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Journal of Cardiovascular Nursing Vol. 21, No. 6, pp 451Y456 x B 2006 Lippincott Williams & Wilkins, Inc.

A Framework for Addressing Disparities in Cardiovascular Health George A. Mensah, MD, FACP, FACC; Sandra B. Dunbar, DSN, RN, FAAN

Health disparities are pervasive in the United States. Life expectancy remains higher in women than in men and

higher in whites than in blacks by approximately 5 years. In general, the health of racial and ethnic minorities,

poor and uneducated people, and those without health insurance is worse than the health of the overall

population. The care of these vulnerable groups tends to be of worse overall quality because they have trouble

accessing the system, because standards of care are applied to them unevenly, and because health professionals

are not consistently trained in culturally sensitive approaches. These disparities have been demonstrated in all

aspects of health and healthcare for cardiovascular diseases, including the use of diagnostic and therapeutic

interventions, prevalence of cardiovascular risk factors, and access to health information. Examination of national

surveys revealed disparities in all cardiovascular disease risk factors, hospitalizations for major cardiovascular

disease, overall mortality, and quality of life. Eliminating these disparities is a major public health challenge

in the United States. Their causes and underlying mechanisms, however, remain incompletely understood.

The healthcare delivery system itself, access to care, quality of care received, communication barriers, individual

behaviors, culture and lifestyles, and discrimination and bias all play a part. The pursuit of systems and policy

changes to address these determinants remains crucial. We present a strategic framework for eliminating health

disparities that takes these determinants into account and provides an opportunity for cardiovascular nurses to

make an impact on this important issue.

KEY WORDS: cardiovascular risk factors, disparities, morbidity, mortality, quality of life, racial/ethnic groups

Health disparities are differences in the healthindicators of populations identified by race, ethnicity, sex, geographical residence, educational attainment, or socioeconomic status. These dispari- ties have been confirmed in many areas of health- care, and nowhere are they more evident than in cardiovascular health. Although disparities have been documented throughout the last 2 centuries, recent data published in the National Healthcare Disparities Report1 and the National Healthcare Quality Report2 have emphasized that preventable disparities are pervasive and that improvements are possible. The evidence for health disparities in car-

diovascular disease (CVD) and treatment is over- whelming and compelling.3 In this review, we address the state of disparities in cardiovascular health3 and present a conceptual framework to assist in efforts to eliminate these disparities.4

Disparities in Cardiovascular Risk Factors

National estimates of the prevalence of measured and self-reported CVD risk factors are available from the National Health and Nutrition Examina- tion Surveys and the Behavioral Risk Factor Surveil- lance System, respectively. As shown in Tables 1 and 2, important differences in the prevalence of tradi- tional CVD risk factors exist, and they vary by race/ ethnicity and educational level. Self-reported physical inactivity was common in all groups, especially in women. Low intake of fruits and vegetables was also common and was lowest in black and white men with low educational level. Importantly, blacks had the highest self-reported prevalence of diagnosed diabetes and hypertension. Black and white men had a higher prevalence of current smoking than did Mexican American men. The prevalence of having 2 or more self-reported CVD risk factors was highest among blacks (48.7%) and American Indians/Alaska

451

George A. Mensah, MD, FACP, FACC Chief Medical Officer, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga.

Sandra B. Dunbar, DSN, RN, FAAN Charles Howard Candler Professor of Cardiovascular Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Corresponding author George A. Mensah, MD, FACP, FACC, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K-40, 4770 Buford Highway, NE, Atlanta, GA 30341-3717 (e-mail: [email protected]).

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Natives (46.7%) and lowest among Asians (25.9%), with similar prevalence in women (36.4%) and men (37.8%). People with less than a high school diploma had the highest prevalence of multiple risk factors (52.5%). These national trends are mirrored in targeted community studies. For example, Jain et al5 reported a higher prevalence of cardiovascular risk factor clustering in African Americans than in whites in the Dallas Heart Study. Hutchinson et al6

also showed that an absence of any CVD risk factors was most common among white subjects in the Atherosclerosis Risk in Communities Study.

According to the National Health and Nutrition Examination Surveys (1999Y2002),3 the highest prevalence of obesity (29.2%) in men was found in Mexican Americans who had completed a high school education (Table 2). However, black women with or without a high school education had a higher prevalence of obesity (47.3%). Hypertension preva- lence was high among blacks (39.8%) regardless of sex or educational status. Hypercholesterolemia was high among white and Mexican American men and white women in both groups of educational status.

The prevalence of low concentrations of high- density lipoprotein cholesterol (an established risk factor for CVD) and hypertriglyceridemia was most favorable among African Americans, although among the most educated women, whites and African Ameri- cans had a similar prevalence of low high-density lipoprotein cholesterol (Table 2).3 The prevalence of hemoglobin A1c at levels of 7% or greater was highest in African American men and women. Differences in the prevalence of emerging risk fac- tors, including C-reactive protein, fibrinogen, homo-

cysteine, microalbuminuria, and macroalbuminuria, were also demonstrated, with the prevalence of al- buminuria highest in blacks (data not shown).3

Disparities in CVD Prevalence, Hospitalization, Diagnosis, and Treatment

Disparities in the measures of CVD burden and care have been extensively documented.1,7,8 For example, in 2003, the prevalence of CVD was lowest in Mexican American men (29.2%) and women (29.3%) and highest in non-Hispanic black women (44.7%) and men (41.1%).7 The prevalence of reported heart dis- ease, ischemic heart disease, hypertension, and stroke was inversely related to education and income.9

Gender and geographic disparities have been noted for CVD hospitalizations. For example, among Medicare enrollees aged 65 years or older, hospitali- zations for acute myocardial infarction, chronic heart failure, and stroke were higher in men than in women.9,10 Whites had the highest prevalence of hospitalization for acute myocardial infarction, but the prevalence of hospitalization for chronic heart failure was higher in African Americans, Hispanics, and American Indians/Alaska Natives than among whites. Within the Medicare population, stroke hospitalization was highest in African Americans, and heart disease and stroke were clustered primarily in the southeastern United States.

Disparities in the use of diagnostic and therapeu- tic interventions have been extensively documented in the United States. A review focused specifically on cardiac care, conducted jointly by the Kaiser Family

TABLE 1 Unadjusted Prevalence of Risk Factors for Cardiovascular Disease Among US Adults

Aged 18 Years or Older: Behavioral Risk Factor Surveillance System, 2003

White African American Mexican American

GHigh School QHigh School GHigh School QHigh School GHigh School QHigh School

% SE % SE % SE % SE % SE % SE

Current smoker Men 40.6 1.1 22.9 0.3 41.8 2.7 27.4 1.0 27.3 1.7 22.6 1.1 Women 34.6 0.9 19.9 0.2 25.6 1.6 17.8 0.7 10.6 1.0 12.9 0.7 Total 37.5 0.7 21.4 0.2 33.0 1.5 22.0 0.6 18.6 1.0 17.7 0.7

No physical activity Men 40.1 1.0 17.7 0.2 42.1 2.7 24.7 1.0 46.5 1.9 24.9 1.1 Women 45.3 0.9 21.5 0.2 50.7 1.9 32.2 0.8 52.2 1.7 33.3 1.0 Total 42.8 0.7 19.7 0.2 46.8 1.6 28.9 0.6 49.4 1.3 29.1 0.8

5 Servings or more of fruit and vegetables Men 13.3 0.7 18.6 0.3 14.6 2.0 18.9 0.9 18.2 1.6 17.4 1.1 Women 20.6 0.7 29.5 0.2 22.5 1.8 25.8 0.8 24.1 1.5 25.3 1.0 Total 17.1 0.5 24.3 0.2 18.9 1.3 22.8 0.6 21.3 1.1 21.4 0.7

Told to have diabetes Men 11.9 0.7 7.0 0.2 14.6 1.7 10.1 0.7 9.0 1.0 5.6 0.6 Women 13.3 0.5 5.9 0.1 19.2 1.3 10.6 0.5 11.5 1.0 6.4 0.5 Total 12.6 0.4 6.4 0.1 17.1 1.1 10.4 0.4 10.3 0.7 6 0.4

Reproduced with permission from Mensah et al.3

452 Journal of Cardiovascular Nursing x November/December 2006

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Foundation and the American College of Cardiology Foundation, concluded that racial/ethnic differences in angiography, angioplasty, coronary artery bypass graft surgery, and thrombolytic therapy persisted even after adjusting for potential confounding fac- tors.8 For example, African Americans were statisti- cally less likely than whites to undergo coronary artery bypass graft surgery in 21 of the 23 most rigor- ous studies.8

The prevalence of hypertension treatment (35%) and control (17%) is lowest in Mexican Americans compared with non-Hispanic whites (49% and 30%, respectively).11 The percentages of Medicare patients with acute myocardial infarction who received the recommended care in 2002 and 2003 were signifi- cantly lower in blacks and Hispanics than in whites.1

The most recent national healthcare disparities report concluded that quality of cardiac care differs by race, ethnicity, and socioeconomic status.1

Disparities in Life Expectancy and Cardiovascular Deaths

In 2003, life expectancy at birth in the United States reached a record high of 77.5 years for all gender and race groups combined; however, marked differences by gender and race persist.

12 Life expectancy for

whites exceeded that for blacks by 5.3 years, with the lowest value in black men (69 years) and highest in white women (80.5 years).12 In fact, Satcher et al13

estimated that the gap in life expectancy between blacks and whites accounts for as many as 83,570 excess deaths each year. Wong et al

14 also estimated

that CVD accounts for approximately a third of the black-white differences in life expectancy.

In both men and women, the age-adjusted mortal- ity rate for heart disease and stroke is highest in blacks (Figure 1).3 Although the mortality rate has progressively decreased in all race/ethnic groups,

TABLE 2 Prevalence of Traditional Risk Factors for Cardiovascular Disease Among US Adults

Aged 18 Years or Older: National Health and Nutrition Examination Survey (NHANES), 1999Y2002

White African American Mexican American

GHigh School QHigh School GHigh School QHigh School GHigh School QHigh School

% SE % SE % SE % SE % SE % SE

Obesity (body mass index Q30 kg/m 2 )

Men 28.4 2.0 27.2 1.1 25.1 1.8 26.9 2.2 22.3 1.7 29.2 2.5 Women 36.8 2.6 29.6 1.5 47.7 3.2 47.1 2.3 37.8 3.0 32.8 2.8 Men and women 32.8 1.7 28.5 1.1 37.2 1.8 38.4 1.6 29.5 1.7 31.0 1.9

Large waist (men, 9102 cm; women, 988 cm) Men 44.9 2.6 39.6 1.2 29.4 1.8 27.2 1.7 25.2 1.7 34.2 2.0 Women 68.0 3.3 52.9 1.8 71.9 2.3 67.0 1.6 62.2 2.6 53.9 2.9 Men and women 56.8 2.2 46.4 1.4 51.9 1.6 49.8 1.4 42.3 1.2 43.9 1.6

Hypertension Men 39.3 2.5 29.8 1.2 45.9 2.8 31.8 1.7 21.1 2.2 16.5 2.1 Women 47.4 2.6 31.3 1.3 51.2 2.8 37.0 1.9 24.2 2.4 15.5 1.8 Men and women 43.5 1.9 30.6 1.0 48.7 2.4 34.7 1.3 22.6 1.8 16.0 1.3

Total cholesterol Q200 mg/dL Men 45.5 3.0 49.2 1.5 37.7 2.8 41.7 2.3 49.2 2.7 45.5 2.8 Women 56.9 2.5 52.4 1.2 45.8 3.0 42.6 2.2 38.7 2.2 37.9 2.2 Men and women 51.4 2.0 50.8 1.0 41.9 2.0 42.2 1.8 44.4 2.0 41.7 1.6

Glycosylated hemoglobin Q7% Men 7.5 1.3 3.8 0.4 10.1 1.4 3.7 0.7 4.9 0.8 4.3 0.9 Women 6.2 1.2 2.2 0.3 10.9 1.9 6.7 0.9 7.8 1.2 3.6 0.7 Men and women 6.8 0.9 3.0 0.3 10.5 1.5 5.4 0.6 6.3 0.7 4.0 0.6

NHANES 1999Y2000 Low high-density lipoprotein cholesterol (men, G40 mg/dL; women, G50 mg/dL)

Men 41.2 3.1 35.9 2.2 27.0 4.3 23.8 3.4 35.6 3.5 25.6 4.6 Women 54.8 4.3 38.8 2.4 33.8 3.9 39.7 3.4 47.4 2.5 45.7 3.6 Men and women 48.0 3.1 37.4 1.9 30.4 2.9 33.0 2.4 41.1 2.4 36.2 3.0

Low-density lipoprotein cholesterol Q130 mg/dL Men 49.5 7.0 46.7 2.9 27.2 5.4 31.0 5.8 46.7 4.6 54.3 7.0 Women 33.6 7.5 42.3 2.8 36.3 7.4 25.1 4.3 30.1 4.8 28.0 4.9 Men and women 41.9 5.8 44.4 2.0 31.9 5.0 27.5 4.1 38.8 2.8 41.0 5.2

Triglycerides Q150 mg/dL Men 38.3 7.7 35.7 3.2 16.8 6.3 Y Y 40.5 4.2 40.2 9.1 Women 39.2 6.2 33.2 3.3 14.0 4.2 11.5 3.0 40.9 5.2 30.0 5.8 Men and women 38.7 4.6 34.4 2.4 15.4 4.2 10.4 2.6 40.7 3.7 35.2 6.6

Reproduced with permission from Mensah et al.3

Disparities in Cardiovascular Health 453

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marked disparities in these rates persist (Figure 1). Men and African Americans had more premature deaths than women and whites did, as measured by years of potential life lost before age 75 years because of these conditions (Figure 2).

3 For ischemic

heart disease and stroke, as well as all diseases of the heart, the years of potential life lost was highest in blacks (Figure 2).3 Asians/Pacific Islanders had the lowest heart disease mortality at all ages, but they had more stroke mortality than did Hispanics and American Indians/Alaska Natives, especially at young ages (data not shown).

Eliminating Disparities in Cardiovascular Health and Health Care

Eliminating these disparities remains a major public health challenge in the United States and will require a concerted effort on the part of all providers, individually and collectively. The causes of these disparities are many, and the underlying mechanisms remain incompletely understood; nevertheless, the healthcare delivery system itself, access to care, inadequate study of vulnerable groups, quality of care received, communication barriers, individual behaviors and lifestyles, and lack of access to relevant, literacy-congruent health information remain important determinants of disparities.15,16

We have proposed a framework incorporating 6 strategic imperatives, 10 focal areas, and multiple targeted settings (Table 3) as one approach to exploring interventions for eliminating health dis-

parities.4 The framework illustrates the opportuni- ties for cardiovascular nurses to take a leadership role in helping to eliminate disparities by addressing

FIGURE 1. Death rates for diseases of the heart and stroke by race, ethnicity, and sex: United States, 1980Y2001; age adjusted to the 2000 US population. Source: CDC, Health United States, 2003. Reproduced with permission from Mensah et al.3

TABLE 3 A Framework for Action to Eliminate

Disparities in Cardiovascular Health

A. Strategic Imperatives 1. Accelerate health impact in disparate populations. 2. Advance policy and systems change. 3. Form strategic multidisciplinary partnerships. 4. Expand community-based participatory research and

research translation. 5. Collect healthcare data by race, ethnicity, and

disparate indicators. 6. Ensure a diverse clinical and public health workforce.

B. Focal Areas 1. Access to healthcare 2. Quality of healthcare delivered 3. Patient preferences, healthcare utilization, adherence 4. Culture, lifestyles, and personal behaviors 5. Regulations, policies, and systems of care 6. Geographic and environmental influences 7. Income and educational levels 8. Prejudice, discrimination, and bias 9. Psychosocial stressors

10. Biology, genomics, and gene-environment interactions C. Major public health settings

1. Communities, cities, counties, regions, states 2. Schools and colleges 3. Worksites of small and large businesses 4. Hospitals, clinics, doctors’ offices, emergency

departments 5. Faith-based settings (eg, churches, synagogues,

mosques) 6. Centers for training health professionals

Reproduced with permission from Mensah. 4

454 Journal of Cardiovascular Nursing x November/December 2006

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relevant domains and elements. The pursuit of sys- tems and policy changes to improve healthcare access and quality; reduce risk factor prevalence; increase minority participation in research; engage in collaborative research-based practice networks; develop programs to increase the cultural compe- tence of the CVD workforce; foster patient-centered care; and increasing community outreach programs in schools, worksites, and faith-based settings are im- portant approaches to eliminating these disparities.

Conclusions and Future Directions

Health disparities are pervasive in cardiovascular healthcare, and they are demonstrable in access to care as well as most domains of quality of care, including treatment standards, effectiveness, prevention, and

patient-centered approaches. Multisectoral, transdisci- plinary partnerships are essential to accelerate efforts to eliminate these disparities in cardiovascular health. Definitive evidence on the strategies likely to be most effective in eliminating disparities is lacking; however, emphasis on quality of care and access to care for all regardless of race/ethnicity, sex, socio- economic status, and geography are crucial first steps.

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2. US Department of Health and Human Services. 2005 National Healthcare Quality Report. Available at: http://www.

FIGURE 2. Years of potential life lost (YPLL) before age 75 years caused by diseases of the heart, ischemic heart disease, and stroke: United States, 2001. Source: CDC, Health United States, 2003. Reproduced with per- mission from Mensah et al.3

Disparities in Cardiovascular Health 455

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