Race, Social Determinants of Health, and Risk of All-Cause and Cardiovascular Mortality in the United States

Social determinants of health and all-cause or cardiovascular mortality in chronic kidney disease: insights from 1999-2018 US National Health and Nutrition Examination Survey

OBJECTIVES

Unfavorable social risk profile has been identified as a fundamental driver for disparate mortality rate. This study aimed to determine the association between social determinants of health (SDOH) and all-cause or cardiovascular disease (CVD) mortality in patients with chronic kidney disease (CKD).

METHODS

Data from adult participants with CKD and available information on SDOH were collected from the 1999-2018 US National Health and Nutrition Examination Survey. SDOH was calculated based on eight factors, including employment, poverty-income ratio, food security, education level, access to healthcare, health insurance, housing instability, and marital status. Cox proportional hazard regression analysis, restricted cubic spline analysis and subgroup analysis were performed.

RESULTS

5,420 participants (mean age 58.13 years, 43.04% men) were analyzed, including 729, 1,713, 1,849 and 1,129 with a SDOH of ≤ 2, 3-4, 5-6, and 7-8, respectively. Over a median follow-up of 92 months, 1,923 (742 CVD-related) deaths occurred. Compared to the reference group (SDOH of 7-8), the hazard ratios and 95% confidence intervals for those with a SDOH of 5-6, 3-4, and ≤ 2 were 1.25 (1.06-1.48), 1.51 (1.26-1.81) and 2.00 (1.54-2.60), respectively, for all-cause mortality, and 1.38 (1.08-1.77), 1.43 (1.09-1.89), and 1.78 (1.15-2.77), respectively, for CVD mortality. Restricted cubic spline analysis indicated linear dose-response relationships between SDOH levels and all-cause or CVD mortality. The association between SDOH and mortality was more pronounced in men than in women.

CONCLUSION

Lower SDOH levels are independently associated with higher all-cause and CVD mortality rates among US adults with CKD, especially in men.

Cumulative social disadvantage and its impact on long COVID: insights from a U.S. national survey

BACKGROUND

The COVID-19 pandemic has exacerbated health disparities, with long COVID emerging as a major global public health challenge. Although clinical risk factors for long COVID are well-documented, the cumulative burden of adverse social determinants of health (SDoH) remains underexplored. This study aims to investigate the association between cumulative social disadvantage and long COVID.

METHODS

Using data from the 2022 and 2023 National Health Interview Survey cycles (n = 16,446 U.S.adults), cumulative social disadvantage was quantified through 18 SDoH indicators and categorized into quartiles. The highest quartile represents the most disadvantaged individuals. Long COVID was defined as self-reported symptoms persisting for three months or longer. Weighted logistic regression models were used to examine the association, adjusting for demographic and clinical variables.

RESULTS

Adults in the highest quartile of cumulative social disadvantage exhibited an increased odds of experiencing long COVID compared to those in the lowest quartile (AOR = 2.52, 95% Cl: 2.13, 2.98). This association persisted across demographic subgroups, with particularly pronounced effects among women and non-Hispanic Blacks. Hispanics and non-Hispanic Whites showed weaker, but still statistically significant. Key contributors included mental health difficulties, economic instability, and healthcare access barriers. Furthermore, cumulative social disadvantage was linked to fair or poor general health status among individuals with long COVID.

CONCLUSIONS

This study highlights the positive association between cumulative social disadvantage and long COVID. Addressing systemic inequities through integrated public health strategies is essential to mitigate the burden of long COVID and reduce social disparities in health.

Associations between social determinants of health and cardiovascular and cancer mortality in cancer survivors: a prospective cohort study

AIMS

The cause-specific mortality implications of social determinants of health (SDOH) in cancer survivors were unclear. This study aimed to explore associations between SDOH and cardiovascular and cancer mortality in cancer survivors.

METHODS AND RESULTS

Data from 2013 to 2017 National Health Interview Survey were used for this prospective cohort study. Social determinants of health were quantified using a 38 point, 6 domain score, with higher points indicating worse deprivation. Associations between SDOH and outcomes (primary: cardiovascular mortality; secondary: cancer and all-cause mortality) were assessed using cause-specific multivariable Cox regression, with cancer survivors and individuals without cancer modelled separately. Post hoc analyses were performed among cancer survivors to explore associations between each domain of SDOH and the risks of outcomes. Altogether, 37 882 individuals were analysed (4179 cancer survivors and 33 703 individuals without cancer). Among cancer survivors, worse SDOH was associated with higher cardiovascular [adjusted hazard ratio (aHR) 1.31 (1.02-1.68)], cancer [aHR 1.20 (1.01-1.42)], and all-cause mortality [aHR 1.16 (1.02-1.31)] when adjusted for demographics, comorbidities, and risk factors. Among individuals without cancer, SDOH was associated with cardiovascular mortality and all-cause when only adjusted for demographics, but not when further adjusted for comorbidities and risk factors; no associations between SDOH and cancer mortality were found. Among cancer survivors, psychological distress, economic stability, neighbourhood, physical environment and social cohesion, and food insecurity were varyingly associated with the outcomes.

CONCLUSION

Social determinants of health were independently associated with all-cause, cardiovascular, and cancer mortality among cancer survivors but not among individuals without cancer. Different domains of SDOH may have different prognostic importance.

Race and Ethnicity Disparities in Cardiovascular and Cancer Mortality: the Role of Socioeconomic Status-a Systematic Review and Meta-analysis

To clarify the role of socioeconomic status (SES) in cardiovascular and cancer mortality disparities observed between Black, Hispanic, and Asian compared to White adults, we conducted a meta-analysis of the longitudinal research in the USA. A PubMed, Ovid Medline, Web of Science, and EBSCO search was performed from January 1995 to May 2023. Two authors independently screened the studies and conducted risk assessments, with conflicts resolved via consensus. Studies were required to analyze mortality data using Cox proportional hazard regression. Random-effects models were used to pool hazard ratios (HR) and reporting followed PRISMA guidelines. Twenty-two studies with cardiovascular mortality (White and Black (n = 22), Hispanic (n = 7), and Asian (n = 3) adults) and twenty-three with cancer mortality endpoints (White and Black (n = 23), Hispanic (n = 11), and Asian (n = 10) adults) were included. The meta-analytic sample for cardiovascular mortality endpoints was 6,199,049 adults (White = 4,891,735; Black = 935,002; Hispanic = 295,623; Asian = 76,689), while for cancer-specific mortality endpoints was 7,745,180 adults (White = 5,988,392; Black= 1,070,447; Hispanic= 484,848; Asian = 201,493). Median follow-up was 10 and 11 years in cohorts with cardiovascular and cancer mortality endpoints, respectively. Adjustments for SES attenuated the higher risk for cardiovascular (HR, 1.46; 95% CI, 1.30-1.64) and cancer mortality (HR, 1.35; 95% CI, 1.32-1.38) of Black compared to White adults by 25% (HR, 1.21; 95% CI, 1.15-1.28) and 19% (HR, 1.16; 95% CI, 1.13-1.18), respectively. However, the Hispanic cardiovascular (HR, 0.79; 95% CI, 0.73-0.85) and Asian cancer mortality (HR, 0.81; 95% CI, 0.76-0.86) advantage were independent of SES. These findings emphasize the need to develop strategies focused on SES to reduce cardiovascular and cancer mortality in Black adults.

Development and Evaluation of a Comprehensive Prediction Model for Incident Coronary Heart Disease Using Genetic, Social, and Lifestyle-Psychological Factors: A Prospective Analysis of the UK Biobank

BACKGROUND

Clinical risk calculators for coronary heart disease (CHD) do not include genetic, social, and lifestyle-psychological risk factors.

OBJECTIVE

To improve CHD risk prediction by developing and evaluating a prediction model that incorporated a polygenic risk score (PRS) and a polysocial score (PSS), the latter including social determinants of health and lifestyle-psychological factors.

DESIGN

Cohort study.

SETTING

United Kingdom.

PARTICIPANTS

UK Biobank participants recruited between 2006 and 2010.

MEASUREMENTS

Incident CHD (myocardial infarction and/or coronary revascularization); 10-year clinical risk based on pooled cohort equations (PCE), Predicting Risk of cardiovascular disease EVENTs (PREVENT), and QRISK3; PRS (Polygenic Score Catalog identification: PGS000018) for CHD (PRSCHD); and PSSCHD from 100 related covariates. Machine-learning and time-to-event analyses and model performance indices.

RESULTS

In 388 224 participants (age, 55.5 [SD, 8.1] years; 42.5% men; 94.9% White), the hazard ratio for 1 SD increase in PSSCHD for incident CHD was 1.43 (95% CI, 1.38 to 1.49; P < 0.001) and for 1 SD increase in PRSCHD was 1.59 (CI, 1.53 to 1.66, P < 0.001). Non-White persons had higher PSSCHD than White persons. The effects of PSSCHD and PRSCHD on CHD were independent and additive. At a 10-year CHD risk threshold of 7.5%, adding PSSCHD and PRSCHD to PCE reclassified 12% of participants, with 1.86 times higher CHD risk in the up- versus down-reclassified persons and showed superior performance compared with PCE as reflected by improved net benefit while maintaining good calibration relative to the clinical risk calculators. Similar results were seen when incorporating PSSCHD and PRSCHD into PREVENT and QRISK3.

LIMITATION

A predominantly White cohort; possible healthy participant effect and ecological fallacy.

CONCLUSION

A PSSCHD was associated with incident CHD and its joint modeling with PRSCHD improved the performance of clinical risk calculators.

PRIMARY FUNDING SOURCE

National Human Genome Research Institute.

Standardizing social determinants of health data: a proposal for a comprehensive screening tool to address health equity a systematic review

Social determinants of health (SDoH) significantly impacts health outcomes and disparities. While the Centers for Medicare and Medicaid Services has mandated hospitals to collect standardized SDoH data, existing tools lack key elements. This systematic review identified 78 studies and 20 screening tools addressing various SDoH domains. However, most tools were missing several key domains and lacked standardization. We propose a comprehensive tool meeting essential criteria: validated questions, brevity, actionability, cultural appropriateness, workflow integration, and community linkage. Our tool addresses gaps in available tools and incorporates standardized and validated questions to enable patient-centered screening for diverse social and environmental determinants of health. It uniquely includes detailed race/ethnicity data collection, housing characteristics, physical activity assessment, access to healthy food measures, and environmental exposure evaluation. The tool aims to provide actionable data for immediate interventions while informing broader population health strategies and policy initiatives. By offering a holistic assessment of SDoH across multiple domains, our tool enables standardized data collection, risk stratification, and focused initiatives to address health inequities at both individual and population levels. Further research is needed to develop evidence-based pathways for integrating SDoH data into real-world patient care workflows, improve risk prediction algorithms, address health-related social needs, and reduce disparities.

The High-Sensitivity HEART Pathway Safely Reduces Hospitalizations Regardless of Sex or Race in a Multisite Prospective US Cohort

BACKGROUND

The high-sensitivity HEART pathway (hs-HP) risk stratifies emergency department (ED) patients with chest pain. It is unknown if its safety and effectiveness vary by sex or race.

METHODS

We conducted a subgroup analysis of the hs-HP implementation study, a pre-post interrupted time series at five US EDs. The pre-implementation period (January 2019 to April 2020) utilized the traditional HEART pathway with contemporary troponin (Siemens) and the post-implementation period (November 2020 to February 2022) used the hs-HP using hs-cTnI (Beckman Coulter). Patients were risk-stratified using the hs-HP to rule-out, observation, and rule-in groups. Safety and effectiveness outcomes were 30-day all-cause mortality or myocardial infarction (MI) and 30-day hospitalization.

RESULTS

Twenty-six thousand and one hundred twenty-six patients were accrued (12 317 pre- and 13 809 post-implementation), of which 35.3% were non-White and 52.7% were female. Among 9703 patients with complete hs-HP assessments, 48.6% of White and 55.4% of non-White patients were ruled-out (p < 0.001). Additionally, 47.3% of males and 54.4% of females were ruled-out (p < 0.001). Among rule-out patients, 0.3% of White versus 0.3% of non-White patients (p = 0.98) and 0.3% of females versus males 0.3% (p = 0.90) experienced 30-day death or MI. Post-implementation, 30-day hospitalization decreased 17.2% among White patients (aOR 0.49, 95% CI: 0.45-0.52), 14.1% among non-White patients (aOR 0.53, 95% CI: 0.48-0.59), 15.6% among females (aOR 0.50, 95% CI: 0.46-0.54), and 16.6% among males (aOR 0.51, 95% CI: 0.47-0.56). The interactions for 30-day hospitalization between hs-HP implementation and race (p = 0.10) and sex (p = 0.69) were not significant.

CONCLUSIONS

The hs-HP safely decreases 30-day hospitalizations regardless of sex or race. However, it classifies more non-White patients and women to the rule-out group.

Associations of neighborhood sociodemographic environment with mortality and circulating metabolites among low-income black and white adults living in the southeastern United States

BACKGROUND

Residing in a disadvantaged neighborhood has been linked to increased mortality. However, the impact of residential segregation and social vulnerability on cause-specific mortality is understudied. Additionally, the circulating metabolic correlates of neighborhood sociodemographic environment remain unexplored. Therefore, we examined multiple neighborhood sociodemographic metrics, i.e., neighborhood deprivation index (NDI), residential segregation index (RSI), and social vulnerability index (SVI), with all-cause and cardiovascular disease (CVD) and cancer-specific mortality and circulating metabolites in the Southern Community Cohort Study (SCCS).

METHODS

The SCCS is a prospective cohort of primarily low-income adults aged 40-79, enrolled from the southeastern United States during 2002-2009. This analysis included self-reported Black/African American or non-Hispanic White participants and excluded those who died or were lost to follow-up ≤ 1 year. Untargeted metabolite profiling was performed using baseline plasma samples in a subset of SCCS participants.

RESULTS

Among 79,631 participants, 23,356 deaths (7214 from CVD and 5394 from cancer) were documented over a median 15-year follow-up. Higher NDI, RSI, and SVI were associated with increased all-cause, CVD, and cancer mortality, independent of standard clinical and sociodemographic risk factors and consistent between racial groups (standardized HRs among all participants were 1.07 to 1.20 in age/sex/race-adjusted model and 1.04 to 1.08 after comprehensive adjustment; all P < 0.05/3 except for cancer mortality after comprehensive adjustment). The standard risk factors explained < 40% of the variations in NDI/RSI/SVI and mediated < 70% of their associations with mortality. Among 1110 circulating metabolites measured in 1688 participants, 134 and 27 metabolites were associated with NDI and RSI (all FDR < 0.05) and mediated 61.7% and 21.2% of the NDI/RSI-mortality association, respectively. Adding those metabolites to standard risk factors increased the mediation proportion from 38.4 to 87.9% and 25.8 to 42.6% for the NDI/RSI-mortality association, respectively.

CONCLUSIONS

Among low-income Black/African American adults and non-Hispanic White adults living in the southeastern United States, a disadvantaged neighborhood sociodemographic environment was associated with increased all-cause and CVD and cancer-specific mortality beyond standard risk factors. Circulating metabolites may unveil biological pathways underlying the health effect of neighborhood sociodemographic environment. More public health efforts should be devoted to reducing neighborhood environment-related health disparities, especially for low-income individuals.

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

METHODS

We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

RESULTS

Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

CONCLUSIONS

Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Palliative Care Across the Spectrum of Heart Failure

Persons with heart failure (HF) often suffer from poor symptom control, decreased quality of life, and poor communication with their health care providers. These needs are particularly acute in advanced HF, a leading cause of death in the United States. Palliative care, when offered alongside HF disease management, offers improved symptom control, quality of life, communication, and caregiver satisfaction as well as reduced caregiver anxiety. The dynamic nature of the clinical trajectory of HF presents distinct symptom patterns, changing functional status, and uncertainty, which requires an adaptive, dynamic model of palliative care delivery. Due to a limited specialty-trained palliative care workforce, patients and their caregivers often cannot access these benefits, especially in the community. To meet these needs, new models are required that are better informed by high-quality data, engage a range of health care providers in primary palliative care principles, and have clear triggers for specialty palliative care engagement, with specific palliative interventions tailored to patient's illness trajectory and changing needs.

Scoping Review of Screening and Assessment Tools for Social Determinants of Health in the Field of Cardiovascular Disease

BACKGROUND

Despite the importance of implementing the concept of social determinants of health (SDOH) in the clinical practice of cardiovascular disease (CVD), the tools available to assess SDOH have not been systematically investigated. We conducted a scoping review for tools to assess SDOH and comprehensively evaluated how these tools could be applied in the field of CVD.

METHODS AND RESULTS

We conducted a systematic literature search of PubMed and Embase databases on July 25, 2023. Studies that evaluated an SDOH screening tool with CVD as an outcome or those that explicitly sampled or included participants based on their having CVD were eligible for inclusion. In addition, studies had to have focused on at least one SDOH domain defined by Healthy People 2030. After screening 1984 articles, 58 articles that evaluated 41 distinct screening tools were selected. Of the 58 articles, 39 (67.2%) targeted populations with CVD, whereas 16 (27.6%) evaluated CVD outcome in non-CVD populations. Three (5.2%) compared SDOH differences between CVD and non-CVD populations. Of 41 screening tools, 24 evaluated multiple SDOH domains and 17 evaluated only 1 domain.

CONCLUSIONS

Our review revealed recent interest in SDOH in the field of CVD, with many useful screening tools that can evaluate SDOH. Future studies are needed to clarify the importance of the intervention in SDOH regarding CVD.

Assessing the Influence of COVID-19 Vaccination Coverage on Excess Mortality across 178 Countries: A Cross-Sectional Study

The COVID-19 pandemic has had a devastating impact on global health, necessitating urgent and effective strategies to mitigate its consequences. Vaccination programs have been implemented worldwide to combat virus transmission and reduce the disease burden. This study aimed to investigate the relationship between COVID-19 vaccination coverage and all-cause excess mortality in 178 nations during the first two years of the pandemic. Multiple regression analysis, after adjusting for life expectancy at birth, confirmed a significant association between higher vaccination coverage and lower all-cause mortality rates (β = -106.8, 95% CI -175.4 to -38.2, p = 0.002). These findings underscore the importance of vaccination campaigns in reducing overall mortality during the COVID-19 pandemic. Evidence-based decision making and resource allocation can benefit from this information, facilitating the optimization of vaccination strategies for maximal impact on mortality reduction. Further research and continuous monitoring are crucial to understanding the long-term effects of vaccination coverage on population health in the ongoing pandemic.