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 variation; (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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