Social determinants of racial health inequities

The Role of Social Determinants of Health in Atherosclerotic Cardiovascular Disease

PURPOSE OF REVIEW

This review seeks to provide important information on each of the major domains of social determinants of health (SDOH) in the context of atherosclerotic cardiovascular disease.

RECENT FINDINGS

SDOH can be classified into five domains: social and community context, health care access and quality, neighborhood and built environment, economic stability, and education access and quality. SDOH are major drivers for cardiovascular health outcomes that exceed the impact from traditional risk factors, and explain inequities in health outcomes observed across different groups of individuals. SDOH profoundly impacts healthcare's receipt, delivery, and outcomes. Many patients fall within various disenfranchised groups (e.g., identify with minority race, low socioeconomic status, low educational attainment, LGBTQ+), which impact overall health status and care. Learning to understand, recognize, and address SDOH as the driving force of disparities are critical for achieving health equity in the prevention and adequate treatment of ASCVD.

Tracheal Stenosis in Open Versus Percutaneous Tracheostomy

OBJECTIVE

This study aims to investigate if there is an increased risk of developing tracheal stenosis after tracheostomy with an open versus percutaneous tracheostomy.

METHODS

The patient cohort included patients receiving open or percutaneous tracheostomies at Catholic Health Initiatives Midwest facilities from January 2017 to June 2023. The primary aim was to compare the differences in the risk of developing tracheal stenosis between open and percutaneous tracheostomy techniques. Between-technique differences in the risk of developing tracheal stenosis were assessed via a Cox proportional hazard model. To account for death precluding patients from developing tracheal stenosis, death was considered a competing risk.

RESULTS

A total of 828 patients met inclusion criteria (61.7% open, 38.3% percutaneous); 2.5% (N = 21) developed tracheal stenosis. The median number of days to develop tracheal stenosis was 84 (interquartile range: 60 to 243, range: 6 to 739). Tracheal stenosis was more frequent in patients who received a percutaneous tracheostomy (percutaneous: 3.5% vs. open: 2.0%); however, the risk of developing tracheal stenosis was statistically similar between open and percutaneous techniques (HR: 2.05, 95% CI: 0.86-4.94, p = 0.108).

CONCLUSIONS

This study demonstrates no significant difference in the development of tracheal stenosis when performing an open versus a percutaneous tracheostomy. Tracheal stenosis is a long-term complication of tracheostomy and should not influence the decision about the surgical technique used.

Joint Association of Polygenic Risk and Social Determinants of Health with Coronary Heart Disease in the United States

Background

The joint effects of polygenic risk and social determinants of health (SDOH) on coronary heart disease (CHD) in the United States are unknown.

Methods

In 67,256 All of Us (AoU) participants with available SDOH data, we ascertained self-reported race/ethnicity and calculated a polygenic risk score for CHD (PRS CHD ). We used 90 SDOH survey questions to develop an SDOH score for CHD (SDOH CHD ). We assessed the distribution of SDOH CHD across self-reported races and US states. We tested the joint association of SDOH CHD and PRS CHD with CHD in regression models that included clinical risk factors.

Results

SDOH CHD was highest in self-reported black and Hispanic people. Self-reporting as black was associated with higher odds of CHD but not after adjustment for SDOH CHD . Median SDOH CHD values varied by US state and were associated with heart disease mortality. A 1-SD increase in SDOH CHD was associated with CHD (OR=1.36; 95% CI, 1.29 to 1.46) and incident CHD (HR=1.73; 95% CI, 1.27 to 2.35) in models that included PRS CHD and clinical risk factors. Among people in the top 20% of PRS CHD , CHD prevalence was 4.8% and 7.8% in the bottom and top 20% of SDOH CHD , respectively.

Conclusions

Increased odds of CHD in self-reported black people are likely due to higher SDOH burden. SDOH and PRS were independently associated with CHD in the US. Our findings emphasize the need to consider both PRS and SDOH for equitable disease risk assessment.

Race as a Component of Cardiovascular Disease Risk Prediction Algorithms

PURPOSE OF REVIEW

Several prediction algorithms include race as a component to account for race-associated variations in disease frequencies. This practice has been questioned recently because of the risk of perpetuating race as a biological construct and diverting attention away from the social determinants of health (SDoH) for which race might be a proxy. We evaluated the appropriateness of including race in cardiovascular disease (CVD) prediction algorithms, notably the pooled cohort equations (PCE).

RECENT FINDINGS

In a recent investigation, we reported substantial and biologically implausible differences in absolute CVD risk estimates upon using PCE for predicting CVD risk in Black and White persons with identical risk factor profiles, which might result in differential treatment decisions based solely on their race. We recommend the development of raceless CVD risk prediction algorithms that obviate race-associated risk misestimation and racializing treatment practices, and instead incorporate measures of SDoH that mediate race-associated risk differences.