The Dangers of Health Disparities and the Urgent Need to Address Them

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Cardiovascular diseases continue to be the leading cause of death in the United States, though many risk factors for these diseases have been known for decades.

Today, researchers and clinicians are continuing to take a much deeper look at the story behind those risk factors. Why do some populations suffer disproportionately? What is the role of environment? Safe housing? Race? Ethnicity? Socioeconomic status? Education? Access to healthy food? Access to health care?

The answers to all of these questions paint a troubling picture: Great disparities in health in the United States remain. People don’t live as healthy, or as long, based on factors known collectively as social determinants of health. These determinants—which could be summarized very simply as environmental, financial and societal factors—are taking a terrible toll on the health of vulnerable populations all over the country.

The American Heart Association (AHA) is dedicated to changing this picture. The organization has worked for years to understand the barriers to health experienced by populations and to find solutions so that all Americans can enjoy longer, healthier lives.

Defining the problem

Addressing health disparities in communities across America is a major priority for the AHA, which is collaborating to do so with government agencies and organizations nationwide. Most recently, with support from the Bristol-Myers Squibb Foundation, the AHA is piloting a multi-faceted initiative in Baltimore to improve health outcomes for at-risk populations.The American Heart Association concurs with the current definition of health disparity provided by The Office for Disease Prevention and Health Promotion: “…a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.”

Their definition continues to state that health disparities “adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion^[1].”

Health disparities are driven by social determinants of risk. The determinants include a wide variety of issues affecting environment, including race bias, income level, education level, stress, pollution, housing availability, access to healthy foods and access to safe ways to exercise.

The World Health Organization (WHO) defines the determinants quite broadly as “the circumstances in which people are born, grow, live, work, and age, and the systems put in place to deal with illness.^[2]” Social determinants of health are identified by^[3]:

• Socioeconomic position Material conditions Health Education Access to valued personal activities Political voice Social connections Environment
• Race, ethnicity
• Social support
• Culture and language
• Access to care
• Residential environment

Three measures of socioeconomic position have been explored extensively with regard to their relationship to cardiovascular health: education, income and occupation. Broadly speaking, lower socioeconomic position in the United States is associated with a greater prevalence of cardiovascular disease risk factors, and a higher incidence of mortality resulting from those diseases^[4].

Impact of health disparities

There is a common belief that the United States outperforms other developed countries in health status. But that is not the case. In fact, for several decades, the US has not kept pace with other high-income countries in terms of life expectancy.

Recent research indicates that worsening social, economic and environmental factors are affecting health in serious ways. According to the Organization for Economic Co-operation and Development, the growing racial and ethnic diversity in the US, coupled with conditions that lead to disadvantages early in life, have serious implications for future health and productivity^[5].

Research has shown low-income populations, particularly those in rural and inner-city settings, experience suboptimal access to quality health care. Some groups are at greater disadvantage than others. The latest data from the CDC indicates African-Americans have fewer years limitation-free activity than white people^[6].

Eliminating health disparities for minorities would have reduced indirect costs associated with illness and premature death by more than $1 trillion between 2003 and 2006, according to a report from the AHA's Community Health in Action initiative. It is estimated that between 2009 and 2018, racial disparities in health will cost US health insurers approximately $337 billion. Obtaining care late in the course of a disease increases cost of care exponentially.

From a business perspective, a healthy, productive workforce is a prerequisite to a thriving economy. The health status of adults can impact productivity and generate higher health care costs.

It is clear that even better health insurance coverage alone will not address health disparities associated with race, ethnicity, socioeconomic status and geography^[7]. What then is the solution to this problem? How do primary and secondary care providers, in their capacity as individuals, ensure equitable access to health care to underserved populations? What can be done at the institutional level, and as members of the community and society at large?

Finding solutions in communities

There are many approaches, in communities, in clinics and elsewhere. “Our increasing cultural and ethnic diversity as a nation also brings with it a unique set of opportunities and challenges related to providing equitable health care for all in the name of eliminating health disparities,” noted Eduardo Sanchez, MD, the AHA’s Chief Medical Officer for Prevention and Chief for the Center of Health Metrics and Evaluation.Taking action in communities of need is crucial. Baltimore is a prime example of a community where environmental problems are associated with poor health. Its poorest areas face a 40% greater age-adjusted mortality than the rest of the city. “This reality is compounded by systemic social, political, economic, and environmental obstacles,” according to a report from the AHA’s Community Health in Action initiative.

The three-year initiative, which is slated to wrap up in 2020, aims to increase equity and improve systems of care across the community. There are several facets to it. The initiative seeks to develop networks and trust; strengthen communication channels; implement city-wide protocols and practices to improve access to care; and coordination of care between primary care providers and specialists.

Rhonda Ford Chatmon, AHA's Vice President of Health Strategies for the Greater Maryland area, highlighted the importance of addressing the entire community: “Paid in Full, a recent article in the Stanford Social Innovation Review, suggests to us that we need to move beyond “isolated strategies” that don’t always reflect authentic community engagement and often are strategies that are “created for them without them.””

The AHA, through the work of the Community Health in Action Task Force, is utilizing input from diverse stakeholders representing clinical, community and patients to develop resources and drive policy, system and environmental changes that create “equitable” access and outcomes for all. In addition, the AHA will collaborate on a collective impact approach that is designed to address disparities and social influences that impact a patient’s ability to navigate complex healthcare systems and achieve optimal health outcomes.

>>> To learn more about strategies to tackle health care disparities, visit bit.ly/ahadisparities. This free resource will guide you to reflect on how best to handle interventions to improve health outcomes in communities disproportionately affected by cardiovascular disease.

Aside from our efforts in the community, a key part of this project includes the development of two curricula to address health care disparities: one each for clinicians and community health care workers. Both programs will be available to people from all backgrounds, including those without medical experience.

The clinician program includes an overview of health disparities spanning from the trailblazing research that gave birth to the Office of Minority Health in 1986 to the latest developments. This program was developed by a group of experts, including Sarah Alexander, MD, FACC; Linda P. Bolin, PhD, RN, ANP, FAHA; Natalie Evans, MD, MS and Katherine Tucker, DNP, RN, APRN-BC, NE-BC, with the input of Kimberly Ketter, MSN, AGNP-C, CDE, African American Cardiomyopathy and Heart Failure Patient from the Baltimore area.

This group of individuals from Yale Health, East Carolina University, Rush Medical Center and Cleveland Clinic has experience in definition of risk assessments and counseling, research on improvement of clinical conditions in minorities, and research on cardiovascular health.

A key development in the work on disparities is the 2015 scientific statement from the AHA titled Social Determinants of Risk and Outcomes for Cardiovascular Disease. And now, as part of the Community Health in Action initiative, the AHA is adding some measures of disparities to two interventions that improve access to evidence-based care: Get with the Guidelines (GWTG) and Target: BP. Both of these tools deliver clinical resources and track process of care measures and outcomes data in care delivery.

GWTG is an in-patient registry focusing on the emergency and specialty care setting, and Target: BP is a programmatic tool focusing on the primary care setting. Using these programs for data tracking will create additional measures within the GWTG Registry and Target: BP quality improvement program.

Solutions in the clinical setting

The program also increases access and equity through engagement of Baltimore’s safety net populations using EmPOWERED to Serve, the AHA’s online and event-based educational series designed to help communities and their leaders understand their health, risk factors and healthy living.“The main challenge in serving all populations equitably isn’t a lack of medical expertise,” Sanchez said. “Rather, it lies in overcoming preconceptions of cultural barriers and being better able to connect with our patients to serve them better. To do that, we need to understand our patients’ varied backgrounds and perspectives, their beliefs and concerns related to health, and how all of these shape behaviors and interactions.”

Failure to understand these perspectives, Sanchez explained, could result in worsened health outcomes, more disparities, and sometimes, “even serious consequences.”

Shawna D. Nesbitt MD, MS, Associate Dean of Student Affairs for the Office of Student Diversity and Inclusion at UT Southwestern Medical Center in Dallas, noted the importance of strengthening cultural competencies in clinical settings.“At an intuitive and experiential level, many health care experts have found that cultural competence does indeed play a role in reducing disparities.” Nesbitt said.

She described a recent incident that illustrates the importance of improving health literacy among patients.

“A 66-year-old from an ethnic minority was diagnosed with atrial fibrillation, prescribed medicines, and given detailed instructions for the medication regimen and follow-up visits,” she said. “However, in 2 months, he came back with internal bleeding because he didn’t follow the instructions on his medicine.”

“When asked why he hadn’t followed instructions, he admitted he couldn’t follow the complicated instructions that were given, felt foolish to voice his doubts, and didn’t want to bother the ‘busy doctor,'” Nesbitt said. “This incident highlights the importance of improving health literacy, but it is key to note that this is not the responsibility of the provider alone.”

Linda P. Bolin, PhD, RN, ANP, FAHA, Assistant Professor at the Department of Nursing Science in East Carolina University — College of Nursing, added that efforts are being made at the provider and system level to improve cultural competence.

“Interventions that lie within the cultural competence circle are those that prompt equitable preventive care or treatment for chronic disease, addressing physical barriers to access, improving our ability as providers to provide health care services, helping us better understand cultural components of clinical encounters with different populations and their own inherent biases, and assisting patients from a population of interest to competently navigate the patient-provider relationship and the larger health system,” Bolin said.

Sanchez said measures to advance care vary from clinic to clinic, but noted some best practices to improve care for underserved population:

1. “Improve efforts to attract and retain students from rural, inner-city, or underserved and underrepresented minority backgrounds. They are more likely to provide care in these settings after completing their training.”
2. “Provide training about social determinants of health and how to assess them and address them as a treatment plan is developed.”
3. "Provide training about implicit biases.”
4. “Increase emphasis on achieving the “Quadruple Aim” — which is a variation of the Institute for Healthcare Improvement’s Triple Aim[8] — a framework that serves as a foundation for optimizing health. It focuses on improving the health of populations, enhancing the experience of care for individuals, and reducing the per capita cost of health care. Some organizations have added pursuing health equity as the fourth aim.”
5. “Develop partnerships with patients, communities, public health providers and social service agencies.”
6. “Implement highly effective collaborative interprofessional teams in primary care.”
7. “Expand the use of technology to increase access to specialty care services and support clinicians in low resource areas.”

Implicit bias and patient conversations

An understanding of implicit bias plays a key role in addressing disparities. Implicit biases are unintentional and automatically activated, and can help perpetuate discrimination and lead to differential outcomes for certain racial and ethnic groups.

Research demonstrates people who endorse values opposed to prejudice are motivated to inhibit the expression of implicit bias. It is heartening to note that about 53% of white Americans agree on the need to keep on making changes to make sure minorities have equal rights. However, this figure is far from ideal^[9].

Although tools to help clinicians reduce implicit bias are diverse, a conversation about how the social determinants of health might impact patients can go a long way. This conversation doesn’t need to be a chore, but rather a way to discover what the patient is all about.

Disparities research projects

An attitude of cultural humility is very useful here, and it can be implemented by emphasizing how providers would benefit from understanding cultural components of clinic encounters and inherent biases, understanding how patient’s perception of physician’s cultural competency affects care and guiding patients to understand how to navigate the health care system.While there is a perception that not enough is being done, multiple research-focused organizations have actually impacted the development of knowledge and understanding of health disparities over the past few decades.

Some examples include the Agency for Healthcare Research & Quality, the National Institutes of Health, the Henry J. Kaiser Family Foundation, the Robert Wood Johnson Foundation, as well as programs dedicated to study health disparities at universities such as John Hopkins, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Hackensack University Health Network, and the University of Colorado School of Medicine.

The scope of interventions has shifted the paradigm to a forward-looking venture that promotes community-based health measures for both the current and future generations. Examples of multi-generational efforts include the Three Generational Approach^[10], which strengthens families and builds children’s skills through adulthood to reach their potential to be a healthy, engaged, productive citizen with full potential to plan for and parent the next generation. An example of a community wide approach is the Community Health in Action initiative currently managed by the AHA with the support of Bristol-Myers Squibb Foundation.

In addition to educating the clinician population, the AHA just published a course for Community Healthcare Workers designed to provide knowledge that will empower them to become active members of the care team of patients impacted by cardiovascular diseases.

Your participation in the CME course and your thoughts on disparities that can be provided in the evaluation will contribute to this important initiative.

[1] Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services (2019, February 15). Disparities. Retrieved February 15, 2019, from https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

[2] World Health Organization. (2018). Social Determinants of Health. Retrieved September 12, 2018, from http://www.who.int/social_determinants/en/

[3]^,6 Havranek EP, Mujahid MS, Barr DA, et al. Social determinants of risk and outcomes for cardio-vascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132:873—98.

[4] Havranek EP, Mujahid MS, Barr DA, et al. Social determinants of risk and outcomes for cardio-vascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132:873—98.

[5] As cited in Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11. 1, The Need to Promote Health Equity. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425853/

[6] Centers for Disease Control and Prevention. (2013, November 22). CDC Health Disparities and Inequalities Report - United States, 2013, p.89. Retrieved September 12, 2018, from https://www.cdc.gov/mmwr/pdf/other/su6203.pdf

[7] National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624, p.7

[8] Institute for Healthcare Improvement. (2019). The IHI Triple Aim. Retrieved February 15, 2019, from http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

[9] Pew Research Center. (2017, June 27). On Views of Race and Inequality, Blacks and Whites Are Worlds Apart. Retrieved March 5, 2019, from http://www.pewsocialtrends.org/2016/06/27/on-views-of-race-and-inequality-blacks-and-whites-are-worlds-apart/

[10] Cheng, T. L., Johnson, S. B., & Goodman, E. (2016). Breaking the Intergenerational Cycle of Disadvantage: The Three Generation Approach. Pediatrics, 137(6), e20152467. http://doi.org/10.1542/peds.2015-2467

The learning activity referred to in this article offers continuing education credit for physicians, nurses and pharmacists, as well as ABIM MOC points and ethics credit. The development of this activity is supported by an independent grant from the Bristol-Myers Squibb Foundation. For questions about this program, contact Marcela Iannini, Program Manager with the Lifelong Learning Division of the AHA at marcela.iannini@heart.org.