Addressing Social Determinants of Health in the Care of Patients with Heart Failure

It has long been understood that the social structures we live in contribute to the genesis of illness and disease. Over the last ten years or so we have seen greater attention paid to this paradigm, particularly with regard to cardiovascular disease. Most research has focused on identifying the social structures, and the economic conditions giving rise to those social structures, that contribute to cardiovascular disease. This research has fit nicely with the parallel rise in investigation into the genetic causes of disease; as cardiovascular disease has been increasingly seen as the product of genetic and environmental interaction the concept of social determinants of health provides a framework for understanding the environmental part of the equation. In order for this line of research to continue to advance, however, our understanding of the role social determinants play in causation of disease must begin to yield successful insights into prevention and treatment.

In this regard, the American Heart Association Scientific Statement “Addressing Social Determinants of Health in the Care of Patients with Heart Failure”¹ is an important contribution to the evolution of our thinking. It represents clear evidence we have reached something of a watershed, where our attention has shifted from proving to ourselves that social conditions affect cardiovascular health² to discussions of what we should do about it. Many insights in the document have value beyond heart failure. I would highlight four of these broad insights:

We should develop sensitivity to the effects of poverty and racial/ethnic bias on our patients’ lives and on their health behaviors. Some of the difficult health behaviors that many practitioners associate with patients from lower socioeconomic strata, such as difficulty keeping appointments, taking medications, and accepting complex treatments, likely reflect the impact of poverty directly. Understanding the reasons for these decision-making behaviors allows us to care for patients better. Some of these reasons are fairly obvious. Health insurance may be absent or inadequate. For some rural patients, access may be limited by geography. Some reasons for puzzling decision-making behaviors may be less obvious. People living in poverty are less tolerant of risk and more likely to value short term gains over potentially larger gains in the future compared with wealthier individuals³. Economic stress appears to impair cognitive function and decision-making capacity. For example, one set of studies showed that inducing poor but not wealthier individuals to think about financially stressful situations resulted in impaired problem solving and cognitive control4. Factors such as these may make individuals less able to accept preventive care with indefinite benefits that are a long way off. Our understanding of the effects of the psychology of race and ethnicity continues to evolve. Examples are stereotype threat⁵, in which the anticipation of being treated according to a stereotype pushes individuals into the very behaviors they wish to avoid, and implicit bias, in which individuals react to others according to unconscious and automatic biases^6-8.

We should build mechanisms for recording health-relevant socioeconomic data in routine patient care, and include socioeconomic variables with co-morbidity variables in clinical research data. Measurement is the first step towards improvement. The statement includes a comprehensive list of instruments that have been used to characterize social determinants in clinical settings, most notably the Social Deprivation Index and the AHC Social Needs Screening Tool. Gathering data of this sort routinely will heighten provider awareness and motivate the mobilization of community resources. In general, social determinants data have not been included comprehensively with baseline data in observational studies and clinical trials. This has hampered our ability to make inferences about the extent to which factors such as housing and income mediate the effects of cardiovascular therapies.

The healthcare system cannot and should not expect itself to solve the social and economic problems that contribute to poor health; partnerships with community organizations are needed to help patients with deficiencies in food, housing, and the like. The statement discusses the potential value of providing housing vouchers, vocational rehabilitation, workplace interventions, and patient assistance programs for patients through partnerships with community resources. The expertise and experience such partnerships bring is invaluable and can’t easily be reproduced within healthcare organizations. Scaling up such programs should be done cautiously; their impacts of many have not yet been evaluated rigorously. There are additional examples of social determinants likely to benefit from greater engagement with the community. Social isolation9 is increasingly recognized as a growing challenge for the healthcare system. Improving health outcomes in patients who do not have family or who are estranged from family is a challenge for which few general solutions have been demonstrated. Transitioning back into the community from the criminal justice system is associated with poor health outcomes and is something the healthcare system is poorly equipped to deal with.

Healthcare practitioners and their professional organizations should advocate for population-level policies that mitigate the effects of social determinants of health. Advocacy for health insurance that includes access to affordable medications is a prime example. Assuring access to health care through adequate health insurance is a first step in mitigating the impact of social and economic conditions on cardiovascular disease. As pointed out in the scientific statement, deploying community health workers or patient navigators to help with things such as access to medication assistance programs is an effective intervention, but widespread implementation of programs employing these workers is limited by absence of means to pay for those programs. Programs to help with the impact of limited health literacy have the same problem. Food and housing security are clearly needed to improve the health of the disadvantaged. The Moving to Opportunity study cited in the statement is an example of an effective policy in this regard. A recent analysis of data from that project¹⁰ showed that those who were under 13 years of age at the time of randomization were hospitalized at a lower rate and had lower annual hospital costs over a median of 11 years of follow-up. There were no differences for individuals randomized as adults. This finding of greatest impact associated with intervention in childhood is born out in other research. Long term follow-up of a randomized trial of a multimodal early childhood intervention conducted in the 1970s¹¹ demonstrated lower blood pressure and, in men, lower overall Framingham risk scores when subjects in the intervention arm were in their 30s. The intervention was remarkably cost efficient, with an estimated annual rate of return on investment of 13.7%¹². Additional support for this concept comes from the Nurse-Family partnership¹³. Disadvantaged women who had received home visits after the birth of a child for up to two years had lower mortality over 20 years of follow-up. Dissemination of such programs is likely to yield important dividends for population cardiovascular health and are deserving of advocacy.

We have made tremendous progress in the prevention and treatment of cardiovascular disease over the past 50 years. Recommendations such as those contained in this scientific statement on approaching social determinants of health will help us ensure that progress will continue into the future.