Social Determinants of Health and Cardiovascular Disease: What's Driving the Shift in Research?Oct. 31, 2022 - Eden McCleskey
Social determinants of health (SDOH), social vulnerability index, health equity, health disparities. Open up nearly any medical journal or attend any medical conference this year, and you'll notice a distinctly sociological theme.
Thanks to a growing public awareness of inequity and inequality in health care and its social and economic costs, SDOH research is growing at an explosive pace. The U.S. Centers for Disease Control, Department of Health and Human Services, Centers for Medicare and Medicaid Services, American Society for Preventive Cardiology and American Heart Association have each named health equity as the top research and policy priority for the decade.
One team that doesn't need any help catching up with the latest research trend is the Houston Methodist Division of Cardiovascular Prevention and Wellness, where epidemiologists, data scientists and preventive cardiologists are redefining the concept of the "heart team."
Since tapping influential and prolific clinician-researcher Dr. Khurram Nasir to lead the division in 2019, Houston Methodist has firmly established itself as a leader in this space, with approximately 50 peer-reviewed articles published annually by a team of 15 researchers.
"The point of preventive cardiology is to stop people from getting heart disease in the first place, and the best way to do that is to identify those at highest risk for developing the disease and experiencing the worst outcomes," explains Dr. Nasir. "It just so happens that some of the most important risk factors for heart disease aren't clinical at all, they are related to where people live and work, community attitudes about health, economic stressors they may face."
Although health care systems may influence a person's health during episodes of injury or illness, social determinants influence one's health from conception onward, with a cumulative effect.
Researchers, policymakers and, increasingly, individual physicians are beginning to recognize the value of incorporating social determinants into their clinical risk models. There is also an increasing recognition of the need to expand the assessment of social disadvantage using social determinants beyond one's education and income, the traditional measures of socioeconomic status.
Dr. Nasir and his team are making a case for developing, validating and incorporating comprehensive SDOH frameworks and polysocial risk assessment tools that capture individuals' social vulnerabilities beyond contemporary risk factors and improve cardiovascular disease diagnosis, care and outcomes.
"Identifying an area of concern or a group at higher risk doesn't necessarily help you solve the problem," says Zulqarnain Javed, Ph.D., M.B.B.S., M.P.H, a cardiovascular epidemiologist and social determinants of health expert at the Houston Methodist Academic Institute. "There needs to be a solution, a pathway to help clinicians connect the dots between the social and clinical determinants of health."
Dr. Javed sat down with Leading Medicine to discuss Houston Methodist's recent efforts, the challenges clinicians face and why he has hope that these issues can be solved.
Q: Why is it important to research social determinants of health?
There is a large body of work on the leading causes of mortality in this country — heart disease, stroke, cancer, chronic obstructive pulmonary disease, COVID-19 — that empirically shows that social determinants are responsible for upwards of 70 percent of a person's health. So if you're a physician and you're only focusing on the clinical determinants of health, you're only addressing 30 percent of the problem. What's even more concerning is that we in the United States spend less than 5 percent of our health care dollars on prevention efforts. We are spending most of our time, money and energy on fixing the downstream consequences of adverse upstream factors — the social determinants of health. That translates to poor outcomes, readmissions, emergency department use and significantly higher costs, for the country, for the hospital or clinic and for the patient. If we truly want to improve population health, we must address the social determinants, and not just their consequences.
In clinical circles, it is widely acknowledged and accepted that providing the very best medical care will only get you so far. Now, the question is: what can we do with that knowledge? Physicians only have so much bandwidth. Most of them feel hard-pressed to adequately address their patient's clinical needs within allotted appointment times, how can we reasonably expect them to address these longstanding social problems and systemic biases? Obviously, we can't. Not without help — new tools or processes that offer a net benefit when it comes to their time, resources and patient outcomes.
Q: You recently published an opinion piece on social vulnerability and COVID-19. What was the big takeaway there?
The COVID-19 pandemic highlighted pervasive social inequities in disease susceptibility and outcomes in the U.S. Individuals experiencing high levels of social vulnerability are more susceptible to COVID-19, and 30 percent more likely to experience adverse cardiovascular sequelae, including major adverse cardiovascular events and mortality, compared to those with a more favorable social risk profile. In line with our group's prior work on the role of SDOH in determining cardiovascular outcomes, the COVID-19 pandemic is a stark reminder of the need to expand our focus beyond the traditional clinical determinants of health, and make sincere efforts to integrate SDOH into clinical workflows and decision support systems in real-world settings.
When a patient is admitted to the hospital, physicians and health care systems very easily tend to ignore the social, economic and environmental factors that may have necessitated hospitalization in the first place. Those social factors are important determinants of the likelihood of COVID-19 infection, and subsequent risk of hospitalization, poor cardiovascular outcomes and mortality. Also, the adverse consequences of unfavorable social determinants continue to affect the patient even after they enter the walls of the hospital, driving up the risk of poor in-hospital outcomes, including mortality. One of our biggest takeaways from the pandemic should be moving from a primarily clinical determinants of health delivery model to a holistic approach that acknowledges, values and integrates SDOH.
Q: Should we be treating these patients differently?
Well, I think it's important to study different types of interventions. Not only can this help point to potential solutions, but it might help identify the specific problem. For instance: Is it related to a patient's inexperience navigating the health care system? Is it not asking for or not receiving some of the more specialized treatments? Is the kind of insurance they have or their copay affecting care? Is it an issue of their family not being able to be with them and provide social support? We don't know.
But a very critical piece of this is — the vast majority of the time, clinical teams have no knowledge of which patients are socially vulnerable and which patients are not. So even before we could do any of those future intervention studies, we have to figure out better solutions to help clinicians identify those patients that have higher risk of poor cardiovascular outcomes simply because of their social background.
Q: I imagine some patients don't want to be identified as socially vulnerable, for fear of discrimination. Is that the case?
Generally, our patients are coming to us for help, they trust us with their health, their life, their protected health information, etc. They are used to discussing intimate health details with providers; I'm not sure it's a really big leap for them to discuss financial or social issues.
But, certainly, if somebody is abruptly hospitalized due to COVID-19 or a cardiac event, that might not be the right time to ask if they graduated from high school or ever had trouble paying a medical bill or have access to reliable transportation. It is important information that can help us identify those at higher risk of complications, yes. But in this situation, it would be best to have an automated system in place that allows the business side of the organization to speak with the clinical side.
Typically, before any health care interaction, a patient will give their name, address and insurance information, and most likely will have had an opportunity to discuss whether there's a need for financial assistance or not. That information is usually enough to identify those with significant social vulnerabilities, and it's already our system. I think it will soon become easy to merge clinical determinants of health information with the electronic medical record.
When that happens, I think we should couple it with provider training. We want to educate providers about why this information is useful, what we are going to do with it and how they can put it to work to help the patient. When the conversation is focused on exploring potential solutions to the patient's most pressing challenges, whether those are strictly financial in nature or a combination of lack of insurance, low income, food insecurity, etc., I believe patients are less likely to fear discrimination.
Q: Could you be more specific about how these solutions might work?
A lot of patients need assistance with their cardiovascular care. We've done an extensive amount of research on the risk of financial toxicity in patients with atherosclerotic cardiovascular disease. But these patients may not even be aware that patient navigation and care coordination programs to address some of these challenges even exist.
So No. 1, health systems need to make a sincere effort to assess patients' social needs. No. 2, health systems should establish partnerships with community (local foundations), state (state Medicaid, Your Texas Benefits) and federal (CMS, CDC, HHS) agencies that can offer critical support — both monetary and technical — to address some of these social vulnerabilities in patients with cardiovascular disease. And No. 3, we should train health care providers and ancillary support staff to discuss available community, state and federal resources with their socially vulnerable patients and design evidence-based interventions to connect patients with such resources. In all of this, community partnerships are key for health systems to address SDOH and achieve their health equity goals.
Houston Methodist has a big data science infrastructure, and we have a CVD registry with almost a million patients, including information on other clinical risk factors and a variety of social determinants of health. It is very well organized and tracks patients' health over time. We also have existing partnerships with social safety net programs and federally qualified health centers like the San Jose Clinic, Harris County Health and the Department of Public Health, and we are hoping to build additional partnerships with state and federal agencies to address some of the major social determinants we have identified through our prior work. The idea — and hope — is to improve both patient and population health outcomes.
We have partnered with our own Office of Diversity, Equity and Inclusion and Community Benefits to create a patient navigation intervention that can help us identify thousands of patients who need help paying for medication, food, transportation, health insurance and other necessities. Recently, we submitted a grant to the NIH to further develop this intervention and launch a full-scale program that will address the social and financial issues putting our patients at risk.
Q: Is this where you think a lot of organizations are heading? Harnessing big data and putting it to better use?
Yes. I think everyone realizes that we can't go on with the status quo, i.e., with a unidimensional focus on clinical determinants or the clinical care delivery model. The bulk of health care expense goes towards tertiary prevention. By that point, you are on medication, seeing a doctor, just trying to prevent complications. We have to move away from that and pivot quickly towards primary and primordial prevention. The future has to be how can we use technology to intelligently and efficiently predict disease risk and intervene? The fact that we're beginning to hear so much about social determinants of health, that's what makes me optimistic that we will be able to turn it around.
This post is the first in a three-part series.