Measuring the effects of CVD interventions and studies across socioeconomic groups: A brief review

Education inequalities in cardiovascular and coronary heart disease in Italy and the role of behavioral and biological risk factors

BACKGROUND AND AIMS

Behavioral and biological risk factors (BBRF) explain part of the variability in socioeconomic differences in health. The present study aimed at evaluating education differences in incidence of cardiovascular disease (CVD) and coronary heart disease (CHD) in Italy and the role of BBRF.

METHODS AND RESULTS

All subjects aged 30-74 years (n = 132,686) who participated to the National Health Interview Surveys 2000 and 2005 were included and followed-up for ten years. Exposure to smoking, physical activity, overweight/obesity, diabetes and hypertension at baseline was considered. Education level was used as an indicator of socioeconomic status. The outcomes were incident cases of CVD and CHD. Hazard ratios by education level were estimated, adjusting for sociodemographic covariates and stratifying by sex and geographic area. The contribution of BBRF to education inequalities was estimated by counterfactual mediation analysis, in addition to the assessment of the risk attenuation by comparing the models including BBRF or not. 22,214 participants had a CVD event and 6173 a CHD event. After controlling for sociodemographic factors, the least educated men showed a 21% higher risk of CVD and a 17% higher risk of CHD compared to the most educated (41% and 61% among women). The mediating effect (natural indirect effect) of BBRF between extreme education levels was 52% for CVD and 84% for CHD among men (16% among women for CVD).

CONCLUSIONS

More effective strategies aiming at reducing socioeconomic disparities in CVD and CHD are needed, through programs targeting less educated people in combination with community-wide initiatives.

Impact of socio-economic status and race on emergency hospital admission outcomes: Analysis from hospital admissions between 2001 and 2012

Socio-economic and racial/ethnic disparities in healthcare quality have been the point of huge discussion and debate. There is currently a public debate over healthcare legislation in the United States to eliminate the disparities in healthcare. We reviewed the literature and critically examined standard socio-economic and racial/ethnic measurement approaches. As a result of the literature review, we identified and discussed the limitations in existing quality assessment for identifying and addressing these disparities. The aim of this research was to investigate the difference between health outcomes based on patients' ability to pay and ethnic status during a single emergency admission. We conducted a multifactorial analysis using the 11-year admissions data from a single hospital to test the bias in short-term health outcomes for length of stay and death rate, based on 'payment type' and 'race', for emergency hospital admissions. Inconclusive findings for racial bias in outcomes may be influenced by different insurance and demographic profiles by race. As a result, we found that the Self-Pay (no insurance) category has the shortest statistically significant length of stay. While the differences between Medicare, Private and Government are not significant, Self-Pay was significantly shorter. That 'Whites' have more Medicare (older) patients than 'Blacks' might possibly lead to a longer length of stay and higher death rate for the group.

The renin-angiotensin-system and left ventricular mass in young adults: the African-PREDICT study

PURPOSE

Raised blood pressure, with the renin-angiotensin system (RAS) as a central regulatory component, is one of the most important contributors to early development of left ventricular hypertrophy. Factors such as increased age, sex, black ethnicity and a low socio-economic status also contribute to left ventricular remodelling. To better understand early contributors to left ventricular mass, we investigated the relationship between left ventricular mass index (LVMi) and the components of the RAS in young healthy adults while considering ethnicity, sex and socio-economic status.

MATERIALS AND METHODS

Black and white women and men (N = 1186) between the ages of 20-30 years were included. By using standard echocardiography, we determined LVMi. Ultra-pressure-liquid chromatography tandem-mass spectrometry (LC-MS/MS) was used to measure the RAS-fingerprint^®.

RESULTS

Components of the RAS such as plasma renin activity (PRA-S), angiotensin I (Ang I), angiotensin II (Ang II) and aldosterone were suppressed in the black compared to the white group (all p < 0.001). No associations between LVMi and the RAS were evident in the total, black or white groups. With additional grouping according to sex and socio-economic status, inverse associations between LVMi and PRA-S (β= -0.168;  p = 0.017), Ang I (β= -0.155; p = 0.028) and Ang II (β= -0.172; p = 0.015) were found only in low socio-economic black women.

CONCLUSION

Despite a suppressed RAS in the black compared to the white group, components of the RAS were not associated with LVMi in this young cohort. The low socio-economic black women of this study population may be vulnerable to future RAS-related increases in left ventricular mass.

Reporting of social deprivation in musculoskeletal trials: An analysis of 402 randomised controlled trials

BACKGROUND

Social deprivation is broadly defined as the restriction of access an individual has to social or cultural interactions due to poverty, discrimination or other disadvantages. While social deprivation is a widely acknowledged determinant of outcome in musculoskeletal conditions, it remains unclear how this is considered in the conduct and interpretation of musculoskeletal trials.

AIM

To determine the frequently to which measures of social deprivation are reported in trials recruiting people with musculoskeletal diseases.

MATERIALS AND METHODS

We conducted a Pubmed search of randomised controlled trials published between 01 January 2019 and 01 June 2020. We included full-text papers of trials recruiting people with musculoskeletal diseases, irrespective of intervention type or origin. We extracted data relating to trial characteristics, setting, trial design, funding source and musculoskeletal disease. We extracted data on any reported social deprivation index or measure of social deprivation based on internationally adopted indicators. We analysed data descriptively to summarise the reporting of each social deprivation index and measure of social deprivation within trials.

RESULTS

From 2133 potentially eligible citations, 402 were eligible. Mean age of participants was 51.7 years; 63% were female. Trials most frequently recruited people with spinal pain (24.6%) or osteoarthritis (10.0%). Two trials (0.5%) reported social deprivation indices/scores. When assessed by discrete measures of social deprivation, 164 trials (40.8%) reported one or more social deprivation measures. The most commonly reported measures were morbidity (20.2%), employment status (17.7%) and educational attainment (15.5%). Race (6.7%), ethnicity (6.2%) and annual salary (1.3%) were infrequently reported. One trial (0.3%) presented subgroup results by social deprivation measures.

DISCUSSION AND CONCLUSION

Social deprivation is inconsistently reported in musculoskeletal trials. Trialists should report baseline measures of social deprivation in trial reports and aid generalisability to target population, and to examine whether social deprivation might modify treatment effects of interventions for musculoskeletal conditions.

Identifying high-need patients with multimorbidity from their illness perceptions and personal resources to manage their health and care: a longitudinal study

Background

A proactive person-centred care process is advocated for people with multimorbidity. To that aim, general practitioners may benefit from support in the identification of high-need patients, i.e. patients who are high or suboptimal users of health services and/or have a poor quality of life. To develop such support, we examined whether knowledge about patients’ illness perceptions and personal resources to manage their health and care is useful to identify high-need patients among multimorbid general practice populations.

Methods

Survey data, collected in 2016 and 2017, of 601 patients with two or more chronic diseases (e.g. COPD, diabetes, Parkinson’s disease) registered with 40 general practices in the Netherlands were analysed by logistic regression analysis to predict frequent contact with the general practice, contact with general practice out-of-office services, unplanned hospitalisations and poor health related quality of life. Patients’ illness perceptions and personal resources (education, health literacy, mastery, mental health status, financial resources, social support) were included as predictors.

Results

The four outcomes were only weakly associated among themselves (Phi .07–.19). Patients’ illness perceptions and personal resources were of limited value to predict potentially suboptimal health service use, but they were important predictors of health related quality of life. Patients with a poor health related quality of life could be identified by their previously reported illness perceptions (attributing many symptoms to their chronic conditions (B = 1.479, P < .001), a high level of concern (B = 0.844, P = .002) and little perceived control over their illness (B = -0.728, P = .006)) combined with an experienced lack of social support (B = -0.527, P = .042) and a poor mental health status (B = -0.966, P = .001) (sensitivity 80.7%; specificity 68.1%).

Conclusions

Multimorbid patients who frequently contact the general practice, use general practice out-of-office services, have unplanned hospitalisations or a poor health related quality of life are largely distinct high-need subgroups. Multimorbid patients at risk of developing a poor quality of life can be identified from specific illness beliefs, a poor mental health status and unmet social needs.

Socioeconomic Status and Cardiovascular Disease: an Update

PURPOSE OF REVIEW

The aim of this paper is to summarize the recent and relevant evidence linking socioeconomic status (SES) to cardiovascular disease (CVD) and cardiovascular risk factors (CVRFs).

RECENT FINDINGS

In high-income countries (HICs), the evidence continues to expand, with meta-analyses of large longitudinal cohort studies consistently confirming the inverse association between SES and several CVD and CVRFs. The evidence remains limited in low-income and middle-income countries (LMICs), where most of the evidence originates from cross-sectional studies of varying quality and external validity; the available evidence indicates that the association between SES and CVD and CVRFs depends on the socioeconomic development context and the stage in the demographic, epidemiological, and nutrition transition of the population. The recent evidence confirms that SES is strongly inversely associated with CVD and CVRFs in HICs. However, there remains a need for more research to better understand the way socioeconomic circumstances become embodied in early life and throughout the life course to affect cardiovascular risk in adult and later life. In LMICs, the evidence remains scarce; thus, there is an urgent need for large longitudinal studies to disaggregate CVD and CVRFs by socioeconomic indicators, particularly as these countries already suffer the greatest burden of CVD.

Lower education predicts poor response to dietary intervention in pregnancy, regardless of neighbourhood affluence: secondary analysis from the ROLO randomised control trial

Objective

To determine if response to a low glycaemic index (GI) dietary intervention, measured by changes in dietary intake and gestational weight gain, differed across women of varying socio-economic status (SES).

Design

Secondary data analysis of the ROLO randomised control trial. The intervention consisted of a two-hour low-GI dietary education session in early pregnancy. Change in GI was measured using 3 d food diaries pre- and post-intervention. Gestational weight gain was categorised as per the 2009 Institute of Medicine guidelines. SES was measured using education and neighbourhood deprivation.

Setting

The National Maternity Hospital, Dublin, Ireland.

Subjects

Women (n 625) recruited to the ROLO randomised control trial.

Results

The intervention significantly reduced GI and excess gestational weight gain (EGWG) among women with third level education residing in both disadvantaged (GI, mean (sd), intervention v. control: −3·30 (5·15) v. −0·32 (4·22), P=0·024; EGWG, n (%), intervention v. control: 7 (33·6) v. 22 (67·9); P=0·022) and advantaged areas (GI: −1·13 (3·88) v. 0·06 (3·75), P=0·020; EGWG: 41 (34·1) v. 58 (52·6); P=0·006). Neither GI nor gestational weight gain differed between the intervention and control group among women with less than third level education, regardless of neighbourhood deprivation.

Conclusions

A single dietary education session was not effective in reducing GI or gestational weight gain among less educated women. Multifaceted, appropriate and practical approaches are required in pregnancy interventions to improve pregnancy outcomes for less educated women.