Disparities in health care are pervasive in America

Disparities in health care are pervasive in America. These disparities adversely impact the cardiovascular health of Americans, especially African Americans, Hispanics, poor and uneducated people, according to a report in a special disparities themed issue of Circulation: Journal of the American Heart Association.

Health disparities refer to differences in health indicators of population groups whether defined by race, ethnicity, gender, socioeconomic status or geography.

Researchers at the Centers for Disease Control and Prevention (CDC) analyzed national health surveys to assess the prevalence of cardiovascular disease and overall quality of life of U.S. adults age 18 and older and found a wide range of differences. They said the disparities data may help develop new public policies and programs to close the gaps.

"In general, the population subgroups most significantly and adversely affected were African Americans, Hispanics/Mexican Americans, people with low socioeconomic status, and residents of the southeastern United States and the Appalachians," said George Mensah M.D., acting director of the National Center for Chronic Disease Prevention and Health Promotion at the CDC.

People with less than a high school education also tended to have more cardiovascular disease and related risk factors, regardless of race or ethnicity.

"These disparities appear to play a key role in the observed differences in the overall life expectancy and quality of life of the population subgroups," he said.

Health care disparities should matter to all Americans, Mensah said. "To paraphrase what Dr. Martin Luther King said about justice, 'poor quality health care anywhere, is a threat to quality care for all Americans everywhere.' As a heart specialist, I am aware of the power of prevention and the remarkable advances we've made in the treatment and care of heart disease and stroke. I am always saddened to admit that many ethnic minorities, persons with low income, those with less than a high school education, women and millions of Americans without health insurance do not get the quality health care we are capable of delivering."

In the study, men and blacks had more premature death due to cardiovascular disease, compared with women and whites, as measured by years of potential life lost before age 75.

In 2001, overall U.S. life expectancy was 77.2 years. Life expectancy was higher in women than men by 5.4 years and higher in whites than blacks by 5.5 years. Men lost 1708.3 years of potential life per 100,000 persons due to "diseases of the heart" compared to women, who lost 765.4 years. Blacks lost 2,248.9 years of potential life per 100,000 persons compared to whites, who lost 1,115 years.

Particularly surprising, Mensah said, were findings about obesity.

"Educational attainment reduced the prevalence of obesity, especially in men," he said. "In contrast, African-American women had a high prevalence of obesity and abdominal obesity regardless of educational status. These data suggest the need for increased emphasis on understanding the determinants of obesity in African-American women and investing in policies and programs to decrease obesity."

Eliminating health disparities is the overarching goal of the Healthy People 2010 national public health agenda, Mensah said. In this study, CDC researchers examined the most recently available population-based data on disparities in cardiovascular disease and its related risk factors.

Researchers reviewed the results from three major studies:

• Behavioral Risk Factor Surveillance System (BRFSS), a random telephone survey conducted by state health departments and the CDC;
• the National Health and Nutrition Examination Survey (NHANES) 1999-2002; and
• the National Health Interview Survey (NHIS), a continuing nationwide sample survey of the civilian non-institutionalized population collected through household interviews.

The BRFSS and NHANES survey results were designed to represent the entire U.S. population.

Also among their findings:

• Hispanics were least likely to have health insurance, least likely to receive flu or pneumonia vaccinations, and had the highest prevalence of poor or fair health.
• Data from the Racial and Ethnic Approaches to Community Health (REACH) showed the median prevalence of obesity was 39.2 percent for American Indian men and 37.5 percent in women, compared with only 2.9 percent in Asian/Pacific Islander men and 3.6 percent in women.
• According to NHANES data, black women have the highest prevalence of obesity at more than 47 percent regardless of education level.
• Data from REACH also showed that cigarette smoking was common in American Indian communities with a median of 42.2 percent for men and 36.7 percent for women. According to BRFSS, black men without a high school diploma have the next highest smoking prevalence at 41.8 percent.
• Blacks had the highest prevalence of hypertension, the highest self-reported prevalence of diagnosed diabetes, and the highest rate of hospitalizations for stroke.
• People with less than a high school education were more likely to smoke and to report that they had been diagnosed with diabetes.
• People with higher education were more likely to have health insurance.
• Ischemic heart disease and stroke were inversely related to education, income and poverty status.
• Among Medicare enrollees, congestive heart failure hospitalization was higher in blacks, Hispanics and American Indians/Alaska Natives than among whites.
• Residents of the southeastern United States had the highest rates of hospitalizations for congestive heart failure and stroke, and the highest age-adjusted death rate for stroke and heart disease.
• Cholesterol levels were highest among white men, Mexican American men and white women regardless of education levels.
• Hospitalization rates were higher in men for total heart disease and acute heart attacks but higher in women for congestive heart failure and stroke.
• Women consume more fruits and vegetables than men; and daily intake of five or more servings of fruits and/or vegetables was low in all groups and lowest in black and white men with less than a high school education.

This study did not examine the reasons for these disparities, or present information on access to care, disease management or indicators of the delivery of quality cardiac care.

Researchers noted that despite several national calls to action for aggressive prevention and control of cardiovascular risk factors, little progress has been made in reducing physical inactivity, poor nutrition and prevalence of hypertension.

"Most importantly," Mensah said, "although some significant improvements – such as reductions in gender disparities in cardiovascular disease (CVD) – have been noted, disparities in CVD mortality based on race/ethnicity have remained largely unchanged, and disparities in the morbidity of major CVD appear to be increasing."

Co-authors of the study are Ali H. Mokdad, Ph.D.; Earl S. Ford, M.D., MPH; Kurt J. Greenlund, Ph.D.; and Janet B. Croft, Ph.D.