Content uploaded by Melissa S Burroughs Peña
Author content
All content in this area was uploaded by Melissa S Burroughs Peña on Jan 02, 2014
Content may be subject to copyright.
RACE AND ETHNICITY DISPARITIES (M ALBERT, SECTION EDITOR)
Meeting Disparities Where they Reside: The Geography
of Racial and Ethnic Health Disparities in Cardiovascular
Health
Melissa Burroughs Peña
#Springer Science+Business Media New York 2013
Abstract Despite the Institute of Medicine report on racial
and ethnic disparities in health care outcomes that was pub-
lished more than 10 years ago, disparities in health outcomes
including cardiovascular disease outcomes persist. The recent
literature on racial and ethnic disparities in cardiovascular
disease outcomes incorporates geospatial-mapping analyses
in order to shed light on the ways in which disparities vary by
location, highlighting variability in access to health care. In
addition the problem of access to health care, the quality of the
health care that is available to minority communities has also
been scrutinized, underscoring the potential of quality im-
provement interventions to reduce existing disparities in car-
diovascular outcomes. Targeted interventions to expand
health education, expand access to primary and tertiary care
and improve the quality of the health care received by racial
and ethnic minorities could reduce disparities in cardiovascu-
lar outcomes.
Keywords Cardiovascular disease .Health status disparities .
Residence characteristics .Quality improvement
Introduction
Racial and ethnic disparities in health outcomes have been
described for decades culminating in the 2002 Institute of
Medicine report Unequal Treatment: Confronting Racial
and Ethnic Disparities in Health Care [1••]. Racial disparities
in cardiovascular disease risk factors, prevalence and out-
comes have been highlighted and contribute to the significant-
ly lower life expectancy of African Americans in comparison
to White Americans [2,3]. However, much of the literature
describing racial and ethnic disparities in cardiovascular dis-
ease generates hypotheses about mechanisms for health dis-
parities rather than informing potential interventions and pol-
icies to reduce health disparities. In the setting of the current
political and economic climate in which the full implementa-
tion of the Affordable Care Act is on the horizon, there is an
urgent need for translational research in racial and ethnic
health disparities that can directly influence health care sys-
tems and policy.
The recent cardiovascular health disparities literature has
taken an important step by incorporating geospatial-mapping
and neighborhood analyses in disparities research. While
narrowing the focus to identifying the geographical spaces
in which racial and ethnic disparities in cardiovascular health
reside, these recent studies have also examined disparities in
cardiovascular outcomes beyond coronary artery disease and
heart failure. These publications underscore the fact that racial
and ethnic identity derive meaning in the context of social,
political and economic environments, and as these environ-
ments vary, so does the relationship between race, ethnicity
and health. This review explores the cardiovascular literature
and examines the geography-related aspects of disparities
research in a manner that has the potential to impact local,
state and federal health policy.
Examples of Cardiovascular Health Disparities by State
and County
Rather than focusing primarily on racial and ethnic disparities
in aggregate, increasingly racial disparities in cardiovascular
care and outcomes are being explored at the state and county
level. For example, Gebreab and Diez Roux looked at Black-
White difference in coronary heart disease mortality by county
using the Centers for Disease Control and Prevention’sWON-
DER database [4••]. They utilized geographically-weighted
M. Burroughs Peña (*)
Division of Cardiology, Department of Medicine, Duke University
Medical Center, Duke Clinical Research Institute, Duke Global
Health Institute, 2301 Erwin Rd, Durham, NC 27712, USA
e-mail: Melissa.s.burroughs@dm.duke.edu
Curr Cardiovasc Risk Rep
DOI 10.1007/s12170-013-0331-z
regression modeling to explore spatial heterogeneity, thus
allowing the relationship of predictor variables and outcomes
to differ across space. These authors found that before con-
trolling for poverty and segregation there was large variability
in the Black-White difference in CHD mortality across
counties. Whereas in certain counties African Americans dem-
onstrated higher observed CHD mortality rates when com-
pared to White Americans, other counties demonstrated no
racial disparity or higher CHD mortality in White Americans
in comparison to African Americans. Higher CHD mortality
was noted in the West South Central, Mississippi-Ohio River,
West Coast and South Florida regions. However, adjustment
for poverty and segregation eliminated the observed CHD
mortality disparity. Moreover, the interaction between race,
poverty, segregation and CHD mortality varied. Poverty was
differentially associated with larger CHD mortality among
White Americans, while segregation impacted CHD mortality
to a greater degree in African Americans. For African Amer-
icans, segregation was associated with higher CHD mortality
in some counties and lower CHD mortality in other counties.
The authors speculated that segregation potentially restricts
access to resources but might also increase social support, thus
impacting different communities in different ways. This study
highlights the complexity of racial and ethnic disparities in
their interaction with county-specific variables.
Notwithstanding CHD mortality rates, peripheral artery
disease is an understudied topic in cardiovascular racial and
ethnic disparities [5]. Jones et al. examined the rates of lower-
extremity amputation for peripheral artery disease by year and
state using data from the Centers for Medicaid and Medicare
Services [6]. While the overall rate of lower-extremity ampu-
tation for peripheral artery disease decreased from 2000 to
2008, significant racial and geographical disparities were un-
covered. After adjusting for covariates, African Americans
were 2.9 times more likely to undergo lower-extremity ampu-
tation when compared to White Americans (p<0.001). This
odds ratio is greater than that for the correlation between
diabetes mellitus and amputation (OR=2.4, p<0.001). Interest-
ingly, the highest rates of lower-extremity amputation were
foundintheEastSouthCentral,WestSouthCentralandSouth
Atlantic regions, which are regions with relatively large Afri-
can American populations. Unmeasured variables including
socioeconomic status, access to care beyond insurance status
and quality of available health care services were identified as
potential explanations for the geographical variability, all var-
iables that potentially contribute to the detected racial disparity.
Examples of Cardiovascular Disparities by Neighborhood
Focusing the lens of racial and ethnic disparities beyond the
county level, neighborhood analyses of cardiovascular risk
factors and outcomes have provided additional depth to the
health disparities literature. An analysis from the Jackson
Heart Study found that independent of individual socioeco-
nomic status and health behaviors, neighborhood socioeco-
nomic disadvantage was associated with the metabolic syn-
drome in African American women [7]. Two studies from the
Atherosclerosis Risk in Communities (ARIC) community
surveillance have examined both coronary revascularization
and mortality after myocardial infarction by neighborhood
income level [8,9]. After adjusting for covariates including
hospital type and comorbidities, African Americans in low-
and medium-income communities were less likely to receive
coronary angiography in the setting of myocardial infarction
in comparison to White Americans in high-income commu-
nities with associated adjusted prevalence ratios (PR) of 0.73
and 0.83 respectively. By contrast, White Americans residing
in low- and medium-income communities did not have statis-
tically significant differences in coronary angiography in com-
parison to White Americans in high-income communities.
Moreover, after receiving coronary angiography, African
Americans in low- and middle-income communities were less
likely to receive coronary revascularization. Within the same
cohort, long- and short-term case fatality after myocardial
infarction was higher for African Americans living in low-
income neighborhoods compared to White Americans living
in high-income neighborhoods with adjusted odds ratios of
2.07 and 2.82 respectively after adjusting for age, sex and
comorbidities [9]. Interestingly, African Americans in middle-
income communities also had higher odds of long-term case
fatality but no difference on short-term case fatality when
compared White Americans in high-income communities;
only White Americans in low-income neighborhoods had
increased short-term case fatality, albeit they had no increase
in long-term case fatality. The authors proposed that
unmeasured health environmental variables might account
for the disparity, as previous studies have found that neigh-
borhood income level is associated with post-myocardial in-
farction mortality even after considering individual income
status [10–12].
In examining the effect of race and neighborhood income
on mortality after coronary artery bypass grafting and/or heart
valve surgery, data from a single center found that neighbor-
hood income level rather than race correlated with increased
mortality [13]. Despite the inconsistent associations between
race and neighborhood socioeconomic status, the literature
suggest that health interventions targeted to higher risk com-
munities have the potential to reduce both socioeconomic and
racial disparities in cardiovascular health outcomes.
At the neighborhood level, another area where staggering
racial and ethnic disparities have been identified pertains to
the delivery of bystander CPR after cardiac arrest. Utilizing
data from the Cardiac Arrest Registry to Enhance Survival
data from 29 sites in the United States, Sasson et al. examined
neighborhoods according to income and racial composition in
Curr Cardiovasc Risk Rep
order to compare the rates of bystander-initiated CPR for
cardiac arrest [14••]. In this work, income and neighborhood
racial composition correlated with the probability of receiving
bystander-initiatedCPR for cardiacarrest, with African Amer-
ican low-income communities having the lowest rates of
bystander initiated CPR. High-income African American
communities still had substantially lower rates of bystander-
initiated CPR than non-African American high-income com-
munities. Targeting CPR training in these communities was
suggested as a potential public health intervention to reduce
racial, ethnic and socioeconomic disparities in survival after
cardiac arrest. Importantly, regardless of residence African
and Latino Americans were 30% less likely to receive
bystander-initiated CPR than White Americans.
Examples of Quality of Care and Cardiovascular
Disparities
Variability in the quality of care received by racial and ethnic
minorities in the United States is also related to the medical
facilities in which they receive care. In an analysis of Medi-
care beneficiaries presenting with acute myocardial infarction
(AMI), after controlling for residential distance from the fa-
cility African Americans were more likely to be admitted to
low-quality hospitals, teaching hospitals, safety-net hospitals
andwerelesslikelytobeadmittedtohigh-qualityhospitals
and hospitals with revascularization capability [15]. More-
over, African Americans and Asian/Pacific Islanders are more
likely to undergo coronary artery bypass grafting by surgeons
with higher risk-adjusted mortality rates [16], a factor in part
explained by hospital characteristics, neighborhood income
level and low volume surgeons.
Interventions to improve the quality of cardiovascular care
for all patients have the potential to decrease racial and ethnic
health disparities in clinical outcomes. In the Get With the
Guidelines- Coronary Artery Disease program, the quality of
care of 142,593 patients with AMI in 443 hospitals was
examined [17•]. Quality improvement interventions increased
the use of evidence-based medications for the treatment of
AMI over the 5-year study period for the entire patient popu-
lation. Moreover, the disparity in the receipt of evidence-based
therapies that existed between White American AMI patients
in comparison to African American and Hispanic American
AMI patients in the beginning of the study period decreased to
the point of losing statistical significance. This improvement
in AMI care was similar in hospitals that cared for dispropor-
tionately more African Americans and Latino Americans
when compared to hospitals lower percentages of African
American and Latino AMI patients. This analysis suggests
that efforts to standardize AMI care might serve to reduce
variability in medical treatment received for AMI, thus reduc-
ing racial and ethnic disparities in AMI treatment.
Similar to AMI care, in the Get With the Guidelines- Heart
Failure program, quality improvement interventions were un-
dertaken to improve the use of evidenced-based therapy for
patients with heart failure. In examining ICD implantation for
the prevention of sudden cardiac death, the increase in ICD
use was greatest among African Americans to the point that
the previously described disparity in ICD implantation in
African Americans in comparison to White Americans was
no longer present at the end of the study period [18].
Despite careful selection of patients for cardiac transplanta-
tion, racial disparities in survival have persisted while survival
for the overall cardiac transplant population continues to im-
prove [19]. Longitudinal data from the Organ Procurement and
Transplantation Network (OPTN) database reveal survival dif-
ferences by race. From 1987 to 2008, survival in the first 6
months after transplant improved for White American, African
American and Hispanic American patients throughout the study
period, yet African Americans remain at higher risk of death in
the first 6 months when compared to White Americans. How-
ever, survival after 6 months improved for White American
patients but not for African American and Hispanic American
patients. The risk of death or retransplantation 6 months after
cardiac transplantation is 111% higher African Americans
when compared to White Americans. The authors postulate
that the both immunologic and socioeconomic variables likely
account for the racial disparity in transplant outcomes.
Conclusion
Acknowledging that the causes of racial disparities in cardio-
vascular disease outcomes are complex and multifactorial,
improving access to care and quality of care will potentially
reduce racial disparities. Access to medical care in the United
States does begin with obtaining health insurance. However,
the attainment of health insurance represents one link in a
chain of processes that should be aimed at eliminating health
disparities by race and ethnicity. Other barriers that must be
addressed include early and sustained access to quality health
education, primary care and tertiary care centers. Through
analyses that include geospatial mapping, health systems and
policy makers are becoming equipped with the ability to target
interventions to specific areas. Future work should examine
the value of combining resources for quality improvement and
disparities research.
Compliance with Ethics Guidelines
Conflict of Interest Melissa Burroughs Peña declares no conflict
of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
Curr Cardiovasc Risk Rep
References
Papers of particular interest, published recently, have been
highlighted as:
•Of importance
•• Of major importance
1. •• Nelson A. Unequal treatment: confronting racial and ethnic dis-
parities in health care. J Nat Med Assoc. 2002;94:666–8.
2. Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of
major diseases to disparities in mortality. New Engl J Med.
2002;347:1585–92.
3. Harper S, Lynch J, Burris S, Davey SG. Trends in the black-white life
expectancy gap in the United States, 1983–2003. JAMA. 2007;297:
1224–32.
4. •• Gebreab SY, Diez Roux AV. Exploring racial disparities in CHD
mortality between blacks and whites across the United States: a
geographically weighted regression approach. Health Place.
2012;18:1006–14.
5. Goodney PP, Travis LL, Nallamothu BK, et al. Variation in the use of
lower extremity vascular procedures for critical limb ischemia. Circ
Cardiovasc Qual Outcomes. 2012;5:94–102.
6. Jones WS, Patel MR, Dai D, et al. Temporal trends and geographic
variation of lower-extremity amputation in patients with peripheral
artery disease: results from U.S. Medicare 2000–2008. J Am Coll
Cardiol. 2012;60:2230–6.
7. Clark CR, Ommerborn MJ, Hickson DA, et al. Neighborhood dis-
advantage, neighborhood safety and cardiometabolic risk factors in
african americans: biosocial associations in the jackson heart study.
PloS one. 2013;8:e63254.
8. Rose KM, Foraker RE, Heiss G, Rosamond WD, Suchindran CM,
Whitsel EA. Neighborhood socioeconomic and racial disparities in
angiography and coronary revascularization: the ARIC surveillance
study. Ann Epidemiol. 2012;22:623–9.
9. Foraker RE, Patel MD, Whitsel EA, Suchindran CM, Heiss G, Rose
KM. Neighborhood socioeconomic disparities and 1-year case
fatality after incident myocardial infarction: the Atherosclerosis Risk
in Communities (ARIC) Community Surveillance (1992–2002). Am
Heart J. 2013;165:102–7.
10. Winkleby M, Sundquist K, Cubbin C. Inequities in CHD incidence
and case fatality by neighborhood deprivation. Am J Prevent Med.
2007;32:97–106.
11. Chaix B, Rosvall M, Merlo J. Neighborhood socioeconomic depri-
vation and residential instability: effects on incidence of ischemic
heart disease and survival after myocardial infarction. Epidemiology.
2007;18:104–11.
12. Wen M, Christakis NA. Neighborhood effects on posthospitalization
mortality: a population-based cohort study of the elderly in Chicago.
Health Serv Res. 2005;40:1108–27.
13. Koch CG, Li L, Kaplan GA, et al. Socioeconomic position, not race,
is linked to death after cardiac surgery. Circ Cardiovasc Qual Out-
comes. 2010;3:267–76.
14. •• Sasson C, Magid DJ, Chan P, et al. Association of neighborhood
characteristics with bystander-initiated CPR. New Engl J Med.
2012;367:1607–15.
15. Popescu I, Cram P, Vaughan-Sarrazin MS. Differences in
admitting hospital characteristics for black and white Medicare
beneficiaries with acute myocardial infarction. Circulation.
2011;123:2710–6.
16. Rothenberg BM, Pearson T, Zwanziger J, Mukamel D. Explaining
disparities in access to high-quality cardiac surgeons. Ann Thoracic
Surgery. 2004;78:18–24. discussion −5.
17. •Cohen MG, Fonarow GC, Peterson ED, et al. Racial and ethnic
differences in the treatment of acute myocardial infarction: findings
from the Get With the Guidelines-Coronary Artery Disease program.
Circulation. 2010;121:2294–301.
18. Al-Khatib SM, Hellkamp AS, Hernandez AF, et al. Trends in
use of implantable cardioverter-defibrillator therapy among
patients hospitalized for heart failure: have the previously
observed sex and racial disparities changed over time? Circu-
lation. 2012;125:1094–101.
19. Singh TP, Almond C, Givertz MM, Piercey G, Gauvreau K. Im-
proved survival in heart transplant recipients in the United States:
racial differences in era effect. Circ Heart Fail. 2011;4:153–60.
Curr Cardiovasc Risk Rep
