Social Determinants of Health Impacting Access to Care for Patients with Cardiovascular Disease

In her closing thoughts, Dr Michos highlights social determinants of health impacting the treatment landscape for patients with cardiovascular disease.

Erin Michos, MD, MHS: Social determinants of health are a major driver of cardiovascular risk, and there are substantial cardiovascular health inequities. There are many, things like a lack of insurance, lower income, and not being able to afford medications or afford physician visits. There are also issues related to transportation and taking time off of work to invest in preventive care. There are concerns with neighborhood safety and neighborhood environment, where it may not be safe to exercise and be physically active in their environment. There can be disparities with access to healthy foods. Some of the healthier foods, fruits and vegetables that are fresh may be more expensive or harder to access than fast foods. There are obvious concerns of bias and structural racism and discrimination, issues related to education and health literacy, and patients not fully understanding their medications and the benefits for those. And there can be a lot of mistrust with the medical system that creates barriers to having an optimal patient-clinician partnership.

These can be really challenging, and indeed there have been a lot of studies that have demonstrated that social determinants of health are related to cardiovascular risk. One of the studies that was presented at ACC [American College of Cardiology meeting] used data from the Behavioral Risk Factor Surveillance System survey, and examined over 3000 counties in the United States, and compared them by the median income from low-income to high-income counties. And unfortunately, it’s what you would expect based on the data, that those from the lowest income counties had a greater burden of cardiovascular risk factors, such as diabetes, hypertension, and obesity. They also had greater use of fast food, by looking at the income from fast food. They also had decreased or lower accessibility to recreational facilities and ability to exercise.

A lot of these are drivers, and it’s going to take a multipronged approach. Just fixing 1 of these things may not be enough. I think [it will take] improving community support, using community health centers, community liaisons, trying to overcome these food deserts by having more fresh produce. We have some studies that looked at bringing in vans of fruits and vegetables, and substantially discounting healthy foods, because there can be a lot of what we call food swamps where the available food is lower quality food. And also trying to have programs that can help increase physical activity. I think it needs to be a family-centered approach, rather than focusing just on the individual.

I think it’s really important for all clinicians to assess the social determinants of health in our patients because medications don’t work in patients who don’t take them. So understanding that sometimes suboptimal or nonadherence to medications is driven by things related to social determinants, such as financial cost of the medications, or reduced health literacy and understanding the purpose of the medications. It’s important to assess these challenges that our patients experience in their environment. And even if the clinician doesn’t feel equipped for how to address them, we’re working as part of a team-based approach to care, and so many health systems or practices have integrated case managers, social workers, and other team members who can help their patients. They can help their patients with signing up for Medicaid or financial assistance programs. Certain medications can have coupons for a reduction in cost. There are a lot of community programs that patients might not be aware of, but a social worker or other members of the team can help direct them the right way and partner with the patient to be successful and engaged in their own cardiovascular disease prevention.

Social determinants of health can be a challenging beast to tackle because it’s not just 1 thing. So much of this is rooted in society, where it’s beyond just what the clinicians and medical practices can do. We also need policy change, and changes in society, and changes in everything, like the grocer services. There are so many different challenges that our patients experience, especially those who don’t have health insurance and access to care. I think the first step is assessing social determinants, what barriers our patients have. But I think there are some exciting trials that are ongoing looking at different methods, implementing community workers, and delivery trucks of fruits and vegetables into communities. Some of this leftover produce from grocery stores that normally would get thrown away, delivering it to homeless shelters or into the community so that patients can have access to high-quality foods for free or little cost. But I definitely think we need more innovative trials and strategies for how we can work as a community to optimize patients’ health.

I do like some of the innovative studies about using nonclinician partners in the community who can be trained to assess and intervene in cardiovascular risk. One of the classic trials was the barbershop trial, where they trained barbers to measure the blood pressure of their male clients. They were able to give them resources, write their blood pressure number down, and be able to refer them to where they can get their blood pressure optimized. There have been studies ongoing looking at using faith-based organizations and partnering with Black churches. You want to get into the communities that are the most vulnerable to help. We need all hands on deck, so I think we need new models of delivering care, and I think these models need to extend into the community.

I think we talked about a lot of the pivotal trials I’m excited about. There are some other studies in the lipid field that we’ll keep our eye on. Another study that was presented was a phase 2b trial looking at an oral PCSK9 inhibitor. It was long thought that you could never inhibit the PCSK9 protein with an oral drug, it would be too hard to reach its target. That’s why our current inhibitors are injection medications, our monoclonal antibodies, and our small interfering RNA [ribonucleic acid]. But in this agent that was testing in a phase 2b trial, it was an oral agent that had a lot of interesting science that went around its development to help it get absorbed and target it to the right place. It showed that it did reduce LDL [low-density lipoprotein] by 60%, which is in the range of what we see with the monoclonal antibody PCSK9 inhibitors, with an oral medication. And there was no obvious safety signal in this very small, 8-week trial. I think that’s now setting the stage, that’s going to move into a larger phase 3 trial, but it’s exciting that we have yet another oral agent that’s not a statin that can lower LDL.

Another trial I think was interesting is a mechanistic trial called Yellow III. We’ve talked already about the importance of lowering LDL, getting the LDL as low as possible for as long as possible, and getting there faster. We know that lowering LDL can reduce major adverse cardiovascular events. Yellow III was a mechanistic trial looking at evolocumab, which is a monoclonal antibody, and looking at plaque morphology on angiography with OCT [optical coherence tomography]. It showed that with potent LDL lowering, you can regress plaque and make plaque more stable. So I think these favorable changes we see in plaque composition likely are driving the known reduction in major cardiovascular events we’ve seen in the outcome trials.

Transcript edited for clarity.

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