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4
Health Disparities
Disparities in health and health care may be found at each step along the continuum of chronic disease, from
primary prevention to disease management. To identify and understand these disparities, a surveillance system
must be able to provide data to analyze disparities in incidence and prevalence, morbidity and mortality, functional
health outcomes, primary and secondary prevention approaches, risk factors, and healthcare delivery. This system
must function not only at the national level but also at the regional, state, and local levels. The system should
be effective in monitoring populations defined by race and ethnicity, gender, age, income, education, social and
physical environments, and geographic factors such as birthplace and years of residence in the United States.
A contemporary national framework for the surveillance of cardiovascular disease (CVD) and chronic obstruc -
tive pulmonary disease (COPD) can drive the development of policies and programs at the local level that help
to ensure high-quality effective preventive and therapeutic programs for the entire U.S. population. Much of our
knowledge of racial and ethnic disparities has been derived from national population samples, but efforts to elimi -
nate health disparities must occur in collaboration with local and regional healthcare organizations, communities,
healthcare institutions, and healthcare providers. Federal databases are the source of much of the information
currently available on racial and ethnic health disparities (Sequist and Schneider, 2006). Although the federal
government will remain a major source of data on racial and ethnic health and healthcare disparities, linkage to
Census data, vital statistics, household surveys, small area data, administrative data, and data from local groups
and healthcare organizations should be an integral part of the national surveillance system.
WHY SHOULD HEALTH DISPARITIES BE MEASURED?
In Healthy People 2010, the federal government established two major goals for health promotion and disease
prevention: (1) to increase life expectancy and improve quality of life; and (2) to eliminate health disparities (HHS,
2000). Healthy People 2010 made the elimination of health disparities one of the highest priorities of the federal
government (Satcher, 2010). Many of these contemporary health disparities in the United States have deep roots
in historical economic and political conditions related to racism and unequal access to resources and opportuni -
ties for better health spanning generations and across the life course. A recent assessment of the nation’s progress
toward meeting the ambitious goals of Healthy People 2010 observed that “although some progress has been made,
there is much work to be done toward the Healthy People 2010 targets and both overarching goals” (Sondik et al.,
2010). Healthy People 2020 continues the focus on this area with the goal to achieve health equity and to eliminate
51
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52 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES
disparities. The National Healthcare Disparity Report, first produced in 2003 and published annually thereafter by
the Agency for Healthcare Research and Quality (along with the National Healthcare Quality Report), found that
even though coronary heart disease- (CHD-) and stroke-related mortality have decreased for all major racial/ethnic
groups between 1980 and 2003, the burden of CVD and CVD risk factors remained disproportionately high in
segments of the population defined by race, ethnicity, socioeconomic status (SES) and geography (AHRQ, 2006).
The selection and definition of population groups for study is critical to the process of building a framework
for national surveillance of health disparities. Margaret Whitehead proposed a conceptual model of health equity
and disparities in the early 1990s that offers a framework for examining the determinants of health disparities and
provides a useful perspective to guide the development of a contemporary nationwide framework for CVD and COPD
surveillance (Whitehead, 1991). Whitehead’s seven determinants of health disparities are: (1) natural biological varia-
tion; (2) health-damaging behavior that is freely chosen; (3) the transient health advantage of one group over another
when one group is first to adopt health-promoting behavior (as long as other groups have the means to catch up fairly
soon); (4) health-damaging behavior in which the degree of choice of lifestyles is severely restricted; (5) exposure to
unhealthy, stressful living and working conditions; (6) inadequate access to essential healthcare services and other
basic services; and (7) natural selection or health-related social mobility involving the tendency for sick people to
move down the social scale. Since Whitehead first outlined these seven determinants of health disparities in 1991,
health-damaging behaviors such as smoking and unhealthy diet, which were presumed to be freely chosen, have
also been linked to social networks that may strongly influence these behaviors (Christakis and Fowler, 2007, 2008).
Therefore, such health behaviors must be considered within their social context, and they cannot be detached from
the historical, sociocultural, and economic conditions that promote and constrain behavioral choices.
Surveillance of health disparities is complicated by the need to provide data from several distinct domains
whose interaction leads to disparities in health and health care. The task is further challenged by the variability of
determinants at the neighborhood, city, county, state, regional, and national levels, as well as between and among
population groups and subgroups defined by race and ethnicity. For example, rather than beginning with race and
ethnicity as the fundamental categories, health disparities could be tracked according to broad categories, such as
social context and physical environment, age, and gender. The more proximate effects of other covariates (e.g.,
income, educational attainment, employment status and discrimination, health behaviors, the healthcare system,
and psychosocial factors) could be assessed within a framework based on social context and physical environment,
age, and gender. In this conceptual model (Figure 4-1), health indicators such as CVD and COPD prevalence
and incidence, morbidity and mortality, obesity, hypertension, diabetes, and hyperlipidemia would be viewed as
products of the interrelationship of the foregoing factors (Schulz et al., 2005).
EVIDENCE OF THE NEED FOR ONGOING SURVEILLANCE OF HEALTH DISPARITIES
Age and Gender
Age and gender are established categories for reporting health and healthcare surveillance data. Concomitant
with the decline in death rates attributed to CHD in Americans over the past several decades, life expectancy has
increased. Between 1980 and 2003, life expectancy increased by 4.8 years in American men and by 2.7 years in
women.
CVD increases with advancing age in both women and men. Across the spectrum of CVD (hypertension,
CHD, heart failure, valvular heart disease, peripheral arterial disease, and stroke), there are corresponding age-
related increases in CVD morbidity and mortality (Yazdanyar and Newman, 2009). In 2007, the leading causes
of death in women as well as men aged 65 and older were diseases of the heart. One in three women aged 65 and
older has coronary artery disease, and the underlying disease process, atherosclerosis, begins at an early age in
both sexes (NCHS, 2010).
In-hospital mortality related to acute myocardial infarction (AMI) is higher in women than in men, and the
long-term prognosis after hospitalization for AMI has been shown to be worse in women than in men (Eastwood
and Doering, 2005). Unadjusted mortality and complication rates remain higher in women than in men treated
with percutaneous coronary interventions (PCIs). CVD risk scores also increase progressively with advancing age
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53
HEALTH DISPARITIES
Fundamental Intermediate Proximate Cardiovascular health
Social context Stressors
• Neighborhood, workplace and • Stressors related to local
housing conditionsd environments (e.g., police stress,
• Community investment (condition safety stress, pollutants)e
A. Race-based residential Cardiovascular risk and
of parks, streets)d,e • Stressors related to employment
segregation and protective markers
• Community capacity and opportunities (e.g., financial stress)e
socioeconomic inequalities • Allostatic load
1 4
participatione • Stressors related to unfair treatmente
• Distribution of material wealtha • Obesity
• Municipal support services Health behaviors
• Distribution of employment – Body mass indexe
(e.g., police, enforcement of • Dietary practicese
opportunitiesa – Hip/waist ratioe
environmental regulations)d,e • Physical activitye
• Distribution of educational • Systolic and diastolic
• Smokinge 7
opportunitiesa blood pressuref
3
• Distribution of political • Micronutrient status
Social integration and social support
influence – Micronutrient intakee
• Social participation and integratione
Physical environment
– Micronutrient blood levelsf
• Social supporte
• Airborne particulate matterb
2 • Fat and cholesterol status
• Land use (industrial, residential)a,d Psychosocial factors
– Cholesterol and
5
• Transportation systemsc,d • John Henryisme
Data sources triglyceride intake
• Services (shopping, banking, • Anger/hostilitye
1970–2000 Census data
a
– Cholesterol blood levelsf
health care facilities, waste • Hopelessnesse
PM10 and PM25 monitors
b
• Oxidative stress
transfer stations)c,d • Depressione
Administrative data sources
c
– Plasma homocysteinef
• Public resources (parks,
(e.g., police crime reports) – Antioxidant enzymesf
recreation centers)c,d,e
Neirhborhood Observational
d
– Plasma isoprostanesf
• Buildings (housing, schools,
Checklist 6
workplaces)a,c,d
Survey (including food
e
frequency questionnaire and
physical measures)
Biomarker (e.g., blood and
f
saliva samples)
FIGURE 4-1 Conceptual model and data sources for Healthy Environments Partnership: Social and physical environmental
Figure 4-1.eps
factors and disparities in cardiovascular risk.
SOURCE: Schultz (2005).
in both men and women in the absence of diagnosed CVD. The prevalence of subclinical forms of CVD—such
as carotid artery atherosclerosis and elevated coronary artery calcium score—have been shown to increase with
advancing age (Rich and Mensah, 2009).
Performance of coronary revascularization soon after AMI in the elderly has become very common. Although
the use of this effective treatment modality over time has increased considerably in men and women of all ages, age
disparities continue (Pagé et al., 2010; Peterson et al., 2004). Because older patients with coronary artery disease
often have additional comorbid illness, it is important to determine whether this procedure in older patients will
translate into increases in quality of life and long-term survival in a cost-effective manner.
Similar to CVD, the occurrence of many chronic lung diseases increases with advancing age. An exception
is asthma, which is more common in childhood (Brown et al., 2008; Mannino et al., 2002). In contrast to CVD,
the occurrence of COPD has been increasing in recent decades, with the highest mortality rates observed among
older white males (Brown et al., 2008; Lewis et al., 2009; Mannino et al., 2002). Although chronic lung diseases
are more common among men, for selected conditions such as COPD the rate of increase has been greater among
women. U.S. mortality rates from COPD, increased from 1980 through 2000, with a greater relative increase
among females (20.1 to 56.7 per 100,000) compared with males (73 to 82.6 per 100,000). In 2000, the abso -
lute number of deaths from COPD was higher among females compared with males. Between 2000 and 2005,
mortality rates for females remained relatively flat, but declined among males (Brown et al., 2008). In addition
to the relatively greater increase in mortality among females, women have a higher rate of use of inpatient ser-
vices (Shaya et al., 2009). This may be partly explained by limited evidence suggesting that women are more
susceptible to the adverse effects of cigarette smoke compared to men (Camp et al., 2009; Chatila et al., 2004;
Dransfield and Bailey, 2006; Sin et al., 2007).
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54 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES
Race and Ethnicity
Because of the major roles race and (more recently) ethnicity have played in American political and social history,
race and ethnic categorization of health and health care has been a distinguishing feature of health surveillance in
the United States. As a result of segregation (racial, social, economic, and residential) throughout much of American
history, race has served as a proxy for social, cultural, and economic features of populations and subpopulations
described by race and ethnicity. The use of race as a social risk marker should be distinguished from the use of race as
a biological risk factor. When used as a risk marker, race suggests a collinear association with some other quantifiable
variable, such as income or education. By contrast, when used as a risk factor, race implies shared genetic heritage and
consequent susceptibility to specific diseases such as sickle cell anemia or cystic fibrosis (Joseph et al., 2006; Osborne
and Feit, 1992). When using race or ethnicity in health surveillance, it is important to acknowledge the social context
in which these terms are used and to avoid presumptions of socioeconomic and cultural homogeneity or biological
and genetic “sameness.” Also important is recognizing that race and ethnicity are not biological or genetic variables
that cause differences in health, but they are instead associated with other biological, social, or environmental risk
factors that contribute to disparities in health between racial and ethnic groups (Ellison et al., 2007).
Understanding the root causes of health disparities requires surveillance at the population level for incidence
and prevalence, predisposing factors, morbidity, mortality, and long-term outcomes. Other important factors are
linkage of such data to environmental, residential, geographic, socioeconomic, cultural, and educational domains.
Racial and ethnic disparities in CVD and COPD prevention, diagnosis, treatment, and outcomes have been exten -
sively documented (IOM, 2003; Kaiser Family Foundation/American College of Cardiology Foundation, 2002).
Prior surveillance data have shown that in comparison with white populations, racial and ethnic minorities generally
have higher rates of CVD risk factors, CVD-related morbidity and mortality, poorer health, less adequate health
care, and worse outcomes (Roger et al., 2010).
Although the overall occurrence of COPD is higher among non-Hispanic white males compared with other
racial and ethnic groups, in recent years the occurrence has been increasing more rapidly among African Americans
compared to whites (Brown et al., 2008; Coultas et al., 1994; Keppel et al., 2010; Kirkpatrick and Dransfield, 2009;
Mannino et al., 2002). Moreover, relative disparities in mortality rates have increased from 1999 to 2006 for heart dis -
ease, from 1990 to 1998 for COPD, and from 1990 to 2006 for chronic lower respiratory disease (Keppel et al., 2010).
For COPD, limited evidence suggests that black men may be more susceptible to the adverse effects of ciga -
rette smoke compared to white men (Chatila et al., 2004; Dransfield et al., 2006). Sarrazin and colleagues (2009)
examined mortality rates among African American (n = 7,159) and white (n = 43,820) veterans admitted for a COPD
exacerbation from 2003 to 2006. Overall mortality was lower among African Americans (7.1 percent) compared
to whites (9.2 percent), with a risk-adjusted mortality ratio of 0.71. Although crude mortality rates from COPD
have been higher among African Americans compared with whites, there may be no difference in these deaths
after adjustment for age, body mass index, smoking, alcohol use, diabetes, hypertension, education, and sports
index (Chamberlain et al., 2009). Among the heterogeneous Hispanic population, limited data are available about
chronic lung diseases (Brehm et al., 2008). Mortality from CVD and COPD is lower among black and Hispanic
immigrants compared to U.S.-born populations of the same race and ethnic groups, suggesting untoward effects of
the American lifestyle (Singh and Hiatt, 2006). The influence of access to health care and quality of care among
different racial and ethnic groups is discussed in greater detail in subsequent sections.
Measurement and classification of populations and subpopulations by race and ethnicity for surveillance has
become more challenging because of increased immigration from Central and South America as well as Asia and
Africa. Changes in the demographic characteristics of the U.S. population have also resulted from increased racial
and ethnic admixture due to growth in the number of intermarriages and evolving conventions of racial and ethnic
self-identification (Waters, 2000). The Pew Research Center reported that in 2008, a record one in seven of all new
U.S. marriages were between individuals of a different race or ethnicity (with significant variation across U.S. regions).
The Pew Research Center has produced estimates of future changes in the proportions of racial and ethnic groups.
According to those estimates, from 2005 to 2050, the proportion of U.S. whites will decrease from 67 to 47 percent;
the Hispanic population will increase from 14 percent of the population to 29 percent; U.S. blacks will remain at
13 percent of the population; and the proportion of Asians will rise from 5 to 9 percent (Passel and Cohen, 2008).
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55
HEALTH DISPARITIES
Nativity and Immigration
Growth in the proportion of foreign-born residents and their progeny in the United States has reinforced the
importance of examining differences in the health and healthcare of immigrants, especially in regions, states, coun -
ties, or neighborhoods with significant proportions of immigrants. Because of their long history of discrimination,
residential segregation, unemployment, and poor SES, immigrant populations can have less favorable risk factor
awareness, diagnosis, treatment, and control. Immigrants and migrants have had a tendency to move to and live in
areas populated by people with similar backgrounds. Residential segregation has held true historically, not only
for immigrants but also for African American “migrants” already living in the United States and for many Native
Americans. According to the 2000 Census, immigrants have settled most often in California, Florida, Illinois, New
Jersey, New York, Pennsylvania, and Texas. Immigrants, particularly those who lack fluency in English, health
literacy, and familiarity with the U.S. healthcare system, are at increased risk for some chronic diseases and injuries.
Observed health disparities in specific racial and ethnic subgroups may result from shared social, economic, and
physical environments as well as race or ethnicity.
The relationship between acculturation and chronic disease indicators is complex and may have a signifi -
cant effect on observed health disparities. Surveillance systems typically have not focused on collecting and/or
combining social, economic, and environmental data when addressing health disparities. Acculturation (or lack
thereof) may influence the health of socioeconomically and culturally homogeneous populations, whether native
born or foreign born, residing in the same neighborhoods. The effects of acculturation may be subgroup specific,
with differing impacts on the burden of disease, risk factors, markers of comorbidities, and outcomes. In a study
of participants in the Multi-Ethnic Study of Atherosclerosis, a higher prevalence of carotid plaque (a marker for
carotid atherosclerosis) was observed among whites, blacks, and Hispanics who had been in the United States
for more generations, as well as in whites with less education and blacks with lower incomes (Lutsey et al., 2008).
Among immigrants from diverse ethnic backgrounds, longer length of residence in the United States has been
associated with increased odds of obesity, hyperlipidemia, and cigarette smoking, even after adjusting for relevant
confounding factors. High levels of acculturation have also been associated with poorer risk factor control or a
higher prevalence of chronic disease risk factors. Immigrants who speak their native language at home or have
resided briefly in the United States may have reduced risk factor control.
Assessing Hispanic ethnicity and disease or risk factor surveillance is complex because of differing geographic
origins and admixture of various subgroups in the United States. The ancestry of Hispanics depends on the coun -
try of origin, the region of the country in which they first settle, and the region in which they ultimately reside.
Hispanics in California emigrated predominately from Mexico, while Hispanics in New York emigrated largely
from Puerto Rico and the Dominican Republic. Although both populations are “Hispanic,” their ancestral origins
differ considerably (Lai et al., 2009).
Furthermore, use of the term “black” to categorize persons of African origin may not be optimal in CVD and
COPD surveillance. Approximately 6 percent of persons who self-identified as black or African American in the
2000 Census were not born in the United States (CDC, 2005). For example, in New York large subpopulations
of people of African origin could be classified into different categories, such as Barbadian, Haitian, Jamaican,
Nigerian, Panamanian, Senegalese, Trinidadian, or from other locations in the African Diaspora. The “black”
category presents difficulties in surveillance because it encompasses a heterogeneous group, but does not account
for variations within the group or among subgroups (Ford and Kelly, 2005).
Geography, Residence, and Environment
In Whitehead’s formulation of health disparities, a distinction is made between damaging behaviors that are
freely chosen (modifiable risk factors) and behaviors in which the degree of choice is severely restricted, such
as birthplace and residence. Unhealthy living and working conditions and inadequate access to essential health
services and other basic services (e.g., screening services) are influenced by environment, region, state, county,
and neighborhood. Despite efforts to address health disparities by improving the quality of health care and health
services delivered at the population, subpopulation, and individual levels, disparities in the major indicators of
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56 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES
high-quality health and health care persist, and differences in damaging or beneficial health behaviors have been
shown to contribute to observed health disparities. These disparities persist in spite of the wide array of interven -
tions available at the individual level, including improving primary and secondary prevention; increasing aware -
ness, treatment, and control of predisposing factors; and increasing access to the latest diagnostic and therapeutic
technologies. This persistence of health disparities has focused attention on other possible determinants of health
disparities, including geography, residence, and environment (Do et al., 2008).
Substantial evidence shows geographic variation in risk factors, prevalence and incidence, morbidity, and
mortality for CHD and stroke. For example, in a report of state-based prevalence estimates of CHD, variations
among states by sex, race/ethnicity, and education were observed, with an approximate twofold difference between
states with the highest and lowest prevalence rates of CHD (CDC, 2007). High heart disease mortality rates also
have been observed in several U.S. regions, such as the “Coronary Valley” of the Ohio-Mississippi River Basin
(Pickle and Gillum, 1999), and the “Heart Failure Belt” of the southeastern United States (Mujib et al., 2011).
The classic example of regional variation in CVD mortality is the “Stroke Belt.” This belt is composed of
11 southeastern states where higher rates of stroke mortality have been observed compared to other U.S. regions
(Lanska, 1993). The numerous hypotheses for the concentration of CVD and stroke mortality in the Southeast
include geographic differences in the distribution of major cerebrovascular disease risk factors (e.g., high blood
pressure, diabetes, cigarette smoking, and obesity) and differences in socioeconomic and environmental factors
(Liao et al., 2009). However, even though many possible explanations for the Stroke Belt have been considered,
the reasons for regional variation in stroke-related mortality have not been definitively established.
A possible explanation for the observed concentration of stroke mortality in the southeastern United States
is the higher prevalence of hypertension among Southern-born blacks than in blacks born elsewhere. Geographic
heterogeneity of hypertension suggests that differences in the prevalence of hypertension between blacks and
whites are not constant, but they may vary depending on which geographic groups are compared. The presence
of large variations in black–white differences suggests that race differences are not immutable (i.e., not simply
genetic or biological) and may vary substantially by social and environmental context (Byers et al., 1998; Kershaw
et al., 2010). Liao and colleagues (2009) observed that “socioeconomic status, hypertension, diabetes, coronary
heart disease, and smoking are still the basic crucial contributors to the disparities. Most of these factors are either
modifiable or potentially amenable to interventions. Given these findings, public health interventions are essential
for progress in reducing the stroke burden in the Stroke Belt region.”
Studies of increased stroke-related mortality in southeastern U.S. residents have generally suggested that stroke
risk is primarily linked to residence in the Stroke Belt. Less is known, however, regarding the importance of birth
versus residence in the Stroke Belt in native- and foreign-born blacks and whites. In a study of the association
between birthplace and mortality from CVD among black and white residents of New York City, similar CVD
death rates were observed for white and black men and white and black women born in the Northeast (Fang et al.,
1996). Black men born in the South had death rates 30 percent higher than northeastern-born blacks and four times
that of Caribbean-born blacks of the same sex and age. Higher rates of CVD mortality among blacks compared
with whites may obscure substantial variation among blacks based on birthplace .
Disparities may be influenced by the characteristics of the local community or neighborhoods, which may
engender healthy or unhealthy behavioral practices. The perception of neighborhood safety is positively associated
with physical exercise, and this association is larger for minority groups than for whites. Neighborhoods also differ
in the existence and quality of recreational facilities and open, green spaces. The availability and cost of healthful
products in grocery stores also has been shown to vary across residential areas, and the availability of nutritious
foods is positively associated with their consumption. In addition, it has been demonstrated that both the tobacco
and alcohol industries heavily market their products to poor minority communities (Williams and Jackson, 2005).
Furthermore, they are more likely to have jobs in workplaces that expose them to dusts, gases, and fumes, which
have been associated with an increased risk for COPD, which disproportionately affects African Americans and
Hispanics (Hnizdo et al., 2004).
Williams and Jackson (2005) observed the factors in Box 4-1 in the social environment that can initiate and
sustain disparities in health.
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HEALTH DISPARITIES
BOX 4-1
Social Environment That Can Initiate and Sustain Disparities in Health
“Socioeconomic status, whether measured by income, education, or occupation, is a strong predictor
of variations in health . . . all of the indicators of SES [socioeconomic status] are strongly patterned by race,
such that racial differences in SES contribute to racial difference in health. Moreover, the differences in
health by SES within each racial group are often larger than the overall racial differences in health. Income
also plays a role in understanding racial differences in CHD (coronary heart disease) mortality. For example,
death rates from heart disease are two to three times higher among low-income blacks and whites than
among their middle-income peers. In addition, for both males and females at every level of income, blacks
have higher death rates from CHD than whites. Mortality from heart disease among low- and middle-income
black women is 65 percent and 50 percent higher, respectively, than for comparable white women. . . .
Health practices. Another pathway underlying the association between race and chronic diseases is the
patterning of health practices by race and socioeconomic status. Dietary behavior, physical activity, tobacco
use, and alcohol abuse are important risk factors for chronic diseases including CHD, stroke, and chronic
lung disease. Moreover, changes in these health practices over time are patterned by social status. Dis-
advantaged racial groups and those with low SES are less likely to reduce high-risk behavior or to initiate
new health-enhancing practices. . . . Stress. Exposure to psychosocial stressors may be another pathway
linking SES and race to the development of poor health and adverse outcomes once disease has been
diagnosed. The subjective experience of discrimination is a neglected stressor that can adversely affect
the health of African Americans. Reports of discrimination are positively related to SES among blacks and
may contribute to the elevated risk of disease that is sometimes observed among middle-class blacks. . . .
Residential segregation. The persistence of racial differences in health after individual differences in SES
are accounted for may reflect the role that residential segregation and neighborhood quality can play in
racial disparities in health. Because of segregation, middle-class blacks live in poorer areas than whites of
similar economic status, and poor whites live in much better neighborhoods than poor blacks. . . . Impact
on income. Residential segregation is a central mechanism by which racial economic inequality has been
created and reinforced in the United States. It is a key determinant of observed racial differences in SES
because it determines access to education and employment opportunities. Violence. In addition, segre-
gation creates health-damaging conditions in both the physical and social environments. Because of its
restriction of educational and employment opportunities, residential segregation creates areas with high
rates of concentrated poverty and small pools of employable and stably employed males.”
SOURCE: Williams and Jackson, 2005.
Socioeconomic Factors
Traditionally, public health data have been stratified primarily by “race,” for many years without the collec -
tion and reporting of socioeconomic data. With recent recognition of worsening economic and social inequalities,
more attention has been focused on the contribution of socioeconomic factors to health disparities. Multiple
socioeconomic factors contribute to health disparities, including income, education, residential segregation, stress,
social and physical environment, employment, and many others. Disparities according to income and education
have increased for smoking, with low-income persons smoking at higher rates. Diabetes prevalence has increased
largely among persons from lower socioeconomic strata (Kanjilal et al., 2006).
Using data from NHANES III (1988–1994), Sharma and colleagues (2004) observed increased CVD risk
factor clustering among Americans with low SES, particularly among non-Hispanic blacks. Among persons with
high SES, Mexican Americans and non-Hispanic blacks have a higher risk of CVD than non-Hispanic whites.
Low educational attainment may also impact mortality rates. In a study examining the relationship of education
and race to mortality, Jemal and colleagues (2008) found that “48 [percent] of all deaths among men aged 25–64
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58 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES
(white, black, and Hispanic) and 38 [percent] of all deaths in women would not have occurred in this age range
if all segments of the population experienced the death rates of college graduates. However, the total number of
deaths associated with low education status was not confined to any single racial or ethnic group.”
Using NHANES data from 2001–2006, Karlamangla and associates (2010) evaluated the association between
SES and ethnic disparities in cardiovascular risk. They observed marked inverse socioeconomic gradients with risk
in all race/ethnicity groups, except foreign-born Mexican American men. Disparities according to race/ ethnicity
were seen in some, but not all, socioeconomic strata, with some non-Hispanic blacks and U.S.-born Mexican
Americans having higher risk, and some foreign-born Mexican Americans having lower risk.
Low SES is associated with a higher prevalence of risk factors, greater chronic disease burden, and higher
expenses for health care, medications, and hospitalization. The sick and poor are at risk of moving even farther
down the socioeconomic ladder (Fiscella and Williams, 2004). The reverse is also evident: those at the highest
socioeconomic rank are likely to be more educated, have better risk factor profiles, improved health, and better
health-related outcomes. With greater access to information, more financial resources, greater access to high-
quality health care, and the capacity and capability to benefit from advances in pharmaceuticals and healthcare
technology, those who are more advantaged can move further up the socioeconomic ladder, while disadvantaged
populations remain mired in unhealthy neighborhoods with the highest burden of CVD and COPD. Improving the
national surveillance of SES and its relationship to indicators of risk and health outcomes is a critical step toward
reducing health disparities.
PRIORITIES FOR SURVEILLANCE OF HEALTHCARE DISPARITIES
Primary Prevention
Reducing the magnitude of clinically evident CVD and COPD in populations that bear a disproportionate
burden of disease is an essential element in the struggle to eliminate health disparities. The principal goals of
primary prevention include risk assessment; reduction of risk by control of key pre-disposing factors, including
cigarette smoking, elevated cholesterol, elevated blood pressure, obesity, and diabetes; and limitation of progres -
sion of subclinical disease.
The prevalence of hypertension in U.S. blacks is among the highest in the world (Roger et al., 2010). Pre-
hypertension (blood pressure levels greater than 120/80mmHG, but less than 140/90) is more prevalent in men than
women, and more prevalent in African American men aged 20–39 years than comparably aged whites and Mexican
Americans. As in other subclinical CVD conditions, primary prevention for individuals with pre-hypertension is
recommended through vigorous lifestyle and diet modification, and may also include affordable pharmacologic
therapy if shown to improve health outcomes (Greenlund et al., 2004; Pimenta and Oparil, 2010).
Secondary Prevention
Successful therapeutic interventions in patients with CVD—particularly myocardial infarction and stroke—
have expanded the population of U.S. individuals who could benefit from the enhanced use of evidence-based
secondary interventions. Interventions for secondary prevention include lifestyle modifications and pharmacologic
treatments to control smoking, hypertension, hyperlipidemia, and diabetes, as well as coronary revascularization
procedures that can relieve symptoms and, in some cases, extend survival. The growing number of older adults
with CVD and COPD requires specific surveillance of health disparities, with special attention to monitoring adher-
ence to healthy lifestyle practices and effective treatment regimens and the effect of different treatment approaches
on quality of life, recurrence, and long-term prognosis. Standardized surveillance approaches for monitoring the
effectiveness of secondary prevention are needed (Willson et al., 2010).
Coronary revascularization procedures such as coronary artery bypass (CABG) and PCI, along with bare-metal
and drug-eluting stents, have advanced the management of CHD. Racial and ethnic differences in the receipt of
catheterization and coronary revascularization were reported in early studies (Gillum et al., 1997; Kressin and
Petersen, 2001); however, more recent investigations suggest a reduction in racial disparities in the use of these
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HEALTH DISPARITIES
interventions. Brown and colleagues (2008) analyzed the receipt of cardiac catheterization, PCI, and CABG by age,
sex, insurance status, and race among black and white patients discharged from U.S. hospitals over a 25-year period
beginning in 1979. They found that consistent and significant disparities in the receipt of cardiac catheterization,
PCI, and CABG by age, sex, insurance status, and race persisted across the 25 years of study; however, attenuation
of these differences were observed from 1979 to 2004 for each subgroup examined. Specifically, although blacks
were 27 percent less likely to receive diagnostic cardiac catheterization in 1979, they were only 11 percent less
likely to undergo cardiac catheterization in 2004 (Brown et al., 2008). Racial disparities in the use of drug-eluting
stents have also been reported (Gaglia et al., 2009; Hannan et al., 2007).
A number of investigations have been conducted in different patient populations to explore potential racial
differences in healthcare use and quality of care for persons with COPD. In a Medicaid population of 9,131 patients
with COPD and asthma, African Americans had lower overall healthcare use and costs when compared to whites,
including physician office visits and outpatient and inpatient services (Shaya et al., 2009). Gordon and coworkers
(2002) examined the quality of processes of care for CHF and COPD at Veterans Administration hospitals and
found no difference in the quality of care provided to blacks and whites. Tsai and colleagues (2009) examined
racial and ethnic differences in processes and outcomes of emergency room care among a cohort of 330 patients
with COPD enrolled from 24 emergency departments from 15 states. Compared to whites, African American and
Hispanic patients had lower SES and primary care access and more frequent exacerbations, but there were no
statistically significant differences in the processes or outcomes of care. Hasnain-Wynia and coworkers (2010)
found that a higher proportion of racial and ethnic minorities were cared for at lower performing hospitals. Among
patients with severe COPD waiting for lung transplantation, African American patients were less likely to have a
transplant and more likely to die (Lederer et al., 2008).
Rates and trends of risk-adjusted hospitalization rates for specific conditions provide population-level evidence
on the adequacy of access to primary care, known as ambulatory care sensitive conditions (ACSCs), and effec -
tiveness of various interventions (AHRQ, 2004). The cardiovascular and chronic lung diseases considered to be
ACSCs include angina, hypertension, congestive heart failure (CHF), asthma, and COPD (AHRQ, 2004). Variations
in risk-adjusted hospitalization rates for ACSCs have been examined to determine racial, ethnic, socioeconomic,
and geographic disparities for these conditions (Bindman et al., 2008; Jackson et al., 2011; Laditka and Laditka,
2006; O’Neil et al., 2010). A nationwide sample of community hospital discharge data demonstrated that compared
to non-Hispanic whites, African American men (adjusted relative rates of 1.9 and 1.6 for ages 19–64 years and
65+ years, respectively) and Hispanic males (2.6 and 2.3, respectively) and females (1.6 and 2.1, respectively) had
higher rates of hospitalizations for COPD, adjusted for disease prevalence (Laditka and Laditka, 2006). On the
other hand, an analysis of admission rates in North Carolina among Medicare beneficiaries for ambulatory sensi -
tive conditions, including COPD, found that African Americans had lower admission rates for COPD compared to
whites (odds ratio 0.67) (Howard et al., 2007). In Texas, wide variations have been found for hospitalization rates
for COPD. The highest rates of hospitalization have been found among rural counties, the elderly, non-Hispanic
whites, and women in urban areas (Jackson et al., 2011). African Americans had lower hospitalization rates com -
pared to non-Hispanic whites, and Hispanics had the lowest rates.
CONCLUSION
Untangling the effects of environment, income, education, race, ethnicity, and genetics may lead to the more
precise targeting of preventive, diagnostic, and therapeutic interventions. This in turn will contribute to the elimi -
nation of health disparities, reduction in the magnitude of chronic disease, and improvements in prognosis and
quality of life in those with established disease. However, there is a lack of standardization in the collection of race,
ethnicity, and language data at the federal, state, and local levels. This lack of standardization creates difficulty
in identifying disparities and appropriately targeting quality improvement efforts. Surveys such as the BRFSS,
NHANES, and NHIS routinely collect self-reported multiple race data on individuals, and collect ethnicity data
independent of race. However, gaps in the collection of disparity data are evident at various levels. For example,
among the sources of data collected by Centers for Medicare & Medicaid Services, only the Consumer Assessment
of Health Plans Survey allows multiple race designation of individuals, and only the Medicare Current Beneficiary
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60 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES
Survey, the Consumer Assessment of Health Plans Survey, and the Medicare End Stage Renal Disease Program
collect ethnicity data that are independent of race. Methodological issues concerning the use of data to assess
racial and ethnic disparities include the validity of the classification of individuals’ race and ethnicity, sample size
limitations, the smallest analyzable geographic or institutional unit, and the availability of data on other cultural
or socioeconomic characteristics (Sequist and Schneider, 2006).
The principal challenge is to develop systems that more effectively and efficiently link conventional sur-
veillance data to more contextually relevant data (e.g., SES, birthplace, acculturation, geography, language, and
insurance). A wide array of factors may interact to determine population health, including biological or genetic
factors, health behaviors and lifestyle practices, socioeconomic status, the environment, access to health services,
and cultural or linguistic isolation. Appreciation of the heterogeneity of the general population and the many
health-related factors that distinguish populations, subpopulations, and groups within subpopulations from each
other has grown over time and in importance. Therefore, a critical need remains for standard definitions of CVD
and COPD data elements, as well as a need for consensus regarding the operationalization of race and ethnicity,
SES, and biological risk factors in the surveillance of CVD and chronic lung disease.
Impressive gains have been achieved in life expectancy for the overall American population, as well as distinct
subpopulations defined by race and ethnicity. However, inequities in health status and health systems remain in
many neighborhoods, cities, states, and regions. A contemporary and ongoing national framework for the surveil -
lance of CVD and COPD disparities will facilitate the development of actionable policies and programs informed
by data gathered at the national, regional, state, and community levels.
For example, at the national and state levels, incidence and prevalence information accompanied by improved
data on race/ethnicity and geographic region will enable more effective goal setting for national and state programs
and policies aimed at eliminating health disparities. This aggregation and reporting can provide information about
where persistent disparities in health and health care exist. Local-level data on health behaviors coupled with
local-area data on race/ethnicity, language, nativity, and immigration can aid health plan managers in developing
culturally and linguistically appropriate interventions to modify unhealthy behaviors. These data will help pro viders
understand the populations they serve, address disparities, and improve and monitor healthcare quality. A lack of
valid race and ethnicity data creates difficulty in identifying disparities and appropriately targeting strategies to
address them.
This framework will support efforts to advance the prevention and effective treatment of chronic disease
to ensure the highest quality health care for the U.S. population as a whole and for important subgroups in this
population. The committee concluded that the national framework for surveillance would be enhanced by the
recommendations of the Institute of Medicine, Race, Ethnicity, and Language Data: Standardization for Health
Care Quality Improvement (2009). Therefore the committee supports these recommendations.
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