Recognizing, Qualifying Social Determinants of Health Essential to Improving Cardiovascular Outcomes

In addition to recognizing social determinants of health (SDOH) in patients, clinicians must be able to assess and address these disparities, according to a session at the American College of Cardiology 2022 Scientific Sessions.

Panelist Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, discussed how clinicians can identify and qualify SDOH. Although many patient populations may have the same intellect and potential, Breathett emphasized that SDOH can result in differing levels of societal power.

“Where you live matters,” Breathett said. “Where you live, who you are, impacts your ability to receive equitable quality of life and equitable outcomes.”

SDOH are a “moving target,” Breathett said, but some common themes include economic stability; education access and quality; health care access and quality; social and community context; and neighborhood and built environment. Although these are broad topics, clinicians must be able to assess the ways in which these issues impact their patients.

One approach to measuring SDOH is through the SMART Program Performance, which stands for specific, measurable, achievable, relevant, and time-bound. Other tools, such as the Everyday Discrimination Scale, can help clinicians assess specific aspects of social determinants and how their patients experience them.

Breathett emphasized that SDOH are caused by racism and not by biological differences. The model of SDOH explains that racism impacts patients’ risk factors as well as determinants of health and outcomes, rather than the other way around. By using this model, clinicians can determine which SDOH risks their patients are facing.

Finally, Breathett said choosing how to evaluate SDOH requires several steps, including having diverse stakeholders, identifying specific problems, using the conceptual model, identifying weights and values, selecting a metric, assessing, and then reiterating. Repeating this process and continuing to evaluate SDOH is an essential step, Breathett said.

“Your goal is not just to identify these—your goal is to fix them,” she concluded.

Next, panelist LaPrincess Brewer, MD, MPH, FACC, FACP, FASPC, discussed how SDOH are specifically related to racial, ethnic, and gender disparities. She noted that cardiologists are largely unaware of racial and ethnic disparities in cardiac care, with a recent survey of more than 300 cardiologists finding that only one-third agreed that health disparities existed in general or in cardiac care.

Furthermore, less than 5 of the respondents felt that disparities existed among their own patients. The majority of these survey respondents endorsed patient- and system-level factors as the cause of these disparities, rather than provider-level factors.

Brewer defined health inequities as systemic, avoidable, and often unjust societal factors that result in avoidable adverse health status and outcomes. This is separate from health disparities, which are specifically adverse outcomes. Together, both issues limit continued improvements in the overall quality of care and make health equity impossible.

Key factors driving these issues include race and ethnicity as social constructs, as well as socioeconomic status. These problems can intersect as well, as frequently seen in Black women. Brewer said African Americans have the highest cardiovascular disease mortality rates, which are more than 30% higher than those seen in white and Latin Americans. Notably, however, African American women have the highest cardiovascular disease mortality rates of all women.

Similarly, lower socioeconomic status is associated with worse cardiovascular disease outcomes, with the strongest association seen in women. Brewer also noted significant disparities in cardiovascular risk assessment, intervention, and prevention.

“We must understand that health is created by more than just clinical care,” Brewer said, emphasizing that holistic health includes environment, health behaviors, and socioeconomic factors, all of which are encompassed in SDOH.

REFERENCE

Breathett K, and Brewer L. It’s On Us: Implementing Social Determinants of Health in Cardiovascular Care. Presented at: American College of Cardiology 2022 Scientific Sessions. April 3, 2022.