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    Social determinants of health affect care for people with congenital
    heart disease

    Date:
    April 7, 2022
    Source:
    American Heart Association
    Summary:
    Improving overall health equity for people with congenital heart
    disease requires recognizing the impact of social determinants of
    health throughout their lifespan. Systemic societal inequities and
    structural racism impact the health of people with congenital heart
    disease from prenatal care through adulthood. A new scientific
    statement suggests strategies to improve equity in congenital
    heart disease care that include research into implicit and
    explicit biases, systemic inequities that result in poorer social
    determinants of health, and examines the population, institutional,
    systemic and individual level contributors to health disparities.



    FULL STORY ==========================================================================
    As medical and surgical treatments have improved and survival has
    increased, the majority of people with congenital heart disease are now
    adults rather than children, yet disparities driven by social determinants
    of health (SDOH) limit access to the lifelong specialty care needed,
    according to a new American Heart Association scientific statement
    published today in the Journal of the American Heart Association, an
    open access, peer-reviewed journal of the Association.


    ==========================================================================
    An American Heart Association scientific statement is an expert analysis
    of current research and may inform future guidelines. The new statement
    focuses on the impact of SDOH -- the conditions in which people
    are born and live, such as education, employment, housing, income,
    and access to food and safety -- among people born with congenital
    heart defects. Societal factors impact the ability of people born with congenital heart disease to get appropriate specialty treatment throughout their lives and particularly when they are transitioning from pediatric
    to adult care.

    The word congenital means existing at birth. The terms "congenital heart defect" and "congenital heart disease" are often used to mean the same
    thing and are used interchangeably in the scientific statement. It's
    important to note, however, that while "disease" is more commonly
    used, "defect" is more correct because the heart problem is a defect
    or abnormality, not a disease. A congenital heart defect results when
    the heart or blood vessels near the heart don't develop normally before
    birth. These structural problems can usually be surgically addressed;
    however, for many, the condition is not completely cured.

    People with a congenital heart defect (CHD) -- particularly those with
    complex heart problems -- may require multiple operations and need
    specialty heart care throughout their lives.

    "Social determinants of health affect every single facet of CHD -- from
    who is born with a heart abnormality to who is diagnosed prenatally, to outcomes of surgery, to clinical follow-up as well as transitioning to
    adult care," said the Chair of the statement writing group Keila N. Lopez, M.D., M.P.H., an associate professor of pediatrics and medical director
    of the transition medicine division of pediatric cardiology at Texas
    Children's Hospital/Baylor College of Medicine in Houston.

    This statement follows a 2020 presidential advisory from the Association, published as a call to action to confront structural racism as a
    fundamental driver of health disparities.

    "When people think about individuals with poorer health outcomes, they
    often assume that these are the direct result of individual choices
    that people make; however, that is often not the case. Differences in
    the social determinants of health are often directly linked to worse
    health outcomes," said Lopez.

    "Disparities in health outcomes, such as life expectancy differences,
    are in large part due to long-standing systemic and structural racism
    factors across society that affect the communities in which people live
    and the care that is available, all of which negatively affects their
    lifelong health." At the population level of care, the statement points
    out that while there has been overall improvement in outcomes due to
    advances in surgical and medical care for congenital heart defects,
    there has been minimal improvement in equitable access across the
    U.S. to that care. Specialty care services are concentrated in urban
    areas, making access difficult for those who live in rural or smaller communities. Availability of care also refers to an individual's access
    to transportation and working at a job with the flexibility to have time
    off for health care needs, which tends to be more challenging for people
    with a complex disease and who have a lower socioeconomic status.

    Referral patterns to specialty care can also affect access to care.



    ========================================================================== Studies have explored referral patterns to congenital cardiac centers by insurance status, revealing a higher proportion of people with private insurance being referred to hospitals with lower mortality compared
    to those who have public insurance. Strategies to address these access
    issues include increasing specialist availability via satellite clinics
    in nonurban areas and increasing telehealth capabilities. Investigating policies for public insurance accessibility both within states and across
    state lines will be important to ensure access to CHD care. Improving
    access to care and insurance coverage can also support a healthier
    transition to adulthood and adult care for people with congenital heart disease.

    "Individuals who lack access for any reason also tend to have the
    highest gaps in care, particularly when transferring from pediatric
    to adult congenital specialty care, making the impact of social
    determinants particularly important between the ages of 18 and 26," said
    Lopez. "Individuals often lose access to insurance during these years
    of early adulthood." At the institutional level of care, the statement
    reports that it is unclear the degree to which hospital-level factors
    influence disparities of care versus the SDOH or individual factors. Some hospitals perform a higher volume of specialty heart care and surgeries,
    yet there is still a wide range of outcomes even across hospitals with
    the same volume. While race, ethnicity and lower socioeconomic status
    have been associated with worse outcomes after congenital heart disease surgery, more research is needed in this area to better understand
    these associations.

    There are, however, nonsurgical factors that affect the type of care
    available at different institutions. These factors include variations
    in home monitoring and visitation programs; the availability of
    programs to support nutrition, growth and cognitive development (such
    as school-based outreach); and varying levels of cultural competence in
    these programs. Also, the availability of non- English language providers
    and resources can make a difference in the quality of care at different institutions. The statement suggests the need for data to understand institutional referral patterns, hospital volume, and the resources,
    income and insurance needed to receive care at the hospitals with
    appropriate specialty care.

    A systemic look at access to care focuses on the availability and
    diversity of the health care workforce. Even for people who have health insurance, a lack of specialty providers is a major concern as the
    population of adults with CHD continues to grow. There are fewer than 500 board-certified specialists in adult congenital heart disease in the U.S.,
    and they are primarily located at specialty heart centers in urban areas.



    ========================================================================== "There is a lack of funding for subspecialty fellowships in pediatric cardiology and adult congenital heart disease," said Lopez. "While
    Medicaid funds most residency slots for internal medicine training, it
    often does not provide funds for pediatric subspecialty fellowships, which restricts the number of available slots. Applicants and institutions must
    then fund their own fellowship training programs, such as those for adult congenital heart disease." In addition to the need for more CHD health professionals, there is ample opportunity to increase diversity among
    pediatric cardiologists. Fewer than 8% of CHD physicians are people from diverse racial and ethnic groups, although the percentage in pediatric cardiology fellowship programs edged up slightly between 2006 and 2016
    (from 7.7% to 9.9%, respectively).

    "Racial and ethnic diversity matters for health outcomes, patient trust
    and research. Studies confirm that having concordant care and a clinician workforce that resembles the population they are serving has an impact on patient outcomes. It's critical to improve the diversity of the pipeline
    by encouraging medical students to enter subspecialties, including
    pediatric cardiology and adult congenital heart disease," Lopez said.

    Suggestions to improve diversity include: 1) establishing high school
    and undergraduate "pipeline" programs that expose young students to
    health care professionals that look like them and encourage them along
    the educational pathway to health care professions; 2) recalibrating
    medical school admission to include holistic assessment of applicants; 3) substantial cost reduction for graduate or medical school; 4) establishing
    and funding minority-serving medical schools; and 5) greater focus on
    retention and promotion of physicians from diverse racial and ethnic
    groups.

    At the individual level, the statement highlights the role of implicit
    bias, microaggression and racism and how they create barriers to care. The statement calls attention to the importance for individuals to serve
    as their own advocates to combat biases and systemic racism within the
    health care system.

    "Race is a social construct," said Lopez. "Using it as a biological
    construct to explain racial differences in outcomes is not valid. We must recalibrate how race is incorporated in scientific and medical research
    moving forward; it is important information to ensure we increase equity
    for all people regardless of race or ethnicity." Although this statement
    is limited to congenital heart disease, the same concerns about transition
    to adult care apply to many other medical conditions in children.

    "We are not alone. Many of my colleagues care for children with lifelong, complex medical conditions -- such as cystic fibrosis, sickle cell
    disease, type 1 diabetes and spina bifida. In the past, many of these
    children may not have survived past childhood, so developing successful transitions to adult care is an urgent need that is universal for all
    children as they age into adulthood," said Lopez.

    This scientific statement was prepared by the volunteer writing group on
    behalf of the American Heart Association's Congenital Cardiac Defects
    Committee of the Council on Lifelong Congenital Heart Disease and
    Heart Health in the Young (the Young Hearts Council); the Council
    on Epidemiology and Prevention; and the Council on Lifestyle and Cardiometabolic Health. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues
    and help facilitate informed health care decisions.

    Scientific statements outline what is currently known about a topic
    and what areas need additional research. While scientific statements
    inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.

    Co-authors are Vice Chair Shabnam Peyvandi, M.D., M.A.S.; Carissa
    Baker-Smith, M.D., M.P.H.; Glenn Flores, M.D.; Michelle Gurvitz, M.D.,
    M.S.; Tara Karamlou, M.D., M.Sc.; Flora Nunez Gallegos, M.D., M.P.H.; Sara Pasquali, M.D., M.H.S.; Angira Patel, M.D., M.P.H.; Jennifer K. Peterson, Ph.D., A.P.R.N.-C.H.S.; Jason L. Salemi, Ph.D., M.P.H.; and Clyde Yancy,
    M.D., M.Sc.


    ========================================================================== Story Source: Materials provided by American_Heart_Association. Note:
    Content may be edited for style and length.


    ========================================================================== Journal Reference:
    1. Keila N. Lopez, Carissa Baker‐Smith, Glenn Flores, Michelle
    Gurvitz, Tara Karamlou, Flora Nunez Gallegos, Sara Pasquali,
    Angira Patel, Jennifer K. Peterson, Jason L. Salemi, Clyde Yancy,
    Shabnam Peyvandi. Addressing Social Determinants of Health and
    Mitigating Health Disparities Across the Lifespan in Congenital
    Heart Disease: A Scientific Statement From the American Heart
    Association. Journal of the American Heart Association, 2022;
    DOI: 10.1161/JAHA.122.025358 ==========================================================================

    Link to news story: https://www.sciencedaily.com/releases/2022/04/220407101028.htm

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