ACC/AHA Clarify How Social Determinants of Health Impact CVD

As awareness about social determinants of health (SDOH) grows in medicine, the American College of Cardiology and American Heart Association (ACC/AHA) have teamed up to develop new data elements and definitions that capture the impact these factors have on cardiovascular disease.

Led by Alanna A. Morris, MD (Emory University, Atlanta, GA), the paper was published online earlier this week in the Journal of the American College of Cardiology.

Frederick A. Masoudi, MD (Ascension, St. Louis, MO), vice chair of the writing committee, noted that the ACC/AHA have a long history of developing data standards, though previous projects have often related to disease states or procedures.

The current document emerged out of growing recognition that SDOH are instrumental in health, he told TCTMD. “In fact, in some cases, social determinants are more important drivers than some of the biological variables that we think about when we think about disease progression and outcomes.”

Here, the authors sought to create a “standard vocabulary” for SDOH in cardiology. “The ultimate goal,” said Masoudi, “is to create an environment where social determinants of health are gathered, they're ascertained systematically, and they're used to support actions to improve health.”

Now more than ever, professional societies in the cardiology space are encouraging clinicians to take note of these factors, the authors point out. “While many clinicians may consider SDOH (eg, economic stability, neighborhood and the built environment, social and community context, or access to and quality of healthcare and education) to be the realm of policymakers and social scientists, there is increasing recognition that SDOH have a major impact on patients’ health outcomes and quality of life across the life course.”

In some cases, social determinants are more important drivers than some of the biological variables that we think about when we think about disease progression and outcomes. Frederick A. Masoudi

Morris and colleagues turned to various sources of inspiration—standards created by the World Health Organization, the US Department of Health and Human Services, the Canada-based Rural Community Health and Well-Being Framework, and the Robert Wood Johnson Foundation, among others—in their efforts to “harmonize and synchronize” concepts across platforms.

Having standard definitions for the SDOH relevant to cardiovascular care is important, they stress, noting that the poor progress in reducing the burden of CVD over the past decade is likely related to these factors.

The ACC/AHA paper specifies that SDOH span across individual, interpersonal, and community levels that can “overlap and are not mutually exclusive.” At an individual level alone, for instance, SDOH cover wide ground in areas like:

• Race/ethnicity, sex, sexual orientation, gender identity, immigration status, and acculturation
• Language and literacy
• Educational attainment, income, and employment
• Health literacy, broadband access, and digital literacy
• Dietary quality and food access and security
• Health insurance

At an interpersonal level, the concepts include such things as discrimination, disparate healthcare quality, and psychosocial stress. On a community level, SDOH come in the form of racial segregation, housing quality, civic participation and voting rights, access to and availability of healthcare services, education and employment, rates of incarceration and violence, transportation access and walkability, research infrastructure and access to clinical trials, and other big-picture factors.

Standardized approaches to data, including how they are conveyed and to what end, are key in both clinical settings and research, they note. “Strategies to integrate SDOH in electronic health records (EHRs) and data repositories will be necessary to ensure that these data standards can be deployed to achieve more equitable health and optimal health outcomes.”

Masoudi described their document “as an important first step” of much work to come.

“We can do more research to understand the extent to which particular social determinants drive specific health outcomes,” he said, adding that he hopes clinicians will begin to address these factors to the extent that they can.

“One of the key areas where the rubber really hits the road in clinical care is medication adherence,” Masoudi said as an example. “Some medications can be really expensive, and patients can't afford them. If that's the case, we can talk from here ‘til Tuesday about: should this patient be on an SGLT2 inhibitor for heart failure? But if they can't get that medication, then there's no point in prescribing it.”

Then, he said, it’s time to ask: “Are there things that we need to do for this particular patient in front of us to see that they get that medication? Or is it something where we say we’ll look for an alternative?”

Regardless of which SDOH are relevant to a given setting—and they might not all apply all the time—what’s important moving forward is that “everyone's [speaking] the same language,” Masoudi commented.