Skip to main content
NCBI home page
Lippincott Open Access logoLink to Lippincott Open Access
. 2024 Nov 11;18(1):e011643. doi: 10.1161/CIRCOUTCOMES.124.011643

Relationship Between Race, Predelivery Cardiology Care, and Cardiovascular Outcomes in Preeclampsia/Eclampsia Among a Commercially Insured Population

Ikeoluwapo Kendra Bolakale-Rufai 1, Shannon M Knapp 3,5, Brownsyne Tucker Edmonds 4, Sadiya Khan 1, LaPrincess C Brewer 6, Selma Mohammed 7, Amber Johnson 8, Sula Mazimba 9, Daniel Addison 10, Khadijah Breathett 3,✉
PMCID: PMC11745621  NIHMSID: NIHMS2034504  PMID: 39523944

Abstract

BACKGROUND:

It is unknown whether predelivery cardiology care is associated with future risk of major adverse cardiovascular events (MACE) in preeclampsia/eclampsia (PrE/E). We sought to determine the cumulative incidence of MACE by race and whether predelivery cardiology care was associated with the hazard of MACE up to 1 year post-delivery for Black and White patients with PrE/E.

METHODS:

Using Optum’s de-identified Clinformatics Data Mart Database, we identified Black and White patients with PrE/E who had a delivery between 2008 and 2019. MACE was defined as the composite of heart failure, acute myocardial infarction, stroke, and death. Cumulative incidence functions were used to compare the incidence of MACE by race. Regression models were used to assess the hazard of MACE by cardiology care for each race. Separate hazards were calculated for the first 14 days and the remainder of the year.

RESULTS:

Among 29 336 patients (83.4% White patients, 16.6% Black patients, 99.5% commercially insured, mean age: 30.9 years) with PrE/E, 11.2% received cardiology care (10.9% White patients, 13.0% Black patients). Black patients had higher incidence of MACE than White patients at 1 year post-delivery (2.7% versus 1.4%) with the majority within 14 days of delivery (Black patients: 58.7%; White patients: 67.8%). After adjusting for age and comorbidities, receipt of cardiology care was associated with a lower hazard of MACE for White patients within 14 days after delivery (hazard ratio, 0.31 [95% CI, 0.21–0.46]; P<0.001) but not Black patients (hazard ratio, 1.00 [95% CI, 0.60–1.67]; P=0.999). The effect of the interaction between race and cardiology care was significant in the first 14 days (P<0.001) but not the remainder of the year (P=0.56).

CONCLUSIONS:

Among a well-insured population of patients with PrE/E, Black patients had a higher cumulative incidence of MACE up to a year post-delivery. Cardiology care was associated with a lower hazard of MACE only for White patients during the first 14 days after delivery.

Keywords: healthcare disparities, major adverse cardiovascular event, maternal health, pre-eclampsia, pregnancy

WHAT IS KNOWN

  • Preeclampsia/eclampsia is associated with a 3× to 5× greater risk of future major adverse cardiovascular events (MACE).

  • Black patients with preeclampsia/eclampsia have higher odds of complications, even after adjusting for clinical comorbidities and social determinants of health.

WHAT THE STUDY ADDS

  • In this cohort of commercially insured patients with preeclampsia/eclampsia, the incidence of MACE was 1.5% within the first-year post-delivery with Black patients experiencing higher rates than White patients.

  • Over 50% of MACE occurred within the first 14 days after delivery. During this period, predelivery cardiology care reduced the hazard of MACE by 69% for White patients, but this benefit was not observed for Black patients.

  • This study indicates that predelivery cardiology care improves early MACE outcomes for White patients with preeclampsia/eclampsia, but further research is needed to understand the lack of similar benefits for Black patients. Additional strategies such as multidisciplinary care, optimal timing of care, and equitable anti-racist treatment may be needed to enhance the impact of cardiology care in Black patients.

Preeclampsia and eclampsia (PrE/E) are hypertensive disorders of pregnancy, highly prevalent worldwide affecting about 2% to 8% of pregnancies.1 PreE/E are leading causes of maternal mortality in the United States and have been associated with 3× to 5× higher risk of future major adverse cardiovascular events (MACE) such as stroke, myocardial infarction, heart failure, and mortality.2–6 PrE/E disproportionately affects non-Hispanic Black women with up to 60% higher rates compared with non-Hispanic White women.7–9 Black women with PrE/E also have higher odds of complications from PrE/E even after adjusting for socioeconomic determinants and comorbidities.10,11

The American Heart Association and the American College of Obstetrics recognize that pregnancy and adverse pregnancy events like PrE/E shape future cardiovascular health.5 With the increased risk of MACE, it becomes pertinent for women with PrE/E to receive cardiology care, undergo cardiovascular risk surveillance, and to follow-up with a cardiologist.5,12 Evidence shows that the receipt of care from a cardiologist for cardiovascular diseases is associated with better clinical outcomes including improved use of evidence-based treatment therapy, lower readmission rates, reduced mortality, and complication rates.13–17 However, significant gaps exist in our understanding of how cardiology care impacts future cardiovascular outcomes in Black and White patients with PrE/E. This is important given the need to identify effective strategies for reducing inequities in maternal cardiovascular health, particularly after removing the barrier of uninsurance/underinsurance. Whether the receipt of cardiology care is associated with the risk of MACE in Black versus White patients with PrE/E remains unknown.

Using a national commercial and Medicare Advantage insurance dataset with a population of insured patients with PrE/E, our study primarily sought to evaluate (1) the cumulative incidence of MACE in Black and White patients with PrE/E up to 1 year post-delivery and (2) the association between predelivery receipt of cardiology care and the hazard of MACE in PrE/E in Black and White patients.

Methods

Data Source

The Optum’s de-identified Clinformatics Data Mart Database (CDM) is a database containing administrative health insurance claims for beneficiaries of large commercial and Medicare Advantage health plans. The CDM has over 19 million annual covered patients, totaling over 65 million unique beneficiaries from January 2007 to December 2021.18 CDM is deidentified using the Expert Determination method in accordance with Health Insurance Portability and Accountability Act and managed according to the customer data use agreements from Optum. Before being included, CDM administrative claims submitted by clinicians and pharmacies for payment are verified, adjudicated, and deidentified. These data, including patient-level enrollment information, are derived from claims submitted for all medical and pharmacy healthcare services and contain information related to healthcare costs and resource utilization. CDM also provides details about clinicians involved in each patient’s care, including their medical specialty. The population is geographically diverse, spanning all 50 states of the United States.18 Race and ethnicity are identified based on a proprietary algorithm developed by Optum that considers geospatial variables and names.19 The CDM data are commercially licensed and can be obtained directly from Optum. According to the data use agreement, the authors do not have permission to share these data. This study was deemed exempt by the Indiana University institutional review board and the data use was approved by Optum.

Cohort Selection

We selected a sample of patients who had International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9-CM) and International Classification of Diseases-Tenth Revision (ICD-10) procedure codes for delivery from 2007 to 2019. Included patients had continuous enrollment in the CDM database for at least 365 days (1 year) before delivery dates. We simultaneously obtained data on the patient’s race and year of birth (to obtain the patient’s approximate age). We excluded patients who were neither non-Hispanic Black nor non-Hispanic White race. Furthermore, we obtained data of patients with preeclampsia or eclampsia within 160 days before delivery date using ICD-9-CM and ICD-10 diagnosis codes (Table S1).

For patients to be deemed eligible for our study, they had to satisfy all the following inclusion criteria: have a delivery date in 2008 or later, be continuously enrolled in the CDM database for a year before delivery, aged between ≥18 years old and ≤50 years old at delivery date, and have a diagnosis of PrE/E within 160 days before delivery. We excluded patients with multifetal pregnancies as these patients represent a unique risk group. We then took the earliest delivery that satisfied the inclusion criteria as the index date and made a selection algorithm for patients with >1 delivery as illustrated in Table S2.

Objectives and Study Outcomes

Our primary outcome was the time to MACE post-delivery. MACE was defined as the composite of heart failure, acute myocardial infarction, stroke, and death. The independent variables of interest were race (non-Hispanic Black or non-Hispanic White), receipt of cardiology care, and race-cardiology interaction. Each medical claim on the CDM had a variable with a code that represented the specialty of the provider rendering clinical care. We examined provider category codes for those that would be considered cardiology. For each patient, we examined the provider category listed for all medical claims to determine whether that patient had been treated by a cardiologist. A patient was determined to have been seen by a cardiologist if any claim within 1 year before delivery had one of the following CDM-designated clinician types: cardiologist, cardiology group, cardiovascular disease specialist, cardiac electrophysiologist, interventional cardiology, diagnostic cardiology, nuclear cardiology, and pediatric cardiologist.

Statistical Analysis

Patient characteristics were summarized using count and percentage for categorical variables and mean and SD for patient age. We first estimated cumulative incidence functions for MACE using the inverse of the Kaplan-Meier estimates (as there were no competing events) for White and Black patients. We also estimated cumulative incidence functions using 4 strata: by the combination of race (White race, Black race) and by whether or not the patient had seen a cardiologist in the 365 days preceding delivery. For each of these, we tested for a difference in cumulative incidence function curves among strata using the log-rank test.

We then analyzed the time from delivery to MACE using a Cox model. Predictors included race, whether or not the patient was seen by a cardiologist in the 365 days preceding delivery, an interaction of race and cardiology care, age at delivery fit using a cubic spline, Charlson Comorbidity Index (binned into 4 groups: 0, 1, 2, and ≥3), and indicators of whether the patient had each of the following diagnosis in the 365 days preceding delivery: a heart condition (including myocardial infarction, ischemic heart disease, valvular heart disease, cardiac dysrhythmia, heart failure, or cardiomyopathy), assisted reproductive technology, diabetes, gestational diabetes, dyslipidemia, hypertension, gestational hypertension, obesity, obesity complicating pregnancy, and stroke. For all time-to-event analyses, observations were censored at 365 days if MACE had not yet occurred. Because of evidence of nonproportionality for some parameters, we used time-dependent coefficients, fitting separate parameters for the first 14 days and the remainder of the year for the following variables: race, cardiology care, the interaction of race and cardiology care, Charlson Comorbidity Index, and the indicators of heart condition, gestational diabetes, gestational hypertension, and stroke. The 14-day cut point was chosen based on the clear shift in the rate of MACE observed in Figure 1.

Figure 1.

Figure 1.

Open in a new tab

Cumulative incidence of major adverse cardiovascular events (MACE) in patients with preeclampsia/eclampsia based on race. Plot of nonparametric cumulative incidence functions for MACE for Black and White patients from 0 to 365 days post-delivery.

We also conducted a sensitivity analysis excluding patients with a diagnosis of stroke or pulmonary embolism in the year preceding delivery. All hypothesis tests were 2-sided and used the alpha=0.05 significance level. Analyses were conducted using R statistical software (R version 4.2.1; Foundation for Statistical Computing, Vienna, Austria).20

Results

Baseline Characteristics

From 2008 to 2019, we had 29 336 patients with PrE/E included in our final analysis. Of these patients, 83.4% were White patients, 16.6% were Black patients, and almost all patients had commercial insurance (99.5%). The mean age of the patients was 30.9 years (31.0 years for White patients and 30.6 years for Black patients). The majority of patients (80.2%) had a Charlson Comorbidity Index of 0 and <4% had a Charlson Comorbidity Index >1. In our cohort, 37.3% had a diagnosis of hypertension (35.8% White patients, 44.6% Black patients), 46.9% had gestational hypertension (47.7% White patients, 42.5% Black patients), 25.9% had a diagnosis of obesity (24.4% White patients, 33.5% Black patients), 8.4% had diabetes (7.8% White patients, 11.7% Black patients) and 4.4% had conception using assisted reproductive technology (4.7% White patients, 2.5% Black patients; Table). Among our patients with PrE/E, only 11.2% received predelivery cardiology care (10.9% of White and 13.0% of Black patients; Table S3).

Table.

Baseline Demographics and Clinical Characteristics of Patients With PrE/E

graphic file with name hcq-18-e011643-g002.jpg

Open in a new tab

Outcomes

Of the 29 336 patients with PrE/E, only 1.5% had MACE during the 1 year after delivery. Black patients with PrE/E had a higher incidence of MACE (up to 365 days post-delivery) compared with White patients with PrE/E (2.7% [2.3%–3.2%] and 1.4% [1.3%–1.6%], respectively; Figure 1). Within each race, the majority of MACE occurred within the first 14 days after delivery (Figure 1; Table S4). Of 121 observed MACE events that occurred among Black patients in a year, 71 (58.7%) of those occurred in the first 14 days. Among White patients, 225 (67.8%) of the 332 MACE events in a year occurred in the first 14 days.

The cumulative incidence functions for MACE were significantly different for White and Black patients (P<0.0001), with the incidence of MACE higher for Black patients at 14, 30, 90, and 180 days (Table S4). In addition, the cumulative incidence of MACE was also higher for Black patients than White patients among those who received cardiology care (log-rank P<0.001) and among those who did not receive cardiology care (log-rank P<0.001), respectively (Figure S1).

After adjusting for age, preexisting heart conditions, and clinical comorbidities, there was a statistically significant difference in the effect of cardiology care between White and Black patients in the first 14 days after delivery (P<0.001), with White patients with PrE/E who received cardiology care having a statistically significantly lower hazard of MACE compared with White patients with PrE/E who had no cardiology care (hazard ratio [HR], 0.31 [95% CI, 0.21–0.46]; P<0.001) but for Black patients with PrE/E, the receipt of cardiology care was not significantly associated with the hazard of MACE compared with patients who did not receive cardiology care (HR, 1.00 [95% CI, 0.60–1.67]; P=0.999; Figure 2). However, after 14 days (up to 365 days), there was no significant difference in the effect of cardiology care between White and Black patients (P=0.56) with both having significantly higher hazard of MACE among those who received cardiology care compared with those who did not (White patients: HR, 2.81 [95% CI, 1.79–4.40]; P<0.001 and Black patients: HR, 2.27 [95% CI, 1.23–4.21]; P=0.009; Figure 2).

Figure 2.

Figure 2.

Open in a new tab

Hazard ratio of major adverse cardiovascular events (MACE) in preeclampsia/eclampsia based on the receipt of cardiology care. The point estimates and CIs for hazard ratio for the effect of cardiology care vs no cardiology care, based on the Cox proportional hazards model which included the effect of race (Black or White race), Charlson Comorbidity Index, age at delivery, preexisting heart conditions (cardiac dysrhythmia, valvular heart diseases, ischemic heart diseases, cardiomyopathies, and heart failure), diabetes, assisted reproductive technology, dyslipidemia, hypertension, gestational hypertension, stroke, obesity, and obesity in pregnancy.

Because of the significant interaction between race and receipt of cardiology care, we also examined if racial disparity still existed when we stratified by the receipt of cardiology care; we examined the HRs for Black patients to White patients within levels of cardiology care. We found that among those seen by a cardiologist, Black patients had a higher risk of MACE than White patients during the 1-year period after delivery. Among patients not seen by a cardiologist, during the first 14 days after delivery, the hazard of MACE was not significantly different for Black patients versus White patients with PrE/E. However, after 14 days post-delivery, the hazard of MACE was significantly higher for Black patients compared with White patients (Figure S2).

Sensitivity Analyses

For sensitivity analyses, we excluded the patients with a diagnosis of stroke or pulmonary embolism (n=187, 0.58% White patients; 0.91% Black patients) in the year preceding delivery from our cohort of patients with PrE/E. The results were qualitatively similar to those of the primary analysis with a significant difference in the effect of cardiology care on the hazard of MACE between White and Black patients in the first 14 days (P=0.005) with a lower hazard of MACE for those who had received cardiology care among White patients (HR, 0.38 [95% CI, 0.25–0.57]; P<0.001) but no effect for Black patients (HR, 0.95 [95% CI, 0.54–1.67]; P=0.87). In addition, there was no significant difference in the effect of cardiology care between White and Black patients in the remainder of the year (P=0.45) with the hazard of MACE being higher among those that had received cardiology care for both White and Black patients (White patients: HR, 2.91 [95% CI, 1.84–4.60]; P<0.001 and Black patients: HR, 2.20 [95% CI, 1.15–4.18]; P=0.17; Figure S3).

Discussion

In our analysis of 29 336 patients with PrE/E, the cumulative incidence of MACE (including heart failure, acute myocardial infarction, stroke, and death) was consistently higher for Black patients compared with White patients across 1 year post-delivery. Within each race, the majority of MACE occurred within the first 14 days after delivery. After adjusting for age, preexisting heart conditions, and clinical comorbidities, the receipt of cardiology care was associated with a 69% lower hazard of MACE for White patients in the first 14 days after delivery. Among Black patients with PrE/E, the receipt of cardiology care was not significantly associated with a change of hazard of MACE in the first 14 days after delivery. Our findings suggest that additional strategies are needed to ensure equitable maternal outcomes among Black patients especially in the few days after delivery.

Our results are consistent with studies that have demonstrated racial disparities in cardiovascular complications with pregnancy-induced hypertension including PrE/E.11,21 In a retrospective study using the National Inpatient Sample data within a 2-year period, authors found that Black patients had higher odds of preeclampsia and higher absolute rates of cardiovascular events such as heart failure, ischemic heart disease, and death with preeclampsia than White patients.11 Another study using similar data from the National Inpatient Sample found that Black patients with preeclampsia had higher odds of in-hospital mortality compared with White women across all income groups.21 This relates to what was observed in our study as nearly all patients in our study were beneficiaries of commercial insurance, which often correlates with higher income levels across US residents.22,23 This shows that despite relative affluence and access to adequate health insurance, racial disparities persist in PrE/E with Black patients having poorer outcomes than their White counterparts.

Contrary to other studies, receipt of cardiology care was not associated with better outcomes for Black patients.15,24 There are several potential reasons for these differences. First, there might be differences in the timing and quality of cardiology care received by Black and White patients with PrE/E. Significant differences in the timing of medical care have been noted for Black versus White patients because of barriers unrelated to the cost of care.25,26 These delays in receiving care can lead to worsened outcomes and increased mortality in patients with preventable and treatable diseases.27 Furthermore, the quality of cardiology care for Black and White patients may differ because of implicit and explicit bias and overt racism from the physicians.28,29 Given the limitation of our database, evaluation of the quality of cardiology care received was beyond the scope of our article, but these factors can often result in disparities in preventive care received,30 leading to missed diagnoses or inappropriate treatment.28,29,31 Further research is needed to understand how patient outcomes may be influenced by biases and structural racism in care delivery by cardiologists. In addition, establishing a set of metrics to standardize the quality of cardiology care received for patients with cardiovascular diseases of pregnancy would be beneficial. Our findings may also reflect racial biases in the delivery of appropriate and timely postpartum cardiology care. Although this was not evaluated in our study, differences in cardiology follow-up care during the postpartum period for PrE/E have been noted based on race and ethnicity.32 Another possible reason why cardiology care was not associated with better outcomes for Black patients could be that Black patients with PrE/E require multidisciplinary care during pregnancy rather than just cardiology care. Multidisciplinary care including care by doulas and midwives has been associated with improved outcomes for patients during pregnancy possibly due to more attentive and patient-centered care.33,34

There is a widespread consensus among experts that women should obtain cardiology care during the prenatal/antepartum period when they have a current history of cardiovascular diseases in pregnancy or an adverse pregnancy outcome such as PrE/E.35–37 During the timeframe of our study (2007–2019), referrals to cardiology were not the standard of care for patients with PrE/E; thus, there may be residual bias for who gets referred to a cardiologist during our study period. Nonetheless, our findings have important implications that need to be addressed. Although the receipt of cardiology care during the prenatal/antepartum period might be an option to mitigate future cardiovascular complications, our study reflects that this might not be sufficient for Black women. To ensure equitable maternal cardiovascular health, further strategies that integrate clinician and community level and patient-centered approaches to care.35,38 The Association of Black Cardiologists provided numerous solutions to improve Black maternal health which include collecting data on quality of care using quality metrics and incentivization of high-quality maternal care, faith-based community partnerships and community outreach programs, diversifying the medical curriculum, and the use of digital technology tools for remote ambulatory monitoring.35,39

Structural racism has contributed to an untrustworthy medical system where policies and patterns of care are often discriminatory towards underrepresented racial and ethnic groups particularly Black patients.40 Restoring these relationships will require rebuilding an ethical medical system that focuses on the needs of the individual patient, which may vary by race, ethnicity, and sociodemographic group.41,42 Steps in this direction have demonstrated better maternal and neonatal outcomes through racial concordance from clinicians and patients from underrepresented backgrounds.43,44 Provider-patient racial concordance could improve mutual trust, healthy communication, and patient satisfaction.43,44 Future studies should explore the effect of provider-patient racial concordance on the future risk of MACE in PrE/E and also examine the factors that influence postpartum referral patterns for Black and White patients with the highest risk of cardiovascular complications. Our study focused on patients with commercial insurance; future studies should broaden the scope to include those with Medicaid or other lower-paying insurance beneficiaries.

Limitations

This study has some limitations. For our cohort selection, we included a sample of patients who had deliveries from 2007 to 2019 and were diagnosed with PrE/E within 160 days before delivery. This approach may introduce survivorship bias, as the selected patients with PrE/E were those who lived long enough to survive delivery. The dataset lacked granularity in terms of how cardiology care was provided. We were unable to ascertain if cardiology care was provided to the patient for treatment or preventative measures. In addition, we were unable to ascertain the frequency and timing of cardiology care throughout the pregnancy period. We appreciate that these factors may have a substantial impact on the care and outcomes for both races; however, because of the complex nature of these metrics, we were not able to incorporate these into our current analysis. Although we adjusted for possible cardiac diseases, the severity of these diseases could not be adjusted given the lack of granularity in disease severity in the dataset. Only recently has care by a cardiologist become a standard of care with PrE/E. These factors may contribute to residual bias in who was referred to a cardiologist and subsequent outcomes during this study time period.

A significant limitation is that race and ethnicity were classified using a proprietary algorithm developed by Optum that considers geospatial variables and names. This algorithm has not been validated, raising concerns about potential misclassification of Black patients as White patients, which could lead to an underestimation of outcomes for Black patients. Furthermore, we were unable to account for patients’ socioeconomic status, as the data use agreement allows researchers to either use date of death or other socioeconomic status variables but not both together. Another limitation of this study was that we were unable to assess the effect of cardiology care on each independent component of MACE as the observations were limited in number. In addition, there was a lack of precision in the exact date and time of delivery with the medical claims dataset which made us develop an algorithm to select eligible deliveries. The patients in our study had full medical insurance coverage in 1 year before delivery and 1 year after delivery, thus results may vary for uninsured or underinsured populations. Lastly, we had no information on patients’ cardiovascular risk before pregnancy as this dataset did not include variables necessary to calculate risk scores like the CARPREG II scores (cardiac disease in pregnancy risk index).45

Conclusions

Among a well-insured population of patients with PrE/E, Black patients had a significantly higher cumulative incidence of MACE up to a year post-delivery compared with White patients. However, receipt of cardiology care was associated with a significantly lower hazard of MACE for White women, not for Black women. This observation does not suggest that cardiology care is detrimental to Black individuals but underscores the necessity to investigate why outcomes are disparate among these racial groups. Additional effective strategies are needed to reduce inequities in maternal cardiovascular health.

Article Information

Sources of Funding

This work was funded by Dr Breathett’s research grant funding from the National Heart, Lung, and Blood Institute (K01HL142848, R01HL159216, R56HL159216) and the Health Resources and Services Administration of the US Department of Health and Human Services. The Indiana University Carbonate platform was used to access the Optum’s de-identified Clinformatics Data Mart Database. The Indiana University Carbonate platform is supported in part by Lilly Endowment, Inc, through its support for the Indiana University Pervasive Technology Institute.

Disclosures

None.

Supplemental Material

Tables S1–S4

Figures S1–S3

Supplementary Material

hcq-18-e011643-s001.pdf (474.5KB, pdf)

Nonstandard Abbreviations and Acronyms

CDM
Optum’s de-identified Clinformatics Data Mart Database
HR
hazard ratio
ICD-10
International Classification of Diseases-Tenth Revision
ICD-9-CM
International Classification of Diseases-Ninth Revision-Clinical Modification
MACE
major adverse cardiovascular events
PrE/E
preeclampsia/eclampsia

For Sources of Funding and Disclosures, see page 36.

This manuscript was sent to Lauren Eberly, MD, MPH, Guest Editor, for review by expert referees, editorial decision, and final disposition.

This work was presented as an abstract at the American Heart Association Scientific Sessions, November 16–18, 2024, Chicago, IL. Dr. Bolakale-Rufai was an early career finalist for this work.

Contributor Information

LaPrincess C. Brewer, Email: Brewer.Laprincess@mayo.edu.

Selma Mohammed, Email: selma.f.mohammed@gmail.com.

Sula Mazimba, Email: sm8sd@uvahealth.org.

Daniel Addison, Email: daniel.addison@osumc.edu.

References

  • 1.Ives CW, Sinkey R, Rajapreyar I, Tita ATN, Oparil S. Preeclampsia—pathophysiology and clinical presentations. J Am Coll Cardiol. 2020;76:1690–1702. doi: 10.1016/j.jacc.2020.08.014 [DOI] [PubMed] [Google Scholar]
  • 2.Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010;376:631–644. doi: 10.1016/S0140-6736(10)60279-6 [DOI] [PubMed] [Google Scholar]
  • 3.MacDorman MF, Thoma M, Declcerq E, Howell EA. Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016–2017. Am J Public Health. 2021;111:1673–1681. doi: 10.2105/AJPH.2021.306375 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Melchiorre K, Sharma R, Thilaganathan B. Cardiovascular implications in preeclampsia. Circulation. 2014;130:703–714. doi: 10.1161/CIRCULATIONAHA.113.003664 [DOI] [PubMed] [Google Scholar]
  • 5.Brown HL, Warner JJ, Gianos E, Gulati M, Hill AJ, Hollier LM, Rosen SE, Rosser ML, Wenger NK; American Heart Association and the American College of Obstetricians and Gynecologists. Promoting risk identification and reduction of cardiovascular disease in women through collaboration with obstetricians and gynecologists: a presidential advisory from the American Heart Association and the American College of Obstetricians and Gynecologists. Circulation. 2018;137:e843–e852. doi: 10.1161/CIR.0000000000000582 [DOI] [PubMed] [Google Scholar]
  • 6.Behrens I, Basit S, Melbye M, Lykke JA, Wohlfahrt J, Bundgaard H, Thilaganathan B, Boyd HA. Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study. BMJ. 2017;358:j3078. doi: 10.1136/bmj.j3078 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Fingar KR, Mabry-Hernandez I, Ngo-Metzger Q, Wolff T, Steiner CA, Elixhauser A. Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality; Rockville, MD. Statistical Brief No. 222. February 2006. [PubMed] [Google Scholar]
  • 8.Breathett K, Muhlestein D, Foraker R, Gulati M. Differences in preeclampsia rates between African American and Caucasian women: trends from the National Hospital Discharge Survey. J Womens Health (Larchmt). 2014;23:886–893. doi: 10.1089/jwh.2014.4749 [DOI] [PubMed] [Google Scholar]
  • 9.Sharma G, Boakye E, Creanga AA, Vaught AJ, Zakaria S, Mehta LS, Blumenthal RS, Hong X, Ogunwole SM, Ji Y, et al. Abstract 16555: the relationship of preeclampsia and maternal region of birth and duration of residence in Non-US Born Black Women. Circulation. 2020;142(Suppl_3):A16555–A16555. doi: 10.1161/circ.142.suppl_3.16555 [Google Scholar]
  • 10.Ghosh G, Grewal J, Männistö T, Mendola P, Chen Z, Xie Y, Laughon SK. Racial/ethnic differences in pregnancy-related hypertensive disease in nulliparous women. Ethn Dis. 2014;24:283–289. [PMC free article] [PubMed] [Google Scholar]
  • 11.Minhas AS, Ogunwole SM, Vaught AJ, Wu P, Mamas MA, Gulati M, Zhao D, Hays AG, Michos ED. Racial disparities in cardiovascular complications with pregnancy-induced hypertension in the United States. Hypertension. 2021;78:480–488. doi: 10.1161/HYPERTENSIONAHA.121.17104 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, et al. ; American Heart Association. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. J Am Coll Cardiol. 2011;57:1404–1423. doi: 10.1016/j.jacc.2011.02.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Selim AM, Mazurek JA, Iqbal M, Wang D, Negassa A, Zolty R. Mortality and readmission rates in patients hospitalized for acute decompensated heart failure: a comparison between cardiology and general-medicine service outcomes in an underserved population. Clin Cardiol. 2015;38:131–138. doi: 10.1002/clc.22372 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Uthamalingam S, Kandala J, Selvaraj V, Martin W, Daley M, Patvardhan E, Capodilupo R, Moore S, Januzzi JL. Outcomes of patients with acute decompensated heart failure managed by cardiologists versus noncardiologists. Am J Cardiol. 2015;115:466–471. doi: 10.1016/j.amjcard.2014.11.034 [DOI] [PubMed] [Google Scholar]
  • 15.Breathett K, Liu WG, Allen LA, Daugherty SL, Blair IV, Jones J, Grunwald GK, Moss M, Kiser TH, Burnham E, et al. African Americans are less likely to receive care by a cardiologist during an intensive care unit admission for heart failure. JACC Heart Fail. 2018;6:413–420. doi: 10.1016/j.jchf.2018.02.015 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Kociol RD, Hammill BG, Fonarow GC, Heidenreich PA, Go AS, Peterson ED, Curtis LH, Hernandez AF. Associations between use of the hospitalist model and quality of care and outcomes of older patients hospitalized for heart failure. JACC Heart Fail. 2013;1:445–453. doi: 10.1016/j.jchf.2013.07.001 [DOI] [PubMed] [Google Scholar]
  • 17.Bolakale-Rufai IK, Knapp SM, Johnson AE, Brewer LP, Mohammed S, Addison D, Mazimba S, Tucker-Edmonds B, Breathett K. Association between race, cardiology care, and the receipt of guideline-directed medical therapy in peripartum cardiomyopathy. J Racial Ethn Health Disparities. 2024;11:3872–3881. doi: 10.1007/s40615-023-01838-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Indiana University. Clinformatics data mart for IU researchers. Accessed February 2, 2023. https://ssrc.indiana.edu/data/optum.html [Google Scholar]
  • 19.Nead KT, Hinkston CL, Wehner MR. Cautions when using race and ethnicity in administrative claims data sets. JAMA Health Forum. 2022;3:e221812–e221812. doi: 10.1001/jamahealthforum.2022.1812 [DOI] [PubMed] [Google Scholar]
  • 20.The R Project for Statistical Computing. 2021. https://www.r-project.org/ [Google Scholar]
  • 21.Zahid S, Din MT, Minhas AS, Rai D, Kaur G, Carfagnini C, Zia Khan M, Ullah W, Gillian Christine Van Spall H, Hays AS, et al. Racial and socioeconomic disparities in cardiovascular outcomes of preeclampsia hospitalizations in the United States 2004-2019. JACC Adv. 2022;1:100062. doi: 10.1016/j.jacadv.2022.100062 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Lee DC, Liang H, Shi L. The convergence of racial and income disparities in health insurance coverage in the United States. Int J Equity Health. 2021;20:96. doi: 10.1186/s12939-021-01436-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Holahan J, Cook A. Changes in economic conditions and health insurance coverage, 2000–2004. Health Aff (Millwood). 2005;24(Suppl1):W5-498–W5-508. doi: 10.1377/hlthaff.W5.498 [DOI] [PubMed] [Google Scholar]
  • 24.Eberly LA, Richterman A, Beckett AG, Wispelwey B, Marsh RH, Cleveland Manchanda EC, Chang CY, Glynn RJ, Brooks KC, Boxer R, et al. Identification of racial inequities in access to specialized inpatient heart failure care at an Academic Medical Center. Circ Heart Fail. 2019;12:e006214. doi: 10.1161/CIRCHEARTFAILURE.119.006214 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol. 2010;202:335–343. doi: 10.1016/j.ajog.2009.10.864 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Caraballo C, Ndumele CD, Roy B, Lu Y, Riley C, Herrin J, Krumholz HM. Trends in racial and ethnic disparities in barriers to timely medical care among adults in the US, 1999 to 2018. JAMA Health Forum. 2022;3:e223856. doi: 10.1001/jamahealthforum.2022.3856 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Gertz AH, Pollack CC, Schultheiss MD, Brownstein JS. Delayed medical care and underlying health in the United States during the COVID-19 pandemic: a cross-sectional study. Prev Med Rep. 2022;28:101882. doi: 10.1016/j.pmedr.2022.101882 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.American College of Obstetricians and Gynecologists’ Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin No. 212: pregnancy and heart disease. Obstetr Gynecol. 2019;133:e320–e356. doi: 10.1097/aog.0000000000003243 [DOI] [PubMed] [Google Scholar]
  • 29.Chambers BD, Taylor B, Nelson T, Harrison J, Bell A, O’Leary A, Arega HA, Hashemi S, McKenzie-Sampson S, Scott KA, et al. Clinicians’ perspectives on racism and Black Women’s Maternal Health. Womens Health Rep (New Rochelle). 2022;3:476–482. doi: 10.1089/whr.2021.0148 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Defense Health Agency. Disparities in the use of preventive care by race/ethnicity. 2024. Accessed June 5, 2024, https://www.health.mil/Reference-Center/Reports/2021/04/22/Disparities-in-the-Use-of-Preventive-Care-by-Race-Ethnicity-March-2021#:~:text=There%20were%20no%20differences%20in,and%20reduce%20health%20care%20expenditures [Google Scholar]
  • 31.Breathett K, Jones J, Lum HD, Koonkongsatian D, Jones CD, Sanghvi U, Hoffecker L, McEwen M, Daugherty SL, Blair IV, et al. Factors related to physician clinical decision-making for African-American and Hispanic patients: a qualitative meta-synthesis. J Racial Ethn Health Disparities. 2018;5:1215–1229. doi: 10.1007/s40615-018-0468-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Countouris ME, Shapero KS, Swabe G, Hauspurg A, Davis EM, Magnani JW. Association of race and ethnicity and social factors with postpartum primary care or cardiology follow-up visits among individuals with preeclampsia. J Am Heart Assoc. 2024;13:e033188. doi: 10.1161/JAHA.123.033188 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Luks FI, Carr SR, Feit LR, Rubin LP. Experience with a multidisciplinary antenatal diagnosis and management model in fetal medicine. J Matern Fetal Neonatal Med. 2003;14:333–337. doi: 10.1080/jmf.14.5.333.337 [DOI] [PubMed] [Google Scholar]
  • 34.Davis MB, Arendt K, Bello NA, Brown H, Briller J, Epps K, Hollier L, Langen E, Park K, Walsh MN, et al. ; American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group. Team-based care of women with cardiovascular disease from pre-conception through pregnancy and postpartum: JACC focus seminar 1/5. J Am Coll Cardiol. 2021;77:1763–1777. doi: 10.1016/j.jacc.2021.02.033 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Bond RM, Gaither K, Nasser SA, Albert MA, Ferdinand KC, Njoroge JN, Parapid B, Hayes SN, Pegus C, Sogade B, et al. ; Association of Black Cardiologists. Working agenda for Black mothers: a position paper from the Association of Black Cardiologists on solutions to improving Black maternal health. Circ Cardiovasc Qual Outcomes. 2021;14:e007643. doi: 10.1161/CIRCOUTCOMES.120.007643 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, Gunderson EP, Stuart JJ, Vaidya D; American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and the Stroke Council. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021;143:e902–e916. doi: 10.1161/CIR.0000000000000961 [DOI] [PubMed] [Google Scholar]
  • 37.American Heart Association. This is our lane-too: joint statement on maternal health crisis from the Association of Black Cardiologists, American College of Cardiology and American Heart Association. Accessed May 7, 2024. https://newsroom.heart.org/news/this-is-our-lane-too-joint-statement-on-the-maternal-health-crisis-from-the-association-of-black-cardiologists-american-college-of-cardiology-and-american-heart-association [Google Scholar]
  • 38.Ogunniyi MO, Mahmoud Z, Commodore-Mensah Y, Fleg JL, Fatade YA, Quesada O, Aggarwal NR, Mattina DJ, Moraes De Oliveira GM, Lindley KJ, et al. ; American College of Cardiology Cardiovascular Disease in Women Committee and the American College of Cardiology Health Equity Taskforce. Eliminating disparities in cardiovascular disease for Black women. J Am Coll Cardiol. 2022;80:1762–1771. doi: 10.1016/j.jacc.2022.08.769 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Cortés YI, Breathett K. Addressing inequities in cardiovascular disease and maternal health in Black women. Circ Cardiovasc Qual Outcomes. 2021;14:e007742. doi: 10.1161/CIRCOUTCOMES.121.007742 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Yearby R, Clark B, Figueroa JF. Structural racism in historical and modern US health care Policy. Health Aff (Millwood). 2022;41:187–194. doi: 10.1377/hlthaff.2021.01466 [DOI] [PubMed] [Google Scholar]
  • 41.Churchwell K, Elkind MSV, Benjamin RM, Carson AP, Chang EK, Lawrence W, Mills A, Odom TM, Rodriguez CJ, Rodriguez F, et al. ; American Heart Association. Call to action: structural racism as a fundamental driver of health disparities: a presidential advisory from the American Heart Association. Circulation. 2020;142:e454–e468. doi: 10.1161/CIR.0000000000000936 [DOI] [PubMed] [Google Scholar]
  • 42.Breathett K, Manning KD. Catalyzing restructure of a broken health care system. Circ Cardiovasc Qual Outcomes. 2024;17:e010009. doi: 10.1161/CIRCOUTCOMES.123.010009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Okpa A, Buxton M, O’Neill M. Association between provider-patient racial concordance and the maternal health experience during pregnancy. J Patient Exp. 2022;9:23743735221077522. doi: 10.1177/23743735221077522 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Jeffers NK, Canty L, Drew M, Grayson N, Amani J, Marcelle E, Amore AD. Beyond “patient-provider race matching.” Black midwives clarify a vision for race-concordant care to achieve equity in Black perinatal health: a commentary on “Do Black birthing persons prefer a Black health care provider during birth? Race concordance in birth.” Birth. 2023;50:267–272. doi: 10.1111/birt.12720 [DOI] [PubMed] [Google Scholar]
  • 45.Silversides CK, Grewal J, Mason J, Sermer M, Kiess M, Rychel V, Wald RM, Colman JM, Siu SC. Pregnancy outcomes in women with heart disease: the CARPREG II study. J Am Coll Cardiol. 2018;71:2419–2430. doi: 10.1016/j.jacc.2018.02.076 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

hcq-18-e011643-s001.pdf (474.5KB, pdf)

Articles from Circulation. Cardiovascular Quality and Outcomes are provided here courtesy of Wolters Kluwer Health

RESOURCES