Cardiovascular risk associated with social determinants of health at individual and area levels

1. In this cohort study, individual and area level social determinants of health (SDOH) were associated with an increased risk in atherosclerotic cardiovascular disease (ASCVD) events. 

Evidence Rating Level: 1 (Excellent) 

Social determinants of health (SDOH) are several conditions that affect people’s health, functioning, and quality of life. Cardiovascular health is often affected by an individual’s SDOH along with the area’s SDOH. Atherosclerotic cardiovascular disease (ASCVD) has previously been studied and found to have an association with both individual and area level socioeconomic status. However, the quantitative risk associated with poor SDOH is poorly characterized. In this cohort study, participants were excluded if they had a history of ASCVD at baseline (6841 individuals), missing SDOH (8453 individuals), missing covariates included in the pooled cohort equations (PCEs) (1472 individuals), or missing ASCVD follow-up incidents (297 individuals). Many of the patient characteristics such as employment status (unemployed, not employed including those who were retired), race and ethnicity (Chinese American, Hispanic, non-Hispanic Black, non-Hispanic White), education level (less than high school, high school, or higher education), and income (less than $35 000, $35 000 or higher), were self-reported by the participants. To understand the effects of SDOH on ASCVD, the time to first ASCVD event was measured as the main outcome. Cox proportional hazard models were used to understand the association between every SDOH and incident ASCVD event. Included in the final study were 26 316 participants (mean [SD] age at baseline, 61.0 [9.1] years). Of the participants, there was at least 1 adverse individual-level SDOH in 11 764 participants (44.7%) and at least 1 in adverse area-level SDOH in 10 908 (41.5%) participants. At the individual level and the area level, SDOH was associated with a greater risk of ASCVD for education (individual: hazard ratio [HR], 1.39 [95% CI, 1.25-1.55]; area: HR, 1.31 [95% CI, 1.20-1.42]) low income (individual: 1.35 [95% CI, 1.25-1.47]; area: HR, 1.28 [95% CI, 1.17-1.40]) and unemployment (individual: HR, 1.61 [95% CI, 1.24-2.10]; area: HR, 1.25 [95% CI, 1.14-137]). Overall, both individual and area level SDOH were associated with a higher risk of ASCVD events. Additionally, adding individual and area SDOH to the PCEs improved discrimination slightly while also improving calibration for estimating ASCVD risk in Black people.

Click to read the study in JAMA Network Open

Image: PD

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