Health equity and the role of the cardiologist: 7 priorities to consider

Residents of rural areas, people in need of chronic care, people with a disability, racial minorities, low-income groups, women, and lesbian, gay, bisexual, and transgender persons are some of the many groups who experience health disparities. In the 52^nd annual Louis F. Bishop keynote lecture, Prof. Michelle Albert (University of California, CA, USA) talked about potential solutions to address health disparities in cardiovascular care [1].

In her keynote lecture entitled “Bringing health equity to the frontlines of cardiovascular healthcare,” Prof. Albert made a clear distinction between ‘equity’ and ‘equality.’ Whereas equality distributes resources equally to everyone, equity allocates resources based on need. Prof. Albert identified 7 top priorities that need to be considered in an attempt to address systemic health inequities:

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      1. Understanding the determinants of health inequities
      2. Access to quality cardiovascular healthcare
      3. Reforming cardiovascular care teams
      4. Enfolding social determinants into cardiovascular care
      5. Cardiovascular professional societies as core influencers
      6. Healthcare workforce diversification
      7. Dismantling structural racism

Prof. Albert proposed solutions for each of these priorities.

 

Understanding the determinants of health inequities

The life expectancy of Black and Native Americans lags behind that of Asian Americans and white Americans by a decade, a difference that is driven mostly by cardiovascular mortality. Women have 3 to 4 times increased mortality compared with men; this difference is again driven mostly by cardiovascular mortality and, most recently, by the COVID-19 pandemic. The COVID-19 pandemic has amplified health inequities that are driven by economics, segregation, housing discrimination, unequal access to healthcare, and institutional neglect of weakened communities. Some of the solutions proposed to resolve these disparities include expansion of access to healthcare, improving internet access, providing safe transportation, and implementing policy initiatives designed to address health disparities.

Prof. Albert referred to a frequently cited study that examined attitudes about race held by medical doctors using the Race Attitude Implicit Association Test (IAT) [2]. The authors recommended steps to reduce implicit bias included raising awareness of inequalities and one’s own biases, along with increasing empathy and motivation to prevent prejudice. Health training institutions are advised to adopt the Society of General Internal Medicine Health Disparities curriculum.

 

Reforming cardiovascular care teams

Prof. Albert argued that the current system in the US is more disease- and illness-based than prevention-focused. In cardiovascular healthcare, this translates to focusing on procedures such as ablation and use of devices as opposed to primary prevention measures such as controlling blood pressure and cholesterol levels, promoting a healthy lifestyle, and helping patients adhere to their treatment regimen. To assist with more prevention-based healthcare, Prof. Albert suggested more active screening, and the inclusion of, for example, primary physicians, pharmacists, and dieticians in cardiovascular care teams.

 

Enfolding social determinants into cardiovascular care

Prof. Albert stated that the day-to-day activities of cardiologists (i.e. clinical interventions, counselling, and education) have less of an impact on health than socioeconomic factors and societal context. Five key social determinants of health are economic stability, education, social and community context, health care, and neighbourhood and built environment (i.e. housing). Re-envisioning the cardiovascular team requires a more holistic approach, which incorporates patient advisors, community health workers, and social workers into the team. Efforts of the team need to be directed towards both the individual and the community level.

 

Cardiovascular societies as core influencers

Prof. Albert outlined several steps that cardiovascular societies can take to address health inequities:

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      1. Move from “late-breaking clinical trials” and high-profile publications to “late-breaking studies” that are inclusive and reflect health equity.
      2. Foster diversity within the ranks.
      3. Promote measurement and accountability within the workforce.
      4. Ensure that guidelines address health equity and social determinants of health.
      5. Science panels and clinical study teams, including principal investigators, must reflect diversity.
      6. Societies must promote and support community-based implementation of science guidelines (Prof. Albert noted that the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease was the first guideline to incorporate social factors into its recommendations [3]).
      7. Professional organisations need to fund science and research that focuses on equity.

Healthcare workforce diversification

“Medicine is not a diverse profession […], we need a workforce that addresses the unmet needs of our society,” stated Prof. Albert. Only 4% of physicians are Black and 6% are Hispanic. More members from minority groups should be recruited and accepted into medical school. Also, more funding support must be provided to members of these groups. Research has shown that physician-patient racial concordance improved outcomes. Prof. Albert shared an excellent infographic to summarise factors involved workforce diversification (see Figure).

Figure: Approaches to diversification of the healthcare workforce [1]

Dismantling structural racism

Prof. Albert reviewed how structural racism is a fundamental driver of health disparities; dating back to slavery, racism has resulted in poor access to healthcare, poorly funded schools, poor housing, and poor access to capital. All of these factors combine to increase toxic stress levels, which in turn increase the risk of stroke, cardiovascular death, and vulnerability to COVID-19 infection.

This excellent keynote lecture served as an inspiration and a call to action for steps that can be immediately implemented to address health disparities in our society.

 

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   1. Albert MA. “Bringing health equity to the frontlines of cardiovascular healthcare.” 52nd annual Louis F. Bishop keynote lecture, 2021 ACC Scientific Session, 15–17 May.
   2. Sabin JA, et al. J Health Care Poor Underserved 2009;20(3):896-913.
   3. Arnett DK, et al. Circulation 2019;140(11):e596-e646.

 

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Posted on 9 July, 202129 July, 2021