Addressing Disparities in Health Care

Disparities in cardiovascular care: Past, present, and solutions

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Release date: September 1, 2019
Expiration date: August 31, 2020
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ABSTRACT

Cardiovascular disease has been the leading cause of death in the United States since the early 20th century. With advances in prevention and treatment, cardiovascular mortality rates are on the decline. Nevertheless, disparities in care persist, with devastating impact in select populations in the United States. This paper reviews the impact of disparate care on risk-factor burden, coronary artery disease, heart failure, and cardiovascular research.

KEY POINTS

  • Although avoidable deaths from heart disease, stroke, and hypertensive disease have declined overall, African Americans still have a higher mortality rate than other racial and ethnic groups.
  • The prevalence of modifiable risk factors for cardiovascular disease is higher in African Americans than in the general US population.
  • Disparities in care exist and may persist even with equal access to care.
  • Since 1993, studies funded by the National Institutes of Health must include minorities that were historically underrepresented in clinical research trials.
  • Solutions to disparities will need to eliminate healthcare bias, increase patient access, and increase diversity and inclusion in the physician work force.
  • Cardiovascular disease makes no distinction in race, sex, age, or socioeconomic status, and neither should the medical community.


 

References

Cardiovascular disease became the leading cause of death in the United States in the early 20th century, and it accounts for nearly half of all deaths in industrialized nations.1 The mortality it inflicts was thought to be shared equally between both sexes and among all age groups and races.2 The cardiology community implemented innovative epidemiologic research, through which risk factors for cardiovascular disease were established.1 The development of coronary care units reduced in-hospital mortality from acute myocardial infarction from 30% to 15%.2–5 Further advances in pharmacology, revascularization, and imaging have aided in the detection and treatment of cardiovascular disease.6 Though cardiovascular disease remains the number-one cause of death worldwide, rates are on the decline.7

For several decades, health disparities have been recognized as a source of pathology in cardiovascular medicine, resulting in inequity of care administration among select populations. In this review, we examine whether the same forward thinking that has resulted in a decline in cardiovascular disease has had an impact on the pervasive disparities in cardiovascular medicine.

DISPARITIES DEFINED

Compared with whites, members of minority groups have a higher burden of chronic diseases, receive lower quality care, and have less access to medical care. Recognizing the potential public health ramifications, in 1999 the US Congress tasked the Institute of Medicine to study and assess the extent of healthcare disparities. This led to the landmark publication, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.8

The Institute of Medicine defines disparities in healthcare as racial or ethnic differences in the quality of healthcare that are not due to access-related factors, clinical needs, preferences, and appropriateness of intervention.8 Disparities can also exist according to socioeconomic status and sex.9

In an early study documenting the concept of disparities in cardiovascular disease, Stone and Vanzant10 concluded that heart disease was more common in African Americans than in whites, and that hypertension was the principal cause of cardiovascular disease mortality in African Americans.

Figure 1. Avoidable deaths from heart disease, stroke, and hypertensive disease, 2001 and 2010. Data from US Centers for Disease Control and Prevention, reference 11

Figure 1. Avoidable deaths from heart disease, stroke, and hypertensive disease, 2001 and 2010.

Although avoidable deaths from heart disease, stroke, and hypertensive disease declined between 2001 and 2010, African Americans still have a higher mortality rate than other racial and ethnic groups (Figure 1).11

DISPARITIES AND CARDIOVASCULAR HEALTH

The concept of cardiovascular health was established by the American Heart Association (AHA) in efforts to achieve an additional 20% reduction in cardiovascular disease-related mortality by 2020.7 Cardiovascular health is defined as the absence of clinically manifest cardiovascular disease and is measured by 7 components:

  • Not smoking or abstaining from smoking for at least 1 year
  • A normal body weight, defined as a body mass index less than 25 kg/m2
  • Optimal physical activity, defined as 75 minutes of vigorous physical activity or 150 minutes of moderate-intensity physical activity per week
  • Regular consumption of a healthy diet
  • Total cholesterol below 200 mg/dL
  • Blood pressure less than 120/80 mm Hg
  • Fasting blood sugar below 100 mg/dL.

Nearly 70% of the US population can claim 2, 3, or 4 of these components, but differences exist according to race,12 and 60% of adult white Americans are limited to achieving no more than 3 of these healthy metrics, compared with 70% of adult African Americans and Hispanic Americans.

Smoking

Smoking is a major risk factor for cardiovascular disease.12–14

Figure 2. Percentage of adults who are active smokers, 2005 and 2014. Data from National Health Interview Surgery, Jamal et al, reference 16

Figure 2. Percentage of adults who are active smokers, 2005 and 2014.

During adolescence, white males are more likely to smoke than African American and Hispanic males,12 but this trend reverses in adulthood, when African American men have a higher prevalence of smoking than white men (21.4% vs 19%).7 Rates of lifetime use are highest among American Indian or Alaskan natives and whites (75.9%), followed by African Americans (58.4%), native Hawaiians (56.8%), and Hispanics (56.7%).15 Trends for current smoking are similar (Figure 2).16 Moreover, households with lower socioeconomic status have a higher prevalence of smoking.7

Physical activity

People with a sedentary lifestyle are more likely to die of cardiovascular disease. As many as 250,000 deaths annually in the United States are attributed to lack of regular physical activity.17

Recognizing the potential public health ramifications, the AHA and the 2018 Federal Guidelines on Physical Activity recommend that children engage in 60 minutes of daily physical activity and that adults participate in 150 minutes of moderate-intensity or 75 minutes of vigorous physical activity weekly.18,19

Figure 3. Prevalence of inactivitya in the United States, 2013. Data from Behavioral Risk Factor Surveillance System, Omura et al, reference 20

Figure 3. Prevalence of inactivitya in the United States, 2013.


aPercentage of US adults eligible for intensive behavioral counseling for cardiovascular disease prevention and not meeting aerobic exercise guideline

In the United States, 15.2% of adolescents reported being physically inactive, according to data published in 2016.7 Similar to most cardiovascular risk factors, minority populations and those of lower socioeconomic status had the worst profiles. The prevalence of physical inactivity was highest in African Americans and Hispanics (Figure 3).20

Studies have shown an association between screen-based sedentary behavior (computers, television, and video games) and cardiovascular disease.21–23 In the United States, 41% of adolescents used computers for activities other than homework for more than 3 hours per day on a school day.7 The pattern of use was highest in African American boys and African American girls, followed by Hispanic girls and Hispanic boys.18 Trends were similar with regard to watching television for more than 3 hours per day.

Sedentary behavior persists into adulthood, with rates of inactivity of 38.3% in African Americans, 40.1% in Hispanics, and 26.3% in white adults.7

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