Catalyzing Restructure of a Broken Healthcare System

”I am, and always will be a catalyst for change.”¹

– Shirley Chisholm

In 1968—the same year that Martin Luther King, Jr. was assassinated—the tenacious Shirley Chisholm would become the first Black woman to obtain a seat in the US Congress.¹ From her humble beginnings growing up in Brooklyn, New York as the child of immigrants, she saw problems as possibilities and set out to change them. Shortly after her election to Congress, she would introduce 50 pieces of legislation and emerge as a champion for racial and gender equality, socioeconomic injustices, and more. Then, just four years later, she would set her sights even higher and entered the race for President of the United States—a previously unthinkable idea for a woman, particularly from a minoritized racial group. The significance of Chisholm and her audaciousness is that it was all rooted in a deep desire for change coupled with a refusal to accept the status quo. Though she faced significant obstacles along the way, she pushed forward, always believing that we could do better and ultimately be better.

Nearly one hundred years ago, it was a widely held belief that heart disease was synonymous with bedrest and imminent death. Shortly thereafter, six cardiologists founded the American Heart Association (AHA)—all ignited by a belief that, through scientific discovery, we could improve outcomes through better understanding, evidence-based treatment, and preventative strategies. Like Shirley Chisholm, these pioneering physicians, social workers, and health care workers in the early days of the AHA were driven by that same idea that we could think big, do more, and effect change.

We have seen improvements in cardiovascular disease (CVD) outcomes since 1924 when the AHA was founded but not equitably. Similar to the racial and socioeconomic gaps noted by Chisholm in her community, those same barriers continue to create imbalances in CVD morbidity and mortality. Though groundbreaking discoveries have been made over the last century, these population-based improvements have not been felt by all demographic groups. Over two decades ago, the Institute of Medicine (currently National Academy of Medicine) produced a report describing the years of systemic unequal treatment of minoritized racial and ethnic groups.² An urgent call for action was made to address discrimination, structural racism, and bias in care.² Yet, there continues to be substantial disparities in the onset of multiple forms of CVD among non-Hispanic African American, Hispanic, non-Hispanic American Indian, Pacific Islander, and South Asian populations compared to non-Hispanic White populations.³ While it is known that these persistent differences in CVD outcomes are multifactorial, their connection to socioeconomic and environmental factors cannot be ignored. Multiple studies have demonstrated that historical redlining- designing a community with the intent to segregate resources from minoritized racial and ethnic groups- has demonstrated a consistently negative impact on the CV health of non-Hispanic Black patients.^4,5 Failure to address these forms of discrimination will prevent CV equity. Paul Dudley White, one of the six founding cardiologists of the AHA, described “a time of almost unbelievable ignorance about heart disease” in those early years.⁶ As policies and ideologies in some parts of the country move away from acknowledging the impact of structural racism, social determinants of health, and bias on inequities in health, there has never been more urgency to embrace these uncomfortable truths.

As a call to action, we encourage AHA partners (patients, community leaders, clinicians) and scientists to think critically about how to perform cardiovascular equity science, to the end that equity is attainable and lasting.^7,8 This starts with a proper conceptual model or framework, which requires expertise in cardiovascular disparities to understand the layers of the disparities. In addition to critical race theory and National Institute of Minority Health and Health Disparities Research Framework, consider our Framework Wheel to Address Bias, Social Determinants of Health and Structural Racism in Cardiovascular Care as an informal guide (Figure). Begin with the inner circle and move outward turning the wheel to align with each goal, which in some cases may overlap. Start by identifying who the team stakeholders should include: e.g. patients, health care professionals, community members, and scientists, particularly underrepresented groups. While this may appear unusual, this first step may prevent production of myopic studies that miss important questions relevant to patients and populations that experience the disparities. The team can be expanded later based upon additional needed expertise. Determine where efforts should align: outpatient, inpatient, or home/community based locations. Determine what area of CVD will be addressed: prevention (i.e. prevention of heart failure or cardiovascular death), treatment (i.e. guideline directed treatment for heart failure), control of risk factors (i.e. ideal treatment and dose of heart failure medications), or diagnostic tests (i.e. appropriate diagnosis of heart failure). Identify the focus on correcting bias (i.e. bias in deciding which types of patients gets prevention, treatment, control, or diagnostics), social determinants of health (i.e. health literacy preventing appropriate use of treatment), or structural racism (i.e. policies limiting/prohibiting outpatient cardiovascular care to Medicaid beneficiaries who are disproportionately represented by minoritized racial and ethnic groups). Select how you will identify the best strategies: community-based participatory research (research co-designed and implemented by community members and scientists), implementation science (research on strategies to bring evidence-based treatments and tools to the real-world population), and/or mixed methods (sequential or simultaneous combination of qualitative and quantitative research to understand a problem or process). Strategies for cardiovascular equity may emerge such as using new technology or risk calculators (particularly artificial intelligence incorporating social determinants of health and mechanisms to address them)⁹, creating financial resources for communities or reallocating resources, changing training, advocating for public policy changes, changing hospital protocols, utilizing media, building a more diverse team, empowering a multidisciplinary team, and other novel ideas. While not included in this model, it is critically important to set metrics for equity designed by the stakeholders, routinely assess for success, and reiterate the strategies as needed to reach equity metrics.

Figure. A Framework Wheel to Address Bias, SDOH, and Structural Racism in Cardiovascular Care.

The framework wheel is an informal guide to the development of study questions that address key factors promoting cardiovascular care inequity. The circles represent moveable wheels that can be aligned to address bias, social determinants for health (SDOH), and structural racism in the delivery of cardiovascular care. Sections between spokes can overlap and this is not meant to be prescriptive rather a starting point. Begin at the center of the wheel and move sequentially to each outer wheel, rotating the wheel clockwise or counterclockwise. Who represents the individuals engaged in performing the research who will identify the topic of importance; where, the location for the study population; what, the type of clinical care that requires change; focus, focus of the strategies; how, scientific methods which may overlap; beyond the dotted line, examples of potential strategies that may be identified using the scientific methods. Additional strategies may develop while conducting the mixed-methods, implementation science, and community based participatory research studies. EMR indicates electronic medical records; HCP, health care professional; R/x, pharmaceutical.

At Circulation: Cardiovascular Quality and Outcomes, we are seeking to highlight science that addresses these strategies described in our framework, particularly foundational work developed with community-based participatory research and mixed-methods. An example of pivotal qualitative work led by Dr. Anika Hines used photovoice to help Black patients with hypertension and chronic kidney disease digitally share, using photographs, how structural racism contributes to their food environment and how cardiovascular equity might be attained.¹⁰ In work published in Circulation, Dr. LaPrincess Brewer used community-based participatory research to understand the reasons for cardiovascular disparities in a faith- based community and together with the community developed a digital application to address risk factors for CVD in Black patients, which statistically improved cardiovascular health status in this population.¹¹ Moving towards CV-kidney-metabolic disease, in JAMA Internal Medicine, Dr. Lilia Cervantes demonstrated that policies allowing only emergency dialysis for undocumented individuals rather than routine scheduled dialysis were associated with increased mortality¹² and increased cost. Public knowledge of these atrocities contributed to state changes in healthcare policy, which now cover routine scheduled dialysis among undocumented individuals due to her research.¹³ These studies demonstrate how research may lead to equity.

As we stride into the next century of American Heart Association science, we want to support impactful work that changes cardiovascular disparities and leads to equity. Much of the published works on cardiovascular disparities have focused on epidemiology, which is vitally important to know trends and current practices, but is unlikely to lead to equity without an increasing amount of scholarship also focused on strategies to reduce cardiovascular disparities. Cardiovascular implementation science trials and studies specifically designed to address cardiovascular disparities are limited.¹⁴ We recognize that cardiovascular disparities research is more difficult to both publish and receive funding, particularly for minoritized racial and ethnic scientists for whom bias has been well documented.¹⁵ Therefore, it is vital for funding organizations and academia to monetarily invest in the development and sustainment of underrepresented groups from elementary school through senior scientists. The American Heart Association has committed to investing 100 million to address structural racism and health inequity by 2024.¹⁶ Perhaps the results of these investments will encourage other national funders to follow suit.

The widely broadcasted murders of George Floyd and countless others catalyzed a movement in the U.S. and elsewhere. Over the past five years, many individuals have been made consciously aware of existing social inequalities, secondary to structural racism, and have vocalized a desire to change this system. While enthusiasm has increased to address worsening cardiovascular disparities, it is less clear whether enthusiasm is matched with willingness for discomfort to support systematic changes that may create equity. Consider how research focused on the endpoint of cardiovascular equity may take the leading steps in societal change. Employ a conceptual model routed in cardiovascular disparities developed by and with experts in cardiovascular disparities.¹⁷ Dare to focus studies on leading contributors of cardiovascular disparities, bias, social determinants of health, and structural racism. Engage in rigorous implementation science, community-based participatory research, and mixed-method studies centered on achieving cardiovascular equity. Here at Circulation: Cardiovascular Quality and Outcomes, we uplift Chisholm’s mission of being a catalyst for change. We welcome and support your pivotal work to restructure our broken healthcare system.