods and point to the need to undo the harms that these historical practices have and continue to have in furthering health disparities.”
Reference:
Perspective
Back to Top
Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA
This study builds upon the increasing body of work that confirms the social determinants of health (SDOH), where people work, live, pray and play, have a profound effect on CVD and chronic illnesses. It adds substantially to the database already described using redlining as a means of showing that the SDOH have a deleterious effect on outcomes related to CV and cardiometabolic diseases.
In the United States, despite spending more per dollar on health care than other Westernized, industrialized societies, we have persistent disparities with higher rates of CVD, decreased mortality and decreased longevity related to socioeconomic status, education, race, ethnicity, sex/gender and geography. There are multiple ways to attempt to determine the driving forces of these disparities. However, the built environment — those neighborhoods that have been previously redlined as indicating a less desirable area for homeownership and business investments by banks — becomes a surrogate for neighborhoods which have a higher proportion of persons of various racial/ethnic minorities, a higher percentage of people who have recently immigrated, lower access to public transportation, less attainment of adequate health care insurance and less easy availability of healthy food choices.
A previous study (Motairek I, et al. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2022.05.010) had shown historical neighborhood redlining had affected CVD burden across a wide range of patients. This study suggests that those adverse social determinants not only affect the general population, but even those who have served in the military. It also suggests that the problem goes beyond simply having lack of access to insurance, since the veteran population, through the Veterans Administration, is indeed often able to get appropriate care. We know from the REGARDS study that diet, especially foods such as processed meats, fried foods, saturated fats, high-fat dairy, sugar-sweetened beverages, bread and foods high in sodium, is associated not only with CVD including stroke but also chronic kidney disease, end-stage renal disease, perhaps certain cancers and even cognitive decline. This new study confirms that these broad SDOH and environmental factors affect anyone who has lived in those adverse conditions, even beyond simply not having insurance.
We do know that these disparities involving race/ethnicity and the suboptimal control of CVD risk factors are persistent. There is a white/Black mortality gap that has been described for decades and which has been difficult to overcome. With the COVID-19 pandemic, we have seen worsened BP control and less attainment of target LDL levels because many patients were not able to maintain adequate primary and specialty care. To overcome these disparities and the worsening of outcomes, especially among certain populations, there are several steps that need to be taken.
No. 1, recognize that 80% of chronic diseases are related to SDOH and assist those neighborhoods with ensuring they have adequate transportation, access to healthy foods at an acceptable cost and community outreach interventions including church- and barbershop-based interventions.
No. 2, also important is ensuring that primary care is available to all citizens and that appropriate care is available for those who need specialists such as cardiologists, endocrinologists and nephrologists.
No. 3, regardless of race, ethnicity, socioeconomic status, geography, sex or gender, we need to ensure that guideline-directed, evidence-based care is equally afforded to all citizens. If we don’t do that, we will not have a just society. It is a moral issue, but it is also a practical issue since health care dollars are wasted in treating HF, end-stage renal disease with dialysis and stroke with permanent disability. These and other conditions reflect the adverse results of not controlling CVD risk factors and living in an adverse environment with high levels of negative SDOH. Unfortunately, the long-term adverse effects of redlining appear to linger into present times.
Collapse
Click Here to Manage Email Alerts