Eliminating Disparities in Cardiovascular Disease for Black Women

Patient-Centered Adult Cardiovascular Care: A Scientific Statement From the American Heart Association

Patient-centered care is gaining widespread acceptance by the medical and lay communities and is increasingly recognized as a goal of high-quality health care delivery. Patient-centered care is based on ethical principles and aims at establishing a partnership between the health care team and patient, family member, or both in the care planning and decision-making process. Patient-centered care involves providing respectful care by tailoring management decisions to patients' beliefs, preferences, and values. A collaborative care approach can enhance patient engagement, foster shared decision-making that aligns with patient values and goals, promote more personalized and effective cardiovascular care, and potentially improve patient outcomes. The objective of this scientific statement is to inform health care professionals and stakeholders about the role and impact of patient-centered care in adult cardiovascular medicine. This scientific statement describes the background and rationale for patient-centered care in cardiovascular medicine, provides insight into patient-oriented medication management and patient-reported outcome measures, highlights opportunities and strategies to overcome challenges in patient-centered care, and outlines knowledge gaps and future directions.

Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association

Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.

Use of Machine Learning for Early Detection of Maternal Cardiovascular Conditions: Retrospective Study Using Electronic Health Record Data

BACKGROUND

Cardiovascular conditions (eg, cardiac and coronary conditions, hypertensive disorders of pregnancy, and cardiomyopathies) were the leading cause of maternal mortality between 2017 and 2019. The United States has the highest maternal mortality rate of any high-income nation, disproportionately impacting those who identify as non-Hispanic Black or Hispanic. Novel clinical approaches to the detection and diagnosis of cardiovascular conditions are therefore imperative. Emerging research is demonstrating that machine learning (ML) is a promising tool for detecting patients at increased risk for hypertensive disorders during pregnancy. However, additional studies are required to determine how integrating ML and big data, such as electronic health records (EHRs), can improve the identification of obstetric patients at higher risk of cardiovascular conditions.

OBJECTIVE

This study aimed to evaluate the capability and timing of a proprietary ML algorithm, Healthy Outcomes for all Pregnancy Experiences-Cardiovascular-Risk Assessment Technology (HOPE-CAT), to detect maternal-related cardiovascular conditions and outcomes.

METHODS

Retrospective data from the EHRs of a large health care system were investigated by HOPE-CAT in a virtual server environment. Deidentification of EHR data and standardization enabled HOPE-CAT to analyze data without pre-existing biases. The ML algorithm assessed risk factors selected by clinical experts in cardio-obstetrics, and the algorithm was iteratively trained using relevant literature and current standards of risk identification. After refinement of the algorithm's learned risk factors, risk profiles were generated for every patient including a designation of standard versus high risk. The profiles were individually paired with clinical outcomes pertaining to cardiovascular pregnancy conditions and complications, wherein a delta was calculated between the date of the risk profile and the actual diagnosis or intervention in the EHR.

RESULTS

In total, 604 pregnancies resulting in birth had records or diagnoses that could be compared against the risk profile; the majority of patients identified as Black (n=482, 79.8%) and aged between 21 and 34 years (n=509, 84.4%). Preeclampsia (n=547, 90.6%) was the most common condition, followed by thromboembolism (n=16, 2.7%) and acute kidney disease or failure (n=13, 2.2%). The average delta was 56.8 (SD 69.7) days between the identification of risk factors by HOPE-CAT and the first date of diagnosis or intervention of a related condition reported in the EHR. HOPE-CAT showed the strongest performance in early risk detection of myocardial infarction at a delta of 65.7 (SD 81.4) days.

CONCLUSIONS

This study provides additional evidence to support ML in obstetrical patients to enhance the early detection of cardiovascular conditions during pregnancy. ML can synthesize multiday patient presentations to enhance provider decision-making and potentially reduce maternal health disparities.

Black women's perspectives on bladder health: Social-ecological and life course contexts

AIMS

This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective.

METHODS

We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American.

RESULTS

Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems.

CONCLUSIONS

Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

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.

Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

The implications of data aggregation on propagating racial and ethnic disparities within the health care landscape: Actionable recommendations and considerations for pharmacists

As the U.S. population becomes more racially and ethnically diverse, it is increasingly important to characterize health inequities for targeted intervention. As it stands, demographic data regarding race and ethnicity for patients and pharmacy trainees alike are aggregated into heterogenous population groups, resulting in findings that may inaccurately reflect the experiences of smaller subgroups. Disaggregation of patient outcomes data can serve to better inform public health interventions for the most vulnerable populations. In pharmacy, disaggregation can allow for better identification of racial and ethnic subgroups who have been traditionally excluded from funding support among other opportunities. In this commentary, we provide historical context and actionable recommendations to better describe our patient and pharmacy trainee populations, with the objectives of improving pharmacist representation and health equity.

Effect of cumulative radiation exposure from Coronary catheterization on lung cancer mortality

BACKGROUND

Coronary catheterization (CC) procedure inevitably exposes patients with cardiovascular disease (CVD) to radiation, while cumulative radiation exposure may lead to higher risk of cancer.

METHODS

This multi-center, retrospective study was based on the CC procedure in Cardiorenal ImprovemeNt II cohort (CIN-II, NCT05050877) among five regional central tertiary teaching hospitals in China between 2007 and 2020. Patients without known cancer were stratified according to the times they received CC procedure. Baseline information from their last CC procedure was analyzed. Cox regression and Fine-Gray competing risk models were used to assess the relationship between cumulative radiation exposure from CC procedures and cancer-specific, all-cause and cardiovascular mortality.

RESULTS

Of 136,495 hospitalized survivors without cancer at baseline (mean age: 62.3 ± 11.1 years, 30.9% female), 116,992 patients (85.7%) underwent CC procedure once, 15,184 patients (11.1%) on twice, and 4,319 patients (3.2%) underwent CC procedure more than three times. During the median follow-up of 4.7 years (IQR: 2.5 to 7.4), totally 18,656 patients (13.7%) died after discharge, of which 617 (0.5%) died of lung cancer. Compared with the patients who underwent CC procedure once, the risk of lung cancer mortality increased significantly with the increase of the number of CC procedure (CC 2 times vs. 1 time: HR 1.42, 95% CI 1.13 to 1.78, P < 0.001; CC ≥ 3 times vs. 1 time: HR 1.64, 95%CI 1.13 to 2.39, P < 0.05). Similar results were observed in all-cause mortality and cardiovascular mortality, but not in other cancer-specific mortality.

CONCLUSIONS

Our data suggest that substantial proportion of CVD patients are exposed to multiple high levels of low-dose ionizing radiation from CC procedure, which is associated with an increased risk of cancer mortality in this population.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05050877; URL: http://www.

CLINICALTRIALS

gov ; 21/09/2021.

Mobile Health Intervention to Promote Hypertension Self-Management among African Americans Receiving Care at a Community Health Center: Formative Evaluation of the FAITH! Hypertension App

BACKGROUND

African Americans (AAs) are at a higher risk of premature death from cardiovascular diseases compared to White Americans, with disproportionate attributable risk from uncontrolled hypertension. These health disparities are rooted in structural racism with resultant adverse social determinants of health (SDOH) including limited access to quality healthcare. Given their high usage among AAs, mobile technologies, including smartphones, show promise in increasing access to reliable health information. Thus, culturally tailored mobile health (mHealth) interventions may promote hypertension self-management among this population.

OBJECTIVE

This formative study assessed the feasibility of integrating an innovative mHealth intervention into clinical and community settings to improve blood pressure (BP) control among AAs.

METHODS

A mixed methods study of AA patients with uncontrolled hypertension was implemented over two consecutive phases. In Phase 1, patients and clinicians from two federally qualified health centers (FQHCs) in the Minneapolis-St. Paul, Minnesota metropolitan area provided input through a focus group series to refine an existing culturally tailored mHealth app (FAITH! [Fostering African-American Improvement in Total Health!] App) to promote hypertension self-management among AA patients with uncontrolled hypertension. Phase 2 was a single-arm pre-post intervention pilot study to assess feasibility and patient satisfaction. Patients receiving care at an FQHC participated in a 10-week intervention utilizing the refined FAITH! Hypertension App synchronized with a wireless BP monitor and support from a community health worker (CHW) to address SDOH-related social needs. The multimedia app consisted of a 10-module educational series focused on hypertension and cardiovascular risk factors with interactive self-assessments, medication/BP self-monitoring and social networking. Primary outcomes were feasibility (app engagement/satisfaction) and preliminary efficacy (change in BP) at immediate post-intervention.

RESULTS

In Phase 1, 13 AA patients (69% age ≥50, 77% female) and 16 clinicians (69% age ≥50, 88% female, 63% AA) participated in focus groups. Based on their feedback, app modifications included addition of: BP/medications-tracking, BP self-care task reminders, and culturally sensitive contexts. In Phase 2, 16 AA patients were enrolled (mean age 52.6 years [SD 12.3], 75% female). Of the 16, 38% completed at least half of 10 education modules. Seven of the 16 completed the post-intervention assessment. These patients rated the intervention a 9 (out of 10) as helpful in hypertension self-management. Qualitative data revealed that these patients viewed the app as user-friendly, engaging, and informative, and CHWs were perceived as providing accountability and support. Of the 7 patients, mean systolic and diastolic BPs decreased by 6.4 mmHg (p=.15) and 2.8 mmHg (p=.78) at immediate post-intervention, respectively.

CONCLUSIONS

A culturally tailored mHealth app, with reinforcement by CHW support, may improve hypertension self-management among under-resourced AAs receiving care at FQHCs. A future randomized efficacy trial of the intervention is warranted.

CLINICALTRIAL

Registration: ClinicalTrials.gov Identifier: NCT03777709.