Advancing Health Equity in Cardiovascular Care: A New Frontier

“How can we advance health equity in cardiovascular care?” asked David Thompson, PhD, professor of nursing, School of Nursing and Midwifery, Queen’s University Belfast, Northern Ireland, on day 2 of the 2024 European Society of Cardiology Congress.

To even know where to begin, it’s important to first understand that health equity and health equality are not the same, he explained in the session, “Diversity in Cardiovascular Care: Advancing Health Equity.”¹

“We use the terms health equity, health equality, disparities, and outcomes interchangeably, and sometimes that can lead to confusion,” he explained. Health equality calls for equal care for everyone, health equity calls for need-based fairness in care even in the presence of social determinants of health (SDOH), health disparities are how measures of health outcomes differ between groups, and health outcomes are just that—results following care.^2-4

Building on data he published last year⁵—and with 40-plus years of research focusing on psychosocial interventions, health-related quality of life in heart conditions, and meta-analyses of cardiovascular disease (CVD) prevention and rehabilitation—he laid out his case for the CV care space, noting that SDOH are not the only determinants of health in CVD. There are other determinants, too—for example, education, language, and lack of health literacy (or having health misinformation); culture; no health care access; social support networks (“We know that people who live alone or have no social support have much poorer outcomes,” Thompson said); home environment and living conditions; and job insecurity and income, to name a few.

However, social determinants can be more important than health care or lifestyle choices in influencing health, he said.

So, how do these tie into barriers to equitable CV care? Health care can be unaffordable, which leads to patients often having inadequate insurance coverage; unavailable, which can translate into delays in care that include diagnoses and rehabilitation; culturally biased, due to treatment preferences when being provided care; geographically inaccessible (ie, poorer countries); impeded by inadequate transportation infrastructure (“One of the big barriers to cardiac rehabilitation is people getting people to cardiac rehabilitation programs.”); and unfamiliar to many. Patients may also have other disabilities, face communication and language barriers, or be unaware of or not offered services.

David Thompson, PhD | Image Credit: Queen’s University Belfast

“All of this can lead to unmet health care needs,” Thompson said.

The Lancet Regional Health-Europe commission on inequalities and disparities in cardiovascular health was recently formed to address “the continued and widening disparities in cardiovascular health, [that] despite overall declines in cardiovascular mortality, highlight the inequities in the distribution of advancements in cardiovascular care.”⁶

So far, research from the commission demonstrates disparities leading to adverse CV health outcomes among 4 patient populations⁶:

• Women typically have limited health care access, low income, and insufficient social support.
• Racial and ethnic disadvantaged individuals also have limited health care access and low income, but more often experience familial instability and systemic racism.
• Persons with mental illness more often face discrimination and have unhealthy behaviors (eg, poor diet, physical inactivity, alcohol or substance misuse).
• Older individuals have higher rates of loneliness, are underrepresented in clinical trials, and lack family and caregivers.

Also to blame are ageism and sexism.

Necessary to advancing health equity are equitable social interventions, access to care, high-quality clinical care, experience of care, and structures of care, “all of which need to be addressed if we are to going to improve health and well-being,” Thompson stated. But these must be preceded by a concerted effort to change how we think, feel, and accomplish.

Suggestions to do this include addressing all determinants of health (not just SDOH), providing effective and equitable access to care, employing a diverse workforce that reflects the patients it serves, adhering to professional and ethical codes of conduct, always being an advocate for health equity in CV care, being aware that health inequities exist and being committed to addressing them with targeted trainings, and empowering patients, their families, and care providers to speak up.

Research from 2 recent studies reinforces these claims.^5,7

Another potential solution is digital CV health innovations and making patients digitally literate by empowering them through training and tech support on the devices and applications they would need to advance their CV care and navigate the health care system better, with Thompson emphasizing that “we should be using technology more.” This can also lend itself to more social cohesion within the community, he added, and greater awareness of social justice.

“As cardiovascular health care professionals, we must acknowledge and celebrate diversity in cardiovascular care, strive to advance health equity to ensure just and fair health care for all, and acknowledge that in cardiovascular care, health inequities are common—in both prevention and management,” he summed.

These efforts to understand and reduce disparities should be fueled by the triple threat of professional, moral, and ethical duty and by working with patients, families, local communities, and members of the care team to establish trusted partnerships.

“I think we are quite good at this, but we could always improve,” Thompson emphasized.

References

1. Thompson DR. Diversity in cardiovascular care: advancing health equity. Presented at: ESC Congress; August 30-September 2, 2024; London, England.

2. About health equity. CDC. Accessed August 31, 2024. https://www.cdc.gov/health-disparities-hiv-std-tb-hepatitis/about/index.html#:~:text=Health%20equity%20is%20the%20state,their%20highest%20level%20of%20health

3. Rosa WE, Hannaway CJ, McArdle C, McManus MF, Alharahsheh ST, Marmot M. Nurses for health equity: guidelines for tackling the social determinants of health. Qatar Foundation/World Innovation Summit for Health. 2021. Accessed August 31, 2024. https://wish.org.qa/wp-content/uploads/2024/01/Nurses-for-Health-Equity.pdf

4. Health equity. World Health Organization. 2024. Accessed August 31, 2024. https://www.who.int/health-topics/health-equity#tab=tab_1

5. Thompson DR, Ski CF, Clark AM. Advancing health equity in cardiovascular care. Eur J Cardiovasc Nurs. 2024;23(3):e23-e25. doi:10.1093/eurjcn/zvad131

6. Bugiardini R, Gale CP, Gulati M, et al. Announcing The Lancet Regional Health-Europe commission on inequalities and disparities in cardiovascular health. Lancet Reg Health Eur. 2024:41:100926. doi:10.1016/j.lanepe.2024.10092

7. Bodine J. The future of nursing 2020-2030: charting a path to achieve health equity: implications for preceptor development. J Nurses Prof Dev. 2023;39(2):115-116. doi:10.1097/NND.0000000000000975